Norma Cuellar R.N. D.S.N.

1

• Norma Cuellar R.N. D.S.N.
• Assistant Professor
• University of PA
• School of Nursing

How did it get so late so soon? Its night
before its afternoon. December is here before
its June. My goodness how the time has flewn.
How did it get so late so soon? Dr. Seuss
2
Purpose

• For consideration of promotion and tenure
• Unless someone like you cares a whole awful lot,
  nothing is going to get better. It's not.
• For the many of you who are undergraduate,
  graduate, pre and post doctoral students who
  often wonder Where am I going?

3
Brief Background

• University of Southern MS (1983)
• Baton Rouge (1983 1992)
• CCU (ACLS, CCRN)
• LSU in New Orleans (1988)
• Adult Health Nursing
• Staff Development
• Teaching
• Baton Rouge
• Message get doctorate! (1993)

4
What would Dr. Seuss think about a dissertation?

• Sometimes the questions are complicated and the
  answers are simple.
• I like nonsense, it wakes up the brain cells.

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Doctoral Dissertation

• A Comparison of Caregiving Self-efficacy,
• Stress, Social Support, Coping, Depression, and
• Life Satisfaction among African American and
• White American Female Caregivers of Elder
• Bedbound Patients.
• University of Alabama at Birmingham.
• Dissertation Chair Dr. Lindsey Davis. DAI AAT
• 9818833, 1997.

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Findings

• Differences in AA and CA on self-efficacy
• Differences in demographics
• Married vs. Single
• Age
• Differences in outcomes
• Support systems/social support
• Depression
• Stress and Coping
• Life Satisfaction

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Publications

• Cuellar, N. (2002). A comparison of African
• American and White American female
• caregivers of elder bedbound patients. Journal
• of Gerontological Nursing, 28(1), 36-45.
• Cuellar, N. Butts, J. (1999). Caregiver
• distress What nurses in rural settings can do to
• help. Nursing Forum, 34(3), 24-30.

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Presentations

• Cuellar, N.G. (October 2002). The Use of
  Complementary and Alternative Medicine (CAM) by
  African American (AA) and White American (WA)
  Elders a Changing World. Paper Presentation
  Canadian Association on Gerontology's 31st Annual
  Scientific and Educational Meeting, Montreal,
  Canada.
• Cuellar, N.G. (February 2001). A Comparison of
  African American and White American Female
  Caregivers of Bedbound Elders in Southern
  Mississippi. Paper Presentation National
  Association of African American Studies, Houston,
  TX.

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ADVANCED PRACTICE
CONSULTING
RESEARCH
ADMINISTRATION
DSN
TEACHING
10
DIRECTOR OF NURSING
NURSE PRACTITIONER
DEAN
LARGE GROUPS OF STUDENTS
RESEARCH POST-DOC
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Post-Doc (2002) in Complementary and Alternative
Medicine (CAM)University of VA, Charlottesville,
VA

• T32 NCCAM
• RLS
• Research Project
• Use of Medications, Herbs, Natural Products and
  Other CAPPs in Persons with Restless Legs Syndrome

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Publications from Post-Doc

• Cuellar, N., Galper, D., Taylor, A.,
• DHuyvetter, K., Miederhoff, P., Stubbs,
• P. (2004). Use of Conventional and Non
• Conventional Practices in Persons with
• Restless Legs Syndrome. Journal of
• Alternative and Complementary Medicine,
• 10(3), 422-423.

13
Presentations from Post-Doc

• Cuellar, N.G. (June 2004). The use of
  Medications, Herbs, Natural Products and
  Complementary and Alternative Practices and
  Products in Persons with Restless Legs Syndrome.
  Poster Presentation Association Professional
  Sleep Societies, 18th Annual Meeting.
  Philadelphia, PA.
• Cuellar, N.G., Taylor, A.G., Miederhoff, P., et
  al. (November 2002). Use of Medications, Herbs,
  Natural Products and Other CAPPs in Persons with
  Restless Legs Syndrome. Poster Presentation
  Restless Legs Syndrome Foundation, State of the
  Art in Restless Legs Syndrome Current Directions
  in the Search for its Cause, Cure and Treatment.
  Orlando, FL.

