Nursing School Theses, Dissertations, and Doctoral Papers
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Item Nurse to Family Communication in Intensive Care Units(2024-05) Dees, Mandy Lynn; Carpenter, Janet; Levoy, Kristin; Longtin, Krista; Reising, Deanna; Wocial, LuciaNurse to family communication is a crucial aspect of high-quality care delivery in adult intensive care units (ICU). Adult ICU nurses hold a unique position to engage in meaningful communication with families, often being the most accessible healthcare team members to family. However, these nurses frequently express a sense of ineptitude in their nurse to family communication skills. Simultaneously, families often find themselves unprepared for these adult ICU interactions yet are regularly tasked with the responsibility of surrogate decision-making when patients are incapacitated. Despite the successful utilization of the COMFORT (Connect, Options, Making meaning, Family caregivers, Openings, Relating, and Team) communication intervention in other settings, its implementation in the adult ICU has not been realized. Exploring the perspectives of adult nurses and nurse leaders on the COMFORT intervention topics could enhance the success of its implementation and sustainability in clinical practice. The overall goal of this three-paper dissertation was to advance scientific knowledge about nurse to family communication in the adult ICU setting. An integrative review was conducted to systematically assess available research evidence on enhancing communication between adult ICU patients/families and nurses. Using qualitative focus group approach, the aims of the next two studies were to gather participants’ perspectives of the practicability, appeal, and relevance of each COMFORT communication intervention topics and strategies for its implementation among adult ICU nurse leaders (second paper) and ICU nurses (third paper). Results of these studies indicate the importance of nurse to family communication in adult ICU environments and nurse leaders’ and nurses’ enthusiasm for the implementation of the COMFORT intervention in the ICU setting. Recommendations emerging from the focus group interviews include providing adult ICU nurses dedicated time to complete training during work hours, allowing early adopters to use the COMFORT app before expanding it to the entire unit staff nurse population, making the app accessible on unit computers, providing training suitable for nurses at all experience levels (from early career to seasoned staff), adopting a phased approach to implementation, and offering education on the COMFORT topics in quick, digestible learning tools suitable for a fast-paced nursing unit.Item Career Decision-Making in Diverse Nursing Students: Choosing a Career in Nursing(2024-04) McCord, Geoffrey Aaron; Otte, Julie L.; Ellis, Rebecca; Carpenter, Janet S.; Schall, Carly E.The nursing profession lacks diversity that reflects the population it serves. The population of LPN/LVN and ADN students are known to be more diverse than BSN students. Little is known about the differences between the students in the three levels of nursing programs (LPN/LVN, ADN, BSN), including reasons for choosing nursing, and barriers and facilitators. The McCord Nursing Career and Educational Decision Pathway Conceptual Framework guided this study. A quantitative survey was conducted of current nursing students in the US. The study asked demographic information as well as motivating factors, barriers, and facilitators for choosing nursing and their program type (LPN/LVN, ADN, BSN). Responses from 741 nursing students in LPN/LVN, ADN, and BSN programs from 26 states. The study found significant differences between the students in the three educational pathways. There are significant racial and financial differences and differences in reasons for choosing nursing, educational background, commitments outside of school, and barriers to goal achievement. LPN/LVN students were more likely to be Black and ADN students were more likely to be Hispanic. There was greater racial diversity in the LPN/LVN and ADN groups. LPN/LVN students are more likely to identify nursing as their first career choice and most want to be an RN. LPN/LVN and ADN students were more worried than BSN students about their family commitments, financial obligations, and their ability to succeed in nursing school. Some of the lack of diversity in BSN programs reflects the challenges that racial minorities face in goal achievement. Identified barriers include outside financial commitments, the cost vii of nursing programs, and the length of time of the programs. The goal to increase diversity in nursing should consider the entire population of those who want to become nurses.Item A Case Study Design Examining New Graduate Registered Nurse Well-Being(2024-01) Zidek, Stephanie Marie; Wonder, Amy Hagedorn; Opsahl, Angela; Reising, Deanna; Rybas, NataliaIn the face of multifarious challenges, including individual stressors, nursing workforce fluctuations, and lingering effects of the COVID-19 pandemic, the well-being of new graduate registered nurses (NGRNs) during their initial months of practice is a pivotal concern. This study, employing a qualitative case study design, investigates the wellbeing of NGRNs during their first three months, with the dual objectives of understanding their state of well-being and identifying its facilitators and inhibitors. Data collection involved reflective journaling and structured focus groups with 12 NGRNs from four neighboring hospitals within a large, not-for-profit system over three months. Braun and Clarke’s thematic analysis revealed three critical themes elucidating NGRNs’ complex experiences: (1) emotional and physical well-being, (2) interpersonal relations and