• A Mixed Methods Study Of The Symptom Experience Following Endovascular Treatment For Lower Extremity Peripheral Arterial Disease

      Gramling, Serena Greenhaw
      Peripheral arterial disease (PAD) is one of the most understudied and undertreated diseases affecting three to ten percent of the general population. Patients with lower extremity PAD must manage multiple symptoms including pain in the hips, thighs, and calves during rest and physical activity. However, evidence is limited about patients' experience, especially following treatment. The purpose of this mixed methods study was to explore the symptom experience of individuals with peripheral arterial disease following endovascular treatment including perceptions of treatment benefit and concerns. Using a convergent parallel mixed methods study design, 65 participants (mean age = 56.9 years, 73.8% female, 95.4% white) participated in a web-based survey. Quantitative data were collected utilizing six questionnaires: a researcher developed demographic and clinical history questionnaire, the Patient Health Questionnaire 9 (PHQ-9), the Walking Impairment Questionnaire (WIQ), the San Diego Claudication Questionnaire (SDCQ), the VascuQOL-25, and the Peripheral Artery Questionnaire (PAQ). Qualitative data were collected using open-ended questions within the web-based survey. The most commonly reported symptom by participants was pain in both legs while walking. Greater age was significantly associated with less symptoms, less pain, being more active, and being more social. Men reported better physical functioning, walking ability, and overall quality of life compared to women. Participants with PHQ-9 scores indicative of depression reported greater difficulty controlling their symptoms. No significant relationships were found between having a diagnosis of diabetes and symptom experience or quality of life. Qualitative data analysis revealed four themes. One theme concerning benefits of treatment was described as continuum of benefit. The three themes related to concerns with treatment were described as outcome, process, and coping. Qualitative data supported the quantitative results related to symptom experience, gender, and depression. Qualitative data diverged with the quantitative results related to age as within the qualitative data younger participants reported more positive treatment outcomes than older participants. The findings from this study have the potential to provide better insight into the experiences of individuals with PAD and guide interventions for improved care and outcomes.
    • Caregivers' Perceptions Of Transition Of A Family Member From Acute Care To Hospice Inpatient Care / By Sandra Elaine Monk.

      Monk, Sandra Elaine
      Sandra Elaine Monk Caregivers' perceptions of transition of a family member from acute care to inpatient hospice care Under the direction of Laura P. Kimble, PhD, RN, FAAN Transition at end of life has the potential for fragmenting the delivery of health services and becoming a burden for patients and families according to the Institute of Medicine (2014). In spite of the family caregiver’s essential involvement in caring for a family member at end of life, less recognition has been placed on the emotional needs of the family caregiver (Harrington, Mitchell, Jones, Swettenham, & Currow, 2012). The purpose of this study was to explore the lived experience of caregivers during the transition of a family member from an acute care to hospice inpatient care. The study addressed the following research questions: “What are the lived experiences of caregivers during the transition of a family member from an acute care setting to a hospice inpatient setting?�? and, “What experience mattered most to family caregivers during this transition?�? Subjective experiences of the caregivers were described by the researcher with a focus on transition according to Meleis’ (2010) theory of transitions and a conceptualization of patient-and family-centered care in hospice and palliative nursing. Giorgi’s (2009) procedural method of descriptive phenomenology was utilized to analyze data and to develop a structure of the experiences of caregivers in the transition of a family member from acute care to hospice inpatient care. Study participants included 13 caregivers with a mean age of 55.2 (S.D. 12.6) years. Of those participating in the study, 77% were female. Participants completed qualitative, semi-structured interviews in a hospice inpatient setting. Seven interrelated constituent parts evolved from descriptive phenomenological data analysis to form the structure of a description of the phenomenon. Constituent parts and variations of the structure for caregivers’ experiences during transition of their family member at end of life included: Context, Caregiving, Chaos, Communication, Candor, Communication, Comfort, and Confidence. Findings of the study suggested caregivers gained confidence when shared goals for patient comfort were met through communication and assistance with navigation. Caregiver assessment and anticipatory planning earlier in the process, informed by caregivers’ experiences for evidence-based interventions, could help ease burden, and support a partnership during transition from acute care to hospice inpatient care.
    • Emergence Of Informal Clinical Leadership Among Bedside Nurses In The Acute Care Clinical Setting: A Mixed Methods Study

