Encouraging Nurses to Embrace Change

Podcast Transcript

Carol Pehotsky:

Nursing is a profession full of change, whether we like it or not. But there is a way to not just like it, but to love it, to lean into it, to embrace it, and to be part of it. I'm joined today by Darlene Morocco to talk more about her passion behind change and how we can all learn to embrace it.

Hi, and welcome to Nurse Essentials, a Cleveland Clinic podcast where we discuss all things nursing, from patient care to advancing your career to navigating tough on-the-job issues. We're so glad you're here. I'm your host Carol Pehotsky, Associate Chief Nursing Officer of Surgical Services Nursing.

We've all probably heard the famous quote by Gandhi, "Be the change that you wish to see in the world." Inspirational? Of course. Easy to do? Depends. You know, throughout my career and my life, sometimes it's way easier said than done to be that change you wish to see. There's a certain beauty in routine, right? You know, being predictable, there's a joy in that sometimes.

But what do we miss out on by getting into the routine and missing out on being that change and taking a risk and putting an idea out there and seeing what happens or listening to an idea and saying, "I want to get on board with that."? That can be hard for us as people, and it can be hard for us as nurses. But if we avoid that change, what do we miss out on in terms of our own personal and professional growth? And more importantly, what do we miss out on the care of the people we serve as nurses?

I'm delighted to be joined today by Darlene Morocco. Darlene is the Chief Nursing Officer at Cleveland Clinic Lutheran Hospital on the West Side of Cleveland. And Darlene is very passionate about change management, change agentry, and being an innovator. Darlene, thank you so much for joining me today.

Darlene Morocco:

Thank you, Carol. I'm looking forward to spending some time with you on this topic.

Carol Pehotsky:

It's going to be a great conversation. Darlene has been with the organization for a couple years. She has a rich career outside of the Cleveland Clinic. So, I'm looking forward to hearing about that as well. But clearly, ever since I got to be part of the interview panel to first meet you, it was very clear the first time I talked to you that you're very passionate about supporting caregivers, supporting nurses, being a change agent, and being an innovator.

So, would you be so kind to kick us off by sharing with our audience a little bit about that passion of yours and your journey that developed that passion inside of you?

Darlene Morocco:

Sure. Thanks, Carol. You know, I think that over my years of nursing, not only at the, when I was at the bedside and realized how we had to adapt to our surroundings and the environment that we work in, then I became a leader. And I was excited to be able to lead other nurses in those challenges and those changes.

Carol Pehotsky:

Sure.

Darlene Morocco:

So, I think that it's definitely twofold. I think that as leaders, we create a psychologically safe environment for our nurses and our caregivers so that we can actually bring them along with us. And we can get ideas from those that really touch the patient every single day and help us with operations and nursing care and practices to make those changes that need to happen take place together.

Carol Pehotsky:

Yeah. Any aha moments during your career where you were like, "I did this thing and I made it come to life," or "I supported a team and really made it come to life," and that really sparked that passion inside of you?

Darlene Morocco:

Well, absolutely. I think that somewhere in your career, you realize that you don't do it in isolation. And the most effective change comes from sharing your ideas and your practices with others and getting all of the people at the table that can work together to make these things occur. I was a cardiac nurse in my early days.

Carol Pehotsky:

Great. Yeah.

Darlene Morocco:

And cardiology changed so rapidly with technology. And we went from very invasive procedures to less invasive procedures and how we were going to make this happen. And so, we had to actually listen to our frontline caregivers on safely making those changes happen.

Carol Pehotsky:

Well, of course. Yeah.

Darlene Morocco:

So sometimes you know, you can have a big idea, but you have to slow it down by working with the people that actually are taking care of the patient every day.

Carol Pehotsky:

And we certainly hear that, you know, no matter where you are, listener, whether you're a nurse or a nursing leader, and no matter where you're practicing, we know that sometimes that's the gut reaction when a change is presented, is, you know, "Who was part of that discussion that actually is going to have to implement this, that actually takes care of the patient?"

Darlene Morocco:

Exactly. And I think that when you pull what's called a multidisciplinary team together you really respect them and understand that everyone has a point of view that will actually impact the outcome of the change.

Carol Pehotsky:

Sure.

Darlene Morocco:

And so, to take that time to listen to all of the players at the table, and then you get that aha moment.

