Caring for Women Living With Ovarian Cancer: Recommendations for Advanced Practice Nurses

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THOUGHTS &QOPINIONS

Caring for Women Living With Ovarian Cancer: Recommendations for Advanced Practice Nurses -

Stephen E. Lammers, PhD, Karen Moore Schaefer, RN, DNSc, Elisabeth CragoLadd, RN, MSN, Robert Echenberg, M D =This article summarizes advice for advanced practice nurses (APNs) that grew out of research with women living with premenopausal ovarian cancer. We claim that the process of diagnosis and being told, battle metaphors, treatment expectations, the patient‘s sense of normalcy, her sense of being heard, her ability to make sense of her new world, her inability to have children, issues of sexuality, and the irrelevance of most support groups are important considerations in the treatment of such women. The APN‘s major role in caring for these women is understanding the experience as it informs the APN‘s practice and serving as advocates for the women. JOGNN, 29,567-573,2000. Keywords: Anger expression-Caring for women-Childbearing years-Fatigue-Hysterectomy-Mean ing of iIIness-ovarian cancer-Sexu ality-Social support-Women’s experience Accepted: March 2000

In an earlier publication, we reported on five women’s lived experience of ovarian cancer during the childbearing years (Schaefer, Crago, Lammers, & Echenberg, 1999). Using van Manen’s (1990) phenomenologic method of writing and reflection, we identified the following themes: (a) serendipitous diagnosis, (b) managing treatment, (c) the horrible hair experience, (d) hysterectomy violating one’s sense of being, (e) unfairness of menopause, (f) body changes, (g) intimate dreaming, (h) being with others, (i) being normaubeing different, ( j ) being vigilant, (k) being heard, and (1) comprehending. A number of clinical implications emerged through the process of preparing the study for publication (see Table 1). Some of these implications were mentioned in that article, but Novem bedDecember 2 000

the focus was the women’s experience. The purpose of this article is to shed a fresh perspective on practice informed by women experiencing ovarian cancer during the childbearing years. This information should be useful for different clinical specialties, but we offer it here because nurses are uniquely situated to make a difference in the treatment of these women. Reflecting on the care of women with ovarian cancer is especially important in the managed care era when there is often a tension between the goal of less costly care and the goal of better care measured by outcomes. The search for better care is essential even though that search may involve an increased investment in further human resources. If patient-centered health care is going to develop (Laine & Davidoff, 1996)’the patient’s perspective on better care must become part ‘of the equation. It is important to note that the women in our study (Schaefer et al., 1999) survived and are living through an experience where survival itself is unexpected. They have something to share about their experiences and what it means to go forward. There is a growing literature in which health care providers become enlightened following their own experiences as patients undergoing treatments for life-threatening diseases (Bone, 1995; Colomeda, 1996). Nurses can learn better communication and intervention techniques from listening to the women’s stories about living with ovarian cancer.

Diagnosis and Being Told An important finding of the study concerned the different assumptions of physicians and

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TABLE 1

Caring for Women With Ovarian Cancer

m

B e i n g told is a process and not an event.

Clinical Implications Listen closely to women’s experiences during diagnosis and treatment. Accept women’s stories as true. Validate women’s experiences through appropriate questions and confirmations. Explain the probability of a total hysterectomy to women and their families. Encourage women and families to express fears and concerns about hysterectomy. Explain the outcome of surgery to women and their families on several occasions. Create a partnership with women so they know that they are not alone in their suffering. Acknowledge potential anger as a normal response to the surgery. Give women an opportunity to express the anger. Support the expression of anger as a normal process. Invite women to share their concerns and fears after surgery. Use caution when referring to treatment as a “battle” or “war” to be won. Prepare women for the loss of all body hair. Explain that fatigue will often result from treatment. Help women find ways to live with the fatigue. Validate women’s effort to redefine normalcy. Support women through their search for meaning in the experience. Empower women to take control of their lives. Explain the treatment options for surgically induced menopause. Help women distinguish the symptoms of menopause from those resulting from treatment. Anticipate and discuss with women and their partners, if appropriate, potential fears associated with sexuality and intimacy. Help women develop a network of support. Become involved in developing and implementing public education programs about ovarian cancer.

women at the very beginning of the experience, when the cancer was discovered. The women suggested that the physicians did not consider ovarian cancer and thus ruling out ovarian cancer was not part of the initial diagnostic process. At the same time, for the women in the study, the finding of ovarian cancer was not expected. Not only unexpected in women this young, it was also a discovery they came to see as quite literally saving their lives.

