As part of the learning curriculum in the DNP program at Wake Forest University School of Medicine, each doctoral student is challenged to create and present a project that highlights concerns and changes in healthcare and how they could help solve them.
The DNP Project Repository contains examples of the exemplary work completed by doctoral graduates. Evidence-based practice and quality improvement projects that impact patient care are highlighted in this repository.
Advances in technology strive to create safer hospitals but may create consequences that can potentially create long-term disability. Bed alarms serve as an audible restraint, restricting patients to the confines of bed without essential movement for maintenance of strength.
The primary purpose of pursuing implementation of this evidence-based practice project was to determine the answer to the clinical question: “For patients admitted within a small rural hospital medical-surgical unit, could a standardized mobility program prevent a decline in level of mobility measured through comparison of admission and discharge mobility scores?”. An evidence-based, nurse-driven mobility protocol was developed using interventions based on the Bedside Mobility Assessment Tool© measured on admission, each shift and at discharge.
Multidisciplinary team efforts encouraged mobility throughout the patient’s hospital stay resulting in maintained or improved level of mobility. Admission BMAT mean score was 3.27 compared to discharge BMAT mean score of 3.35. Standard deviation was .375 with negative upper and lower confidence intervals of the difference which created df 763, with significance of <.001 with p-value indicating that the discharge BMAT score after the project implementation was statistically significant.
Mobility must be considered as common of a metric as a vital sign. Focus on improvement of this vital statistic for maintaining an independent life and ability to care for oneself is essential. A multi-disciplinary, collaborative approach with a nurse-driven mobility program has the essential elements to prevent deconditioning and maintain an independent state.
Geriatric behavioral health patients are at an increased risk for mobility related issues and sustaining a fall-related injury. The purpose of this project was to implement an evidence-based bedside mobility assessment tool, the BMAT, among an inpatient geriatric behavioral health unit to standardize the method for safe patient handling and mobility to decrease falls.
The nursing team was taught how to use the BMAT and asked to use it to assess patients over six months. The Johns Hopkins Patient Mobilization Survey evaluated nursing staff’s knowledge, attitudes, and perception of barriers to mobility pre and post implementation. Compliance using the BMAT tool was calculated as a ratio of patients assessed with the tool to the number of eligible patients. Fall rates were calculated as the number of falls reported by staff per 1000 patient days.
During the project, each eligible patient had a documented BMAT score indicating 100% compliance. Fall rates decreased from 10.56 to 6.60. A paired t test using SAS (version 9.4, Cary, NC, USA) measured the Johns Hopkins Patient Mobilization Survey among 12 pairs extracted from both the pre and post surveys. The p scores for knowledge, attitude and behavior were 0.2323, 0.6906, and 0.6171. Statistical significance was defined as a two-sided P <0.05. While there was slight improvement in the categories, there was no significant difference among the groups.
Standardizing mobility assessment using the BMAT among geriatric, behavioral health patients may improve patient outcomes. Successful implementation of the BMAT relies on effective education, ongoing training, and leadership support. Future implications include adoption of the BMAT tool on the remaining psychiatric units within the organization.
To enhance nurses’ knowledge about the special considerations required for rural obstetric patients and to minimize biases that impact care.
Program of Development using a Quasi-experimental Design to inform the development of an education program for rural obstetrical care.
Rural obstetric care faces multifaceted challenges influenced by social determinants of health, accessibility issues, and inherent biases within healthcare systems.
Included a convenience sample of 1,200 NC AWHONN (Associate of Women’s Health, Obstetric, and Neonatal Nurses) members.
The results from an initial needs assessment and knowledge survey informed the development of an educational program to address identified biases toward rural healthcare delivery. To better understand the impact of the education program an evaluation assessment of knowledge was provided to those who attended the educational offering.
Post-education assessments indicated a significant improvement in awareness of the obstacles faced by rural OB patients, including social determinants of health and legislative efforts aimed at improving access to care. Participants reported increased knowledge and proposed actionable strategies for positively influencing rural OB patient care by acknowledging and mitigating personal biases.
Future research should examine how these biases affect maternal health outcomes and explore continuous education as a means to improve patient experiences, particularly when women are required to seek obstetric services outside their rural communities.
Keywords: rural obstetrics, labor and delivery nursing, social determinants of health
Simulation techniques are of higher quality than ever before. The inconsistency in clinical sites and clinical learning scenarios makes it difficult to properly assess students’ clinical judgement and critical thinking skills. The objective of this evidence-based project was to understand if a student’s clinical judgement is enhanced by increasing the amount of high-fidelity simulation hours within a nursing program. Simulation prepares the student for real-life clinical practice. The use of high-fidelity simulations in the educational setting allows for an increase in theoretical knowledge, clinical judgement processing, critical thinking skills, and increased confidence in clinical performance and self-efficacy skills. The fidelity of the simulation and the learning environment promotes evidence towards increased clinical proficiency and judgment.
A pre and post intervention qualitative study utilizing a Likert Scale survey tool and open-ended questions was performed at a rural community college Associate Degree Nursing program.
This evidence-based project supports the idea that simulation experiences can be just as beneficial, if not more than, clinical experiences. Fisher’s exact test reveals a significant difference between pre and post implementation data and faculty data.
The inefficiency of time spent in the clinical setting can impact learning. The increased complexity of clinical judgment required by a high-fidelity simulation, the standardization of the experience, and the direct correlation of curriculum objectives to the simulation objectives impacts the attainment of learning significantly in simulation experiences.
Studies show the benefits of APP inpatient utilization in improving continuity of care, communication, and education. This project evaluated the impact of APP involvement in the plastic surgery inpatient discharge process in an academic medical center on the volume of outpatient triage calls and inpatient experience ratings of provider communication.
A retrospective review of volume of triage calls related to postoperative care, drain care, and discharge instructions, as well as the department’s inpatient experience survey scores on four provider-related communication questions, was conducted three months before and during the APP intervention. The APP rounded on 55 patients aged two months to 78 years old, provided comprehensive discharge instructions, verified scheduled follow-up appointments, and provided patients with contact phone numbers for the outpatient triage nurse and APP.
Postoperative care calls increased from 84.3% to 93.1%. Drain care questions decreased from 6.4% to 4.4%, and discharge questions decreased from 9.4% to 2.5%. Analysis revealed a significant relationship between the APP intervention and the call data with a Pearson’s chi-square of 12.870, 2 degrees of freedom, and a p-value of 0.002. Patient survey scores on 3 of the four communication questions improved; doctors and nurses provided consistent information increased from 87.5 to 89.7, the care provider explained things increased from 65.0 to 70.6, and the care provider listened increased from 75.0 to 81.8.
The project emphasizes the benefits of utilizing APPs in the discharge process by decreasing triage call volume and increasing provider communication scores on inpatient surveys.
New graduate nurses entering the workforce are faced with the challenge of working with multiple healthcare disciplines and communicating effectively. One study estimated that interprofessional communication contributed to 60-70% of poor patient outcomes (Davis et al.,2021). A variety of tools have been developed to improve interprofessional communication. One tool that is used widely is Situation, Background, and Assessment (SBAR)(IHI, 2022). We identified that our undergraduate curriculum lacked a systematic strategy to build communication skills nor appropriate methods to evaluate performance.
This evidence-based practice project aimed to improve undergraduate nursing students’ confidence and abilities with interprofessional collaboration and communication by incorporating SBAR and interprofessional communication systematically into an existing undergraduate curriculum.
A cohort of 48 fundamentals level nursing students were observed during high-fidelity simulation and measured on their use of SBAR. The Interprofessional Critical Incident Report Evaluation Tool (Guhde, 2014) was used to measure competency. Curriculum redesign incorporated SBAR, interprofessional communication, and members of the interprofessional team into lecture, active learning, clinical, and simulation. Following varying instructional methods on best practice for interprofessional communication, students were reevaluated in high-fidelity simulation using a more complex scenario. Qualitative feedback was also obtained from both faculty and students.
Comparison of pre-intervention versus post-intervention scores on the Inter-professional Critical Incident Report Evaluation Tool were analyzed using inferential statistics. Analysis identified Person correlation of 0.047, P two-tail analysis of 0.013, and Wilcoxon Signed Rank tests of normalcy of 0.015. Test analysis identified 71% of students achieving mastery level for communication and 100% for collaboration questions.
Future qualitative data will include feedback from new graduate preceptors and nurse managers regarding nurse performance and interprofessional communication skills. Implementation of a systematic interprofessional communication curriculum in undergraduate nursing programs prepares students for successful transition to practice and improved patient outcomes.
Teamwork and collaboration among perinatal clinicians depend on accurate, timely, and complete communication. Inadequate communication and lack of collaboration are associated with a potential for patient harm and poor maternal outcomes. This evidence-based practice project was to conduct interdisciplinary AWHONN Intermediate Fetal Monitoring education to focus on communication strategies to improve attitudes toward collaboration among the perinatal team.
Guided by Bridges and Bridges theory of transitional management, ECU Health Medical Center physicians, nurses, and midwives (n = 53) participated in interdisciplinary education from January-March 2024. Participants were surveyed pre-class, at the immediate conclusion of the in-person class, and within 60-days post-class using the Jefferson Survey of Attitudes Toward Physician-Nurse Collaboration (JSAPNC). Survey results compared the total scores and four domains of the JSAPNC Scale (shares education & collaboration, caring vs. curing, nurse’s autonomy, and physician’s authority).
