Walden University College of Health Sciences This is to certify that the doctoral study by Rickey King has been found to be complete and satisfactory in all respects, and that any and all revisions required by the review committee have been made. Review Committee Dr. Marisa Wilson, Committee Chairperson, Health Services Faculty Dr. Murielle Beene, Committee Member, Health Services Faculty Dr. Deborah Lewis, University Reviewer, Health Services Faculty Chief Academic Officer Eric Riedel, Ph.D. Walden University 2015 Abstract Development of Emotional Intelligence Training for Certified Registered Nurse Anesthetists by Rickey King MSNA, Gooding Institute of Nurse Anesthesia, 2006 BSN, Jacksonville University, 2003 ASN, Oklahoma State University, 1988 Project Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Nursing Practice Walden University February 2016 The operating room is a high stress, high stakes, emotionally charged area with an interdisciplinary team that must work cohesively for the benefit of all. If an operating room staff does not understand those emotions, such a deficit can lead to decreased effective communication and an ineffectual response to problems. Emotional intelligence is a conceptual framework encompassing the ability to identify, assess, perceive, and manage emotions. The research question for this project is aimed at understanding how an educational intervention could help to improve the emotional intelligence of anesthetists and their ability to communicate with other operation room staff to produce effective problem solving. The purpose of this scholarly project was to design a 5-week evidence-based, educational intervention that will be implemented for 16 nurse anesthetists practicing in 3 rural hospitals in Southern Kentucky. The Emotional and Social Competency Inventory - University Edition will be offered to the nurse anesthetists prior to the educational intervention and 6 weeks post implementation to determine impact on the 12 core concepts of emotional intelligence which are categorized under self-awareness, social awareness, self-management, and relationship management. It is hoped that this project will improve emotional intelligence, which directly impacts interdisciplinary communication and produces effective problem solving and improved patient outcomes. The positive social change lies in the ability of the interdisciplinary participants to address stressful events benefitting patients, operating room personnel, and the anesthetist by decreasing negative outcomes and horizontal violence in the operating room.

Up to 80% of serious medical errors occur due to miscommunication from one provider to another (The Joint Commission, 2012). In order to ensure ongoing safe patient care, it is imperative that anesthesia providers communicate effectively and consistently when transferring patient responsibility to other providers, especially to post-anesthesia care unit (PACU) nurses. Multiple patient transfers occur each day and patients are commonly transferred between multiple providers during the same hospital stay. These opportunities are extremely vulnerable to communication errors. Structured patient handoff checklists or tools increase the consistency of information transferred from anesthesia providers to other providers. The Joint Commission recommended in 2012 that all anesthesia providers utilize a standardized patient handoff checklist to increase and improve the quality of data transferred from anesthesia provider to the PACU nurse. Certified Registered Nurse Anesthetists (CRNA) at a local surgical unit provide the bulk of patient handoffs in this postoperative unit, and currently, there is no mandated use of a standardized handoff checklist. As a result, the CRNAs provide a verbal patient handoff that is unscripted. Verbal patient handoffs differ among providers due to individual provider preference. Without using a standardized handoff checklist, there is a risk of increasing communication errors which increase medical errors and negative patient outcomes. Salzwedel (et al., 2013), in a study when utilizing a handoff checklist, concluded that critical patient data conveyed during patient handoffs increased by 32.4% to 48.7% (Salzwedel et al., 2013). Tscholl et al. (2015) and McElroy et al. (2015) through surveys, determined that data transferred between anesthesia providers was more structured. Handoff checklists increased PACU nurse satisfaction regarding the overall handoff experience (McElroy et al., 2015). No studies, to date, were found that understand the perceptions and thoughts of CRNAs regarding the utilization of patient handoff checklists or tools in clinical practice. This Doctor of Nursing Practice (DNP) project assesses the perceptions and thoughts of utilizing standardized handoff checklists among CRNAs. The hope of this study is to better understand CRNA perceptions in order to identify potential barriers or knowledge gaps regarding the benefit of utilizing a standardized patient handoff checklists. Data from this project may be used to structure future quality improvement projects aimed at decreasing communication errors and improve patient outcomes. The results of this project show the majority of CRNAs (89.5%) surveyed for this project were already familiar with handoff checklists. However, only 26.3% of those same participants agreed they currently use a standardized patient handoff checklist. Of the surveyed participants, only 36.8% were interested in utilizing a standardized patient handoff tool even though nearly 50% agreed that using a handoff checklist would increase the consistency of information transferred from anesthesia provider to nurses. This correlates with the 73.7% of participants who already believe they currently transfer pertinent patient information successfully without utilizing a standardized handoff checklist or tool. Despite studies reporting improved patient outcomes, decreased medical errors, and the Joint Commission’s recommendations to use standardized handoff checklists or tools, the majority of anesthesia providers at this facility do not choose to use handoff checklists. By surveying anesthesia providers' thoughts and perceptions, the researcher attempted to answer why anesthesia providers are not utilizing handoff checklists in their daily routines.