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The women indicated that if they had not listened to their bodies, they would not be alive. Some of them were very persistent in obtaining medical treatment. The women’s persistence in seeking care was related to physicians not listening to their concerns. There is a lesson in the women’s persistence in seeking care. Listening to patients involves hearing the stories that patients tell, accepting the stories, validating truth with appropriate questions, and attending to all cues within their specific context. Advanced practice nurses can be supportive of the women by relaying information to the primary care physician. By encouraging the physicians to attend to the women’s stories, APNs support the reality of the women’s experience. APNs can also suggest that the women bring a trusted friend or relative with them to reinforce the importance of the women’s lived experience during the diagnostic process. In the end, it is the woman who knows her body and who can relate what the health care provider needs to know. Listening closely may lead to earlier diagnosis and treatment. In the rush to confirm the diagnosis of ovarian cancer and begin treatment, surgical interventions were standard. Typically, the diagnosis of ovarian cancer was confirmed through surgery. Until that point, some of the women did not even suspect that they might have cancer and often were not prepared for what happened afterward. Most of the women were told about the cancer when they were still under the influence of anesthesia. Many physicians do not wish anyone else to tell the patient about the diagnosis. This desire to take responsibility is commendable. It has, however, unintended consequences. Physicians often fail to realize how much of the first discussion of diagnosis and treatment the women never hear. One of the women stated that at this point she was “listening with half an ear.” Informing patients of their cancer diagnosis is a process and not something that is “once and done.” Just as the process of obtaining informed consent takes place over time and depends upon listening to the patient so that uncertainties and fears can be addressed, so “being told” is itself part of a process. Three strategies can facilitate this process. If the women agree, family or friends should be present when information about the diagnosis is first given. In this study, when family members were present, they were able to help the woman recall what was said. However, it is important to note that family members Volume 29, Number 6

may also be devastated by their loved one’s diagnosis and may require assistance from clinicians. This experience supports using the team approach to provide care to women with ovarian cancer. With the APN, physician, and family and friends included, information and care can be reinforced and clarified for the women and their families as they live through the experience. Second, APNs can work closely with physicians and other health care providers to continue to discuss what is happening with the women in the days immediately following surgery. The APN or primary care nurse may be the only person who consistently interacts with the women during their recovery. The APNs will be informed by the women’s experiences and their knowledge of ovarian cancer. The APN can assure that all questions are appropriately answered and that all care provided is timely and specific to the needs of each woman. Third, APNs and primary care nurses should repeat the information they provide to the women. The more the information is repeated to the women, the more likely it is that they will be able to integrate it into their lives. However, repetition alone may not be enough. Nurses can encourage continued discussion by asking the women during follow-up visits about issues associated with this disease. For example, after the initial period of recovery, women might be asked how they feel when they are around friends who have children. They also might be asked, “How have your friends been able to help you?” or “Tell me about your relationship with your husband since your surgery.” “DO you feel differently toward your husbandpartner?” Of course, these questions might call for follow-up or referral to specialists as needed. The women in this study have taught us that being told is a process and not an event. Respecting that lesson can help us care for the next generation of women with ovarian cancer.

“Battling” the Disease Another point emerging from the study relates to the often-used metaphors of battle and war. Although these metaphors are used to clarify the women’s experiences, they should be used with caution. Women are encouraged by physicians and oncology nurses to fight the disease. The women perceive this fight as their responsibility. Because of their expectations that fighting cancer is a battle to be won, the women look for evidence of success. They perceive that they are winning when indicators show the cancer receding and the blood counts returning to normal. They are encouraged by their success. Unfortunately, learning that all the cancer is not gone or that there is a recurrence is interpreted by the women as their failure. When the cancer recurred, one of the women in the NovemberlDecember 2000

study felt defeated “for the first time” and temporarily lost her ability to live with the illness. The women often engaged in self-blame. This can be damaging to women’s self-esteem and sense of who they are when they are trying hard to define themselves in their new reality (Selder, 1989). They learn that living with cancer is a process and not a battle to be fought and won. The presence of an incision, a coming checkup, or an adopted child serve as small or major

L i v i n g with cancer is a process and not a battle to

be fought.

reminders of who they are, the illness they have endured, and who they have become. It is recommended that APNs and other health care providers use the terms “battle” and “war” with caution. These metaphors have long been used and even imprinted on sweatshirts to raise awareness of ovarian cancer. The use of the terms may set up the devastating possibility that women take responsibility for the failure of treatment if it occurs. It is possible that attempting to get women involved in their treatment by giving them the battle charge sets them up for failure. Even the correct claim that individuals should be responsible for their health may lead them to believe that they are also responsible for their illness. It is unlikely that any woman would choose to live with cancer.