Carol Pehotsky:

Sure.

Darlene Morocco:

And you say, "Oh I didn't think about that."

Carol Pehotsky:

Yes.

Darlene Morocco:

But, but you're right.

Carol Pehotsky:

Yes.

Darlene Morocco:

So, I think there's a humility to change.

Carol Pehotsky:

Certainly.

Darlene Morocco:

I think that all nurses can be agents for change. Even nursing students, I think, are actually very good agents for change. Oftentimes, when I round on the units, and I see a nursing student out on the floor, I like to ask them, "What is the latest technology and practice that you're learning in school?"

Carol Pehotsky:

Oh okay.

Darlene Morocco:

And I like to bring in what I’m currently learning. Our students are so enthusiastic. And I want them to know that even their inexperienced voice is very important to us.

Carol Pehotsky:

Yeah. Absolutely. And you think about that's a great point, is that, so yeah, if you're a nursing student listening right now, you know, there, there may be, because of technology or implementation or et cetera, there may be a disconnect from what you're seeing in your sim centers and your, your simulations in your school versus what you're seeing on the floor.

What a great opportunity that you've created, Darlene, and if you're a nurse and you're listening, you should also be creating as you're rounding to say, "It might not be right now that we can do that thing, but tell us what you're seeing and hearing in nursing school that maybe we can say, "Yeah, that's actually coming our way in six months. We can't wait for you to graduate. You're going to see it in place when you come work with us, wink, wink, wink, when you graduate," or "Wow, we hadn't thought of that. Let's start looking into that." What a great way to feel invested as a student, too, and to that location. And students have lots of options when it comes to graduating. But being invited to have their voice heard in their schooling is pretty impactful.

Darlene Morocco:

Yes. And also, that student then knows that it's a lifetime of learning and a lifetime of change. I think the difference today is that we used to change very slowly in healthcare.

Carol Pehotsky:

Yeah.

Darlene Morocco:

And clinicians, nurses, physicians, we felt that, you know, our goal was to be proficient. We wanted to do the same thing over and over and over again because then we felt very good.

Carol Pehotsky:

We know what to do. Yep.

Darlene Morocco:

We knew how to do it, you know, we, like they say, with our eyes closed. But what's happened is the difference today is that our healthcare environment is changing rapidly. And so, what we need to do is help folks along with that and work together so that really change becomes a norm. We adapt to change because it's the best thing for our patients, and we do that together as a team so that we do that safely and effectively.

Carol Pehotsky:

And that's so important, right? You can have the best idea in the world, but if the timing isn't right or we haven't considered the safety implications, then it behooves all of us to have that ethical imperative that says, "We need to pause this to make sure this change is safe." It still can be the right thing to do, but it might not be the right time.

So, we've talked about the nursing students, so let's talk about the phases of life of a nurse, right? So I'm a brand new nurse, I've just finished nursing school, I've finished my residence or whatever that initial training program is, and perhaps I've heard about in the high ed classroom or in school sort of "the way things are supposed to be done," and what I'm seeing is maybe not the same thing, for better or for worse.

So obviously, we know the leader has a really important role in that, and we'll circle back to that. But as that nurse, what advice would you give me? I don't have a preceptor anymore. I'm out of orientation. How do I make my voice heard? I've got this idea, and I just don't know what to do with it.

Darlene Morocco:

Well, we definitely want to tap on that passion.

Carol Pehotsky:

Yes.

Darlene Morocco:

The passion of a new nurse is so exciting, and we want to tap on that, and we want to let them know that they'll have opportunities with our organization or another organization to be a continuous learner and to bring their ideas forward. So, there are many, many ways to do that.

I think the leader and the organization sets the tone for the m- methodology of the organization or the mission of the organization.

Carol Pehotsky:

Sure.

Darlene Morocco:

And here in particular at Cleveland Clinic, many of our facilities are magnet organizations. A magnet organization is an organization that has a nursing excellence about themselves like no other. And so, part of being a magnet organization is to have something called shared governance.

Carol Pehotsky:

I was hoping we were going to go there. Yep. Here we go.

Darlene Morocco:

Here we go. You're not going to get away with me not talking about magnet and shared governance.

Carol Pehotsky:

Absolutely.