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CAM Book

• Cuellar, N.G. (2006).
• Conversations in
• Complementary and
• Alternative Medicine
• Insights and Perspectives
• from Leading Practitioners
• (Ed.). Jones Bartlett
• Publishers, Sudbury, MA .

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UNIVERSITY OF PENNSYLVANIA SCHOOL OF NURSING
(2003)
Afaf Meleis
Terri Weaver
Kathy Bowles
Roz Watts
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• What great things I did see!!!
• Resources
• Opportunities
• Mentoring
• What is a good mentor?
• Someone who wants you to be better than who they
  are and to encourage that you can do better than
  imaginable.
• You can get help from teachers, but you are
  going to have to learn a lot by yourself, sitting
  alone in a room. Dr. Seuss

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Norma
Terri
Neville
ONR Linda M,
Eileen
Matthew, Family, and Friends
Kathy M.
Afaf
My Mentees and Students who I learn from
Drs. Cantor, Pack, Gooneratne, Bliwise
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Hartford Grant

• Cuellar, N.G. (PI) (2003-2005). A
• Comparison of Idiopathic an Secondary
• Diagnosis of Elder Persons with Restless
• Legs Syndrome. Hartford Center of
• Geriatric Nursing Excellence, Jones Fund
• Foundation, 4138.

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Participants

• 39 adults
• 65 years of age and older
• diagnosed with RLS with symptoms at least 3
  nights per week
• stratified by symptom severity based on scores
  from the RLS Symptom Severity Scale
• Exclusion criteria dementia, cognitive
  impairments, and sleep disorders other than RLS

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Significant differences

• PSQI
• Subjective sleep quality (p0.007)
• Sleep duration (p0.042)
• PSQI global score (p0.007)
• RLS-QLI (related to PSQI)
• sleep quality (b-0.12, 95 CI-0.18 to -0.06,
  plt0.001)
• sleepiness (b0.35, 95 CI0.09 - 0.61, p0.01)
• Subjects with severe symptoms were 5 times more
  likely to use medication to treat RLS (OR5.3,
  95 CI1.2 - 22.2)
• Despite the fact that they still had SEVERE
  symptoms!!!!!
• Meds were not working!!!

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Publications

• Cuellar, N., Strumpf, N. Ratcliffe,
• S. (2007). Symptoms of Restless Legs
• Syndrome in Older Adults Outcomes on
• Sleep Quality, Sleepiness, Fatigue,
• Depression and Quality of Life. Journal of
• The American Geriatrics Society, 55,
• 1387-1892.

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Publications from this study

• Cuellar, N., Ratcliffe, S., Chien, D. (2006).
  The effects of depression on sleep quality,
  fatigue, and sleepiness in persons with Restless
  Legs Syndrome. The Journal of the American
  Psychiatric Nurses Association, 12, 262-271.
• Cuellar, N.G., Rogers, A.E., Hisghman, V.
  (2007). Sleep in the older adult evidenced based
  research in complementary and alternative
  medicine (CAM). Geriatric Nursing, 28(1), 46-52.
• Cuellar, N., Rogers, A.E., Hisghman, V., Volpe,
  S. (2007). Assessment and treatment of sleep
  disorders in the older adult. Geriatric Nursing,
  28(4), 254-263.

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Presentations

• Cuellar, N.G., Strumpf, N., Ratcliffe, S.J.
  Cantor, C., Chien, D., Hyslop, A. (June 2007).
  The Use of the International RLS Rating Scale in
  Older Adults Impact of Severity of Symptoms on
  Sleep Quality, Sleepiness, Fatigue, Depression
  and Quality of Life. Paper Presentation
  Association Professional Sleep Societies, 21st
  Annual Meeting, Minneapolis/St. Paul.
• Cuellar, N.G. (November 2007). A Global
  Perspective of Restless Legs Syndrome and Impact
  on Health Outcomes in Older Adults. Poster
  Presentation Geriatric Society of America, 60th
  Annual Meeting. San Francisco, CA.
• Cuellar, N.G., Rose, K., Smith, M. (March
  2009). Sleepy, Grumpy, and Dopey More than Just
  a Fairytale Sleep Disturbances in Older Adults.
  Paper presentation American Association of
  Geriatric Psychiatry, Honolulu, HI.