Traditionally, nurse anesthesia educators have utilized prior academic achievement to predict student success. However, research has indicated that prior academic achievement offers an inadequate assessment of student success in graduate healthcare programs with extensive clinical residencies. The educational literature has identified many non-cognitive factors, such as self-efficacy and locus of control, that may provide a more holistic prediction model of student success. An experimental study with pretest-posttest design and stratified random assignment was conducted to evaluate the effectiveness of an educational intervention to promote self-management, professional socialization, and academic achievement among first semester graduate nurse anesthesia students. Participants (N = 66) were demographically similar to the national graduate nurse anesthesia student body, though Hispanics and younger students were a little over-represented in the sample (56% female, 75.8% White, 15.2% Hispanic, 6% Other, 59% ≤ 30-years-old, 67% ≤ 3 years of ICU). The results showed that most graduate anesthesia students had strong self-management and professional socialization characteristics on admission. The results did not support the effectiveness of this educational intervention. Thus, ceiling effect may have accounted in part for statistically non-significant results regarding self-efficacy (p = .190, ω2 = .03), locus of control (p = .137, ω2 = .04), professional socialization (p = .819, ω2 = .001), and academic achievement (p = .689, ω2 = .003). Future researchers may need to expand the scope of the intervention, use a more powerful and sensitive instrument, and utilize a larger sample.

The role of Certified Registered Nurse Anesthetists (CRNAs) in the delivery of anesthesia care is evolving given the recent recommendations for Institute of Medicine and provisions in the Affordable Care Act. Despite rigorous clinical training and consistent outcomes studies to support quality care given by CRNAs, the scope of practice of nurse anesthetists is frequently limited, and they do not practice to the full extent of their education and training. As health care spending becomes more constrained and demand for anesthesia services rises, the role of nurse anesthetists as more autonomous providers of anesthesia may be required to maintain access to quality care in a cost-conscious environment. Understanding the factors that influence one’s decision to engage in a broad scope of practice may guide training and recruiting practices. Using Bandura’s Self-Efficacy Theory as a framework to conceptualize scope of practice, an internet based survey of a cross-section of practicing CRNAs was conducted. Subjects responded to questions to describe the geography of their practice, experience as a civilian or military CRNA, and detailed clinical training variables. A composite score was created to gauge overall quality of clinical training. Each CRNA then rated their global scope of practice using a novel SOP-VAS, from 0-100. 1409 subjects participated in this study, yielding 1202 usable data sets. CRNAs practicing in rural locations exhibited higher mean SOP scores than those practicing in urban and suburban locations (p<0.001). CRNAs practicing in states that had opted-out of physician supervision had higher mean SOP scores (p<0.001). Years in Practice was positively correlated with SOP (p<0.01), however months on active duty in the military as a CRNA did not show a statistically significant correlation with SOP. Gender and the composite quality score also demonstrated a statistically significant affect on SOP. Regression modeling using significant predictors from prior analyses resulted in predictive model to describe SOP (p<0.001). Use of the novel SOP-VAS was found to be a reliable and valid tool to measure SOP among nurse anesthetists. Further study is warranted to identify additional factors that may contribute to scope of practice among nurse anesthetists.

For several decades, the field of nursing has focused on the integration of cultural competence content into its prelicensure educational programs. Despite this focus, little is known about the cultural competence of nurses extending their education past initial licensure into an advanced practice nursing specialty, such as nurse anesthesia. Researchers in other fields have found that provider race and previous cultural competence training are associated with higher levels of cultural competence. This research, guided by the culture care diversity and universality theory, sought to determine the relationship between the two subscales, Cultural Awareness and Sensitivity (CAS) and the Cultural Competence Behavior (CCB) of the Cultural Competence Assessment (CCA) tool, and describe the relationships that exist between selected demographic variables and the total cultural competence scores for nurse anesthetists. One hundred and fifty-eight members of the American Association of Nurse Anesthetists participated in the study. The total CCA score for the population was 4.98 out of a potential total score of 7 (SD = .79). Mean scores were 5.64 (SD = .73) and 4.38 (SD = 1.19) for the CAS and CCB subscales, respectively. Hierarchical multiple regression analysis confirmed a positive relationship between post graduate diversity training and total CCA score (B = .28, p < .05). Identifying the cultural competence of this population and the characteristics that are associated with high levels of cultural competence could lead to better provider awareness of their own interactions and perceptions of patients and improved patient-centered care for patients in minority populations who are served by certified registered nurse anesthetists, resulting in positive social change.