Darlene Morocco:

So, I'm a firm believer in shared governance. Leadership does not make decisions in isolation. And so, what we promise our nurses in a magnet organization is that we will partner with you, and we will identify opportunities together, and we will make decisions together not in isolation of each other.

Carol Pehotsky:

Yeah.

Darlene Morocco:

Shared governance does not mean self-governance.

Carol Pehotsky:

Right.

Darlene Morocco:

But it's the Venn diagram with the overlap in the middle for sure.

Darlene Morocco:

Yes. But it does mean shared governance where we really value the ideas and the thoughts of our nurses and all nurses. So, I like to think of nursing as a generational profession where each generation has something to offer.

Carol Pehotsky:

Absolutely.

Darlene Morocco:

And we learn from each generation.

Carol Pehotsky:

Yes.

Darlene Morocco:

Even though the seasoned 20-year, 30-year veteran has not been in school for a long time, they are continuous learners.

Carol Pehotsky:

Absolutely.

Darlene Morocco:

And through continuous education and certification we are learning all the time. But that new grad nurse has just come out of an accredited program where the best practices are being taught at the academic level.

Carol Pehotsky:

Yeah.

Darlene Morocco:

So, I think that when we make ourselves present to our caregivers through rounding and huddles, staff meetings, one-on-one check-ins those should be meaningful times to engage with our caregivers and to ask them the question of what what's going well, what's not going well.

Carol Pehotsky:

Yes.

Darlene Morocco:

And I think that that gives the caregiver a comfort level of, "It's okay for me to speak up."

Carol Pehotsky:

Yes.

Darlene Morocco:

"They really do want to hear from me."

Carol Pehotsky:

Yes.

Darlene Morocco:

So, we do have to drive it. And then once you establish that psychologically safe culture and environment, you'll start to see your caregivers be more comfortable at bringing things to your attention.

Carol Pehotsky:

Sure. It's that phrase of empowered and expected to share your ideas. It's, it's both, right? We're going to open the door, but we also set out that expectation that says, "We need to hear from you because we can't be better if we don't hear your ideas."

Darlene Morocco:

That's right. And we focus this on safety and patient outcomes. So, what we say to our nurses is, "Tell me about a safety story."

Carol Pehotsky:

Yeah.

Darlene Morocco:

"Okay. What did you possibly prevent from happening that could have caused harm?"

Carol Pehotsky:

And how do we learn from it?

Darlene Morocco:

And how do we learn from that? And then we peel the onion back on that.

Carol Pehotsky:

Yeah.

Darlene Morocco:

And we turn it into a performance improvement project or a continuous improvement project. And here at Cleveland Clinic, we're so fortunate, because we really have a model of continuous improvement here.

Carol Pehotsky:

Yes.

Darlene Morocco:

And we have tools and resources. But the number one most impactful thing that we do is we form multidisciplinary teams that identify the problem, and we start putting a team together that can help us to come up with the best interventions to solve the problem.

Carol Pehotsky:

Yeah.

Darlene Morocco:

And this is when the change occurs.

Carol Pehotsky:

Right. So, for those of you who are listening, if you're saying, "I'm just a nurse," please remove just from your vocabulary. But as you're looking around your organizations, your assignments, after listening to this podcast, just to look around you at your units, are there opportunities, whether it's comment cards, there's a, some, you know, the old school idea box (laughs), you know, where you slip an idea in a box and it gets mined for possibility within there? Is your manager sitting down with you and saying, "What can we do to make care safer, a higher quality, a better patient experience?"

And if your leaders aren't having those conversations, what can you do as a bedside nurse? We have a moral obligation, a right, to do the very best for our patients. And so, some of that comes back to that code of conduct and the code of ethics we say as nurses, that we uphold the best evidence-based care. And there is a bit of a moral obligation, say, that if I have an idea, it's in my patient's best interest to bring it forward.

And so, everybody listening, your assignment is to go are you part of a shared governance group? Is your organization a magnet? And if it is and you haven't learned about that, go educate yourself. What are some avenues that already exist? It's the leaders' job to help set up the multidisciplinary team. So, if you're a bedside nurse saying, "A multi what? Am I supposed to do that?" The answer is no. We will help you do that. That's what your leaders are for. Sometimes, it's a decision entirely within nursing where we can say, "This is entirely this unit. We can bring together our own nursing team and figure out how to implement this."

