07 January 2013

Meet Stolle: An educator's educator

There is a compelling quote from an unknown source that immediately centers me when I consider the power of positive role modeling and the importance of a life well lived: “I strive to be the person my dog believes I am.” Dog lovers know exactly what this means. The lessons we learn from our furry friends have a lasting impact and make an indelible imprint on our lives.

We have an assortment of shelter pets—dogs and cats—that others have thoughtlessly tossed along the roadside, both literally and figuratively. One of them, Stolle (STOW-lee), is an Australian shepherd and border collie mix. She is named after Stolle Meadow, an incredibly beautiful mountain meadow nestled near the South Fork of Idaho’s wild and spectacular Salmon River, a magical place where visitors and local hikers watch chinook salmon spawn in late summer.


Stolle

Our Stolle is pretty magical. too. We rescued her from the local animal shelter when she was 7 months old. It was clear from the outset that someone had mistreated her, perhaps badly. Initially, she acted afraid most of the time—cowering, skittish around strangers, especially terrified of men. I remember very clearly the day the cable guy came to hook up our TV. As he exited his truck and approached our door, Stolle nearly came unglued. Although frightened to the point of panic, she nonetheless fiercely defended her home and family. Despite her fear of others, Stolle loved us from the beginning.

We’ve learned many life lessons from Stolle during the short time we’ve owned her—she just turned 2 years old—as we have from all of our other dogs, past and present. It’s easy to lose sight of what’s important in our lives, but dogs keep us on track, mindful of life’s treasures. Yes, misfortunes occur and hardships happen, but it’s how we deal with such matters that makes us strong, our lives memorable.

Our dogs have taught me to bark less and wag more often. They have shown us that life is an adventure worth living and that it is a privilege to be loved by a canine friend. Having a dog reminds me that it is OK—if not mandatory—to have fun and to take life a little less seriously; to play more and enjoy the thrill of the outdoors, no matter the weather; that snow is meant to be tossed exuberantly into the air with one’s nose and that newly raked leaves are fair game for jumping and diving and finding out what’s underneath that cushion of color. Being a dog is synonymous with going for the gusto. No matter how old we are, in people years or dog years, we can choose to be youthful and playful—puppies at heart.

Our canine friends remind us in so many ways that life doesn’t need to be so complicated or complex. They teach us the importance of simplifying and decluttering our lives—to take lots of naps; to curl up by the fire with a favorite toy or person; to spend lots of quiet, lazy days lying in the sunshine with your belly in the air. Stolle makes me strive to be a better person; a better wife and mother; a better teacher and friend; really, a better everything. She is a faithful and loyal friend who loves us unconditionally and guards us with her very life. Dogs are more than dogs—they are the epitome of caring and compassion.

Stolle has a warm and sheltered place to relax, but she chooses to wait, sometimes in pouring rain, drenched to the bone, anticipating the sound of our vehicle coming up the lane, signaling our arrival home. Jumping for joy, her enthusiasm and excitement is a sight to behold and a heartwarming delight. At the end of a busy day, it’s the perfect, love-filled greeting to come home to. Dogs are always happy to see us, even when we leave for only a few minutes. Stolle reminds us to slow down, pay attention, and take delight in life’s simple pleasures. Often, they are what bring us the greatest joy.

The time will come when Stolle will leave this earthly place. It won’t be easy to say good-bye. We have bid farewell to several loyal and treasured furry friends over the years, and it is one of life’s most difficult moments. Mack, our beloved Labrador retriever, lived to a ripe old age of 15 years. Putting him down was terribly sad. We still miss him and cherish our memories of one of the best dogs ever to grace our lives. I am comforted in my belief that there is a special place in heaven for dogs like Mack and Stolle—loving, affectionate, and kind friends who inspire me to be the person they believe I am.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

13 November 2012

Living the joy of authentic conversations

For many of us, the world is a busy and noisy place, a high-tech, digital environment—often stressful—where we are besieged with text, e-mail, phone calls and other instant messaging. We madly check, send, receive, exchange and process a vast amount of information every day. And, if we teach in the virtual environment, our days are filled with managing and responding to an incredible amount of complex and multifaceted data. This explosion of technology and our preoccupation with it can interfere with our privacy, disrupt our relationships and create yet another venue for incivility.