      Rogers, Darlene
      Quality and safety initiatives direct all nurses to lead practice change. Existing nurse leadership research predominantly focuses on formal nursing leaders and overlooks a critical resource pool: informal leaders at the point of care. This study explored influences on the emergence of informal clinical leadership among bedside nurses in the acute care hospital setting. Nurse personal attributes (demographic characteristics, professional experience, and psychological capital) and situational context in the acute care workplace setting were examined as predictors of clinical leadership behavior. The study used a convergent parallel mixed methods design with an exploratory correlational quantitative strand and a descriptive qualitative strand. A convenience sample of 134 nurses (mean age = 35.62 years, 94% female, 81% white, 85% BSN-prepared) were recruited from eight acute care hospitals in three different geographic areas in the United States. The data collection instrument included a researcher-developed personal attributes questionnaire, the Clinical Leadership Behaviors Questionnaire (CLB-Q), the Psychological Capital Questionnaire 12-Item (PCQ-12), and three open-ended questions. Data collection occurred through an online survey. The findings supported nurses are interconnected in practice, and informal clinical leaders can emerge from this network. Nurses described preferring to seek clinical guidance from peers with a positive attitude about providing help or work in general or from experienced peers. Psychological capital was the only significant predictor in the regression model accounting for 42% of the variance in clinical leadership behavior scores. Whereas, the professional experience variables were not supported statistically as predictors of clinical leadership behavior. Additional research is needed to further explore the complexities of the interpersonal relationships among nurses and the resulting influences on informal leadership at the point of care. However, given the strength of the association between psychological capital and informal clinical leadership and the other positive nursing practice outcomes associated with psychological capital, nurse professional development in the clinical setting, in academia, or informally among nurse peers should afford opportunities for nurses to increase their psychological capital. Given the emphasis on positive attitude, nurses with specialized knowledge and skills should be afforded opportunities to develop interpersonal skills to promote their emergence as informal clinical leaders.
    • Experiences Of Registered Nurses Who Encounter Incivility During The Clinical Education Of Nursing Students Within Hospital Settings: A Phenomenological Analysis

      French, Kimberly
      ABSTRACT KIMBERLY M. FRENCH EXPERIENCES OF REGISTERED NURSES WHO ENCOUNTER INCIVILITY DURING THE CLINICAL EDUCATION OF NURSING STUDENTS WITHIN HOSPITAL SETTINGS: A PHENOMENOLOGICAL ANALYSIS Under the direction of SUSAN SWEAT GUNBY, PhD, RN Incivility is disrespectful and unprofessional behavior consisting of negative attitudes with verbal and physical characteristics which negatively affects registered nurses' work environments and nursing students' clinical education. These behaviors are associated with increased healthcare costs (Joint Commission, 2008), negative patient outcomes, and poor patient satisfaction (Joint Commission, 2008; Randle, 2003). Additionally, incivility occurring during the clinical education of nursing students is a problem that can inhibit learning and communication (Institute of Medicine, 2010; Joint Commission, 2008). Research indicates these behaviors persist on nursing units, creating a challenge for stakeholders in both nursing education and patient care (Academy of Medical-Surgical Nurses, n.d.; Hunt & Marini, 2012; Lucian Leape Institute, 2013). Therefore, this descriptive qualitative study was conducted to explore registered nurses' experiences with incivility during the clinical education of nursing students within hospital settings in an effort to identify sources and contributing factors of incivility as well as effective strategies to counter incivility in these settings. A purposive sample of thirteen registered nurses, including staff nurses and clinical faculty, participated in mostly face-to-face, semi-structured interviews. With the support of an integrated conceptual framework utilizing Clark, Olender, Cardoni, and Kenski's (2011) conceptual model for fostering civility in nursing education (adapted for nursing practice) and the reflection-in-action theory by Donald Schön (1983), Giorgi's (1985) descriptive phenomenological method for qualitative research was used to analyze the transcribed verbatim narratives. Analysis of the data revealed three themes and sixteen subthemes. Themes included influences on uncivil actions, experiencing and responding to incivility, and aftermath of incivility. Stress was an underlying factor within all of the registered nurses' encounters with incivility. Most participants were surprised by the incivility they encountered. Some participants were tearful while others became anxious while describing their experiences. Findings revealed a need for educating registered nurses, nursing students, and administrators about incivility. Through participants' reflections on their encounters, strategies for addressing incivility were revealed. Recommendations for further study include examining gender differences regarding perceptions of uncivil and civil behaviors, comparing perpetration of incivility between experienced and less experienced nursing students, and the influence of different levels of nursing education on uncivil actions.
    • Exploring The Invisible Work Of Nursing: A Case Study Of Simulated Increases In Intensity Of Care On Nurses' Cognitive Load, Clinical Judgment, Stress, And Errors

      Vasel, Laura Anne
      Nurses have never before had so much data at the bedside, nor the complex patients and practice environments found in acute care settings today. Processing large amounts of information from multiple sources may result in cognitive overload which may negatively impact patient outcomes. To meet the challenge of improving quality of care, a conceptual model was created to guide research exploring the associations between the cognitive work of nursing, nursing care, and the complex context of the hospital setting. The purpose of this research was to explore the invisible cognitive work of nursing by examining relationships between cognitive load, nursing surveillance and clinical judgment, contextual complexities, and their potential impact on patient care outcomes. Research question 1 examined how simulated increases in intensity of care influenced nurses’ cognitive load, clinical judgment, perceived stress, and errors. Research question 2 asked how nurses describe the cognitive work of nursing while engaging in a simulated patient care scenario. A novel multiple-case study design with multiple sources of evidence was used. Eligible cases included three new to practice baccalaureate-prepared RNs employed in acute care medical-surgical settings. A patient care simulation with increasing intensity of care was developed in collaboration with a simulation center in a large healthcare system in the Southeastern US. Time series analysis and pattern matching compared outcomes of cognitive load, performance, and stress using the NASA-TLX instrument at seven time points. Errors in nursing care were counted and clinical judgment using the Lasater Clinical Judgment Rubric (LCJR) was assessed. Explanation building used data from participant interviews during simulation debriefing. Cross-case synthesis compared findings from the other analytic strategies to determine similarities across cases. Findings suggest as the intensity of care in the simulation increased, cognitive load and stress increased. Performance findings were equivocal; in each case errors or omissions of care were noted, but LCJR scores ranged from 37-42 indicating exemplary clinical judgement. Convergence of findings supported the conceptual model of the invisible work of nursing and identified an additional component, social capital, as a mechanism to support clinical judgement of new to practice RNs.
    • Exploring Voluntary Turnover of Nurse Practitioners in the United States