<p><strong><p>Abstract</p><p><strong>Aim:</strong> The purpose of this study was to gain a deeper knowledge of how nurse anesthetists feel about their own profession. It was hoped that by gaining a deeper understanding of how the nurse anesthetist is experiencing its own profession, it will create better conditions for development and evolution of the nurse anesthesia profession and skills. <strong>Method:</strong> for the study a qualitative approach was used in which ten anesthesia nurses were interviewed, aged 27-55 years, four men and six women participated in the study. The interviews were processed and analyzed based on qualitative content analysis. As a theoretical framework Patricia Benner seven skill domains was used. <strong>Result:</strong> the analysis resulted in six themes: <em>1. Difficult working conditions which are handled by its own systematic controls. 2. The meaning of being a professional nurse anesthetist. 3. Satisfaction for professionals, has a good relationship with the patient, family, team and develop their professional role. 4. Poor health professionals, has its own misjudgements and situations are not self-control. 5. Prerequisites for a good teamwork, clear communication, trust with their colleagues and to be responsive within the team. 6. A characteristic of the lack of team co-operation is lack of communication and trust, and to feel redundant in the professional role. </em>The category <em>less important</em> remained at the category level. <strong>Conclusion:</strong> the results show that despite the anesthesia nursing regarded as an independent professional, anesthesia nurses were very dependent on the team around them. The conclusion is that much emphasis is placed on being able to work independently and to have good medical knowledge in the field, but it is also important to be able to cooperate and respected by other team members.</p></strong></p> / <p><strong><p>Sammanfattning</p><strong><p>Syfte:</p></strong>studiens syfte var att få en djupare kunskap om hur anestesisjuksköterskan upplever sin egen profession. Förhoppningen var att genom att få en djupare kunskap om hur anestesisjuksköterskan upplever sitt arbete skapa bättre förutsättningar för utveckling och vidareutveckling av anestesisjuksköterskans yrkesroll och kompetens. <strong>Metod:</strong> för studien användes en kvalitativ metod där tio anestesisjuksköterskor intervjuades i åldrarna 27-55 år, fyra män och sex kvinnor deltog i studien. Intervjuerna bearbetades och analyserades utifrån kvalitativ innehållsanalys. Som teoretisk referensram används Patricia Benners sju kompetensdomäner. <strong>Resultat</strong>: resultatet utmynnade i sex teman, <em>1. Svåra arbetsförhållanden hanteras med eget systematiskt kontrollsystem. 2. <strong></strong>3. Tillfredställande för professionen är god relation till patient, anhörig, teamet och att utveckla sin yrkesroll. 4. Otillfredsställande för professionen är egna missbedömningar och situationer man inte själv kan råda över.<strong> </strong>5<strong>. </strong>Förutsättningar för ett bra teamarbete är tydlig kommunikation, att känna tillit till sina kollegor och vara lyhörd inom teamet. 6. Utmärkande för bristande teamsamarbete är bristande kommunikation och tillit, samt att känna sig överflödig i yrkesrollen. Kategorin mindre betydelsefullt stannade på kategori nivå.</em> <strong>Slutsats:</strong> resultatet visar att trots att anestesisjuksköterskeyrket betraktas som ett självständigt yrke, var anestesisjuksköterskorna mycket beroende av teamet runt omkring dem. Slutsatsen är att stor vikt läggs på att kunna arbeta självständigt och att ha goda medicinska kunskaper inom området, men det är även betydelsefullt att kunna samarbeta och respekteras av övriga team medlemmar. </strong></p>