Attitudes towards collaboration demonstrated significant improvement among the perinatal team following participation in this interdisciplinary class. Across the time periods (pre-class vs. 60-day post-class) the team demonstrated significant improvements in the domains of shares education & collaboration (U = 1177.50, z = 2.048, p = 0.041) and nurse’s autonomy (U = 1138.50, z = 1.988, p = 0.047).
Implementation of an innovative collaborative learning model nurtures a culture of effective communication and nurse’s autonomy. The findings of this project support Bridges’ theory of transitional management and firmly establish that interdisciplinary education improves attitudes towards collaboration.
Burnout, a result of long-term stress, contributes to poor morale and decreased retention of nurses in the inpatient hospital setting. There is a knowledge gap present in terms of interventions that may address burnout in nurses. The purpose of this evidence-based practice project is to decipher to what extent a yoga intervention can reduce stress, and therefore over time, potentially reduce the burnout experienced by nursing staff and improve their well-being.
Participants completed the Perceived Stress Scale as a pretest and posttest. Two classes were held quarterly. The first class was an hour long and the second class was thirty minutes in length. The education consisted of both lecture and a yoga practice that combined breathwork and physical movement.
Unlike the literature, it could not be established whether yoga made a statistically significant difference on stress levels in nurses. It was established that nurses at our organization reported a moderate level of stress. Furthermore, the qualitative data provided the rich insight that participants were receptive to the yoga training and practiced the techniques beyond the implementation days.
Next steps include partnering local yoga teachers with our hospital system to address the lack of employee wellness initiatives.
Clinical supervisors in the ambulatory setting often do not receive sufficient onboarding and leadership development, creating a need for a program to ensure their success. Focused on improving emotional intelligence (EI), a program was developed to address an identified gap. The aims of this project were to 1) create and implement an EI training program for clinical supervisors in the ambulatory setting, 2) observe any improvement in their EI scores in any of the five domains within three months, and 3) achieve an overall increase in EI scores from baseline for at least 75% of participants.
The program was developed for clinical supervisors within one year of hire using Transformational Learning Theory and a blended teaching model with the first session in-person and subsequent virtual sessions. A multi-modal approach was utilized to deliver instruction to participants along with ongoing learning activities. All materials were curated from evidence-based references and assembled for distribution. Pre- and post-class assessments were conducted via a REDCap survey using the Wong and Law EI tool.
A total of 31 participants completed the program and corresponding surveys. Results showed participants had an increase in any of the EI five domains, all domains increased from their baseline scores. and an overall class EI score improvement of 80.65% exceeding the 75% goal.
EI training to improve leadership development allowed participants to improve their personal EI scores. Additionally, it has led to additional positive outcomes, including fostering connections among leaders and expanding their existing leadership network.
Compassion fatigue (CF) is a phenomenon commonly experienced by caregivers, characterized by overwhelming emotional exhaustion and a diminished capacity for empathizing or feeling compassion for others. Presently, no evidence-based program exists to assist in managing or treating CF in advanced practice providers (APPs). To address this gap, a 90-day program was developed to determine whether self-care interventions, mindfulness, and gratitude training can alleviate CF levels and augment compassion satisfaction (CS) among APPs in comparison to prevailing practices.
This program has been tailored for APPs serving in inpatient and/or outpatient settings. The program was structured into three 30-day modules. Participants were able to access program materials through various mediums such as YouTube, Spotify, or PDF documents and were assessed using the ProQOL tool. APPs completed an initial survey, followed by subsequent surveys every 30 days after each module, thereby resulting in four surveys per participant.
Forty-eight participants completed the program. Upon the CF training program's conclusion, participants who had initially exhibited lower levels of CS experienced an average increase of 2.3 points in their overall CS score, reduction in BO by 3.3 points and STS by 4.8 points.
Data analysis demonstrated that the implementation of a CF training program for APPs significantly enhanced overall scores, surpassing prevailing practices that lack such targeted interventions.
Resources and support for leadership development often occur once a nurse is in a formal leadership position. Transition to formal leadership is typically based on clinical expertise rather than leadership competencies. Leadership development enhances current direct care roles on the unit and introduces leadership competencies to help evaluate interest of growth. As leadership turnover rates increase, introducing and preparing direct care nurses for formal leadership positions is imperative. The purpose of this project was to introduce leadership competencies to direct care nurses through a leadership development program.
Guided by the American Organization of Nurse Leaders (AONL) framework, a pilot of eleven nurses completed three 4-hour educational workshops over six weeks. Participants completed the AONL Nurse Leader Competency Self-Assessment Tool prior to the first class and after completion. Five qualitative questions were also distributed at the conclusion of the final class.
Results comparing the pre and post self-assessments identified a statistically significant increase in overall knowledge of leadership competencies. When analyzing the individual domains, three of the five identified a statistically significant change.
Leadership development for nurses in direct care roles is imperative. This development can assist in supporting growth of current informal leadership roles on the unit, preparing an internal pipeline for leadership transition, reducing replacement costs of leadership vacancies, and support professional development. Leadership development targeting direct care nurses must be prioritized to support the ever-changing healthcare environment.
Carboplatin is a chemotherapeutic agent given to patients with a gynecologic malignancy. It is especially effective in the recurrent disease setting, but some women develop hypersensitivity to the drug. The carboplatin desensitization (CD) was developed to help women continue to receive carboplatin. There is no standard CD. Instead, hospitals have developed their own CD to implement. The Society for Gynecologic Oncology has recommended adoption of a universal 4 bag 4-hour CD in the treatment of gynecologic malignancies. An 872-bed academic medical center in the Southeastern United States had a 12-step 8.5-hour CD in place. The purpose of this project was to update the CD in accordance with the SGO recommendation and to determine safety, tolerability, and examine cost savings.
Approval was granted to update the protocol from the gynecologic oncology department and the Pharmacy and Therapeutics Committee. The target population was any female with recurrent gynecologic cancer with known carboplatin hypersensitivity. Each desensitization performed would be analyzed for safety and tolerability using the National Cancer Institute’s standardized definitions for adverse events known as the Common Terminology Criteria for Adverse Events (CTCAE) v5. Cost savings were evaluated with direct comparison of supplies used and labor time.
Two patients were identified and underwent a total of 5 desensitization’s. There were no adverse events greater than a grade 2. Cost savings were seen in the pharmacy department as well as nursing.
The newly implemented protocol has been successful. Ongoing research is needed to examine more desensitization’s to demonstrate safety and tolerability with more patients. Given the small number of desensitization’s in this project, ongoing research is needed to demonstrate cost savings for the institution.
Breast reconstruction is achieved over multiple surgeries and can be a grueling process for patients. More recently, 3D nipple tattooing has become an emerging trend. While it optimizes patient satisfaction post-reconstruction, 3D tattooing is not widely available. For years, 2D tattooing was available and used in a limited capacity at a level-I trauma, 885 bed, academic medical center, which currently houses a comprehensive breast care team. The purpose of this DNP project was to implement a new program to offer 3D tattooing as the last step of breast reconstruction.
A new program was implemented to offer the 3D tattoo. At this project site, we completed a retrospective chart review identifying patients who received 2D tattoos versus the number of patients who chose to receive 3D tattoos over a 16-month time period.
There was a total of 10 patients identified, three of these patients had a 2D tattoo and seven patients had the more realistic 3D tattoo procedure.
Clinicians and medical staff should be educated about the offering of 3D nipple tattoos. More research is needed on this topic and the 3D nipple tattoo should be widely offered in conjunction with the breast reconstruction process. For patients who have undergone mastectomy and reconstruction, the 3D nipple tattoo is a restorative and advanced aesthetic result to culminate the breast cancer journey.
Since the time of Florence Nightingale, the nursing profession has understood that the environment affects health. Nurses worldwide are being called on to expand their awareness and knowledge beyond that historical perspective and embrace a new paradigm that makes planetary health an essential part of nursing practice, education, research, and policy. The importance of planetary health as a science and a movement comes at a time in our history when the interconnectedness of human and planet health is becoming better understood, and the impacts of climate change on human health are increasingly evident. Additionally, health care as an industry contributes to the problem. The purpose of this project was to develop and implement a continuing education program that would not only increase eco-consciousness (awareness) and eco-literacy (knowledge) but, most importantly, inspire eco-competence (action) in nurses.
In the spring of 2024, three live online webinars were developed, implemented, and delivered to holistic nurses through a professional membership organization in the United States. Quantitative and qualitative data were collected and analyzed.
Post-webinar participants’ evaluations indicated a high correlation to stated learning objectives (4.7/5.0). After completing the learning activity, 71% of participants identified an action or change they could make. These included simple actions such as “I will turn off the water while washing my hands,” specific actions such as “I will integrate a discussion about eco-anxiety into the professional leadership term in the Summer 2024 semester,” and spiritual actions, perhaps reflective of the holistic nursing background of the participants, such as “I plan to invite local nurses to participate in eco-spirituality programming at our center that focuses on integrating changes in personal lives and professional practice.”