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Presentations

• Cuellar, N.G. (November 2006). Outcomes of
  Complementary and Alternative Medicine in Older
  Adults Imagination or Evidenced Based?.
  Colloquium Paper Presentation Geriatric Society
  of America, 59th Annual Meeting. Dallas, TX.
• Cuellar, N.G. (November 2005). The use of CAM in
  the Older Adult Implications to Sleep.
  Colloquium Paper Presentation Geriatric Society
  of America, New Orleans, LA.
• Cuellar, N.G., Strumpf, N. Ratcliffe, S.
  Cantor, C. (June, 2007). The use of the RLS
  Severity Scale in Older Adults Implications on
  Sleep, Sleepiness, Fatigue, Depression, and
  Quality of Life. Poster Presentation Center for
  Sleep and Respiratory Neurobiology, School of
  Medicine, University of PA.
• Cuellar, N.G., Strumpf, N., Ratcliffe, S.,
  Cantor, C. (May, 2007). The use of the RLS
  Severity Scale in Older Adults Implications on
  Sleep, Sleepiness, Fatigue, Depression, and
  Quality of Life. Poster Presentation Institute
  of Aging, University of PA.

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STTI/AADE Grant

• Cuellar, N.G. (PI) (2004-2006). A
• Comparison of Type 2 Diabetics with
• and without Restless Legs Syndrome on
• Diabetic Control, Sleep, Fatigue, and
• Depression. Sigma Theta Tau
• International and American Association
• of Diabetic Educators, 5816.

26

• Screened 121 patients with type 2 diabetes
• 54 (45) of the screened sample met the 4
  diagnostic criteria for RLS
• 18 of these 54
• enrolled in the study
• compared with type 2 DM without RLS
• Mean age of developing RLS after diagnosis of
  type 2 DM was 2 years

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Findings from RLS patients (n18)

• Along with diabetes, the participants had a
  variety of co-morbid health conditions
• hypertension, neuropathies, RA, renal failure,
  and irritable bowel syndrome
• Only 1/3 of the participants were being treated
  for RLS
• 39 of the type 2 diabetics (with RLS)
• used insulin to manage DM with oral agents
• more than those without RLS

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Findings comparing RLS and non-RLS groups

• n39 participants
• adults over 21 years of age
• diagnosed with type 2 diabetes
• had a HbA1c in the last 3 months
• stratified based on RLS diagnostic criteria
• exclusion criteria
• severe hypoglycemia identified by seizures/coma
  related to hypoglycemia
• known sleep disorder other than RLS (like OSA)

29
Participants with Type 2 diabetes with RLS
reported significant difference on

• quality of sleep (p0.001)
• sleep latency (p0.04)
• sleep efficiency (p0.035)
• sleep medications (plt0.001)
• daytime dysfunction (p0.005)

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Findings of overall group (n39)

• higher HbA1c were positively correlated with
  sleepiness (p.038)
• Global PSQI scores were positively correlated
  with
• fatigue (r0.58, p0.002)
• depression (r0.74, plt0.001)
• Fatigue and sleepiness were positively correlated
  (r0.36, p0.04)

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Publications

• Cuellar, N.G. Ratcliffe, S. (2008).
• Restless Legs Syndrome in type 2 diabetes
• implications to diabetes educators. Diabetes
• Educator, 34(2), 218-224.
• Cuellar, N.G. Ratcliffe, S. (2008). A
• comparison of glycemic control, sleep, fatigue,
• and depression in type 2 diabetes with and
• without Restless Legs Syndrome. Journal of
• Clinical Sleep Medicine, 4(1), 50-56.

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Presentations

• Cuellar, N.G., Cantor, C., Schutta, M. (June
  2006). Prevalence of RLS and Depression in Type 2
  Diabetics. Poster Presentation Association
  Professional Sleep Societies, 20th Annual
  Meeting. Salt Lake City, UT.
• Cuellar, N.G., Ratcliffe S., Cantor, C.
  Schutta, M. (June, 2007). A comparison of
  Patients with Type 2 Diabetes with and without
  RLS. Paper Presentation Center for Sleep and
  Respiratory Neurobiology, School of Medicine,
  University of PA.

