The objective of this dissertation was to understand the relationship between organizational domains and provider attitudes as well as the relationship between ICU provider attitudes and ABCDE bundle adherence. A one-time interprofessional electronic survey in ten ICUs across the United States was conducted to examine association of organizational domains with provider attitudes regarding the ABCDE bundle. Protocol attributes (rs=0.44-0.58), role clarity (rs=0.42-0.59), training/understanding (rs=0.33-0.46), coordination (rs=0.33-0.46), and peer advocates (rs=0.37-0.48) were positively correlated with provider ABCDE bundle confidence and perceived safety and strength of evidence. Task autonomy was positively correlated with provider attitudes of ABCDE bundle perceived safety (rs=0.35) and confidence (rs=0.47). For every unit increase in workload burden, there was a 53% decrease in adherence to the ABCDE bundle (OR=0.47, CI=0.28-0.79, p=0.004). Perceived difficulty carrying out the bundle, perceived safety, confidence, and perceived strength of evidence were not associated with ABCDE bundle adherence. ABCDE bundle adherence was greater on ventilator-free days compared to ventilator days (97% vs. 72%, z=5.47, p<0.001). There are organizational domains that positively influence provider attitudes. Protocol attributes, role clarity, coordination, peer advocates, and teamwork factors explain the most variance in provider perceived difficulty with carrying out the bundle. Focusing interventions on factors influencing these organizational domains may facilitate ABCDE bundle implementation.

Healthcare organizations have incorporated updated safety principles in the analysis of errors and updating of norms, policies and standards. Error is an ongoing concern in healthcare, especially preventable adverse drug events, which include medication errors. Approximately one-quarter of medication errors occur at the administration phase, which is solely under the purview of the bedside nurse. Yet no research exists that assesses bedside nursesâ perceived skills or attitudes toward updated safety concepts. Based on identified gaps in the literature related to variables that impact medication administration errors (MAEs), the primary goal of this pilot study was to further explore the relationship among individual, unit and organizational mediated variables related to updated safety concepts and MAEs. Specific Aims were to: 1) develop and test the psychometrics of a scale assessing nursesâ perceived skills and attitudes about updated safety concepts, and 2) examine associations between perceived skills and attitudes and their impact on unit-level MAE rates and unit-level adherence to safe medication administration practices.

An Exploration of Nurse Manager Work Activities in Acute Care Settings Amanda Stefancyk Oberlies Dissertation under the direction of Professor Ann F. Minnick The nurse manager has been described as one of the most important assets to a hospital success and is believed to be critical to inpatient unit operations. The purpose of this study was to explore nurse manager work activities including where, and with whom the work activities take place. There is a scarcity of literature about nurse manager work activities, and what has been published is flawed methodologically. This study examined the work activities of eight nurse managers at two academic medical centers in the Midwest. Work activity data were collected using non-participant observation and each nurse manager was observed for two, eight-hour work days. Twelve observations were recorded each hour and included at least one activity, one location, and one person. Interview, self-report, and artifact collection were used to capture additional data about the nurse manager, the unit, and the nurse managerâs work activities. During four months of data collection 1,518 observations were made. Nurse managers were observed most frequently conducting desk work, schedule meetings, and personal activities. The nurse managerâs office and meeting room were the most frequently observed locations. The nurse manager was observed performing work activities most frequently alone and with a subordinate nurse. Nurse managers reported spending the most time in desk work and scheduled meeting activities. The absolute difference was calculated for the observed and self-reported activities. There were statistically significant differences between observed and self-reported clinical and personal activities (p = .002 and p = .001, respectively). Intraclass correlation statistics were generated and statistically significant agreements were observed for scheduled meetings, unscheduled meetings, desk work, telephone and rounds (ric = 0.72-0.83, p <.01). With this foundational work completed, future research may build upon the knowledge generated including the linkage of nurse manager activities to patient and staff outcomes. This study added to the knowledge that self-report is an acceptable research method for certain activities.

Economic, educational, and social challenges in the United States have fostered continued reliance on the family for financial and emotional support amongst late adolescents (18-24 years of age): a health care trend known as delayed adolescent transition which encompasses the failure to meet major developmental changes and challenges such as acquisition of competencies, attitudes, values, and social capital. Obesity trending in late adolescence has also become epidemic, affecting approximately 1:4 late adolescents. A cross-sectional, descriptive, correlational approach to delayed transitioning in this population and the role coping and other unique factors trending in the last decade such as internet use, social media use, and video gaming was conducted. Data was collected primarily through online social media recruitment and documented in REDCap data base. Descriptive and correlational data analysis concluded that the delayed transition variable as currently conceptualized in the literature was unable to be quantified as previously defined. Cognitive appraisals to stress were strongly correlated with copying styles. Internet use, social media use, and video gaming were associated with dysfunctional coping. A cluster analysis revealed that participants who had completed transition to adulthood in this age period were more likely to be financially independent, not live with their parents, graduated high school, have income to support themselves, have lower perceived stress, higher perceived competence and social support, and use the internet and social media less than their peers. Nurses are in a prime position to better advocate for the late adolescent population through research, education, and health promotion efforts. The nurse clinician should recognize the importance of stress and coping in relation to psychosocial components of life that can impact physical and mental health.