But sometimes, these big ideas require us and benefit from bringing in other voices. And that's your leader's responsibility to say, "But further, let me think about who else we need to bring to the table and help you bring this idea to life."

Darlene Morocco:

That's right. And I think one of the most effective things that we do, Carol, is when something doesn't go as planned, okay?

Carol Pehotsky:

It does happen. Yes.

Darlene Morocco:

It does happen. We have something called a just culture. We really look to say, "Was it process that broke?"

Carol Pehotsky:

Right.

Darlene Morocco:

"And how can we make that better?" And so here, again, is where change lies. We don't want to change things just to change things.

Carol Pehotsky:

Right.

Darlene Morocco:

Okay? That's frustrating for our caregivers.

Carol Pehotsky:

And sometimes, it feels like that, even though the intentions are good. Yes.

Darlene Morocco:

Exactly. But what we want to do really is say, "How can we make the process better to put you in an environment where the work is actually, you've heard, smarter, not harder?"

Carol Pehotsky:

Right.

Darlene Morocco:

Right? And so that's really true. We really do that. And we do something called root cause analysis when something goes wrong. But we never want to have a root cause analysis without the frontline bedside caregiver there with us, because we value what the nurses say. So, what I'd like to make sure that all nurses know today whether you are a new nursing student, or you are a 40-year veteran which they're out there at the Cleveland Clinic we want them to know that we want to hear from them, that what they have to say matters to us and that we really are not going to make change just to make change.

Carol Pehotsky:

No.

Darlene Morocco:

But we're going to actually listen to ideas and thought processes and ways to improve our technology our operations to make it the best environment for nurses to practice in.

Carol Pehotsky:

Yeah. So, let's go back to that s- sometimes change does feel like change for change's sake. And certainly, if it hadn't been before the pandemic, ooh boy you know, the amount of change, the pace of change, the policy changes between 8:00 AM and 3:00 PM some days, you know, a lot of us have lived through that. Some of us are coming into the profession post that. But sometimes, the volume of change, it is easy to feel like as the recipient of that, "Oh my gosh. It's one more thing," or it does feel like change for change's sake.

So, let's dig into that a little bit. So first, we'll go to the perspective of the nurse that's in receipt of the 15th thing that's going to change in a matter of time. And it's very human to have that wall go up that says, "I can't do one more thing. I can't change one more thing." What advice would you give that nurse to really compartmentalize and embrace all 15 of those changes, so to speak?

Darlene Morocco:

I'm so glad you brought that up, Carol, because, really, this is where the leader does have to be able to assess that. And I have an example for you.

Carol Pehotsky:

Okay.

Darlene Morocco:

I was so happy that you brought this up, because you mentioned the pandemic. And during the pandemic, we were making rapid change like you just mentioned. Within the course of a day, we were changing policies and procedures as you know, we were just in total sync with the CDC and all of the regulatory bodies that we work with. And we had to implement this change rapidly. But I had a unit that I was over at that time. And we were putting a lot of changes in place. And I was in a staff meeting, and I could see the look on the nurses' faces of exhaustion of total exhaustion. And I actually had to pause.

I actually paused and I said, "You know, we have about five different things going on right now."

Carol Pehotsky:

Right. Yeah.

Darlene Morocco:

And they clearly looked exhausting to me. And I was losing them, quite honestly.

Carol Pehotsky:

Sure. Yeah.

Darlene Morocco:

And so, I made a promise that we would not add anything additional right now until we worked our plan on these five things that were going on, and that I was not going to add a new change to them. And I think them knowing that we wanted to not be; how do you say, we wanted to be reasonable, not reckless.

Carol Pehotsky:

Yes.

Darlene Morocco:

And I think that that helped them to also compartmentalize. You do have to prioritize. You have to prioritize change.

Carol Pehotsky:

Yes.

Darlene Morocco:

You have to prioritize even how much you're asking people to do.

Carol Pehotsky:

Absolutely.

Darlene Morocco:

So, I think that student nurses will learn in nursing school all about prioritization.

Carol Pehotsky:

Oh, yes.

Darlene Morocco:

And then, you know, our bedside nurses are definitely prioritizing. And then leaders have to prioritize, too.

Carol Pehotsky:

Yes.

Darlene Morocco:

So, you really do look at what is the most critical thing that has to happen right now, and then what are some things that you would just like to happen?