At a recent community event, I was seated next to a civic leader who expressed concern about the impact of technology on relationships. She told me about having an important conversation with her grown son who, in the middle of their discussion, took a call that lasted several minutes. Annoyed, she asked her normally well-mannered son why he chose to take the call when they were obviously engaged in an important dialogue. He thought for a moment and then said, “I think it’s because I wanted to stop the noise, to quiet the jarring disturbance of a ringing cell phone.” Ah, there it is again. We are torn between our desire to silence the noisy din of our busy, hurried world and our preoccupation with responding in “real time” simply because technology makes it possible.

What will it take for us to engage in meaningful, genuine, face-to-face conversation; to carve out time from our hectic schedules to seek and savor the quiet and calm that often comes with open, honest communication? Margaret Wheatley (2002) reminds us that we can “change the world if we start listening to one another. Simple, honest, human conversation … a chance to speak, to feel heard, and where we each listen well. The simple art of conversation may ultimately save the world (p. 3).” If Wheatley’s assertion is true, and I believe it is, then faculty play a key role in facilitating this process with students by creating learning environments for teaching, learning and practicing the complex skills needed for authentic conversations.

My students and I spend a good deal of time practicing and improving our skills for engaging in conversation with patients, members of the health care team, one another and with the people who matter most in our lives. We discuss mental and cognitive preparation for critical conversations, how to gauge and create emotional safety, setting goals and determining mutual interests, and seeking common ground. We practice giving and receiving constructive feedback, and we use that feedback to set realistic short- and long-term goals for life and for nursing practice.

I challenge my students to use their newly acquired skills to engage in meaningful conversation with others. I ask students to select someone in their lives with whom they wish to have an important conversation, using the skills we’ve practiced in class, and then, if comfortable, to share their experiences with the class. If students agree to report back, I have them briefly describe the situation and the person or people involved, key issues and reasons for the conversation, and steps used to engage in the conversation. I also ask them to describe how the conversation started, progressed and ended. Many students rise to the challenge and openly share their experiences, which, of course, help all of us learn and improve.

I challenge my students to use their newly acquired skills
to engage in meaningful conversation with others.
This semester, I had a very interesting experience. After our “critical conversations” class, I was working in my office when one of my students—I’ll call him Harry—knocked on the door and asked if I had time to meet for a few moments. I did, so invited him to have a seat. Taking the chair across from me, he sat quietly for a few moments, seemingly to compose his thoughts, and then said, “Dr. Clark, you suggested that we find someone with whom we would like to engage in a critical conversation, right?” I nodded, and he continued, “Well, I picked you!”

I was surprised and flattered, all at the same time, but more than that, I was very curious, so I asked him to proceed. Harry seemed to gather himself, and then asked, “Do you remember a couple of weeks ago when I was playing computer games and not paying attention to the class discussion?” I nodded, asked him to continue, and he said, “What I did was wrong. My behavior was rude, and I came to apologize. You deserve better—and you deserve more respect. I promise that, from here on out, I am going to do better. You will see a different me. I am going to be more involved in class, pay closer attention and show you that I mean it.” I thanked him, expressed how impressed I was with our conversation, and then he left.

The following week, I arrived at my classroom early, as usual, to give me time to visit with my students before class began. I immediately noticed that Harry was sitting in a different seat. Instead of his normal spot in the last row in a far corner, he had selected a new seat—just a bit off center and only two rows from the front of the classroom. I approached him and said, “Good morning, Harry. I see you have a new seat.” He smiled and said, “I promised you that I would make every effort to be involved in class, and that’s what I’m doing. Sitting here helps.”

Since the day of our critical conversation, Harry has lived up to his promise. He is fully engaged and participates in small and large classroom discussions. He is a very impressive young man and well on his way to becoming an excellent nurse.

Engaging in critical conversation is an art that must be developed and honed over time. Being a positive role model and teaching this important skill is integral to preparing our students for successful nursing careers. The end goal is to create a safe space for authentic dialogue, to treat one another with civility and respect, to seek common ground, to give a little, pursue a win-win outcome and, ultimately, to improve our relationships.