Treatment Chemotherapy is known to be a traumatic experience. Women who have had ovarian cancer learn this from other cancer survivors and from their health care providers. However, what they hear has personal meaning only when they begin to experience the ravages of the treatment. The women had good days and bad days, and severe fatigue was one of the most difficult side effects they encountered. Some women began to question whether the treatment was worth feeling worse than they did when they had untreated cancer. There is some relief from fatigue when the blood counts indicate the body is severely compromised and “time off” from chemotherapy is needed for the body to recover. Nurses can help support women through these traumatic times by acknowledging that the experience of fatigue with chemotherapy is difficult, but will gradually subside when the chemotherapy is completed. For women who need to work for financial and psychosocial reasons, nurses can suggest schedules (working part-time; work-

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ing a different shift) that may permit them to work during the period when they are receiving chemotherapy. Although the women expected to be ill from their chemotherapy, the actual experience of hair loss was extremely disconcerting. Health care providers regularly tell their patients that “most patients” lose their hair. This leaves the patient thinking that there is a chance that she might not lose her hair. Hair loss during chemotherapy is not similar to what a balding man experiences. These women experienced “body baldness.” They lost their hair, eyebrows, eyelashes, nasal hair, and pubic hair. They learned that bodily functions would change, in addition to their appearance. The loss of nasal hair meant covering their faces with scarves on cool days; the loss or thinning of eyelashes meant their eyes were sensitive to light. It would be more realistic to tell patients that they probably will lose their hair during chemotherapy, inform them of the probable extent of that hair loss, and describe for them what that might mean to them. What the women described as “the horrible hair experience” might be turned into something less traumatic with a little more candor and sensitivity on the part of health care providers. Little things, such as advising the use of sunglasses in bright weather and wearing colorful scarves instead of wigs, providing tips on how to keep airways moist, and teaching how to wear makeup to achieve a natural look, are types of information appreciated by patients.

Being Normal and Being Different Health care providers know that disease, especially life-threatening illness, changes people. These women noted that they changed in significant and important ways; they were not the same persons they were before their illness. Fatigue, physical changes, chemotherapy, radiation therapy, and altered perception of self affected their sense of normalcy. Again, the women were not prepared for this by their physicians or nurses, even though these health care providers were aware that there were going to be changes and that these changes would occur over a long period of time. Although health care providers have learned from experience the effects of a long fight with ovarian cancer, they do not consistently share this information with patients. Advanced practice nurses providing treatment and follow-up care to these patients can, as appropriate, share other women’s experience to help prepare their patients for the physical and emotional changes they will undergo. Feeling that they were not normal as a consequence of their disease, the women strove for a return to some kind of normalcy. Health care providers can be sympathetic to their patients’ struggle and can use it to gauge how the patient is coping with disease. The process of seeking normalcy starts early. One of the

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women in this study started her journey toward normalcy when she began planning for the house she would build and the trips she would take with her husband in the future. For others, the quest for normalcy involved redefining for themselves what being normal meant (May, 1991). In this study, clues to living with a new reality also included initiating discussion about adoption and reaffirming faith in a supreme being. Nurses can be aware of patients’ desires for things to be normal and, if necessary, support them through the process of redefining normalcy. According to Selder (1989), seeking and redefining normalcy helps recovering women live with a new reality. Advanced practice nurses can be sensitive to the process of redefining normalcy and help women learn how to live with their new reality. This can be accomplished through active listening, validating, counseling, referring them to others, and returning control to them. Recognizing and acknowledging signs of normalcy with particular patients will provide them with the positive feedback they need to move forward.