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Lindback Grant

• Cuellar, N.G. (PI) (2005-2007). The
• Use of Alternative Medicine for the Sleep
• Disorder Restless Legs Syndrome.
• Lindback Minority Junior Faculty Award, 15,000
• University Research Foundation, University of PA,
  14,998
• ONR Junior Faculty Seed Money, 2,000

34
Design

• a prospective, double blind, randomized,
  placebo-controlled, parallel design
• compared the efficacy of valerian with placebo on
  sleep quality and symptom severity in patients
  with RLS
• primary outcome of sleep sleep quality
• secondary outcomes sleepiness and RLS symptom
  severity
• 37 participants were randomly assigned to receive
  800 mg of valerian or placebo for 8 weeks

35
Results

• Data was collected at baseline and 8 weeks
  comparing use of valerian and placebo on sleep
  disturbances (Pittsburgh Sleep Quality Index and
  Epworth Sleepiness Scale) and severity of RLS
  symptoms (International RLS Symptom Severity
  Scale)
• 37 participants ages 36-65
• Both groups reported improvement in RLS symptom
  severity and sleep.

36
Nested Analysis

• comparison of sleepy versus non-sleepy
  participants who received 800 mg. of valerian
  (n17)
• significant differences before and after
  treatment were found in sleepiness (p0.01) and
  RLS symptoms (p0.02)
• a strong positive association between changes in
  sleepiness and RLS symptom severity was found
  (p0.006)

37
Ancillary Findings Iron parameters on outcome
measures

• Objective data was collected on serum iron,
  transferrin, transferrin saturation, and
  ferritin.
• Subjective reports included severity of RLS
  symptoms (International RLS Symptom Severity
  Scale), sleep quality (PSQI), sleepiness (ESS),
  depression (CES-D), fatigue (fatigue severity
  scale), and quality of life (RLS-QLI)
• 48 participants ages 23-77

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• Correlation coefficients were used to evaluate
  relationships with serum iron and were found to
  be significant with
• sleepiness (p0.001)
• depression (p0.02)
• fatigue (p0.007)
• RLS QLI for social function (p0.005)
• RLS QLI for daily function (p0.03)

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There were relationships between

• transferrin and
• depression (p0.01)
• emotional well being (p0.03)
• transferrin saturations and
• sleepiness (p0.04)
• depression (p0.02)
• social functioning (p0.03)
• Ln-ferritin and
• RLS QLI daily function (p0.04)

40

• There were no relationships with iron metabolism
  on RLS symptom severity or sleep quality when
  testing for quadratic or other nonlinear
  relationships.
• Why?
• All of them had to have RLS at least 3
  nights/week so no differences seen in RLS symptom
  severity or sleep quality (homogeneous group)
• Iron parameters are NOT diagnostic of RLS

41
Ancillary Findings Comparison of Black and White
Participants on Iron parameters and outcome
measures

• Myth of Iron Overload protecting Blacks from RLS
• Blacks do not have RLS
• Blacks have not been studied in RLS as much as
  other cohorts
• Implications of sleep deprivation on morbidity
  and mortality in Blacks
• Huge Health Disparities Issue!!!

42
Significant differences were found between Black
and White patients on

• ferritin (p0.001)
• severity of RLS symptoms (p0.02)
• sleepiness (p 0.004)
• fatigue (p0.02)
• social functioning (p0.005)
• emotional well being (p0.03)

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Presentation

• Poster Presentation at NIH Summit The Science of
  Eliminating Health Disparities
• Sponsored by the National Center on Minority
  Health and Health Disparities
• Dec. 2008

44
Publications

• Cuellar, N.G. Ratcliffe, S.J. (in
• press). Does Valerian Improve Sleepiness
• and Symptom Severity in Persons with
• RLS? Alternative Therapies in Health and
• Medicine. 23 pages.