Human immunodeficiency virus (HIV) is a sexually transmitted disease with opportunity for transmission when barrier protection is not used during sex. The incidence rate for infections in the US has been approximately 45,000 per year for the past several years. There are significant social, psychological, and physical health costs associated with each infection. Given these realities, better methods for influencing safe-sex behavioral intention are needed in order to minimize transmission of HIV. <p> The purpose of this descriptive correlational study was to assess the strength and direction of possible associations among psychological adjustment characteristics (depressive symptoms, impulsivity, overall psychological adjustment, and condom use self-efficacy) with safe-sex behavioral intention. In addition, this study examined the strength and direction of possible associations among gain-framed and loss-framed safe-sex messages related to personal health or relationship risks with safe-sex behavioral intention. <p> A convenience sample of 150 men and women with HIV receiving care in a large Southeastern HIV clinic provided the data analyzed in this study. In this cross-sectional study, depressive symptoms, impulsivity, psychological adjustment, condom use self-efficacy, message framing preferences and safe-sex behavioral intention were measured.<p> After controlling for demographic characteristics (age, race, gender, years with HIV), findings did not support hypothesized associations among the majority of psychological characteristics and safe-sex behavioral intention. However, there was a statistically significant positive association between condom use self-efficacy related to relationship concerns with safe-sex behavioral intention. After controlling for demographic variables, findings revealed a statistically significant association between net scores on relationship statements and safe-sex behavioral intention, with higher scoring of relationship-focused statements correlating positively with higher scores for safe-sex behavioral intention. An analysis controlling for both demographic and psychological characteristics revealed statistically significant positive associations among both gain-framed and loss-framed relationship-focused statements with safe-sex behavioral intention. Findings related to personal health-focused statements and safe-sex behavioral intention were not statistically significant.

The objective of this dissertation was to explore strategies for the design and statistical development of probability-based nursing decision support tools within the context of in- hospital cardiopulmonary arrest (IHCPA). A descriptive phenomenological study of 18 nurses explored information-gathering activities related to IHCPA to understand how probability-based clinical decision support (PB- CDS) tools might best be implemented. Fifteen individual interviews and a focus group revealed Patient, Other People, and Technology information sources with information gathered in no consistent order. Participants expressed they: (a) search additional sources during uncertainty, (b) prefer being prepared for worst-case scenarios regardless of projections, and (c) desire more detailed probability-based information, such as hourly predicted values. The words probability, risk, and uncertainty were used interchangeably by participants and did not appear to have consistent, intrinsic meanings. We then compared two statistical modeling strategies (logistic regression and Cox proportional hazards regression) and two machine learning strategies (random forest and random survival forest) for IHCPA with respect to prediction accuracy and interpretability. We used a retrospective cohort study with prediction model development from de-identified electronic health records at an urban, academic medical center. Although the classification models had greater statistical recall and precision (F1 scores ranging 0.27-0.33 versus 0.19-0.26), the time-to-event models provided predictions that might better indicate to nurses and other clinicians whether and when a patient is likely to experience an IHCPA. Participatory design sessions with bedside nurses, charge nurses, and rapid response team nurses (n=20) identified preferred design considerations for an IHCPA PB-CDS tool. Themes focused on "painting a picture" of the patient condition over time, promoting empowerment and autonomy, and alignment of probability information with what a nurse already believes about the patient. The most notable design element consideration included visualizing a temporal trend of the predicted probability of the outcome along with user-selected overlapping depictions of vital signs, laboratory values, and outcome-related treatments and interventions. These studies serve as a foundation for designing and developing future PB-CDS tools intended to aid nurses because they provide insight on current cognitive and physical workflows for IHCPA recognition while seeking to create tools that support, rather than interrupt nursesâ work.

The purpose of this two-phase study was to describe the effects of social influence on critical care nursesâ hand hygiene behavior. Guided by the Theory of Planned Behavior, the phase-one qualitative study captured a modal set of nurse salient hand hygiene beliefs using a free response open-ended survey. Findings indicate nurse participants look to nurses as their hand hygiene referent. Phase-two was a cross-sectional descriptive study designed to determine the contributions of nursesâ hand hygiene attitudes, subjective norms, and perceived control on observed and self-reported hand hygiene performance using the self-administered Patient Safety Opinion Survey (informed by phase-one findings) and iScrub application (used for hand hygiene observations). There was no statistically significant association of nursesâ attitude scores with hand hygiene behavior (beta=-0.10 (observed), beta=0.03 (self-report), p > 0.05). Nursesâ subjective norm and perceived control scores were statistically significant contributors to their observed (Norms: beta = 0.32, p = 0.001; Control: beta = 0.20, p = 0.036) and self-reported (Norms: beta = 0.21, p = 0.028; Control: beta = 0.35, p < 0.001) hand hygiene. These findings suggest that interventions to increase hand hygiene subjective norm and perceived control scores may increase hand hygiene. Consequently, future hand hygiene work should focus on exploring social strategies with particular attention to the nurse leader because nurses identified them as the most important referent. Nurses observed hand hygiene median was 55% with their tendency to self-report a much higher median of 90% suggesting if actual hand hygiene performance statistics are desired, self-report is an inaccurate measure.

