In an era of value based purchasing and healthcare reform, hospitals face the challenge of delivering high quality care in an environment of diminishing resources. This performance improvement project describes the use of master’s prepared nurses on medical surgical units to improve quality and patient satisfaction. The setting was five medical surgical units in a 200+ bed hospital in the southeastern United States. Declining resources necessitated an increase in the nurse to patient ratios on the units (from 5:1 to 6:1). The project involved the modification of the model of care through the change in nurse/patient ratios and the addition of master’s prepared nurses to coordinate and supplement the care of the staff RNs for complex patients. While inconclusive, the literature review confirmed the impact of master’s prepared nurses on quality metrics and did not conclusively confirm that delivering high quality, safe care was not possible with nurse/patient ratios of 1:6. The goal of the project was to determine if the presence of the master’s prepared nurse could mitigate the changes in ratios and produce high quality and satisfaction outcomes. Measures of success were drawn from archived standardized quality measures in the realms of service (HCAHPS questions), patient safety (CABSI, HAPU) and quality outcomes (core measures and 30 day readmissions). The project design was a retrospective, one-group pre-post design looking at two six-month intervals—before and after project implementation. Results demonstrated sustained or improved quality in six of ten measures. Highest positive impact was in readmissions and nurse sensitive indicators. The most negative results were in patient satisfaction. Modifying the model of care is an iterative process requiring continued evaluation and changes to improve outcomes. Results of this project supported the further evaluation of staffing and expansion of the number of master’s prepared nurses on medical surgical units.

Cervical cancer, a completely curable disease with early detection and management, is an international concern. Early identification allows for treatment of the disease, which prevents or slows progression, ultimately reducing morbidity and mortality. Due to the regressive nature of most cervical lesions, the duration between cervical cytology has been lengthened to prevent over diagnosis and treatment. This was reflected in the 2012 United States Preventative Services Task Force (USPSTF) clinical practice guideline for cervical cancer screening. The purpose of this project was to determine the effectiveness of a quality improvement initiative to increase adherence to the 2012 USPSTF guideline at a volunteer medical clinic for the working uninsured. In this retrospective, time series observational evaluation, data were collected via chart review regarding adherence to the guideline. The intervention consisted of the placement of a visual algorithm educational tool for clinical decision-making for cervical cytology screening in each exam room. Data were collected during three time periods: (1) the 3 months prior to initial education of clinic staff regarding the guideline; (2) the 3months between initial education and introduction of the algorithm; and (3) the 3 months post introduction of the algorithm. A total of 335 charts were reviewed. There was a significant difference in the proportion of appropriate screening among the three groups (Χ2= 6.83 p=.03). There was also a significant difference in appropriate screening rates between the new and established patients’ group, controlling for group (p<.0001). The use of the interventional algorithm is recommended to improve adherence to evidence-based practice guideline related to cervical screening as it decreases harm(s) to the patient by reduction of fear, cost to the patient, and overtreatment of benign regressive lesions.

Patient outcome data are an important factor in healthcare. Reports by the Institute of Medicine between 1999 and 2001, as well as recent research by Linda Aiken and her colleagues have added more emphasis to measures that can be taken to improve patient outcomes. Because of the role they play in healthcare facilities, nurse leaders are in a position to take the lead in improving patient outcomes. There is evidence to suggest that nurse leaders' transformational leadership behaviors are associated with positive patient outcomes. The purpose of this project was to identify the effect of transformational leadership skill-building training on nurse leaders' behavior in the acute care setting. The project included assessments of nine nurse leaders by those nurses which are supervised by the nurse leaders. The results indicated the nurse leaders' behavior score of 3.1 was in the transformational range (3.0-3.75.) Transformational leadership skill-building training followed the assessment process. A post training evaluation by the previous assessors followed the training. The distribution of the transformational leadership behavior scores did not change following the training.