45
Publications in Development

• Relationship of Iron Metabolism on Symptom
  Severity, Sleep Quality, Sleepiness, Depression,
  Fatigue, and Quality of Life in Restless Legs
  Syndrome
• Differences in Iron Metabolism in African
  American and Caucasian Patients with RLS
  Implications to Clinical Practice

46
Presentations

• Cuellar, N.G., Graves, N., Ratcliffe, S. (June
  2008). Valerian (valeriana officianalis) improves
  sleepiness and symptoms of Restless Legs
  Syndrome. Poster Presentation Association
  Professional Sleep Societies, 22nd Annual
  Meeting, Baltimore, MD.

47
Grants not funded ANF Acupuncture and RLS R21
MfM in AA in Community
NIH FUNDED GRANTS Is everyone getting these
grants but me?
48
Whats a person to do?

• Keep writing
• Keep meeting with mentors
• Keep the faith!
• Never stop writing grants
• Never stop getting published

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Other pubs

• Cuellar, N.G. (2008). Mindfulness
• Meditation (MfM) in veterans implications for
• occupational health care providers. Journal of
• Occupational Health Nursing, 56(8), 357-363.
• Weaver, T. Cuellar, N. (2006). A
• Randomized Trial Evaluating the Effectiveness
• of Sodium Oxybate Therapy on Quality of Life in
• Narcolepsy. Sleep, 29(9), 1189-1194.

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CONFUSION
DISAPPOINTMENT
51

• Am I doing the right thing?
• Am I where I am supposed to be?
• Can I make it at a research intensive university?
• Is my research good enough?

52
WAITING

• Grant reviews
• Publications
• Aim high
• Presentations
• Always get a publication out of a presentation
• Lectures
• Awards
• Year 6!!!!!

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Its a life experience! Make the most of it.
54
K01
55
K01

• Cuellar, N.G. (P.I.) (2007-2010). The
• use of Valerian on Sleep in Persons with
• Restless Legs Syndrome. National
• Institute for Nursing Research, 1 K01
• NR009570 01A2, 276,748.

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Design/Methods/Findings

• Builds on Lindback
• Adds objective measures of sleep
• Actigraphy
• Psychomotor Vigilance Testing
• Cross over design
• Participants will receive both placebo and
  valerian
• In data collection

57
WRITING THE R01
58
R01

• NCCAM Research on Sleep and Sleep Disorders
  (R01) PA-07-140.
• Dose Dependent Effects of Valerian in Restless
  Legs Syndrome

59
RESUBMIT!!! ANSWER REVIEWERS QUESTIONS
60
Starting over with care and great tact You can
get mixed up with many strange birds, you
know!!! Life is a balancing act
61
Genetics and RLS

• Cuellar, N.G. (P.I.) (2008-2009) Genetic Variance
  of RLS in persons with Type 2 Diabetes. Hartford
  Center of Geriatric Nursing Excellence, Jones
  Fund Foundation, 7220.

62
Presentations

• Cuellar, N.G. (November 2008). Role of Genetics
  in Restless Legs Syndrome. Poster Presentation
  International Society of Nurses in Genetics,
  Philadelphia, PA.
• Alexander, S., Founds, S., Cuellar, N.G.,
  Henderson, W. (April 2009). Bridging Genetics
  into your Program of Nursing Research. Paper
  Presentation Eastern Nursing Research Society,
  Boston, MA.

63
Education Initiatives

• CAM Case Study 362/562
• Conferences in CAM
• Cultural Diversity Taskforce

64
Conferences in CAM

• 2007 - 2008 Building Partnerships with CAM
  Clinicians and Researchers in the Treatment of
  Sleep Disorders. Office of Nursing Research
  (co-author Dr. Terri Weaver)
• 2005 2006 School of Medicine, Herbal
  Symposium, Planning Committee sponsored by the
  School of Medicine, Nursing, and Morris Arboretum
• 2004 2006 School of Medicine, Tai Sophia
  Institute Retreat representative for School of
  Nursing on Complementary and Alternative Medicine
  Education at University of Pennsylvania

65
Cultural Diversity Taskforce

• Cuellar, N.G., Walsh-Brennan, A.M., Vito, K. de
  
• Leon Siantz, M.L. (2008). Cultural Competence in
  the
• Undergraduate Nursing Curriculum. Journal of
• Professional Nursing, 24(3), p. 143-149. INVITED
• Manuscript.
• Watts, R., Cuellar, N.G., Sullivan, A. (2008).
• Establishing a Blueprint for Cultural Competence
• Education. Journal of Professional Nursing.
  Journal of
• Professional Nursing, 24(3), p.136-142. INVITED
• Manuscript.