These results demonstrate that this continuing education program can potentially transform the nursing profession. The findings suggest that this model can be replicated to rapidly and cost-effectively educate a broader audience of nurses and other healthcare professionals. By expanding the ethical principle of “do no harm” to include both people and the planet and incorporating a planetary health framework into nursing practice, education, policy, and research, we continue Nightingale’s pioneering legacy as an eco-enlightened global nursing workforce for the 21st century.
Keywords: planetary health, environmental health, nursing education, holistic nursing
To implement a sustainable aromatherapy program in the adult post-anesthesia care units offering a complimentary therapy option for patients experiencing post-operative nausea or vomiting.
The IOWA model was used to guide decisions and implementation for this evidence-based practice project, providing a framework for practice change through the incorporation of critical thinking, an in-depth review of clinical practice, and multidisciplinary collaboration. Through the use of electronic surveys, pre- and post-implementation data was gathered regarding the nurse teammates knowledge, experience, perception, and sustainability of the use of aromatherapy in patient care. Additionally, metrics surrounding the total number of antiemetic pulls related to patient volume and an average of minutes per stay were analyzed for trends in the pre- and post-implementation phase.
Descriptive statistics were calculated to delineate data derived from questionnaires. This project is unique in that it evaluated the nurse's perception of aromatherapy on the care they provide. Givin the small sample size a non- parametric Kruskal-Wallis test was utilized to obtain a p-value for AIM survey questions. When comparing pre-and post-implementation p-values, there are no significant associations between AIM. Additionally, there appears to be no significant association between the AIM statements and employment status at a 0.05 significance level. The individual responses relative to a score of 3; if significant, the p-value indicates that the scores are consistently below the tested value of 3, which shows acceptability of aromatherapy. There were no significant associations with the AIM score pre or post implementation, but that acceptability is favorable.
The implementation process increased awareness of aromatherapy in the PACU setting with steps towards increasing usage. Observation and general feedback suggest that aromatherapy would be utilized by nurses in the PACU setting. Barriers to electronic medical record documentation on patients that received aromatherapy were not captured.
Research Focus: Seeking to understand if educating Advanced Practice Providers to Jean Watson’s Theory of Human Caring improves provider wellness and has positive implications for patient care.
School: Wake Forest University, School of Medicine, Department of Academic Nursing
Student Level: Doctoral
Presentation Type: Oral
Faculty Advisor: Kellie Griggs, DNP, MSN-Ed, RNC-OB
Advanced Practice Providers (APPs) are integral to the healthcare system in the United States. The stress of the recent unexpected global healthcare crisis further deteriorated the mental, emotional, and physical well-being of bedside clinicians.
This time of turmoil in healthcare highlights the need to explore and develop coping and resistance strategies to alleviate stress and improve provider well-being in the workplace. Although many evidence-based strategies are positively correlated with provider well-being, the patient-provider relationship and its impact on provider well-being has yet to be explored. This study seeks to understand the relationship between human caring and its impact on the APP experience providing patient care through implementation of theory guided practice based on Jean Watson’s Theory of Human Caring.This mixed method, single institution study was piloted between 2022 and 2023. The overall objective of this exploratory study was to explore APP understanding and experience with theory guided practice in the inpatient setting and to improve inpatient APP well-being through a patient centered approach to care guided by theory. Participants were recruited via electronic correspondence and participated in an interventional education program based on Jean Watson’s Theory of Human Caring was created called “Doing the HART Work”. Participants were given 6 weeks to do the HART work and both quantitative and qualitative description methodologies, using a pre intervention and post intervention survey, were used for data capture.
Our research findings indicate that APPs derive a strong sense of personal satisfaction from caring for their patients, even while working in high stress, high acuity areas that lack sufficient resources. Based on our findings, it’s evident that APPs wish to have meaningful relationships with their patients, but their practice environment often precludes this. Data reveal respondents’ desire to feel connected to their patients while caring for them in a nurturing environment, and paints a compelling picture of teamwork, healing, and providing care for others in need. Three overarching themes from the data 1) patient centered caring, 2) a sense of caring, and 3) teamwork and caring, describe the beauty APPs find in caring. Our research reflects the strength of caring and how the humanistic relationship between providers and their patients plays an important role in provider well-being.
This pilot study demonstrates that APPs find joy in compassionately caring for their patients and are in desperate need of the space and resources to do so. Helping patients and providing comfort brings a sense of fulfillment to APPs in clinical practice, but this experience is often precluded by their working environment. Placing human-to-human relationships as the cornerstone for practice with a patient centered approach to care, can help improve provider well-being in the workplace by focusing on providers’ sense of fulfillment. Patient centered care has positive implications for both provider and patient well-being. Providers with higher levels of job satisfaction tend to be more productive and deliver better quality care which have large financial implications for organizations. The findings of this study provide a foundation to characterize factors that influence provider well-being and additional studies exploring the impact the patient-provider relationship and provider well-being are needed.
The COVID-19 pandemic initiated new and dormant stressors for healthcare clinicians resulting in burnout. When burnout and stress reach an all-time high, it is hard to regulate emotions like sadness, anger, and guilt, which may result in decreased quality of care for patients, increased medical errors, and clinician exhaustion. Therefore, employers must focus on stress-reducing measures, such as mindfulness. Our study aims to evaluate the impact of practicing a mindfulness technique on workplace satisfaction, work environment, and work engagement on telehealth clinicians.
The methodology included implementing a pre-and post-survey and an instructional mindfulness technique video from April 2023 through June 2023 via REDCap to telehealth clinic employees. Use of the Hennepin Healthcare Mini-Z tool to assess percentage changes from baseline and after-intervention scores—statistic and data analysis involved frequency distributions, one and two-sample t-tests, and effect sizes.
The results from pre- and post-intervention scores indicate a joyful workplace with a 49% increase in scores from baseline, reasonable pace/manageable EMR stress with a 50% increase in scores from baseline, and a highly supportive work environment.
The variable outcome data indicate post-intervention improvements when using mindfulness to improve workplace satisfaction and engagement while maintaining a supportive work environment.
Sexual and gender minority (SGM) adolescents make up less than 1% of the entire adolescent population. This population of adolescents are faced with stigma, homophobia and heterosexism on a daily basis (Cafferty et al., 2020; Dowshen & Ford, 2019; Hagan et al., 2017 & Shattuck et.al, 2020). SGM adolescents are more likely to engage in high-risk sexual activities, self-medicate with illegal drugs for anxiety and depression, have a higher risk of suicide and defer healthcare due to stigmatization (Stern, 2021; Cafferty et al., 2020 & Boswell et al., 2019). The discrimination, stigma, and harassment experienced by SGM youth in their daily lives should not carry over to their healthcare. In an effort to boost best practice in the care of SGMY, an evidence-based practice approach to the implementation of providing safe, quality and affirmative healthcare to SGMY in the pediatric primary care setting. Training of Advance Practice Providers (APP) to understand the similarities and differences of SGMY to their cisgender peers better prepares the APP to treat and follow guidelines in place for all adolescents.
The implementation of this EBP initiative was divided into four phases. In phase one, the sample of APPs were given education on evidence-based approaches to care for SGM adolescents and training on documenting care for SGM adolescents in the electronic medical record. Providers were made aware of two quick-text tools designed in the electronic health record for documentation for use with all adolescent patients aged 11-18 years. The second phase evaluated the utilization of the quick-text tools and the follow up free text documentation were measured during a twelve-week implementation period. In phase three a post-implementation electronic survey was sent to all participating providers at 12 weeks. This survey included open-ended questions focused on reflection and overall provider perspectives of the SGM EBP initiative. The use of the quick-text tools were extracted from the EHR through a specialized report generated by the project leader in phase four. Four main data points were extracted from the EHR: (1) total number of quick-text tools (concerns or no concerns) used for SGM identity screening, (2) total number times a follow up plan and discussion were documented after a positive screening with concerns for SGM identity, (3) patient age, and (4) patient gender assigned at birth.
Quantitative: Quick-text tools were used 165 times in the 12-week period. Eight adolescents were found to have concerns regarding sexual and gender identity. Referrals to behavioral health counseling, acknowledgement of questioning and safe sex practices were discussed with those identified as having concerns.
Qualitative: Perspectives and thoughts of the providers related to the EBP implementation to practice implications were explored. A text analysis with descriptions and verbatim comments was completed for this paper. A variety of learning needs met were expressed by the providers.
Evidence suggests SGM care is subpar and that more resources are needed for providers and patients. Thus, providers must be encouraged to speak about gender and sexual identity at all appointments and facilities must have the staffing and interprofessional collaboration needed. The ease at which providers were able to incorporate the new quick-text tools suggest training can be expanded to a variety of healthcare institutions who utilize a similar electronic healthcare record. Policies and procedures can be implemented in order to assist providers and patients in smooth transition and success. The evidence also points to missing education in programs for advanced practice providers. Therefore, our programs for nursing and medicine should be charged with enhancing curriculum on sexual and gender minority care and equity.
With an aging population, the complexity of patients has increased with greater prevalence on chronic disease inadvertently which has increased the acuity of patient care. This impact has challenged the healthcare system increasing the demand on emergency services and healthcare workforce making nurse practitioners (NP’s) and physician assistants (PA’s) an integral part of the healthcare team. Therefore, post graduate training for Advanced Practice Providers (APPs), nurse practitioners and physician assistants, is an opportunity to further provide a standardized approach for education, professional development, knowledge acquisition, and mentorship. Post graduate training for APPs is not the standard of practice. Residencies and fellowships have been developed for APPs to foster professional growth, improve medical knowledge, and improve clinical practice. APP Fellowships are an opportunity to improve retention, assist health care systems with complex patients, improve professional development of nurse practitioners and physician assistants, and decrease institutional costs.