support, and (3) professional development and work environment. These insights underscore the diverse challenges the NGRN participants experienced during the transition to practice period, as well as identify facilitators (e.g., preceptor impact, peer support, patient interaction, self-care, supportive services) and inhibitors (e.g., disappointment, fatigue, schedule constraints, shiftwork, overwhelmed feelings, stress, and bullying). Derived from participant insights, the findings advocate for nuanced interventions across various nursing disciplines and settings. Recommendations include integrating emotional resilience curricula in nursing schools, promoting adaptive strategies and supportive policies by nursing boards, developing criteria for program support effectiveness by accreditation agencies, and adopting flexible scheduling and supportive environment policies by health organizations. These strategies address key findings such as disappointment, workplace bullying, and shiftwork complications, bridging the expectation-reality gap for NGRNs. This study contributes to the discourse on NGRNs’ well-being, presenting a structured approach for enhanced support and policy adaptations, facilitating an improved transition into the nursing profession. The comprehensive exploration and thematic insights contribute to the understanding and addressing the well-being of NGRNs, providing a roadmap for enhanced support and policy implementation, ultimately aiming to facilitate a successful transition into the nursing profession.Item A Simulation Pre-Brief Scaffold to Support Clinical Judgment and Independence in Clinical Judgment Decision Making(2024-01) McIntire, Emily S.; Friesth, Barbara Manz; Hendricks, Susan; Reising, Deanna; Danish, JoshuaIt is essential that nurses independently assume patient care, yet new nurses lack necessary clinical judgment skills. The purpose of this study was to examine a simulation pre-brief scaffold to support nursing students’ clinical judgment development and clinical judgment independence. The pre-brief experiential learning scaffold for clinical judgment independence (PELS-CJI) framework informed simulation pre-brief in this experimental study. A convenience sample included traditional and accelerated Bachelor of Science in nursing students in their senior year. Participants were randomly assigned to complete a simulation pre-brief with or without the Interactive-Video Recorded Simulation (I-VRS). Nursing student’s total clinical judgment and individual components of clinical judgment (noticing, interpreting, and responding) in simulation were measured by a single evaluator blinded to condition using the Lasater clinical judgment rubric (LCJR) (Cronbach’s alpha .932). To measure clinical judgment independence, the number of unintended conceptual cues during simulation were counted. Participants in the intervention group had higher clinical judgment scores during simulation (n = 31, M = 28.45, SD = 5.163) as compared to the control group (n = 36, M = 25.06, SD = 5.275), t(65) = -2.653, p < .01. A significant relationship for the noticing and responding subscales of clinical judgment was observed between groups, but not for the interpreting subscale. No significant difference in the number of unintended cues was found between groups. Results support that using an I-VRS in simulation pre-brief enhanced clinical judgment in simulation. The use of the I-VRS adds to the existing limited evidence related to simulation pre-brief to support clinical judgment development among undergraduate nursing students. Future research using an I-VRS during pre-brief is necessary to determine if improvement in clinical judgment is retained and transferrable to the clinical setting. Additional testing of the PELS-CJI to guide simulation pre-brief is encouraged.Item Teaching Gun Violence Prevention in Undergraduate Nursing Programs(2023-12) Holmes, Sarah Margaret; Draucker, Claire; Moorman, Meg; Halverson, Paul; Otte, Julie; Reising, DeannaGun violence is an epidemic that kills over 40,000 persons in the United States annually. Despite that gun violence is a significant public health problem, the topic is not often included in undergraduate nursing curricula. To understand this gap, the purpose of this study was to describe the teaching behaviors and perceptions of undergraduate nursing faculty related to gun violence prevention (GVP) and to explore factors that are associated with their behaviors. A survey was developed to measure faculty behaviors and perceptions. A sample of 102 nursing faculty recruited via social media communications, professional organization electronic discussion boards, and an electronic listserv completed the survey. Descriptive and inferential statistics and content analysis were used to analyze their responses. Whereas most participants were favorable to including GVP topics in curriculum, only 31 had taught about GVP in an undergraduate nursing course. Participants most frequently indicated the following topics and skills should be taught: the role of guns in unintentional injuries, suicide, and intimate partner violence; assessing for gun access; counseling about safe gun storage; and counseling about lethal means restrictions to prevent suicide. Participants indicated that key barriers to teaching about GVP included having too many other topics to teach, lack of standardized educational materials, lack of guidance from accrediting bodies, lack of faculty expertise, and the current political atmosphere. Perceived level of knowledge, level of confidence, and beliefs about teaching GVP were significantly associated with teaching GVP. The findings highlight the need for faculty development programs to increase awareness of gun violence as a public health issue and assist faculty to integrate GVP