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Cultural Diversity

• Cuellar, N.G. (March 2007). The Use of CAM in
  Research in Health Disparities and Ethnically
  Diverse Populations. Paper Presentation National
  Coalition of Ethnic Minority Nurses Association,
  San Antonio, TX. INVITED SPEAKER

67
Mentorship

• National Coalition of Ethnic Minority Nurses
  Association
• Hispanics, Black, Asian, American Indian, and
  Filipino
• Shortage of minority nurse researchers
• Mentor young nurses or junior faculty in their
  development as Nurse Researchers

68
Mentorship Publications with Students

• Cheng, J. Cuellar, N.G. (in review). The Use of
  Honey for
• Wound Care Management a Traditional Remedy
  Revisited. Home
• Healthcare, 18 pages.
• Nault, M., Cuellar, N.G., Gatto, M. (in review).
  An Overview
• IGM Therapeutic Acupressure Use in Palliative
  Care. Holistic
• Nursing, 23 pages.
• Dobson, A. Cuellar, N. (2006). The Use of
  ropinirole in
• RLS implications for advanced practice nurses.
  Nurse Practitioner,
• 31(12)46-48.
• Wislowski, A. Cuellar, N. (2006). Voting rights
  for older
• adults with dementia implications for health
  care providers.
• Nursing Outlook, 54(2), 68-73.

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Mentorship Program at PENN for Junior Faculty

• Mentorship Team
• Cuellar, N.G. (November, 2007). The Development
  and Implementation of the Faculty Mentorship
  Program at the University of PA, School of
  Nursing. Poster Presentation NIH Office of
  Research on Womens Health, Women in Biomedical
  Research National Leadership Workshop on
  Mentoring Women in Biomedical Careers, Bethesda,
  MD.
• Results since August 2003
• Under 500,000 in funding
• 20 publications (data based and clinical)
• MENTORSHIP IS ESSENTIAL!

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Clinical Publications

• Cuellar, N.G. (in press). RLS A clinical
  overview. American Nurse Today. 15 pages.
• Cuellar, N. (2005). Hypnosis for Pain Management
  in the Older Adult. Pain Management Nursing,
  6(3), 105-111.
• Cuellar, N. (2004). Diagnosis and Treatment of
  Persons with RLS. Clinical Excellence for Nurse
  Practitioners, 8(1), 5-13.
• Cuellar, N. (2003). Restless Legs Syndrome A
  Case Study. Journal of Neuroscience Nursing,
  35(4), 193-201.
• Cuellar, N., Cahill, B., Ford, J., Aycock, T.
  (2003). The development of an educational
  workshop on complementary and alternative
  medicine (CAM) what every nurse should know.
  Journal of Continuing Education in Nursing,
  34(3), 128-135.

71
Final quotes from Dr. Seuss

• Dont cry because its over, smile because it
  happened!
• Just tell yourself, Duckie, you're really quite
  lucky!
• And will you succeed?

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(No Transcript)
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Thank you! Special thanks go to

• Theresa Lake for helping me with my slides!
• My mentorship team Dr. Sullivan-Marx, Weaver,
  Strumpf, and K. McCauley
• ONR Dr. L. McCauley, Denise Scala, Ruthanne
  Porreca
• My Research Assistants Darlene Chien, Amanda
  Hyslop, Nicola Graves, and Trent Sorenson
• My students and mentees!!!
• Dr. Allen Pack, Dr. Nalaka Gooneratne and CSRN
• Dr. Roz Watts and Dr. Marylou de Leon Sciantz

IT TAKES A VILLAGE!!! IT REALLY DOES!!!