The development of post graduate fellowships improves Advanced Practice Providers effectiveness, competence, and retention. The utility of these fellowships positively impacts institutions. Therefore, establishing fellowship training is pivotal for the new advanced practice providers skills, competency, confidence, decrease in institutional and health care cost, and improvement of retention.
Although, a need for APP fellowship was identified given specific barriers: cost, funding, cultural readiness, supply and demand, an emergency medicine fellowship was unable to be established. However, implementation of the APP emergency medicine fellowship would include design of the curriculum, anticipated production guidelines, program objectives, program benchmarks, skill development, knowledge acquisition, mentorship, simulated exams, oral exams, with final requirements for graduation from the program.
No active results were measured. However, in comparison to other studies, the expected results would demonstrate a decrease of cost to the institution, improved retention, with confident and competent APPs post fellowship meeting national metrics and benchmarks yielding improved patient care.
As the complexity of patient’s increase, healthcare trends with increase of demand, aging baby boomers, decrease in resident work hours, physician shortages, and value based care. APPs have been an integral part of bridging the gap of demand and supply for access and quality. Job dissatisfaction, burnout and low retention of new APPs was found to be associated with poor patient care outcomes. Therefore, APP fellowship programs are a solution to provide a foundation for transition into practice by providing specialty education, skills, mentorship, yielding confident and competent providers with the ability to delivery of improved patient care.
The complexity of violence against nurses and other healthcare professionals is compounded by widespread underreporting by victims and witnesses of violence. Many of the identified barriers to reporting, can be mitigated through leader support. The purpose of this quality improvement project is to improve workplace violence reporting practices at a community hospital.
Three interventions were designed and implemented to improve workplace violence reporting practices: a survey to all staff to understand current reporting practices and barriers; a leader training course to improve knowledge of workplace violence and documented barriers to reporting; and a staff training module to improve knowledge of reportable violence, the procedure to report, and resources for victims.
In six months, workplace violence reporting improved from an average of 2.3 reports every two weeks to 4.8 reports every two weeks, a 108% increase from the previous 12-month average.
Leader acknowledgement and support to report workplace violence is a core factor in improving reporting practices. Reporting violence is a product of knowledge, communication, and trust between frontline staff and leadership. Increased reporting is necessary to develop meaningful and successful workplace violence prevention programs that keep staff and patients safe.
Telephone triage is a common daily practice within physician offices aimed at managing patient needs between routine appointments. Nurse-led triage practice is widely accepted for after-hours patient management and a strong body of literature exists regarding the implementation of clinical decision support (CDS) tools and their benefits in this setting. Less is known about provider acceptance and satisfaction when daytime triage uses these same tools. The project aim is to understand provider satisfaction and acceptance of triage practices during daytime hours using CDS tools while identifying and understanding barriers to implementing this practice model.
Three practice pilot locations were enrolled after voluntary self-selection. Inclusion criteria included full support and interest from their dyad leadership and locations with established and experienced telephone triage nurses were eligible. Reports for most common patient calls for prior six months were generated from the electronic medical record (EMR), and decision trees were developed and built for the top ten. Intake EMR documentation for patient calls was built and staff trained on use. Providers and nurses were surveyed prior to implementation and six weeks after.
Post-survey responses reside in the “agree” categories without indication of statistical differences between the two surveys. Although project results didn’t demonstrate hypothesized change, the pilot did change daily clinical practice with the implementation and adoption of nurse-led telephone triage in two of the three pilots.
Studying provider satisfaction and acceptance of evidence-based practice content with CDS tools, demonstrated providers are interested and willing to participate in this practice change.
Nurses improve the quality of health news stories yet are seldom sourced by journalists. The Future of Nursing 2020-2030 identified professional associations as integral to developing media-competent nurses. Nurses need training to be capable and confident when speaking to the media. However, nurses do not receive media training in their curriculum, and limited media training resources are available. This project aimed to develop a media competency training program for neuroscience nurses to be used by a professional nursing association.
The program is structured into three chapters: uses and benefits of media, necessary media skills, and developing a media plan. The chapters are based on the 10 media competencies for nurses identified in Myers et al.’s Delphia study. The framework used is Kirkpatrick’s four levels of training evaluation model which states that successful training starts with identifying the desired result and instilling the necessary behaviors through skills and attitudes.
The Media Competency Training Program for the Neuroscience Nurse is a complete, self-paced, distance learning course. The program is visually appealing, with activities throughout to reinforce desired behaviors. The program includes a guidebook and two evaluation tools.
Nurses who receive media training will be equipped to improve the quality of neuroscience health stories, increase the visibility of neuroscience nursing impact on patients, and collaborate with the media to improve population health. The professional nursing association can use their media competency-trained neuroscience nurses to speak to journalists as an authority in neuroscience nursing.
After implementing a comprehensive fall program, a critical process for investigating a patient fall event, known as a post-fall huddle form (PFHF), needs to be completed by nurses consistently. The PFHF was a manual process in paper format only and compiled approximately 50 questions. A cross walk reviewing sustainability and leverage opportunity from the vendor identified that the number of completed PFHFs were more than 53.8% less than the actual number of fall events.
An electronic post-fall huddle form was implemented with forced functions, de-identification, EMR interoperability, and automated notification embedded. The project included mimicking the paper PFHF using REDCap® software, education for entering and validating the data, testing workflow, interoperability, and a pre/post-implementation survey was conducted.
Completion rates improved from 11.1% to an overall average of 99.6%. There was statistical significance related to decrease time to complete the form electronically for the Initiator (P=.04) and the Validator (P=.02). Frustrations and concerns expressed during the pre-implementation survey significantly decreased upon using the ePFHF.
By combining theories and frameworks for complex adaptive systems like nursing, electronic data capture increased completion rates, standardization, data collection, satisfaction, reduced expressed concerns and frustrations, produced opportunities for future cost savings, and strengthened interdisciplinary partnerships.
The Clinical Ladder Program (CLP) at Atrium Health Wake Forest Baptist saw decreased participation and project completion by those participating over the last five calendar years. From 2015 to 2020, there was a 78.33% decline in letters of intent (LOIs) and a 57.14% decline in project completion. The purpose and value of the CLP is the professional development of the direct, sharp edge bedside caregivers. The CLP promotes and rewards participants who optimize quality care and outcomes – these contributions foster and empower expert practitioners at the bedside.
A decision was made to redesign the CLP and align all existing CLPs across the region to a single regional program. The authors reviewed CLPs at other organizations and discussed options with stakeholders in conjunction with key leaders. The authors decided that the redesign would be a points-based system with two tiers for registered nurses and a single tier for licensed practical nurses. The points-based system allows flexibility for the program participants to choose their pathway. To promote well-rounded professional development, the points were divided over five categories with a required minimum in four of the five categories. The categories are built around the acronym CLIMB: Clinical practice, Learning, Innovation, Model, and Benevolence.
The new CLP roll-out occurred during the ANA recognized Nurses Month 2021. Utilizing highly visible, multimodal regional marketing strategies was critical to promote the redesigned program and reach all levels of potential participants. Regional committee representatives joined the project owners at their respective practice sites to tailor the communication to their teams. In-person, advertising ranged from stationary tables in shared areas with flyers to rounding on the nursing units. These sessions occurred daily for one week and were beneficial in prospective participant question and answer sessions.
As the nursing shortage continues to expand, taxing nurse leaders and healthcare administrators, the authors have shared this work encouraging others to join their efforts in applying best practices through evidence-based research. The impact of this CLP redesign is yet to be fully determined; however, through application consistent with other CLPs and strong leader involvement, the authors hope to promote positive engagement and retention outcomes in nursing. Continuing to build and disseminate knowledge of nursing CLPs is warranted and only stands to strengthen the nursing profession, enabling us to retain talent while optimizing our patients' care.
Lower levels of work engagement are associated with higher turnover intent (Memon et al., 2016), and nursing turnover has both financial and quality implications. The cost of replacing one nurse ranges from $37,700 to $58,400 for nurses that require advanced skills and training (Nursing Solutions, 2016). Reduced experience at the bedside may mean fewer nurses are in the workforce who have astute assessment skills, can think critically, and have an intuitive understanding of the most important patient needs. This doctoral project sought to study the impact of in-person structured peer feedback sessions on work engagement as measured by the employee version of the Work Engagement Scale developed by Schaufeli et al (2002). The tool measures nurses’ connection to the work they do every day through three constructs: vigor, dedication, and absorption.
Baseline scale responses and additional information about nurse’s level of experience, background, and participation in professional development activities. Nurses were gathered in small groups of two to three during a normally scheduled shift. Participants received a brief 15-minute overview module on the concept of peer review, the need for specific feedback, as well as strategies for giving and receiving actionable feedback with positive intent immediately as part of the first peer dyad session. At each dyad session, participants were provided with a peer reflection tool and were asked to thoughtfully consider their partner’s clinical practice and provide feedback using the IDEA message methodology. Each nurse had the opportunity to participate in two peer dyad sessions before engagement levels were reassessed with the Shaufeli tool.