Reference:
Wheatley, M.J. (2002). Turning to one another: Simple conversation to restore hope to the future. San Francisco, CA: Berrett-Koehler Publishers.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

29 August 2012

The final chapter and a new beginning

More than seven years have passed since my doctoral-program adviser died from metastatic lung cancer. Since then, I have struggled to find the words to describe our scholarly and personal journey together but, in this blog post, I will attempt to pay fitting tribute to the experience.

When I first considered pursuing a doctoral degree, I met with my adviser to seek his counsel about my academic options. When I arrived at his office, we immediately connected. Our first meeting lasted two hours as we shared our perspectives about the academy, love for learning and passion for education. We quickly formed a strong student-professor bond, and when he was diagnosed with bilateral lung cancer a year later, everyone who knew him was devastated. Soon after his diagnosis, our discussions began to shift. While we continued to discuss the merits of graduate school and the trajectory of my research program, our conversations also centered on the fragility of life and living each day with purpose.

In the months following his terminal diagnosis, there were times when my scholar-mentor was utterly exhausted and in a severely weakened state, yet his spirit remained resolute. By January of 2005, I began finalizing my proposal. Two months later, in what I believed would be a routine meeting, my adviser suggested we “fast track” my program. He proposed an ambitious course for completion and, in retrospect, I should have realized his health was swiftly failing. I worked hard to accomplish the plan, and in May I went to his office to make plans for the summer.

It was pouring rain that day. After our meeting, he asked me to meet him in the parking lot, because he had a gift for me. When I met him, he was carrying a large cardboard box. He placed it in my car and told me not to open it until I got home. I drove away absorbed in curiosity. What could be in the box? When I finally opened it, I found 30 books inside. Most were used, and many were marked with personal notes and thoughts that must have struck him while he read. I gently closed the box of books and considered their meaning, but did not want to dwell too long on their significance.

In early July, we met for a lengthy meeting at a local coffee shop. We had a wonderful time discussing my study and my future as a scholar. At the end of our meeting, he suggested we set a date for defending my dissertation. This was clearly not what I expected and, with staggering clarity, it hit me. His prognosis was bleak. He told me his current chemotherapy treatment was not effective and that he had only a few weeks to live. I was shaken to my very core. I could only imagine his state of mind.

For the next few weeks, we kept in touch by phone and e-mail. Toward the end of July, we met at his home because he was too ill to keep office hours. His condition had deteriorated, and it frightened me. We continued to discuss my study and its implications, but we also talked about the circle of life and the process of living and dying. I was nervous about my proposal defense, but he was undaunted. He said, “Dr. Clark, you are going to do an excellent job.” Of course, he had never called me that before, as I had not yet earned the title, though it occurred to me later that, if he didn’t do it then, he would never address me as Dr. Clark.

Our meeting on August 5, 2005 would be our last. We met again at his home. When he opened the door, I was dismayed to see he was attached to oxygen and having difficulty breathing, but he had a twinkle in his eye, a big smile on his face and said he was happy to see me. Because of the death and dying process, our conversations had become more personal. We talked as colleagues and as friends. We talked about my children and his grandchildren and our unlimited dreams for each of them. We talked about our hopes and fears, and then he told me about his experience as a young doctoral student.

He described how he had endured crushing put-downs and belittling remarks by one of his professors, and how angry and hurt he had felt. His professor had questioned whether my future adviser would even graduate and attempted to rob him of his confidence. But he did graduate and went on to do great things.

Then my adviser’s true spirit shone through. He told me how, just recently, in the final weeks of his life, he had contacted his former professor and had worked through the past acts of incivility. He felt as though he had come full circle.

Then the meeting was over. I hugged him tightly, sensing that his life was slowly ebbing away. Standing on his doorstep, he waved goodbye until my car was out of sight. He died 10 days later.