In today's hospital environment, good care has become synonymous with positive patient outcomes. Marring this landscape is the alarming rate of hospital acquired (nosocomial) infections. Urinary tract infection (UTI) is one of the most common hospital acquired infections. The major cause associated with these infections is the use of indwelling urinary catheters. Bacteria invade the lower urinary tract by ascending through or around the catheter. Morbidity associated with urinary catheter-associated UTI can be minimized by prudent decisions concerning catheter usage and good catheter care. The principle route of dispersal of nosocomial infections is likely from patient-to-patient via transiently contaminated hands of hospital personnel. The purpose of this evidence-based project was to determine if hospital-acquired catheter-associated urinary tract infection rates among patients admitted to an acute care facility could be decreased through staff education and consistent application of nursing care using selected perineal infection control interventions. The setting was a 43-bed medical/surgical floor in a 321 bed not for profit Magnet hospital in Northeast Florida. Twenty-four registered nurses and 18 patient care technicians completed targeted in-service education on general nosocomial infections, perineal care, and hand hygiene. A catheter dwell time notification system was also implemented. Chart review data was obtained from 383 admissions (197 pre-intervention, 133 after the educational intervention, and 53 after the dwell time notification). There was a significant difference in catheter-associated urinary tract infection rates after the interventions (11.17 pre-intervention, 10.53 after the educational intervention and 0.392 after the dwell time notification). A longer length of time in practice an on this hospital unit was associated with lower infection rates.

The purpose of this project was to evaluate the effectiveness of a practice-based dermoscopy training program for dermatology healthcare providers in order to improve their technique of performing clinical skin exams for the early detection of melanomas. The overall incidence of melanoma continues to rise. More than 75% of all skin cancer deaths are from melanoma. Advanced melanoma spreads to lymph nodes and internal organs and can result in death. One American dies from melanoma almost every hour (American Cancer Society [ACS], 2009). Early diagnosis and excision are essential to reduce morbidity and to improve patient survival. This one-group before-and-after study design utilized a convenience sample of three dermatology healthcare providers (DHPs). The primary investigator conducted a retrospective review of the pathology logs for each provider. The time frame for the review was a three-month period in 2010, which represented the same time frame that the study was conducted in 2011. The DHPs participated in a four-hour training workshop that included pattern analysis recognition using dermoscopy. Following the workshop, each DHP was given a DermLite 3Gen DL100 to use in practice when performing clinical skin examinations. All DHPs completed a data collection sheet to document their pattern of decision making with and without a DermLite. The outcome of interest was the use of dermoscopy by DHPs to demonstrate an increased detection of melanoma when compared to naked-eye examination. The outcome was evaluated 12 weeks post-workshop training. There were 120 evaluations made with the DermLite as compared to the naked eye. The overall agreement was 0.52, AC1 coefficient (95% CI) was 0.36 (0.30, 0.42), p < .001, and kappa coefficient (95% CI) was 0.27 (0.20, 0.43), p < .001. Overall, the risk of lesion under exam being suspicion for skin cancer was higher on 27.5% (33 out of 120) of the evaluations and lower on 20.8% (25 out of 120) evaluations. The risk of lesion was evaluated the same on 51.7% (62 out of 120) of the evaluations. This is an indication of “Poor” agreement between the two methods. The diagnosis and disposition made using DermLite compared to naked-eye results for both coefficients provided an “Intermediate to Good” agreement between the two methods in assigning diagnosis and disposition. This indicates that there is no difference between DermLite and naked-eye evaluations. More studies are needed in order to provide better evidence on the value of dermoscopy in clinical practice at the Dermatology and Laser Center. Future projects should be more explicit regarding the methods used and lesion selection in order to better understand the benefits of dermoscopy.

The purpose of this quality improvement project was to increase physical activity among postoperative adult liver transplant patients, improve documentation of daily activity, and ultimately influence quality of life (QOL). Quality of life has been shown to improve dramatically after liver transplant, as patients enter transplant severely debilitated with limitations on their physical activity which carry over following transplant. The literature supports that liver transplant patients should engage in physical activity which may improve QOL. Thirteen liver transplant patients were recruited within the seven days of their post-operative hospitalization. Twelve patients consented, were educated about the benefits of walking, given instructions for how to gradually increase their walking activity, and how to track this activity in a daily log. The International Physical Activity Questionnaire (IPAQ) that calculates level of physical activity (metabolic equivalent or MET score) was conducted at baseline and six weeks. Patients were also asked to rate their perceived quality of life on a ten point scale. Eight patients completed the study with four patients medically unable to complete the walking program. Baseline MET and QOL scores were compared between Time 1 and Time 2 (six weeks). The IPAQ baseline score increased from 407.5 MET to 1,711.5 MET, however, results were not statistically significant. Quality of life improved from Time 1 average score of 5.5 (SD=2.51) to Time 2 average score of 8.25 (SD=1.67) and was statistically significant (P=0.27). Liver transplant patients gradually increased their walking activity over a six week period and documented that activity daily. QOL was also purported to increase which is consistent with findings in the literature. Implementing a post liver transplant walking program is feasible and beneficial for patients and should be a standard of care.