For the Vigor subscale, illustrated in Figure 3, the median score pre-intervention was 22 (n=26) and the post peer feedback sessions the median score was 23 (n=26), a 4.4% increase. For the Dedication sub-scale, illustrated in Figure 4 below, the median score was 20 for both pre-intervention and post-intervention groups. For the Absorption sub-scale, the pre-implementation median was 18, and the post-implementation median was 19, a 5.5% increase. Changes in the median score was not statistically significant for any of the subscales.
This doctoral project was not able to answer the question of how implementing in-person feedback sessions consistent with the ANA recommendations impacts work engagement. Work engagement is a complicated metric with multiple variables that contribute to the overall result. In a natural system, it is difficult to analyze the results without considering other system influences. The results of this project can be used to help others design and implement a project. Assurance of dedicated time, and allowing for a longer duration of implementation before evaluating the impact of behavioral change may be beneficial. A deeper understanding of skills that could allow staff to improve work engagement and increases the desire for experienced nurses to stay engaged in frontline nursing is of critical importance to hospitals interested in delivering high-quality care. Further study of how interventions impact staff engagement is essential in helping to stabilize turnover in our increasingly valuable bedside leaders.
The North Carolina Association of Nurse Anesthetists (NCANA) lacks membership engagement and leadership recruitment as evidenced by a history of unopposed ballots and the board of directors providing dual responsibilities as committee chairs. In addition, the NCANA has lacked a structured scholarship pathway to engage members and student members in NCANA leadership roles.
To provide a structured guideline that supports financial assistance linked with a customized leadership development opportunity to selected NCANA members and student members matriculated in a doctoral degree program. The LEAD Scholarship Program aims to prepare and inspire doctoral students to become NCANA leaders who are ready to advocate for Certified Registered Nurse Anesthetists (CRNAs), the association, and our profession.
By investing in members’ educational pursuits, the association is investing in the future of our organization and profession by growing new leaders who are prepared for future governance. This is significant because the NCANA needs a succession of leaders who are prepared to advocate for and negotiate through the complex and dynamic educational, regulatory, legal, and political landscapes that impact North Carolina’s CRNAs.
A detailed guideline provides a structured pathway for establishing, maintaining, and promoting the NCANA Doctoral LEAD (Leadership, Education and Development) Scholarship Program. Funds will be routed through the American Association of Nurse Anesthetists (AANA) Foundation to ensure donations will be tax deductible. Additionally, the AANA Foundation will manage all student applications, recipient selection, and fund allocations. The NCANA is tasked with providing the initial financial resource of two $3,000.00 awards, attracting student applicants, and recruiting donors for the LEAD scholarship. A detailed financial plan is designed for growth and sustainability through member donations and endowment opportunities. A marketing plan provides a comprehensive strategy to recruit donors and attract student applicants via website ads, virtual events, and social media. The guideline also includes a LEAD scholarship recipient engagement process that offers customized leadership training experiences via engagement in NCANA leadership roles. The LEAD scholarship program will be evaluated via a specifically designed annual survey given to recipients to measure leadership and professional outcomes for five (5) consecutive years.
To evaluate if the implementation of a Transition to Practice (TTP) program improves retention of newly licensed nurses at Wake Forest University Baptist Medical Center.
The TTP program was implemented in November 2019 with newly licensed nurses from five hospitals within the health system participating in monthly workshops. Support to nurses was offered through small group “Tales from the Bedside” groups which served a dual purpose in debriefing workshop content and presenting an evidence- based presentation. Covid -19 resulted in workshops transitioning to virtual. Turnover rates were compared at baseline and at the conclusion of the first cohort completing the program. Because the organization tracks turnover data on a monthly basis, a control chart was utilized to demonstrate the variability month over month. The control chart indicated a downward trend between fiscal years, although not significant. A midpoint and final evaluation was administered to the participants to elicit feedback about the program.
Nurses hired in July and August 2019 began the TTP program in November 2019. The cohorts consisted of 89 and 67 nurses respectively. Nurses completed the program in July 2020. Prior to the implementation of the TTP program in fiscal year 2019, the baseline turnover rate was 22%. At the conclusion of fiscal year 2020, organizational data revealed a 3% decrease in the turnover rate at WFBMC.
Nursing retention is not only a nation-wide issue but a local one as well. The nursing shortage will continue to create burdens for health systems. Development of a TTP program can assist with a reduction in turnover by providing an avenue for socialization for newly licensed nurses and introducing them to resources and best practices. This project was an important first step to re-designing opportunities for newly licensed nurses. Evaluation and implementation of improvements to the TTP program is key for sustainability of the program. During the course of this program, the turnover rate for newly licensed nurses dropped by 3%. Tracking retention and constantly looking for opportunities to enhance the program will be critical for ensuring the organization is promoting optimal learning opportunities for newly licensed nurses while providing the support nurses need and desire.
Following exposure to adverse events, medical errors, or unanticipated clinical outcomes, healthcare providers manifest a predictable trajectory of emotions, including depression, guilt, embarrassment, questioning clinical skills, PTSD, and, even, suicide. The patient is the first victim and healthcare provider, second victim. This phenomenon was studied by a team of clinicals at The University of Missouri Healthcare System; out of that research, The Second Victim Experience Support Tool (SVEST) was created and identified that clinicians desire more organizational and colleague “peer support” following adverse events. The Second Victim Transpersonal Caring Model was created and implemented to provide emotional first aid to all levels of healthcare providers to foster more rapid return to pre-event functioning without lingering effects. There remains a gap in healthcare providers’ understanding of second victimization and availability of peer support programs in a large number of healthcare organizations. The purpose of this DNP project was to implement a pilot peer support program to provide ongoing empathetic peer support to second victim teammates.
The methodology included distribution and analysis of the SVEST to determine needs of healthcare providers in the pilot departments, increase awareness, and build momentum for the program. Secondly, creation of program guidelines and protocols for tracking of program metrics and utilization. Third, to recruit and train a cross-disciplinary cadre of peer supporters, including members from outside the pilot area. Finally, increase institutional awareness of the second victim phenomenon to promote further awareness and buy-in from stakeholders.
The SVEST instrument resulted in high percentages of employees that completed the survey had experienced manifestations of the second victim phenomenon, a perceived lack of organizational resources, and, 80% desired a respected peer colleague to discuss events. Implementation strategies included increasing department and institutional awareness of the second victim phenomenon, allowing further buy-in from stakeholders via meetings, presentations, and marketing strategies. Using the Second Victim Transpersonal Caring Model and in collaboration with Employee Assistance Program and Chaplain services, program guidelines and peer support training programs were executed successfully, with the initial cohort of seven, including two outside the pilot area. Further implementation included development of program guidelines, an organization-wide Share point site, and private email address to the peer support team. Marketing strategies to build awareness included use of badge buddies, business cards, Facebook live discussion and presentations, and posters displayed in prominent areas of the surgical services suite.
Although healthcare organizations offer various resources for support via Employee Assistance Programs or Chaplain services, there remains a gap in many organizations in providing a respected peer colleague to provide emotional support to all levels of employees following exposure to unanticipated clinical outcomes. It is impossible to obliterate adverse events and unexpected clinical outcomes; this was heightened by the Covid-19 pandemic crisis. The ability to provide desired peer support to those suffering from the second victim phenomenon can mitigate the negative consequences and allow the employee to return to their pre-event level of functioning.
Standard nursing programs often lack specialized training, resulting in new graduates that are under-prepared to function independently in professional practice. Due to this, Tennessee Oncology (TO) has opted to hire only experienced nurses and has no program to incorporate new graduate nurses into the system. The primary objective of this project was to implement an ambulatory-focused new graduate nurse residency program (NRP) to increase nurse retention through the provision of a specialized curriculum and professional support. Secondary goals include improvement in nursing confidence, increased knowledge base and clinical skill development, and improved job satisfaction.
A comprehensive literature review identified the need for effective NRPs to transition new graduates into practice however, only four oncology focused NRPs were found in the literature. It was anticipated that the development of an oncology-specific curriculum to support newly graduating nurses would provide the level of support and education necessary to promote safe patient care and nursing retention. A planning committee was formed with representation by executive leadership, clinical education, nursing, and human resources. A NRP length of 12 months was determined and small cohorts of five graduates twice per year was chosen based on organizational need and preceptor resources. A curriculum was planned to deliver oncology specific education in areas such as care delivery, supportive cancer care, and clinical skills.
Due to COVID-19, the NRP was unable to be fully implemented. Upon successful implementation, retention will be measured at one and two years post-NRP completion. Secondary objectives of nurse resident confidence levels, knowledge and skill development, and job satisfaction will be measured utilizing the Casey-Fink Graduate Nurse Experience Survey.
Although this program encountered several barriers at the implementation stage and outcomes could not be assessed, a number of valuable lessons were learned during the planning and organization of this project. Obstacles included: changes in the nursing students’ clinical experiences, reduced hiring capacity at TO, NCLEX testing delays, limited TO training space due to social distancing requirements, and limited program applicants. Based on these issues, it was decided that the program start date would be moved forward to allow for an increased number of applicants, NCLEX results before program start date, and more comprehensive clinical experiences prior to graduation.