Today, as I reflect on my time with him, I see the experience for what it truly was—a gift of discovery, transformation and human connection. After successfully defending my dissertation and after feeling the weight of my doctoral hood settle on my shoulders, I finally emptied the box of books and ceremoniously and lovingly placed them where they belonged—on the bookshelves of my office—where they serve as a constant reminder of our scholarly and personal journey, and a special friendship I will always remember.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

26 June 2012

The power of mentoring: My story

Nearly three decades ago, I started my first nursing position. It was a dream job for an energetic and eager, newly minted nurse. I worked on a surgical floor where my major responsibilities included educating and preparing patients for pending procedures, and caring for them when their procedures were completed. I loved my job, my patients, my colleagues and my free time! I began my shift at 5 o’clock in the morning and ended at 1 p.m. In good weather, I rode my bicycle, because I didn’t own a car. During the harsh winters of the upper Midwest, I rode to work in a taxi driven by a trusted cabbie. My hours were awesome, especially for a young, single person who loved to recreate and be outdoors. But, as with so many times in life, change happens.

The author, circa 1980
About a year and a half into my job, the hospital hired a new director of nursing. I have to believe that her heart was in the right place and that she was doing what she thought best for the hospital and patients, but for me, her decisions would be life changing. She decided, for reasons that still perplex me, to reassign many of the nurses to various units, according to seniority and date of hire. Though I was thoroughly enjoying my role on the surgical unit and thriving, I was one of the nurses reassigned. I was moved to the evening shift on what was then known as the “terminal unit.” It was a dismal setting compared to where I had been working , because I am a “morning person,” it was a like a death sentence. But very quickly, I grew to love my teammates and our patients, and I was surprised to discover that I had a knack for being present and listening to patients’ stories.

Many patients were in the end stages of their illnesses and in various phases of the dying process. Although a highly competent nurse, I clearly needed improvement in my timeliness and efficiency. I discovered—and, of course, so did my charge nurse—that because I enjoyed engaging in prolonged conversations with patients, my task completion often fell short. My charge nurse genuinely liked me and believed I was a skilled nurse but, on many occasions, she was compelled to admonish me on my inability to complete my work on time. I realized that I needed to improve my timeliness, and I was working on it, but there were times when I still fell short of my goals. And then one night, I experienced a defining moment in my young career.

It was a busy night, late in the shift. One of my tasks was to remove the irrigation apparatus from an elderly male patient who had recently undergone surgery for a transurethral resection. This surgery required an elaborate series of bottles and tubing, including a urinary catheter inserted through the male genitalia and progressing into the bladder where fluids could be used for irrigation. The charge nurse asked me to remove the apparatus and to do it with expediency, because there was much more work to be done. I was determined to show how well I could perform the task, and to do it in a swift and efficient manner.

I walked into the patient’s room, greeted him and began to explain the procedure. He gazed at me with tired eyes and asked, “Will it hurt?” I paused, and then said gently, “Of course, I’m not a man, but when I have done this procedure for other gentlemen, they have told me it is pretty uncomfortable.” He responded, “I’m not ready yet. Can we talk for awhile?” So, I sat beside him, and we talked. He had recently lost his wife of many decades. He spoke of her that night—about their life together, their children and how aggrieved he was when his beloved wife took her final breath. We talked for about 10 minutes, and then he said he was ready. I briefly explained the procedure and went about removing the tubing and disengaging the apparatus.

I started to say good night when I noticed tiny, unshed tears in the corners of his eyes. I couldn’t just leave, so I sat with him for a few more minutes. Then, I gathered the equipment and, as I was rolling it down the hall, bolstered myself for a “talking to” by my charge nurse. Clearly, I had not performed my responsibilities in the desired time frame. Sure enough, as I walked down the hallway, she met me, politely asked me to dispose of the equipment, finish my assigned responsibilities and meet her in the conference room after completing my shift.

Believe me, I was pretty worried. I prepared myself for the possibility of that night being my last on the job. After our shift, we entered the conference room and the charge nurse gently closed the door, folded her hands, and said, “Cindy, you have missed your calling. I want you to think seriously about going back to school to become a psychiatric nurse. You have a genuine gift for being present with people and listening with real compassion and interest.” And then she sat back quietly in her chair.

Imagine my surprise. I looked at her, acknowledged her suggestion and promised her I would give it serious thought. Later, I reflected on our conversation, realized she was right and began making plans to return to school to become a psychiatric nurse. She was right—I loved my clinical career as a psychiatric nurse. I am forever grateful, and will never forget the care shown me by my charge nurse who saw something in me I did not. Rather than reprimand, discourage or suggest I find another position, she shined a light on a pathway of new discovery that launched a fabulous career in psychiatric nursing.