Carol Pehotsky:

Sure. Yes.

Darlene Morocco:

So, you start to kind of work away on those things that must happen. But then you have to give a change time to do something called get hardwired to where then it becomes just part of practice.

Carol Pehotsky:

Yes.

Darlene Morocco:

It's not something that you just think or say, and then it becomes part of practice. You have to really have a well thought out problem that then you say, "Let's put a well thought out plan together," and then we have to work our plan.

Carol Pehotsky:

Yes. It's the nursing process, right?

Darlene Morocco:

It is. It is. As a matter of fact, I've used the nursing process more as a leader than I feel like I ever did as a nursing student or even a new nurse. But I use it now every single day.

Carol Pehotsky:

Yeah.

Darlene Morocco:

And it is truly the nursing process at work.

Carol Pehotsky:

Yeah. Yes.

Darlene Morocco:

And so, we just have to kind of stay true to that. You know, remember our responsibility as a nurse is to provide the best, safest care that we can for our patients.

Carol Pehotsky:

Right.

Darlene Morocco:

So, when things around us are changing, we have to come up with new adaptable ways to still have great patient outcomes.

Carol Pehotsky:

And that's another way for a nurse to give voice, because sometimes the change has been created, the policies in place, but one more voice wasn't at that table. And as nurses, with as little emotion as possible ideally, but being able to say, "I have this concern about this change, because it's left out this patient population or it hasn't considered those things," so as nurses, we're still obligated to respectfully voice our concern when presented with that change to make sure we can either have that question answered, "Oh, yes. I'm sorry. Thank you for bringing that up. Here's how this will apply to that patient population," or "Gosh, we thought we had this figured out, but maybe there's one more piece we need to take back to the drawing table."

Sometimes, we as leaders don't know everything that's been asked of our team, right? We know what we've asked of the team. But maybe the physician had just rounded and said, "I'm changing my order sets starting today," or other pieces of data we don't know.

So to our nurses in the audience who are at the bedside, it's another great opportunity to speak up to say, "Did you know that we were just asked to change these other three things, too?," so that as a leader, they can have a full understanding of what is being asked of the team to make sure is it a yes to everything or is it a yes if we can really to go back to what you talked about, as, "What is most, highest priority in terms of safe patient care?," versus, "These are things that are longer term," or, "Let's start this change knowing that this one's going to take us a year. We're apprising you of it. We're going to keep you up to speed. But this thing isn't changing right now."

Darlene Morocco:

That's right. And that speaks to the importance of the multidisciplinary team. Sometimes, what the responsibility that I like is when somebody identifies a problem, but they just don't know which direction to take it in.

Carol Pehotsky:

Sure.

Darlene Morocco:

I love being that person that says, "Let's pull a team together."

Carol Pehotsky:

Let's do it. Yeah.

Darlene Morocco:

But we are not going to get anything accomplished if we don't have all the players at the table.

Carol Pehotsky:

Right.

Darlene Morocco:

So, I love pulling that team together and, like you said, that physician, or maybe it's an environmental service person.

Carol Pehotsky:

Yeah.

Darlene Morocco:

Maybe it's a transporter. But a nurse, you know, that takes care of the patient, there are many people that help to support the nurse in taking care of the patient. So, I do like to just always make sure that, that the first thing we do is we have all the key stakeholders at the table.

Carol Pehotsky:

Sure.

Darlene Morocco:

And from there, you make sure you don't miss somebody's point, right?

Carol Pehotsky:

Yes.

Darlene Morocco:

And then you start to just do great work together.

Carol Pehotsky:

And the idea comes to life.

Darlene Morocco:

It does. It comes to life. It's a beautiful thing. And I tell my managers and directors the thing I love about change is, when you do it well and you do it effectively, the outcome is so fantastic.

Carol Pehotsky:

Absolutely.

Darlene Morocco:

Once you've experienced these great outcomes, you'll start to like change. So, I think that it's really key to have those experiences. They call them wins.

Carol Pehotsky:

Yeah.

Darlene Morocco:

You know, we partner very closely here with our continuous improvement team here at the Cleveland Clinic, and I'm really blessed at Lutheran, because I have a great continuous improvement representative there and team. And we really do tap on them for all of their tools.

And one thing that we like to do is we keep revisiting, like you mentioned, you know, you can put a plan in place and think it's just running perfectly well, but nobody's really ever checked on the progress.