Despite the evidence supporting the benefits of adopting enhanced recovery after surgery (ERAS) protocols in orthopedic procedures, numerous barriers exist to successful implementation. This evidence-based practice project's overall objective was to improve CRNA adherence with ERAS protocols through the implementation of a comprehensive, sustainable education program by addressing the knowledge-to-practice gap.
A comprehensive review of the evidence identified strategies for implementation and adherence to ERAS protocols with educational interventions identified a key factor. Department-specific barriers were identified via a survey of the staff CRNAs, followed by the development of three educational modules based on the ACE-Star Model and Knowles’ Theory of Adult Learning. A pre-test/post-test format was used to assess the participants' knowledge transformation, and scores were analyzed using a paired t-test. Retrospective data collected from the electronic medical record were compiled on all patients receiving a primary total hip or knee arthroplasty and analyzed to CRNA protocol adherence based on four outcome measures: average fentanyl administration, average midazolam administration, average ketamine administration, and PACU length of stay.
The results from the pre-test (M=62.04, SD=10.02) and post-test score (M=80.08, SD=11.69), t(11) = -4.275, p < 0.001, reflected a significant improvement in scores based on participation in the educational interventions. Paired sample T-tests performed on the hip data set demonstrated a statistically significant decrease in fentanyl use over the course of the project from August 2018 (M = 81.93, SD = 44.90) to August 2019 (M = 48.61, SD = 28.39), t(11) = 2.12, p < 0.05. Mean midazolam use decreased throughout the evaluation period but did not demonstrate statistical significance. Mean ketamine use increased, but without evidence of clinical or statistical significance. PACU length-of-stay remained constant.
Successful implementation of an ERAS protocol requires multidisciplinary collaboration, designated oversight, identification of barriers, continuous education, and ongoing evaluation of outcomes. Clinician adherence to a standardized change in practice is determined by the organizational support, addressing barriers, and structured education. Educational modules and awareness campaigns on the advantages of facility-specific ERAS programs should be accessible and ongoing. Protocol adherence is directly impacted by clinician education, and adherence has the most significant impact on the achievement of desired patient outcomes.
Experienced nurses re-entering the workforce offer a solution to a critical nursing shortage unmet by new graduates alone. Yet, re-entry is often delayed due to a lack of clinical training resources. This quality improvement project piloted virtual simulation, an evidence-based educational intervention, to accelerate clinical completion. The purpose of this quality improvement project was to determine whether replacing a portion of traditional clinical hours with virtual simulation education would enable RN refresher students to satisfy clinical learning outcomes, maintain self-efficacy, reduce preceptor training hours, and complete the course in less time.
From June 2020 to June 2021, Charlotte Area Health Education Center offered virtual simulation to eligible RN refresher students to replace up to 50% of traditional clinical hours as a solution to reduced clinical opportunities amid COVID-19. Guided by the Iowa Model Revised: Evidence-Based Practice to Promote Excellence in Health Care, the team reviewed the evidence, vetted simulation products, and consulted with simulation experts to decide which product to pilot. Four virtual simulation online modules from Shadow Health were chosen. The project compared course completion time, the number of precepting training hours, satisfactory rates of clinical learning outcomes, and post-clinical self-efficacy scores between those using virtual simulation and those not.
Ten (n=10) Charlotte AHEC RN refreshers completed traditional clinical hours, and twelve (n=12) used a combination of SIM and traditional clinical hours to satisfy the clinical requirement of the program. Using independent t-tests, there were no significant differences in age, experience, and length of practice break between the two groups. 100% of students in both groups satisfactorily met clinical learning outcomes. Self-efficacy scores increased among SIM users by 19%, but the increase did not demonstrate a statistical significance, p=.068124. Preceptor training hours decreased by 42%, reflecting a significant reduction, p=00001. Course completion time was reduced by 22%, demonstrating a significant improvement, p=.048298.
The initial results of this quality improvement project demonstrate that vSIM education can be an effective pedogeological tool used to prepare re-entry nurses for their transition back to practice. Incorporating vSIM into RN refresher programs can reduce course completion time while maintaining clinical learning outcomes, increasing self-efficacy, and decreasing preceptor training hours. NC AHEC RN Refresher program plans to continue offering vSIM as an option to replace a portion of traditional clinical hours while monitoring key performance indicators such as course completion time, preceptor training hours, satisfactory clinical learning outcomes rates, self-efficacy, student satisfaction and employment orientation time.
Breast cancer is the second leading cause of death in women over 40 in the United States. Evidence demonstrates that for these patients undergoing surgery, the choice of anesthesia technique can influence outcomes and recurrence rates. The purpose of this project was to implement an evidence-based anesthesia technique for breast cancer surgery at Appalachian Regional Healthcare System (ARHS).
Using Stetler’s Model of Evidence Based Practice, unit-level inservices were given to certified registered nurse anesthetists, and physician anesthesiologists and general surgeons were guided on an individual basis. The technique implemented was the introduction of regional anesthesia in the form of pectoral nerve blocks (PECs), the use of propofol-based total intravenous general anesthesia, and the avoidance of intraoperative opioids. Data was collected for the implementation of this technique for anesthesia providers to patients presenting to ARHS for mastectomy and breast biopsy with sentinel lymph node biopsy.
Two patients did not receive PECs blocks; one patient did not receive a propofol-based anesthetic; and 8 out of 36 patients received opioids. The goal of data collection for this project was 40 patients. 36 patients were subject to the protocol during the project period. Feedback from the general surgeons and patients has been positive: The general surgeons forward compliments of tolerable pain controlled at home without the use opioids.
The review of outcome variables has resulted in changes at ARHS. As the project continues, the following changes are anticipated: the addition of erector spinae blocks to provide anesthesia to the axilla; new provider orientation checklist; and the creation of a service line position.
Improved cancer screening and treatment has resulted in lung cancer (LC) survivors living longer than ever before with late and long-term treatment effects impacting their overall quality of life (QOL). The Survivorship clinic is a new and emerging service at our institution lacking a formal screening program to identify QOL issues in cancer survivors. Guided by Katherine Kolcaba’s comfort theory, the purpose of our DNP project was to implement a process improvement project to identify physical and psychosocial barriers affecting QOL in LC survivors at our institution.
A 100% completion rate using the pen and paper PROMIS-29 profile was achieved. The nurse, medical assistants, and providers agreed the training was organized. No challenges were identified in assisting patients with profile completion. Analysis of PROMIS-29 standardized T-Scores indicated physical function (41.2) and pain interference (55.5) were the most impacted QOL domains while depression was the least impacted. Providers agreed the PROMIS-29 was instrumental in providing patient care and guiding LC survivors to appropriate resources.
A guideline and education session was provided to nursing staff and healthcare providers prior to implementing a pen and paper version of the Patient-Reported Outcomes Measurement Information System® (PROMIS-29) profile in adult LC survivors. Medical assistants transferred patient responses into our institution’s electronic health record. Advanced practice providers used the information obtained for patient care, teaching, and referrals.
While technology encourages completion of patient reported outcome measures (PROMs) electronically, introducing and educating a predominately older population on the completion and usefulness of PROMs with a more familiar pen and paper method of data collection helped ensure reliable and accurate QOL data. Identifying physical function and pain as the most impactful QOL issues among our LC survivors is key in promoting meaningful clinical interventions and developing future resources beneficial to this emerging population of cancer survivors.
Providing consistent care via a standardized approach utilizing a golden hour protocol is essential for the vulnerable premature infant during the first hour of life. Despite the evidence supporting the benefits of adopting a golden hour protocol for very low birth weight, premature infants, numerous barriers exist to successful implementation. This evidence-based practice project's overall objective was to identify the limitations and barriers that prevented the successful implementation of a proposed golden hour protocol bundle.
Quality improvement methodology and Statistical Process Control methods were utilized. Retrospective baseline data was collected from August 2019 until December 2020 using EPIC (electronic medical record). Baseline data included all inborn infants weighing < 1500 grams and < 32 weeks gestational age, who survived initial resuscitation in the delivery room and were subsequently admitted to the NICU. At the initiation of implementation, 146 infants met the specified criteria. Plan-do-study-act (PDSA) cycles were planned to evaluate the proposed interventions. The NICU staff received a PowerPoint presentation portraying the baseline data and general information about the golden hour concept, including different roles, and a paper copy of the presentation. The authors created and distributed a step-by-step detailed process flow chart outlining the interventions. A nursing golden hour admission checklist was created and easily accessible in the golden hour notebook. Additional face-to-face and WebEx education sessions were provided to NICU staff. However, when the proposed golden hour bundle was unable to be successfully implemented within the desired timeframe, the author’s focus was redirected to identify the barriers and limitations that surrounded successful implementation. A quantitative survey was created and distributed to all NICU staff via the REDCap platform.
The planned interventions for the golden hour admission bundle were highly supported by literature and evidence-based practice. Although we could not implement the planned interventions fully, increased awareness of the importance of the golden hour and a desire for improvement overall was achieved. The REDCap results provided the desired intrinsic data needed to determine further steps for project implications.