      Strobehn, Patricia K; Georgia Baptist College of Nursing
      Access to care has been hindered by turnover in the NP workforce. The purpose was to describe the voluntary turnover behaviors of NPs to inform a contemporary model of NP voluntary turnover. A cross-sectional, descriptive, and exploratory secondary analysis of participants who self-identified as nurses with active certification, licensure, or other legal recognition to practice as an NP from a state board of nursing in the United States from the 2018 National Sample Survey of Registered Nurses (NSSRN) was used. Participants were excluded if they didn’t provide patient care or indicated involuntary reasons for leaving. Descriptive statistics were used to analyze four NP voluntary turnover groups informed by Herzberg’s Dual-Factor Theory of Job Satisfaction (i.e., dynamic leavers, static leavers, dynamic stayers, and static stayers). Two-step cluster analyses were used to distinguish subgroups of NP dynamic leavers reporting similar NP differences, reasons for leaving, working conditions, and training topic needs. Dynamic leavers (those who changed jobs but stayed in nursing) reported the highest percentages (35.2%) of job dissatisfaction. The study culminated in two cross-validated models best distinguishing dynamic leavers (i.e., Model 1: Burnout and Model 2: Job Satisfaction). The findings highlight job satisfaction, lack of good management, burnout, and other working conditions as contributors of NP voluntary turnover for dynamic leavers and support a wide variety of literature emphasizing job satisfaction as a predictor of NP turnover intention. Both models demonstrated strong validity evidence. The population estimates from the 2018 NSSRN parent study revealed findings related to race should be cautiously considered. Further refinement of Model 1: Burnout and Model 2: Job Satisfaction could maximize retention strategies, promote workforce development, shape healthcare policy, and project the future supply and distribution of NPs in the U.S. health care system. Future NP training initiatives should focus on working in underserved communities, social determinants of health, and evidence-based care. Accurate workforce projections related to scope of practice and the estimated costs of NP turnover would be beneficial. Instrumentation measuring burnout, stress, organizational climate, and satisfaction should be validated in the NP population. This study should be replicated using accurate race and ethnicity variables.
    • Factors Associated with Transition to Student-Centered Pedagogy in Nursing Educators: A Cross-Sectional, Correlational Study

      Slocumb, Rhonda Harrison; Georgia Baptist College of Nursing
      Student-centered pedagogy (SCP) has positively affected student performance, but transition to SCP in nursing education has not been fully progressed. To facilitate transition to SCP, factors affecting transition to SCP should be examined from nursing educators’ perspectives because of their important roles in the transition. Multidimensional factors that may be associated with transition to SCP have not been frequently examined from educators’ perspectives. Therefore, the purpose of this study was to examine factors associated with transition to SCP in the total sample and in the subgroups based on age, program, and teaching experience. In this cross-sectional, correlational study, a convenience sample of 108 nursing educators were enrolled using social media, online forum, and emails with study information. Data on demographic characteristics, earned degree, knowledge of SCP, belief in effectiveness of SCP, support, situation, strategy, and transition to SCP were collected through an online survey. Multiple regression analyses with the Enter method were used to address the study purpose. The majority of the sample were > 50 years old (52.8%) and female (96.3%). The level of transition to SCP was low (2.76 out of 4), and the levels of knowledge of SCP and belief in effectiveness of SCP were moderate (30.27 and 31.42 out of 40, respectively). Knowledge of SCP was consistently, significantly associated with transition to SCP in the total sample (p < .001) and in all the subgroups: age ≤ 50 years old (p = .001), age > 50 years old (p = .007), teaching associate program (p < .001), teaching baccalaureate and graduate programs (p = .012), teaching experience ≤ 10 years (p = 001), and teaching experience > 10 years (p = .030). In addition, belief in effectiveness of SCP (p = .017) and degree earned (p = .046) were significantly associated with transition to SCP only in the age > 50 years group. Thus, interventions need to be developed and delivered to nursing educators to increase their knowledge of SCP and belief in effectiveness of SCP, and, in turn, to facilitate transition to SCP, especially for nursing educators > 50 years old with higher earned degree.