education into curricula. The findings also indicate that national nursing organizations should develop guidelines, identify competencies, and provide resources related to the inclusion of GVP content in undergraduate nursing programs.Item Instrumental Activities of Daily Living Among Patients with Heart Failure(2023-12) Algashgari, Elham Yousef; Otte, Julie Lynn; Jung, Miyeon; Jung, Miyeon; Pressler, Susan J.; Wierenga, Kelly L.; Stewart, Jesse C.Heart failure (HF) is a prevalent public health concern affecting 6.2 million Americans. HF is associated with decreased cognitive and physical functioning that may decrease patients' ability to perform instrumental activities of daily living (IADL). IADL are central to maintaining independent living, taking care of oneself, and having a satisfactory quality of life. Little is known about theory-based approaches to IADL in HF and about the facilitators and barriers to treatment fidelity of cognitive interventions, which limit the ability to identify factors amenable to intervention to improve IADL. Thus, a theoretical model was developed to identify explanatory variables influencing IADL in HF based on theoretical and empirical literature. The overall purpose of this dissertation was to establish a theoretical model for IADL and assess the treatment fidelity of supporting clinical trials. Specific aims included: (1) characterizing IADL performance in patients with HF, (2) testing the newly developed theoretical model to assess the relationship between the explanatory variables of age and gender, HF severity, depressive symptoms, physical and cognitive dysfunctions, and IADL performance; and (3) identify facilitators and barriers to treatment fidelity perceived by intervenors while delivering computerized cognitive interventions to patients with HF. The study findings provide knowledge about the level of IADL performance in HF and identify factors that could be targeted for intervention in future studies.Item Exploring Evidence-Based Practice Norms Among Bedside Nurses in Magnet-Designated Hospitals: A Q Methodology Study(2023-08) Ramsey, Rachel Anne; Wonder, Amy Hagedorn; Opsahl, Angela; Reising, Deanna; Gonzalez-Mulé, ErikEvidence-based practice (EBP) is a recognized standard of professional nursing due to its positive impact on care quality and patient outcomes. Despite ongoing efforts to maximize EBP at the point of care, current estimates indicate that only 30% of healthcare decisions are evidence-based. Individual and organizational factors are commonly identified for their influences on EBP in nursing, but group factors have been largely unexplored. Group-level factors, such as norms, are essential to investigations of phenomena that occur within multilevel organizations (i.e., hospitals) where individuals work in groups. Understanding the EBP norms that emerge among groups of nurses in direct care roles may support the goal to increase evidence-based nursing care. The purpose of this dissertation study was to explore and describe the EBP norms that exist among groups of RNs who practice at bedside within Magnet-designated hospitals. Magnet-designated hospitals are recognized for their positive EBP cultures and infrastructures that support nurses’ EBP beliefs and goals, making them an ideal context to investigate shared viewpoints about EBP. Eligible Registered Nurses (RNs) were recruited from eight units within two Magnet-designated hospitals in the Midwestern United States. Using Q methodology, the participants’ individual perspectives about EBP were collected, then correlated and interpreted to uncover the shared viewpoints, or EBP norms, that existed within and across the study sites. Multiple EBP norms were discovered within each Magnet-designated hospital: four were found at Site A (Engaged, Overextended, Skeptical, and Reliable) and three were found at Site B (Amenable, Resistant, and Discerning). Two higher-order norms were also discovered (Invested and Marginalized). Differences were observed among these norms, especially regarding nurses’ viewpoints around time for EBP, input on EBP, and trust in EBP. The findings confirm that group-level factors should be considered in the study of evidence-based nursing. They also suggest that Magnet designation alone cannot ensure a unified EBP viewpoint. Consequently, standardized approaches for enhancing EBP should be reexamined, and more holistic interventions should be considered to address the variety of complex EBP viewpoints that exist among RNs who practice at bedside in Magnet-designated hospitals.Item Peer Collaborative Clinical Decision-Making in Virtual Reality Nursing Simulation(2023-05) Ngo, Thye Peng; Reising, Deanna L.; Draucker, Claire Burke; Barnes, Roxie; Kwon, KyungbinIn nursing education, it is common for students to collaborate and make decisions as a group in simulations. One of the vital nursing competencies is students’ ability to make sound clinical judgments and decision-making in simulation. Teamwork among students in simulation significantly affects their critical thinking and clinical reasoning. However, how students collaborate and make decisions in simulation is a complex phenomenon and not well studied and understood. In addition, most existing decision-making frameworks, such as Tanner’s Clinical Judgment Model and the National Council of State Boards of Nursing’s Clinical Judgment Measurement Model, focus solely on individual decision-making. Alternatively, teamwork and collaboration frameworks, such as TeamSTEPPS®, emphasize interprofessional collaboration rather than intraprofessional or peer-to-peer collaboration. Furthermore, peer collaboration and decision-making cannot be accurately measured without a theoretical framework. Because clinical decision-making in nursing practice is a complex