The proposed implementation of a golden hour bundle for premature infants will increase awareness of the significance of the evidence-based interventions within the first hour of life. In the future, and to ensure the sustainability of a quality improvement project, early buy-in and the assurance of buy-in will be essential. While we provided perceived effective education, hands-on experience and simulation are desired. Future project implications should focus on the assurance of obtaining buy-in and simulation to promote concept attainment through experiential practice. Implementation of this evidence-based, golden hour bundle will improve outcomes for premature infants in a level IV NICU in the southeastern United States.
Introduction of a new informatics system, REDCap – Research Electronic Data Capture program for use by an internal employee wellness program to improve data intake, analysis, identification of trends, and identifying program successes and failures. The health and wellness of employees are essential for employers and the employees themselves. Data collected from wellness programs is valuable to track and can ultimately be used to analyze program success or failure, and individual employee health improvements or declines. The REDCap program has the capability to send and receive surveys and track specific employee data collected by coaches and advocates for future analysis.
Meetings were held with the wellness department to identify specific needs for information they desired to capture and analyze. Survey necessity identified as demographics, well-being/interest, nutrition class, and stress class. Assistance received from the institution REDCap expert for guidance and build out. The well-being/interest survey incorporated the SF-12(short form 12), with additional questions related to burnout and workplace culture and one question related to chronic illnesses and barriers to participation.
Successful development of intrinsic data system utilizing REDCap program, including initial and follow up survey’s along with the timeframes for being sent, and Training manual compiled which included departmental algorithms and step-b-step instructions for REDcap data input and analysis. Presentation of the total project and manual was provided to the internal wellness program employees. Go live of the program was postponed in part due to COVID-19 and change in laboratory testing utilization.
The primary goal surrounding this quality improvement project was to improve a system and how it operates while providing valuable feedback as APRNs. Pairing internal wellness programs with a robust database such as REDCap, initiating protocols, and education regarding the use of data-driven approaches to program evaluation has the added benefits of providing information on success and failures and a potential overall reduction in both employee and employer healthcare costs. The REDCap program's use allows for data analysis to occur using SPSS Statistical Software for statistical data analysis and identify significance related to programs offered by the internal employee wellness department. A significant passion surrounding this project would have been to identify nursing units experiencing high annual turnover based on the statistical analysis obtained through REDCap on employee health and how it correlates to burnout.
The COVID-19 pandemic required an emergent transition to telemedicine and away from traditional in-office visits with little preparation. In 2020, telemedicine use grew by over 150% compared to pre-pandemic levels (Koonin et al., 2020). Rapid implementation affected metrics commonly assessed with standard practice (in-person visits), including patient satisfaction, safety, and health care costs. An understanding of this impact and an exploration of telemedicine can improve future use.
A descriptive study was conducted to evaluate telemedicine compared to in-office visits at an ambulatory clinic. A comprehensive literature review and synthesis were completed for emerging telemedicine research. TAM and RE-AIM conceptual models were used. Organizational metrics measuring telemedicine and in-office visit volumes throughout the pandemic were compared. Patient satisfaction/experience, patient safety, and patient and departmental costs were also compared through organizational data. The five RE-AIM dimensions (Reach, Effectiveness, Acceptance, Implementation, and Maintenance) were applied throughout the project. An interview with a national telemedicine expert was conducted to inform the project. Recommendations for telemedicine visits were developed.
Advanced practice providers in the clinic conducted nearly 18,000 telemedicine visits over the last two and a half years. At the height of the pandemic, telemedicine averaged between 98-100%. Use rates have declined as conditions have improved with COVID-19 but currently trending at approximately 20% of the total clinic volume, consistent with national averages. Patient satisfaction scores were slightly higher for in-office visits. Reported telemedicine-related safety incidents/occurrences were null. Telemedicine-related costs were not increased for patients. Indirect cost-savings in travel, fuel time, and reduced missed work time were realized. Departmental costs were not significantly impacted by telemedicine, but federal guidelines affected telemedicine reimbursement in certain circumstances.
The unprecedented telemedicine resurgence during the COVID-19 pandemic demonstrated a safe, effective, and satisfying alternative for patients. Future telemedicine can address health equity through flexible access. Telemedicine expansion in telepsychiatry has already been extremely transformative. Additional policy, training, and research are needed for optimal clinical and patient use. Close monitoring of federal and state policy is necessary to ensure compliance with changing regulations.
The lack of participation in health policy and nursing organizations through the nursing profession has far-reaching impacts. Nurses make up a large portion of the healthcare industry, yet nurses are not present at the table when decisions are made about the profession and the healthcare mandates regarding patient care. The overall goal of this project is to understand nursing policy awareness and its barriers, educate nurses on ways to find and inform policy, promote association involvement to elevate the nursing profession, and promote patient and nursing safety through advocacy.
A qualitative survey was sent to the University of South Alabama's well-connected Faculty and Master of Science and Doctorate Nursing program students. The Qualtrics survey system allowed for data collection. A qualitative review for themes was used for processing qualitative data. The project's authors intended goal was to use this data to create modules around the thematic issues to promote topic awareness, health policy participation, and associational nursing involvement.
The initial survey was completed by 71 participants. The participant demographic revealed a diverse population that lived in 12 different states across the United States. A majority of the participants are involved in organizations, but 10% did not have memberships in organizations. Their interests in joining were largely the same, and they valued membership for networking and educational purposes. Surveyed participants revealed a wide range of issues that they feel are valuable. These themes included: Pay, Scope of practice/Autonomy, Burnout/stress, violence/prosecution, staffing issues, travel nursing, equality in pay/diversity/racism/inclusion, education, and access to care for patients.
One of the goals of this project was to assess nursing involvement. The project aimed to identify important issues of nurses working and studying in the field, leading to the initial phase of identifying themes that will be used for future learning opportunities. In the future, early buy-in and the assurance of continued buy-in will be essential in creating a successful and sustainable quality improvement project. This author hopes to continue building and creating a positive promotion of nursing associational involvement and advocate for current topics that are important to nurses working in the profession. Further study of how barriers impact nursing involvement is essential in helping to promote not only the profession but how the quality of patient care is tied to nursing political and associational involvement.
To implement an aromatherapy program to enhance the patient experience by providing a therapeutic environment while complying with Joint Commission standards at Atrium Health Wake Forest Baptist.
The Iowa Model Revised: Evidence-Based Practice to Promote Excellence in Health Care served as a guide in identifying an opportunity for improvement, assembling a taskforce, conducting a literature review, determining the needed practice changes and a timeline for each task, and integrating the program into practice. On June 1, 2022, an aromatherapy program was implemented at Atrium Health Wake Forest Baptist. Pre-implementation electronic surveys were sent to registered nurses that measured their knowledge, beliefs, experience, and feasibility of using aromatherapy on their nursing unit. Demographic data were also collected.
Of approximately 4,000 RNs at Atrium Health Wake Forest Baptist, 636 completed the survey. 9.6% of respondents were advanced practice providers, 3.2% were assistant nurse managers, 5.7% were clinical educators, 11.2% were nurse managers, and 70.3% were staff nurses. The most interest in aromatherapy was found in medsurg nursing units (23.6%), followed by the intensive care units (16.9%), operating room (16.2%), emergency department (5.2%), post-anesthesia care units (4.5%), and behavioral health (2.4%). 68.4% of participants would like to offer essential oil recommendations or therapies to their patients; 23.4% neither agreed nor disagreed. The data showed an interest in an aromatherapy program.
An aromatherapy program will improve the patient experience and allow nurses to work within their scope of practice while improving patient outcomes by providing a therapeutic environment. The ability for nurses to work in their scope of practice can lead to greater job satisfaction as they will feel pride and a sense of accomplishment. The Joint Commission requirements will be met by offering non-pharmacological modalities to patients. Patient satisfaction and overall health will increase, and patient costs for prescription medications will decrease. Measuring the use of aromatherapy and patient satisfaction are essential in the future to determine the program's success.
On-the-job training has the potential to fill gaps in nursing knowledge and improve nursing awareness of fundamentals, as well as nuances of caring for specialty populations, such as obstetric patients. This project created a professional development program for nurses in an obstetric post-anesthesia care unit (PACU) in a newly-opened Birth Center, as well as an orientation course for new hires to the unit.
Input was sought from multiple stakeholders, including the obstetric anesthesia department, to formulate the most effective and applicable course curriculum. The impact was then evaluated using surveys sent to recent orientees and attendees of the programs. The surveys utilized a retrospective pre-test/post-test design and sought feedback for ways to make the program better in future iterations.
Participants reported substantial gains in understanding of the relevant topics following the intervention and expressed a collective desire for more such training.
These future endeavors will create an institution-supported, sustainable staff development effort that utilizes online learning modules and simulations, as well as in-person classes, to increase the nursing staff’s abilities and thereby improve patient care.
The purpose of this project was to evaluate the effectiveness of spaced repetition learning to improve rhythm interpretation and documentation of rhythm strips in first year critical care nurses.
This was an evidence-based practice (EBP) project utilizing the Iowa Model of evidence-based practice, Kristen Swanson’s Theory of Caring and the learning theory of constructivism. Participants were new graduate nurses in critical care units of a large multiple hospital academic medical center. Three spaced education modules were the interventions developed sequential completion in a Learning Management System (LMS) on a biweekly basis after participants had completed the Rhythm Introduction Basics course. Smartsheets© automations was utilized to send notifications and reminders to participants and unit leadership regarding project inclusion and module completion. All participants received a post knowledge assessment with their results compared to the results of rhythm revalidation outcomes for established staff on the unit. Rhythm strip documentation audits were to be collected as part of normal expectations of a champion role in the units.