This doctoral research examined the medication management work of older heart failure patients, with a focus on cognitive work amenable to tool and technology interventions. Older adults with chronic disease struggle to manage complex medication regimens as evidenced by high rates of errors and non-adherence leading to increased rates of disability, death, and reduced quality of life. Health information technology has the potential to improve medication management, but only if it is based on a thorough understanding of medication management work as it occurs in natural settings. Few studies address the design of patient-facing tools, patient work in context, or test methods to acquire this knowledge. The first phase of this study applied human factors/system engineering theories to guide the analyses of four work system elements: performance shaping factors, cognitive workflow, cognitive artifacts, and adaptive strategies. Data from 61 older heart failure patients and 31 accompanying caregivers revealed medication management as a fragile system of interacting people, artifacts, time, and space. Cognitive, collaborative, and individual processes were influenced by multiple performance shaping factors that directed the system towards and away from optimal performance, risk and harm. Strategies supported medication management performance, but patients had difficulty adapting to unexpected situations and events. Patients had few tools to support medication management, and these tools were not designed with an understanding of patient health work. In the second phase of the study, fifteen older adults with heart failure and two caregivers participated in a pilot test of a digital diary method by recording medication management activities for one week using a tablet device. The evaluation revealed the digital diary method as an effective, efficient and satisfactory data collection method to capture rich work systems of older adults with heart failure. In conclusion, patients strived to control their system and achieve goals. In this way patient work is similar to professional work and likely could benefit from tools and research methods adapted from professional work settings. Patient medication management was highly distributed and collaborative, indicating the need for technology that facilitates communication, coordination, information sharing and integration across locations, time, and people. If designed for usability and acceptance, technologies can improve medication management for older adults living with heart failure.

Of the patient populations in acute care facilities, the critically ill are most vulnerable to the development of pressure ulcers. The most commonly used pressure ulcer risk assessment tool in the United States, the Braden Scale, demonstrates low levels of specificity when used to predict pressure ulcer incidence in the critically ill, suggesting that additional risk factors may help to focus prevention efforts. As the framework for the investigation of pressure ulcer risk factors in critically ill patients, additional risk factors identified in the literature that are specific to this patient population were evaluated simultaneously with the Braden Scale using a case-control study design. The Braden Scale scores and additional risk factors were compared in pressure ulcer positive and negative patients. Hierarchical logistic regression determined that the Braden Scale was statistically significantly associated with pressure ulcer development when used alone, and the addition of other variables at both 24 and 48 hours did contribute statistically significantly to the overall model. Male gender and low hematocrit values were statistically significantly associated with pressure ulcer development when analyzed at univariate and multivariate levels, and increased age demonstrated a statistically significant association with pressure ulcer incidence with multivariate analysis. Restraint use was identified as a statistically significant protective factor with multivariate analysis.

The ecological perspective, which posits that the individual cannot be understood outside of context, was used to guide this research. The purpose of this comparative-descriptive study was to investigate survival among male homeless adolescents. Forty seven straight and 23 queer (gay, bisexual and transsexual) male homeless adolescents (16-20 years old) were compared on how they came to be homeless, residential stability, survival strategies, and psychological indicators (state and trait anxiety, self-esteem, and collective self-esteem). Standardized instruments were used to obtain data on psychological indicators; other variables were developed from structured interivews. Approximately equal numbers of youth became homeless due to their own volition, their parents choice, and due to a social service system problem, with a small percentage homeless due to tragedy - without variation by orientation. Over one-third of queer youth became homeless due to their orientation, with the highest percentage among transsexual youth. Queer youth were younger, dropped out of High School more often, and were principally sofa-surfing, whereas straight youth were principally staying in shelters. While some youth stayed in one place, there was no pattern to movement from one residence to another. Survival strategies included accessing homeless services, asking friends or family for money, drug work, gang activity, panhandling/dumpster diving, robbing/stealing, running scams, sex trade work (hustling and pimping) and working. Straight youth were involved in more other-harmful survival activities than queer youth. The sexual orientations did not differ significantly on psychosocial indicators. Differences were found between queer orientations for residential stability, path to homelessness, and survival strategies. Overall 64% of youth said they were better off since leaving home. The results indicate that there are some differences between straight and queer homeless adolescents that need further exploration. These data suggest that interventions for homeless adolescents may be tailored to sexual orientation to be most effective.