Carol Pehotsky:

Right.

Darlene Morocco:

So, it's nice to kind of be revisiting the process. So, we have regular meetings when we put a big change project in place. We have regular meetings and we kind of debrief the interventions that we've put in.

Because sometimes, you need to pivot and you need to say, "You know, we tried this and it's not working." And you want people to feel that we're going to try this and, if it doesn't work, we'll try something else. You know, something I love doing is pilot projects.

Carol Pehotsky:

Sure.

Darlene Morocco:

At one point in my career, I was asked to pilot so many projects that I felt that I should get a private pilot's license because I was always asked.

Carol Pehotsky:

Give it to Darlene. She'll try anything.

Darlene Morocco:

Well, I had a unit that, you know, was, that, that saw a lot of different types of populations of patients. And so, they always wanted to try everything on my unit. And I always volunteered to pilot a project.

Carol Pehotsky:

And you get to put your fingerprints on it.

Darlene Morocco:

You know.

Carol Pehotsky:

Yeah.

Darlene Morocco:

And before you roll it out to the whole enterprise. So, you try to project. You run it for a while. And then if it's effective, then you make it, say, enterprise wide.

Carol Pehotsky:

Yeah.

Darlene Morocco:

And with that, you know, it should make your team feel very proud.

Carol Pehotsky:

Absolutely.

Darlene Morocco:

So, I think that there's a lot of inspiration and a lot of reward in change agentry. And I think that the nurses inspire me. I hope that I inspire them to become change agents.

Carol Pehotsky:

Beautifully said. Well, with that, I don't know that, I mean, we could talk about this for hours. But I think you've wrapped it up beautifully, is that it's reinforces itself. When you see a win, then you want to try something else. What a beautiful thing. Change doesn't have to be scary. It can be exciting and reinforcing, too.

So, with that, we're going to flip to the portion of the podcast where we let our audience get to know a little bit more about you as a person, not just as an amazing nurse and leader. So, my first question for you is if you weren't a nurse, what would your passion career be?

Darlene Morocco:

Oh, my goodness. I would be a sous chef. I have, you know, everybody has a bucket list. And on my bucket list would be to go to culinary school.

Carol Pehotsky:

Oh, fun.

Darlene Morocco:

I absolutely love to cook. I love to entertain. I think that a lot of times we share our love for people with food.

Carol Pehotsky:

Yeah. It's your love language, huh?

Darlene Morocco:

It's my love language. And I also think it's a hobby of mine.

Carol Pehotsky:

Yeah.

Darlene Morocco:

I don't do it professionally. But I think it would be awesome to go to culinary school.

Carol Pehotsky:

Okay. And then who was one of your nursing influences?

Darlene Morocco:

Well, I'll tell you who I refer to until this day is Florence Nightingale.

Carol Pehotsky:

Oh, okay. There you go. The original influence.

Darlene Morocco:

She's the original. When I think of best practices and the tradition of nursing, I do really love the traditional element of nursing even though we just talked about all of this change.

Carol Pehotsky:

That's right. She was the original change agent, right?

Darlene Morocco:

Yes. She was the trailblazer, right? I do think that she gave us a voice where we make a difference. You know, being a nurse is really something that I hold of high esteem. And when you mention, you know, we don't want nursing students saying, "I'm just a student."

Carol Pehotsky:

Right.

Darlene Morocco:

I mean, I think that that pride that we take in our profession is really influenced by our great nursing leaders. So, I have to say I still refer to Florence Nightingale to this day.

Carol Pehotsky:

There you go. Beautifully said. Well, Darlene, thank you so much for joining us today.

Darlene Morocco:

Thank you, Carol. It was my pleasure.

Carol Pehotsky:

As always, thanks so much for joining us for today's discussion. Don't miss out. Subscribe to here new episodes wherever you get your podcasts. And remember, we want to hear from you. Do you have ideas for future podcasts or want to share your stories? Email us at NurseEssentials@ccf.org.

To learn more about nursing at Cleveland Clinic, please check us out at ClevelandClinic.org/nursing. Until next time, take care of yourselves and take care of each other.

The information in this podcast is for educational and entertainment purposes only and does not constitute medical or legal advice. Consult your local state boards of nursing for any specific practice questions.