Loss of Voice/Being Heard The women in this study recognized that they lost their voice early in the lived experience of ovarian cancer. They reported that physicians did not hear what they were saying as they begged for their symptoms to be taken seriously. For several women, persistence in seeking health care resulted in what may have been an earlier diagnosis of ovarian cancer than if they had accepted the first diagnosis. The APN who invests time and effort into listening to the women’s stories may prevent delay in diagnosis and treatment. By modeling this attentiveness to the physician, the APNs presence to women and their concerns can also help to break the traditional physiciadpatient encounter and assist that encounter in becoming a joining of two or more persons (Barnard, 1995). A partnership with the nurse and physician provides women with reassurance that they are not alone in their suffering and gives them space to change and grow spiritually and psychologically. Being heard was made even more difficult. The women reported being abandoned not only by their physicians, nurses, and social workers but also in some instances, by their friends. The women reported that others feared catching the disease, believed that cancer was a death sentence, and did not know how to approach or what to say to a person with cancer. All of the changes we discuss in this article that occur as a result of ovarian cancer and its treatment often left the women feeling out of control. This feeling is profound, especially at the time of diagnosis. Returning some control to women will help reduce this sense of loss. Keeping women informed of their progress and posVolume 29, Number 6

sibilities and validating their experiences will empower women to take part in their own care. When the women in this study were encouraged to speak about their concerns they praised their health care providers who helped them regain some control over their lives. Giving women the opportunity to make their own decisions about treatment helps. Often, however, women may be so fearful of the possible outcomes that they will want assistance in making the best choice. Sustaining a partnership in decision making helps to maintain the women’s sense of control. Advanced practice nurses can act on a second level, as well. Through multiple forms of public information, APNs can inform the general public, which includes family and friends, that cancer is not contagious, some new treatments have been successful, early diagnosis often improves the outcomes, and cancer screening programs improve early diagnosis.

Hysterectomy, Surgical Menopause, and (Not)Having Children Hysterectomy with oophorectomy is a traumatic event. This procedure and its associated surgically induced menopause is especially traumatic for women of childbearing age. Hysterectomy and oophorectomy in the context of ovarian cancer has a number of features to consider. First, some women in this study did not really understand that they were at risk for hysterectomy. Given the urgency with which the surgery was approached, anxiety and fear may have interfered with the women’s abilities to hear what was said before surgery about treatment options. However, it is important for APNs to be clear and candid to strengthen the development of a trusting relationship. Health care providers must remember that these women often sought treatment from them because they did not trust the medical advice they previously had been given. It is crucial to build the opportunities for trust as often as possible. Second, unlike hysterectomy in the perimenopausal and postmenopausal years, this surgery in younger women results in the loss of childbearing capacity. Although this result is apparent to the health care provider, its profound emotional impact on the woman may not be obvious, at least initially. The women were angry because they did not have a voice in the decision to give up their chances for childbearing. They felt that they lost a major purpose in life, and in fact, blamed the physician for taking the choice away from them. Even if the women had children before the cancer or were able to adopt children after the cancer, the inability to bear children was traumatic. In our sample, NovemberlDecember 2000

the women were in their prime childbearing years when the cancer was discovered. Part of the expected narrative for women in our culture was denied them in that they would not be able to have their own children in the future. The explanation that their lives were saved only made them angry. This was perceived as “choice robbing”; the women’s lives were saved but their ability to choose childbirth was not. Nurses need to attend to this result of the disease and be prepared to discuss it with such women. Each woman will find her own way of assuaging the emptiness. One woman suggested that doing some community service activities or having relationships with other children might help. Third, the consequences of surgically induced menopause and the options in controlling some of the consequences of menopause are rarely explained to women. Surgically induced menopause is traumatic for the body and calls for careful monitoring and further medications and treatment as appropriate. Low dose estrogen therapy may be a perfectly reasonable course for some patients; for others it may be too risky. Menopausal symptoms may seem of little importance in the context of a potentially terminal illness, but these symptoms may be devastating reminders of the consequences of therapy and the quality of daily life. The possible benefits of hormonal therapy to the cardiovascular, skeletal, and, probably, neurologic systems should be balanced against any realistic cancer related concerns. Ultimately, with adequate informed consent, it should be the woman herself who makes these very important choices. In reality, the women often felt alone and adrift. These women saw themselves as different from other women their own age because they could not bear children. Unable to discuss how to cope with menopause with women their own age, these women saw menopause not as something natural but as another consequeilce of the disease. Treating it as if it were natural is not the best option in these circumstances. Advanced practice nurses can help these women sort out their menopausal symptoms, their reaction to chemotherapy, and their own grief processes, all of which may overlap. In addition, APNs can explain and reinforce options available to relieve or control menopausal symptoms.