I learned many lessons from that experience. I learned that when we look for what’s right and good, and when we genuinely care about people, we can change their lives. In the course of my own career, I have tried to model for others the guidance my charge nurse bestowed on me more than 30 years ago. As a clinical nurse, I looked for and celebrated the strengths of my patients, and now, as a nursing professor, I try to do the same for my students. These valuable lessons have made and continue to make an impression on how I view and navigate the world.

For Reflections on Nursing Leadership  (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

08 May 2012

The groundskeeper of Boise State

The campus of Boise State University is spectacular this time of year. Spring has definitely arrived. Shrubs, trees and flowers bursting with vibrant, vivid and bold colors—every hue of the rainbow—are displayed against a carpet of green, surrounded by mountains and contrasted with skies so blue, you think you’re in heaven. As finals week approaches and crescendos into commencement and the promise of a bright and fresh tomorrow, faculty and students bustle from here to there, crowding the Quad and every nook and cranny of the campus. The advent of spring brings a sense of renewal and a multitude of possibilities and new beginnings.

Last week, as I was walking across campus, I noticed a groundskeeper busy at work—weeding, preparing the earth and planting flowers. His head was bowed as his strong and weathered hands dug and scooped the soil. I stopped to admire his work and thank him for making the campus such a beautiful and welcoming place. I told him how happy the grounds make me—and so many others—feel.

I was quite moved by his response. Instead of a simple thank you, he stood to his full height and, with a quiet dignity in his voice and a sparkle in his eyes, explained that he enjoyed his work; that adding to the beauty of campus life was important to him and gave him a sense of pride. I was reminded of one of my favorite quotes by Martin Luther King Jr., who said, “If a man is called to be a street sweeper, he should sweep streets even as Michelangelo painted, or Beethoven composed music, or Shakespeare wrote poetry. He should sweep streets so well that all the hosts of heaven and earth will pause to say, here lived a great street sweeper who did his job well.”

The groundskeeper of Boise State
Like the street sweeper referred to by King, the campus groundskeeper of Boise State is doing his job well. Not only does he find dignity in his work, he brings dignity to his work. He reveals a deep level of self-respect and a sense of accomplishment. His attitude inspires me and makes me want to do better, to leave a footprint of which I can be proud and a legacy of making a difference—to bring my “A” game to each encounter and situation.

To bring dignity to our work, we need to develop daily habits. I try to greet each person I meet with a smile, to be grateful for my blessings, to do something meaningful and to stand for something good. What are your daily habits? What footprint do you wish to leave? What will others say about you—about me—when all is said and done? Will you—will I—be remembered as someone who left an indelible mark and brought dignity to your—to my—work? This is our challenge.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

09 April 2012

Filling the reservoir of good will

In my previous blog, I introduced you to my mother-in-law, Margaret—a beautiful, spiritual and soon-to-be nonagenarian. She has long been a role model for me and so many other people whose lives she’s touched. Exceptionally reflective, Margaret lives by certain principles that shape her life and interactions with others. I try to follow her example by living by my own deeply held principles, including those that guide my professional life.

For example, my professional mission includes being an outspoken and ardent leader in creating and sustaining communities of civility and inspiring healthy workplaces and relationships. My goals are to raise awareness of the existence and consequences of incivility, to amplify the national dialogue on fostering civil work and learning environments, and to be an ambassador for lasting change. I also believe in the principle of filling the reservoir of goodwill as close to the brim as possible so that, when we need to draw from that reservoir, we have an abundant supply.

As a young undergraduate student, I was a very hard worker, attended all my classes and always turned my assignments in on time. I spoke up in class, added value to discussions and made an effort to get to know my professors. I did this because I loved learning, had made a substantial investment in my education and because I was the mother of a very young son who needed me to achieve so I could “be there” for him in every sense of the word. It was high stakes for me, and I knew that having an education would provide unimaginable opportunities.