The practice of obtaining blood as part of the placement of a new peripheral venous access device (p-VAD) is a frequent practice in the emergency department (ED). Of the concerns related to this practice is the possibility of laboratory specimen rejection due to p-VAD catheter size, use of the wrong collection device, and the absence of a standardized collection process. The objective of this study, therefore, was to examine the effect of the use of evidence-based venipuncture and p-VAD blood collection protocols on the rejection rate of blood specimens drawn by staff in the adult areas of an urban academic medical center ED. A convenience sample of 28 ED nurses and 39 ED technicians (51.94% of all eligible ED employees) consented to using these evidence based protocols when they collected blood from adult ED patients. Blood specimen rejections rates were measured for four consecutive weeks prior to and at weeks 1-4, 5-8, 9-12, and 1-12 after the evidence-based blood collection practices training intervention. Laboratory analysis of all specimens was automated with rejection results provided in the form of computerized reports. There was a significant decrease in the 12-week rejection rates for two of the three ED adult care areas, with the overall ED adult area rejection rate significantly decreased from 3.19% to 2.38% (X2at Df1, p < .05). The most common reasons for rejection were hemolysis (65.39%) and clotting (10.68%) followed by specimen mis-labeling, tube missing, insufficient quantity for testing, incorrect packaging, specimen contamination or dilution, and label missing, Though the use of theses evidence based blood collection protocols significantly decreased the overall rejection rate, the high percent of rejections due to hemolysis may further be reduced by having all ED staff use these protocols, and by exploring other collection techniques in the literature that have been found to significantly decrease rejection rates.

Glass particle contamination of medication occurs when opening ampules which may cause patient harm. The use of filter needles reduces this risk. Many anesthesia providers use ampules daily, but do not use filter needles when aspirating medications from ampules. In addition, filter needles may not be readily available at the anesthesia medication preparation site. Not using filter needles or having them available for use can increase the risk of patient harm by glass particle contamination. The purpose of this project was to increase anesthesia provider’s knowledge thereby improving compliance with evidence-based standards when preparing medications from ampules. The goal is to increase filter needle use when medication is aspirated from an ampule in order to decrease the risk of glass particle contamination to the patient. This project consisted of a one-group pre/post intervention design using a piloted self-developed survey, an education intervention, and tracking of filter needle use. The convenience sample of eighty-three recruited anesthesia providers included anesthesiologists, nurse anesthetists, and anesthesiologist assistants that consented to participate. The filter needle inventory was tracked via an existing software program to determine filter needle use three months prior and three months after the intervention. Data were collected and analyzed using descriptive statistics. The results of this project found greater awareness among participants of standards and organizations regarding filter needle use with ampules, greater awareness of availability of filter needles on anesthesia carts, and a five-fold increase in filter needle usage by participants three months following the intervention as compared to three months prior to the intervention.