Sexuality and Intimacy Sexuality and intimacy were often in conflict. Intimacy was a necessary component of emotional support. Initially, there was no interest in sexuality, a natural consequence of the loss of natural estrogen and progesterone as well as the trauma of illness. Later, when the women thought about sexuality, they perceived themselves as inadequate sexual partners for their husbands. Further, they did not think of themselves as complete women. One woman, overwhelmed by the uncertainty

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of it all, told her husband to go find someone else to meet his sexual needs. There is a well-recognized reluctance of health care providers to address issues of sexuality (Reamy, 1984). These issues, however, can be addressed and even initiated by the APN if patients are unwilling or unable to bring them up. In most cases the women and their husbands will welcome the discussion as a means of handling their frustrations and fears. Assuming that sexuality issues are not important or do not exist simply because the patient does not bring them up for discussion compromises the quality of care (Anderson, 1985).

Support Groups One of the features of modern cancer treatment is the support group. The women who have ovarian cancer at a young age often have difficulty with cancer support groups. The issues raised by other support group participants often were not those of greatest concern to these women. For example, age differences among participants often resulted in differences in the family issues the women faced. Imagine placing them in a cancer support group where women were worrying about caring for a young child or commenting that childbirth was the most significant event of their lives. In this context, the presence of family and friends is important not only at the time of diagnosis but also throughout the woman’s experience with cancer. The inadequacy of many traditional cancer support groups in addressing issues important to young women with ovarian cancer leaves many of them searching desperately for other sources of strength. Learning to ask for and find support from a variety of sources is difficult for many women. It is crucial for APNs to help the patient build networks of support by being sensitive to the roles family, friends, and coworkers can play. Studies indicate that family and friends most often provide the physical and emotional support needed in the face of devastating chronic illness (Primomo, Yates, & Woods, 1990; Smith, Rodman, Burns, & Sagert, 1995).

I

nformation gained through clinical

experience should be shared with the patients from whom the physicians and nurses learned in the first place.

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Trying to Make Sense of It It is a truism to claim that humans are meaning seeking beings, and it is never truer than in the face of life-threatening illness (Nelson, 1996). These women tried to put their illnesses into some larger context, some narrative over which they did not have complete control. However, it was a constant among the women we interviewed that their physicians neither encouraged this search nor facilitated it. Nurses can attend to women’s desires to make sense of their illness by recognizing their need to find meaning and by supporting this process for women who express that their personal search is important to them. For many women this process may be spiritual. It is important for APNs to be in touch with their own spirituality and encourage what often may be self-discovery for the women. Advanced practice nurses can encourage women to keep a journal of their feelings and experiences. This will facilitate personal growth through reflection and sharing of the contents at the discretion of the women. At some point women will have or raise questions about why they are first, the subjects of disease, and second, the survivors of this particular disease. This search for meaning in their illness means that patients often experience a myriad of emotions that can challenge their basic beliefs. Anger at their deity, for instance, was not uncommon among these women, who thought of their illness as unjust. Advanced practice nurses should be prepared to hear this anger and understand it as a normal response.

Summary The phenomenologic approach to qualitative study of the lives of young women with ovarian cancer was revealing and clinically helpful. The life experiences of these women have some important and profound benefits to the APN engaged in the overall management of these challenging patients. The goal of health care is not simply to prolong life, but to treat patients in such a way to promote the highest quality of life. Learning what patients experience as a result of their disease and its treatment allows us to continue assisting them in living with their illness. For this reason, we would like to thank these women.

REFERENCES Anderson, B. (1985). Malignant neoplasm. In M. Farber (Ed.), Human sexuality: psychosocial effects of disease (pp. 178-188). St. Louis: Macmillan Publishing Co. Barnard, D. (1995). The promise of intimacy and the fear of our own undoing. Journal of Palliative Care, 11(4), 22-26.