Rhythm identification accuracy scores for established staff were significantly higher than program participants confirming previous studies that demonstrate rhythm interpretation abilities decrease over time. There was not a statistically significant association with the use of spaced interval education and perception of rhythm documentation by participants however, there was an 8% increase in the percent of participants that agreed/strongly agreed they routinely observed their preceptors/colleagues documenting strips and a 12% increase in the percent of participants that agreed/strongly agreed they routinely document rhythm strips. Two-thirds or more of participants agreed the modules enabled them to use rhythm interpretation skills, reinforced rhythm strip documentation and the modules were a valuable learning experience. Audits of rhythm strip documentation were not consistently obtained by the Cardiac Monitor champions and were unable to be evaluated. Each micro module took less than 10 minutes per participant to complete resulting in an average of five dollars per new graduate nurse to complete.
The low accuracy of rhythm identification by participants is concerning yet reflective of many studies. Project participants had less experience than established staff. During the project, uncontrollable variables were many: COVID-19 surges, staffing strains and an organizational monitoring re-education initiative. Further examination of the rhythm strip documentation gaps revealed that 97% of staff demonstrated accurate understanding of rhythm strip documentation expectations. In discussion staff verbalized that easier access to methods of documentation would improve strip documentation. Low rhythm interpretation accuracy, positive staff reception, as well as the minimal time and costs involved in spaced repetition learning make this a viable option for reinforcing rhythm interpretation skills and unit leadership is in support of including this in developmental plans for new staff. Improving rhythm identification and documentation is an important part of patient assessment of the monitored patient providing critical data that is not easy to discern without measuring parameters. It may be interesting to explore if staff were to measure and document rhythm strips according to recommendations and policy, to what extent their rhythm identification skills would improve.
The purpose of this DNP project was to design an evidence-based clinical ladder for the Certified Registered Nurse Anesthetists (CRNAs) in an academic integrated healthcare system in the southeastern United States. Clinical ladders are professional development and advancement programs to reward and recognize excellence in clinical practice. Clinical ladders can improve work engagement, job satisfaction, and retention. Currently, CRNAs in the local system are experiencing staffing shortages and exhaustion due to the COVID-19 pandemic. There is added strain on the CRNA leaders to recruit and retain valuable employees. The local system lacks a formal professional development program for CRNAs.
The design of the clinical ladder is based on current literature, a survey of CRNAs in the system to seek feedback on professional activities or components to be included in a CRNA clinical ladder, and a guideline from a CRNA clinical ladder at an enterprise partner organization. Common themes throughout the literature include the benefits of clinical ladders, the design of clinical ladders, and the importance of leadership support and mentorship in professional development programs. Evidence-based practice (EBP) is incorporated into the design of this clinical ladder. Healthcare quality and safety are improved by incorporating EBP into professional development programs. Organization and leadership support are vital to the success of a clinical ladder program. The project leader formally met with the Chief CRNAs to share key points about the benefits of clinical ladders, emphasizing employee engagement, job satisfaction, and a clinical ladder as an innovative strategy for retaining valuable employees.
An evidence-based clinical ladder for CRNAs in an academic integrated healthcare system was designed and is ready for implementation. The project leader recommends pre-implementation and annual assessments of employee engagement, job satisfaction, and retention. A detailed Guideline for the CRNA Clinical Ladder and an Application Packet for Advancement to CRNA II status were developed.
Clinical ladders have been studied widely in nursing, but there has been a gap in the literature concerning clinical ladder programs for CRNAs and other Advanced Practice Registered Nurses (APRNs). This project is a step forward in the exploration of clinical ladders and their benefits for CRNAs. CRNAs will be empowered in their own professional development and advancement while engaging in a clinical ladder. The CRNAs who participate in the clinical ladder will engage in departmental and organizational activities, leading to improved interprofessional collaboration and job satisfaction. The design of this CRNA Clinical Ladder can serve as a guideline for organizations seeking a CRNA professional development program. This clinical ladder design can be generalized to all APRNs and Advanced Practice Providers (APPs) with modifications to fit individual organizational systems and cultures.
Burnout is a three-component occupational syndrome characterized by emotional exhaustion, cynicism, and a low sense of personal accomplishment that results from prolonged work-related stress (Maslach & Leiter, 2016). As CRNAs and SRNAs experience high levels of work-related stress, burnout is now a significant problem in these populations (Horvath & Grass, 2020; Mahoney et al., 2020). This doctoral project sought to reduce the burden of burnout in CRNAs and SRNAs by implementing a learning management system (LMS) to teach brief burnout interventions.
Feasibility, acceptability, and effectiveness of the following three brief burnout interventions will be determined: Yoga stretching, breathing techniques, and mindfulness. Feasibility will be measured from the extensive literature review of each technique. Acceptability will be measured by descriptive statistical analysis of a REDCap® survey of the convenience sample population of CRNAs and SRNAs at Winchester Anesthesiologists Inc. and Wake Forest School of Medicine; Qualitative REDCap® survey data will also be examined for themes. Effectiveness of the LMS will be determined through pre-post test instruments embedded into the LMS.
The literature review yielded 17 studies supporting the feasibility of yoga stretching, breathing techniques, and mindfulness as brief, effective interventions for reducing burnout. Acceptability of the brief interventions was measured as moderately favorable. A two-questions Maslach Burnout Inventory score indicated an 84% incidence of burnout in the sampled populations while subjective assessment of burnout indicated a 34% incidence of burnout. Visual and kinesthetic learners dominated the sample. The major theme within the qualitative data centered around issues involving time at work. The effectiveness was not able to be determined as the LMS was not launched during the timeframe of this project.
There is support for the feasibility and acceptability of a LMS instructing in the brief burnout interventions of yoga stretching, breathing techniques, and mindfulness. Further work will determine the effectiveness of such an intervention in the population of CRNAs and SRNAs. Visual and kinesthetic-based education in burnout and it’s symptoms is central to any holistic approach to burnout reduction, and the lack of such education may help explain the gap between objective and subjective assessments of burnout. As in other fields of Nursing and Medicine, burnout remains a devastating threat to providers, patients, and healthcare organizations. Future projects should seek to optimize the relationship between time at work and this burnout threat.
Ultrasound guided regional anesthesia (UGRA) has numerous benefits for patients when used appropriately, such as reduced postoperative pain and postoperative opioid use, reduced hospital length of stay, reduced postoperative respiratory complications, and improved patient satisfaction. Despite the fact that UGRA is an essential skill that all anesthesia providers must possess, the traditional method for teaching these skills leaves many trainees lacking the ability to perform UGRA confidently and competently upon graduation. In order to create more graduate certified registered nurse anesthetists (CRNAs) who are proficient in the skills of UGRA, a simulation based training program was developed and implemented to address this training and educational practice gap.
A simulation based training program for UGRA was developed and implemented in four phases. Phase 1 involved delivering a needs assessment to current student registered nurse anesthetists (SRNAs) to gather baseline data and guide curriculum development. Phase 2 involved delivering online modules with lectures and readings aimed at improving participants’ anatomical knowledge. Phase 3 involved in-person workshops aimed at developing participants’ image acquisition and needling technique skills. Phase 4 involved data analysis. Three workshops were created to divide UGRA procedures into three anatomical categories. These three workshops were: “Approaches to the Brachial Plexus”, “Lower Extremity Blocks”, and “Abdominal and Thoracic Wall Blocks”. The four outcome measures evaluated during this project were: anatomical knowledge; image acquisition skills; needling technique; and participant confidence assessed with the Confidence Scale (C-Scale).
Posttest scores related to anatomical knowledge went up dramatically for each of the three UGRA workshops. The “Approaches to the Brachial Plexus” workshop had a mean pretest score of 0.60 with a standard deviation of 0.13 (n=10) and a posttest mean of 0.75 with a standard deviation of 0.09 (n=5). The “Lower Extremity Blocks” workshop had a mean pretest score of 0.60 with a standard deviation of 0.11 (n=7) and a posttest mean of 0.87 with a standard deviation of 0.08 (n=6). The “Abdominal and Thoracic Wall Blocks” workshop had a mean pretest score of 0.41 with a standard deviation of 0.17 (n=2) and a posttest mean of 0.80 without a calculated standard deviation due to only one participant taking this examination (n=1). All image acquisition (IA) skills were found to improve with positive percent change values from pre to post workshop assessment checklist (AC) scores in each of the three workshops. Needling technique (NT) was found to have a positive percent change for each of the three workshops. Additionally, all C-Scale scores increased for each workshop throughout this entire project.
Findings from this project suggested that implementation of a simulation-based curriculum for teaching UGRA created improvements in anatomical knowledge, trainee confidence, image acquisition skills, and needling technique. These simulation-based workshops are a necessary supplement to traditional methods for teaching UGRA in nurse anesthesia programs that involved didactic lectures followed by clinical rotations. Despite a limited sample size from a single training program, the benefits of simulation-training for UGRA were dramatic. Further research would be needed with larger samples of SRNAs and CRNAs to truly determine the magnitude and generalizability of the benefits for adding simulation-based training curriculums for UGRA.