Les raves sont des événements festifs gagnant en popularité chez des jeunes adultes qui y consomment des drogues pour un usage récréatif. Cette consommation chez des jeunes qui sont généralement en bonne santé engendre une morbidité et une mortalité évitables. Des recherches menées depuis les 20 dernières années suggèrent de déployer des interventions de réduction des méfaits dans les raves, sans toutefois élaborer les conditions de l’environnement qui sont favorables à une telle pratique. Le but de cette recherche est de décrire l’environnement physique et social de raves publiques de grande envergure afin d’identifier des repères pouvant contribuer à l’introduction d’une pratique infirmière de proximité de réduction des méfaits dans un tel milieu. Cette recherche exploratoire de type qualitatif descriptif interprétatif (Thorne, 2016) s’appuie sur des repères théoriques du cadre socio-écologique de Bronfenbrenner (1979) et sur la Théorie de l’Acteur-réseau. Située dans un champ épistémologique constructiviste pragmatiste, cette étude comporte une entrée progressive sur le terrain de trois raves publiques de type festival de musique électronique dans la grande région de Montréal, Canada en 2016-2017, et un processus itératif de collecte et d’analyse de données. Le constat principal de la recherche est que l’environnement physique et social du type de rave étudié comporte une dynamique de plaisir surveillé au travers de laquelle les divers acteurs en interaction poursuivent des intérêts différents qui se traduisent par des méfaits potentiels ou réels à réduire. Ainsi, pour concevoir une pratique infirmière de proximité de réduction des méfaits qui soit viable, il s’agirait d’en assurer la contextualisation par l’analyse attentive des interactions qui lient les acteurs et leurs usages d’objets matériaux ou symboliques dans l’espace physique de la rave. Comprendre le rôle, l’identité, la position sociale et les atouts de chaque acteur permettrait de se situer à l’interface de divers intérêts et méfaits à réduire. La pratique infirmière de proximité de réduction des méfaits dans une rave serait ainsi celle d’un acteur stratégique à l’interface d’un complexe de méfaits à réduire dans l’optique de création de nouvelles ententes de collaboration. Partant de l’idée que l’environnement est constitutif de la pratique infirmière, cette recherche répond au besoin de développer des connaissances sur le concept d’Environnement dans la discipline. / Raves are festive events that are increasingly popular among young adults. Recreational drug use among young adults that are otherwise known as healthy, has been associated with avoidable morbidity and mortality. Research conducted over the last 20 years suggests the implementation of harm reduction initiatives in raves. However, little is known as to how this particular environment could be conducive to such interventions. The purpose of this research is to describe the physical and social environment of large-scale public raves in order to identify conditions that could be favourable to the introduction of a harm reduction nursing outreach practice in this setting. An interpretive and descriptive qualitative research design (Thorne, 2016) based on Bronfenbrenner’s socioecological framework (1979), Actor-Network Theory concepts and pragmatic constructivist epistemology, was conducted in the greater Montreal area, Canada, in 2016-2017. Gradual entry into the three public raves that qualify as “electronic music festivals” was combined with an iterative process of data collection and analysis. The main finding of this exploratory study is that the physical and social environment of large-scale public raves comprises a dynamic coupling of pleasure and surveillance interactions through which diverse actors each pursue different interests. These interests convey, respectively, different kinds of potential or actual harms to reduce. Thus, a viable harm reduction nursing outreach practice would require careful analysis of the interactions that connect actors with the material or symbolic objects that they use in the physical confines of the rave to ensure its contextualisation in this particular environment. Close attention to the role, identity, social position, and potential assets of each actor could help nurses to situate themselves at the interface of various interests and harms to reduce. A rave located harm reduction nursing outreach practice would then appear as strategic action, at the interface of a nexus of harms to reduce, that attempts to build collaborative arrangements. Taking on the idea that environments are constitutive of nursing practice, this study recognises the need to further develop disciplinary knowledge about the concept of Environment in nursing.

The purpose of the study is to explore past and current professional nursing organisations by means of historical inquiry and to explain the factors that influenced the development of such organisations, as well as the contribution that these organisations made to the professional development of South African nursing in the period between 1914 and 2014. The researcher conducted a literature review and collected data from archival primary and secondary sources. A priori codes provided structure and historical context, yet allowed flexibility. Philosophically critical realism guided the research and enabled the researcher to explain and critique the social world in which South African nursing organisations historically functioned and exerted their professional influence. The findings revealed that in the past one hundred years political, economic and cultural factors present in the social world influenced the nature of South Africa’s professional nursing organisations. Determined to create a female professional image, status and educational exclusivity, South African nursing leaders of the 20th century opted to establish the South African Trained Nurses’ Association (SATNA), a professional nursing association. Influential associations such as SATNA and the South African Nursing Association (SANA) guided the profession to develop a nursing culture based on philosophical and ethical principles of practice. The result was a recognised, respected and trained nursing corps. Over time, however, a social class system, religion, political ideology and nurses’ economic needs reshaped South Africa’s nursing associations and consequently the profession. By the end of the 20th century, South African nursing leaders accepted that nurses needed their socio-economic welfare to be prioritised and therefore the Democratic Nursing Organisation of South Africa (DENOSA), a professional organisation with a trade unionist stance, was established. The result was a trained, politicised, fragmented nursing corps struggling to find its collective professional voice. The greatest legacy bestowed on South African nursing by its first influential organisations is the professional associations evident today. Over time, the South African Nursing Association’s discussion groups that had been established in the 1950s to discuss nursing-related topics evolved into the specialist groups and associations that were present in 2014. / Health Studies / D. Litt et Phil.