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Bone, R. (1995). A piece of my mind. The taste of lemonade on a summer afternoon. Journal of the American Medical Association, 273(7), 518. Colomeda, L.A.L. (1996). Through the northern looking glass. New York: NLN Press. Laine, C., & Davidoff, F. (1996).Patient-centered medicine: A professional evolution. Journal of the American Medical Association, 275(2), 152-156. May, W. (1991). The patient’s ordeal. Bloomington, IN: Indiana University Press. Nelson, J.P. (1996). Struggling to gain meaning: Living with the uncertainty of breast cancer. Advances in Nursing Sciences, 18(3),59-76. Primomo, J., Yates, B.C., & Woods, N.F. (1990). Social support for women during chronic illness: The relationship among sources and types of adjustment. Research in Nursing and Health, 13(3), 153-161. Reamy, K. (1984). Sexual counseling for the nontherapist. Clinical Obstetrics and Gynecology, 27(3), 781-788. Selder, F. (1989). Life transition theory: The resolution of uncertainty. Nursing and Health Care, 10(8), 437-440. Schaefer, K., Crago, E., Lammers, S., & Echenberg, R. (1999). In your skin you are different: A phenomenological study of women living with ovarian cancer. Qualitative Health Research, 9(2),227-242.

Smith, E.M., Rodman, R., Burns, T.L., & Sagert, K.M. (1985). Perception of social support among patients with recently diagnosed breast, endometrial, and ovarian cancer. Journal of Psychosocial Oncology, 3(3), 65-8 1. van Manen, M. (1990).Researching lived experience: Human science for an action sensitive pedagogy. New York: State University of New York Press.

Stephen E. Lammers is a professor in the Religion Department at Lafayette College, Easton, PA. Karen Moore Schaefer is an assistant professor at the College of Allied Health, School of Nuvsing, Temple University, Philadelphia, PA. Elisabeth Crago Ladd is program director, Breast Health Services, Lehigh Valley Hospital, Allentown, PA. Robert Echenberg is a private practice physician in Bethlehem, PA. Address for correspondence: Stephen E. Lammers, PhD, Department of Religion, Lafayette College, Easton, PA 18042. E-mail: 1ammerssQlafayette.edu.

J O G N N Review Panel: 2000 Rebecca Attenborough, RN, M N Jana L. Atterbury, RNC, MSN Linda Bell, RN, MSc Caroline Brown, RNC, MS, DEd Mary Brucker, CNM, DNSc Lynn Clark Callister, RN, PhD Sandra K. Cesario, RNC, PhD Barbara Dion, RNC, ICCE, MA, MSN Grace-Elizabeth Djupe, RNC, MS Patricia M. Dunphy, MSN, CS, RNC Susan M. Ellerbee, RNC, PhD, IBCLC Robin G. Fleschler, RNC, CNS, MSN Catherine Ingram Fogel, RNC, PhD, FAAN Peggy Gordin, RNC, MS, FAAN Jeanne T. Grace, RNC, PhD Annette Gupton, RN, PhD Carol Hartwig, RN, MS, CNAA Mary Henrikson, RNC, MN, ARNP, WHCNP

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JoAnne Kirk Henry, RN, CS, EdD M. Katherine Hutchinson, RNC, MS, PhD Debra Jackson, RNC, BSN, MPH Shirley L. Jones, RNC, PhD Suzan Kardong-Edgren, RNC, MS, FACCE Margaret H. Kearney, RNC, PhD Cheryl P. Kish, RN, EdD, WHCNP Linda J. Kobokovich, RNC, MScN Judith Lewis, RNC, PhD, FAAN Kelly Lindgren, RN, PhD, CNM, WHNP Sharon Lock, RNC, FNP, PhD M. Cynthia Logsdon, DNS, ARNP Laura Mahlmeister, RN, PhD Cathleen R. Maiolatesi, RN, MS Judith Maloni, RN, PhD Linda J. Mayberry, RN, PhD Tara McComb, RN, MSN, PhD Emily S. McKinney, RN, C, MSN

Dianne Morrison-Beedy, RNC, WHNP, PhD Paulina G. Perez, RN, BSN, LCCE, FACCE, CD Cynthia Amstrong Persily, RN, PhD Martina Letko Porter, RNC, MS, MBA Kristen D. Priddy, RNC, MSN, CNS Diana J. Reiser, RN, MAEd, MN Beth Collins Sharp, RN, PhD Mary Ann Stark, RNC, PhD Rosemary Theroux, RNC, PhD Suzanne Thoyre, RN, PhD Cecilia Tiller, RNC, DSN, WHNP Judith Carveth Trexler, RN, PhD, CNM M. Terese Verklan, RNC, PhD Tina Weitkamp, RNC, MSN Luanne Wielichowski, RNC, MSN Lenore R. Williams, RN, MSN

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