During finals week and just before I was to graduate with my bachelor’s degree, my son became gravely ill. Diagnosed with a life-threatening condition that required extended hospitalization, his life hung in the balance. Freaking out on every level, I wondered how I would take my final exams—much less pass them. I had gambled everything on achieving my degree, and I was scared. All of this occurred before cell phones, e-mail and the other immediate ways students now have to contact professors.

So, in between the times that my husband and I sat vigil at my son’s bedside, I sought out my professors and tried to explain my situation to them. And guess what? They listened and, without exception, responded with understanding. Apparently, I had filled the reservoir of goodwill full enough that each and every one of my professors said that whatever grade I had achieved at the point of my son’s illness was the one I would receive as a final grade. All declared that I did not need to take the final exam, as I had proven myself to be an exceptional student. What a relief!

Today, I remember that experience with gratitude and appreciation, and I pay it forward. When my colleagues and students fill the reservoir of goodwill, I respond and give them the benefit of the doubt. That’s what it’s all about.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.

16 March 2012

What can you learn from a mother-in-law?

My mother-in-law, Margaret, will celebrate her 90th birthday this summer. I have had the honor and joy of knowing Margaret for the past 31 years, after meeting and marrying her youngest son. Margaret is an amazing woman, role model and inspiration.

Each day, she rises and greets the morning by walking several miles through the Colorado mountains with Zoe, the family's beloved Labrador retriever, then returns home to enjoy a hearty breakfast, engage in an hour of yoga and meditation, and later rides her stationary bike to stay in shape for hiking and climbing nearby hilltops. Margaret spends several weeks a year in Boise visiting our family, and one of my favorite things to do is to walk with her and our dogs along the many miles of hiking trails in the high deserts of Idaho.

Margaret, age 89, prepares for another day.
Her pace is brisk, deliberate and certain. Her energy level is beyond comprehension-for anyone, but especially for a woman of such advanced age. As we hike the rolling hills outside our country home, surrounded by mountain ranges, we are delighted by the myriad birds and wildlife that accompany us.

The high desert of Idaho
Margaret was born in southern Virginia on a tobacco farm. Her family was very poor by monetary standards, but rich in love, family and community. As she ran barefoot through the fertile soil of Virginia during her childhood and adolescence, she became forever bonded to the earth-and has remained connected to the earth throughout her long and active life.

Margaret is also a thoughtful, wise and deeply reflective person. We have spent countless hours walking and talking-sharing our innermost thoughts about life, family and our mutual love of the earth. An avid journalist, she handwrites all of her journal entries and has neatly maintained them in notebooks over the past several decades. She often shares her philosophies with me-including her “tenets for life”- principles by which she lives her life. I would like to share some of them with my readers as a source of inspiration and as a catalyst for intentional living.

First, Margaret suggests that “spend time in quietness” to listen to the voices of our soul and to stay in tune with nature; that the energy of the universe is available to all of us, especially if we integrate life's processes and experiences from birth to the end of life. Margaret's life partner, soul mate and husband of nearly 60 years died in 2010 after losing his hard-fought battle with brain cancer. Ed was a brilliant and gifted college professor, environmentalist and author. He died peacefully amidst the mountains of Colorado, administered to and cared for by Margaret, who was always at his side. His life ended quietly, gently and without pain as the two said their final goodbyes.

Since Ed's death, Margaret has helped many of us realize that “we can experience joy to the same degree we experience sorrow,” paraphrasing her favorite poet, Kahlil Gibran, who reminds us that “sorrow expands our ability to experience joy,” that being fully present and having a life philosophy to guide us is all-important.

Both of us admire the simple wisdom of Yvon Chouinard, founder and owner of Patagonia, Inc., who describes a process to reduce harm to the environment and ways for each of us to make a difference. One of Chouinard's philosophies is “Lead an examined life.” He suggests that we often cause harm as a result of ignorance and a willful avoidance to learn, because we don't want to act on what we know.

I spoke about this concept in my previous post, “Knowing better and doing better in uncertain and uncivil times,” Only after we make a conscious effort to seek the truth, to ask questions and become aware are we able to move to action. Another Patagonia philosophy is “Support civil democracy,” reminding us that organizations large and small, as well as individuals who deeply care about an issue, can make an incredible and important difference. Small groups of dedicated and passionate people can make extraordinary changes.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International.