process that involves peer collaboration, more research is needed to explore how nursing students collaborate and make decisions in simulation. This qualitative study comprises of a hybrid concept analysis and Charmaz’s constructivist grounded theory to explore prelicensure nursing student’s peer collaborative clinical decision-making (PCCDM). The concept analysis develops a comprehensive definition of PCCDM based on theoretical and empirical data. The grounded theory develops the theoretical framework that captures the process of PCCDM, which consists of the three major domains of group cognition, behavior, and emotion. These domains undergo the peer regulatory process of awareness, communication, and regulation within the individual and collaborative space at various simulation phases. Additionally, a thematic analysis further explores group emotion in PCCDM as the domain is the least studied in nursing simulation. This study provides the framework to support healthcare and nursing simulation involving peer collaboration and decision-making.Item How Older Adult Caregivers Manage Wound Care Procedures, Resources Needed, and Public Policy Implications(2022-10) Swartzell, Kristen Leigh; Fulton, Janet S.; von Gaudecker, Jane R.; Bartlett Ellis, Rebecca J.; Huber, LesaAs healthcare increasingly shifts to home and community-based settings, informal caregiver responsibilities are increasing beyond assistance with activities of daily living to include complex care procedures previously performed by licensed caregivers in clinical settings. With an aging population, increasing numbers of older adults are assuming a caregiving role, a trend that is projected to continue into the foreseeable future. These older caregivers performing complex care procedures such as wound care. The purpose of this dissertation study was to understand how older adult caregivers manage complex wound care procedures. Aims were to 1) develop a theory for how caregivers manage; 2) identify themes related to resources needed, and 3) determine resources available through the existing Medicaid 1915(c) waivers program. Aims 1 and 2 were achieved using qualitative analysis of interviews with 18 older adult caregivers aged 65 and older who were performing wound care in the home for a care recipient. Grounded theory methods were used to develop a theoretical framework describing the process of how the participants managed caregiving. The resultant theory, Pushing Through, consisted of five phases: 1) accepting the role, 2) lacking confidence, 3) creating a system, 4) trusting in self, 5) owning the outcomes. Secondary analysis of the interview data used thematic analysis methods to identify resources used or needed for the caregiver role. The resultant themes were (a) connection to a healthcare professional, (b) written instructions, (c) access to wound care supplies, (d) access to durable medical equipment, (e) financial resources, (f) personal care coverage, and (g) socialization and emotional support. Aim 3 used descriptive analysis of Medicaid 1915(c) home- and community-based services waivers for adults aged 65 and older for all 50 states plus the District of Columbia to identify the frequency and type of waiver services available for supporting caregivers. Results revealed that the number of services offered by state Medicaid waiver programs varied greatly across the country. Respite in varying forms was the most frequently available service. Findings from this dissertation will contribute to the development of evidence-based strategies to sustain older adult caregivers within their caregiving role.Item Hospital Transfers: Perspectives of Nursing Home Residents and Nurses(2022-05) Ahmetovic, Alma; Hickman, Susan E.; Draucker, Claire Burke; Huber, Lesa; Unroe, Kathleen T.Between 1 million and 2.2 million nursing home residents are transferred to a hospital emergency department each year. These transfers are costly, have negative health outcomes, and can increase the morbidity and mortality of residents. Few studies, however, have provided in-depth descriptions of transfer experiences. The purpose of this study was to examine the transfer process between the nursing home and the hospital from the perspectives of nursing home residents and nurses, focusing on how decisions were made to transfer residents. Using a qualitative descriptive method, 22 participants (10 residents and 12 nurses) were recruited from four nursing homes located in rural Indiana. Purposive sampling, semi-structured interviews, and conventional content analysis were used to collect and analyze narratives obtained from residents and nurses about their experiences with a recent transfer and to develop four in-depth case descriptions of these transfers. The participants described four aspects of the transfer process: transfer decisions, transport experiences, hospital stays, and returns to the nursing home. The most common reason for transfers was an acute exacerbation of a chronic condition, and the decision to transfer was often made by a nurse. Most participants found aspects of the transfer, including their hospital stay, to be aversive or upsetting. The return to the nursing home was typically welcomed but often challenging due to problems with mobility, medication adjustments, and cognitive changes. Participants also provided several recommendations for avoiding potentially preventable transfers including adding “in-house” diagnostic testing and treatment equipment, improving staff competencies in managing acute exacerbations, increasing staffing, improving communication among staff, and increasing staff familiarity with resident histories and preferences. The findings have several clinical and policy implications for preventing or decreasing the negative effects of hospital transfers.