Abstract Aim: The purpose of this study was to gain a deeper knowledge of how nurse anesthetists feel about their own profession. It was hoped that by gaining a deeper understanding of how the nurse anesthetist is experiencing its own profession, it will create better conditions for development and evolution of the nurse anesthesia profession and skills. Method: for the study a qualitative approach was used in which ten anesthesia nurses were interviewed, aged 27-55 years, four men and six women participated in the study. The interviews were processed and analyzed based on qualitative content analysis. As a theoretical framework Patricia Benner seven skill domains was used. Result: the analysis resulted in six themes: 1. Difficult working conditions which are handled by its own systematic controls. 2. The meaning of being a professional nurse anesthetist. 3. Satisfaction for professionals, has a good relationship with the patient, family, team and develop their professional role. 4. Poor health professionals, has its own misjudgements and situations are not self-control. 5. Prerequisites for a good teamwork, clear communication, trust with their colleagues and to be responsive within the team. 6. A characteristic of the lack of team co-operation is lack of communication and trust, and to feel redundant in the professional role. The category less important remained at the category level. Conclusion: the results show that despite the anesthesia nursing regarded as an independent professional, anesthesia nurses were very dependent on the team around them. The conclusion is that much emphasis is placed on being able to work independently and to have good medical knowledge in the field, but it is also important to be able to cooperate and respected by other team members. / Sammanfattning Syfte: studiens syfte var att få en djupare kunskap om hur anestesisjuksköterskan upplever sin egen profession. Förhoppningen var att genom att få en djupare kunskap om hur anestesisjuksköterskan upplever sitt arbete skapa bättre förutsättningar för utveckling och vidareutveckling av anestesisjuksköterskans yrkesroll och kompetens. Metod: för studien användes en kvalitativ metod där tio anestesisjuksköterskor intervjuades i åldrarna 27-55 år, fyra män och sex kvinnor deltog i studien. Intervjuerna bearbetades och analyserades utifrån kvalitativ innehållsanalys. Som teoretisk referensram används Patricia Benners sju kompetensdomäner. Resultat: resultatet utmynnade i sex teman, 1. Svåra arbetsförhållanden hanteras med eget systematiskt kontrollsystem. 2. 3. Tillfredställande för professionen är god relation till patient, anhörig, teamet och att utveckla sin yrkesroll. 4. Otillfredsställande för professionen är egna missbedömningar och situationer man inte själv kan råda över. 5. Förutsättningar för ett bra teamarbete är tydlig kommunikation, att känna tillit till sina kollegor och vara lyhörd inom teamet. 6. Utmärkande för bristande teamsamarbete är bristande kommunikation och tillit, samt att känna sig överflödig i yrkesrollen. Kategorin mindre betydelsefullt stannade på kategori nivå. Slutsats: resultatet visar att trots att anestesisjuksköterskeyrket betraktas som ett självständigt yrke, var anestesisjuksköterskorna mycket beroende av teamet runt omkring dem. Slutsatsen är att stor vikt läggs på att kunna arbeta självständigt och att ha goda medicinska kunskaper inom området, men det är även betydelsefullt att kunna samarbeta och respekteras av övriga team medlemmar.

Advanced practice nurses fill a vital need in the U.S. by increasing access to needed healthcare. Certified Registered Nurse Anesthetists (CRNAs) are one type of advanced practice nurse with a long history of safe and effective peri-anesthetic care. Nurse anesthetists have a rich tradition of providing anesthetic care for rural and underserved communities, and are a primary provider of anesthesia for active and retired military personnel. CRNAs comprise over one-half of the actively practicing U.S. anesthesia workforce currently, and are able to function in any anesthetic care model. Nurse anesthesia educational programs (NAEPs) are the single source for new graduate nurse anesthetists in the U.S. Demographic, geographic and epidemiological factors have combined to produce a predicted increase in the demand for peri-operative anesthesia care among a complex, aging and increasing patient population. The uninterrupted or increased supply of CRNAs to the anesthesia workforce is important. The goal of this study was the production of a comprehensive analysis of potential resource constraints upon the NAEPs in the U.S. This was accomplished through a focused, prospective and correlational research design, grounded conceptually in Resource Dependence Theory. A novel survey tool was developed for the assessment of critical resource constraints, completed by U.S. NAEP administrators and faculty. This research was exploratory in nature and is the basis for continued work in critical resource planning tools for U.S. NAEPs.

Bakgrund: Det är fastställt i tidigare studier att sjuksköterskans arbetsglädje direkt påverkar omvårdnadsnivån och att det är flera faktorer som påverkar dennes arbetsglädje. Forskning saknas beträffande vad som ger specialistutbildade anestesisjuksköterskor arbetsglädje. Syfte: Syftet med studien var att beskriva vad som skapar och hur anestesisjuksköterskor ser på arbetsglädje. Metod: Studien genomfördes med en kvalitativ design där datainsamlingen genomfördes via åtta semistrukturerade intervjuer, dataanalysen genomfördes genom kvalitativ innehållsanalys. Resultat: Åtta områden relevanta för anestesisjuksköterskans arbetsglädje presenteras; psykosocial arbetsmiljö, fysisk arbetsmiljö, god omvårdnad, kompetensutveckling, ledning, självständighet, arbetstider och personalomsättning. Ett nionde område, lön, utreddes men visade sig inte vara direkt kopplat till arbetsglädje Slutsats: Arbetsglädje visade sig vara en viktig faktor för att anestesisjuksköterskan ska trivas med sitt arbete. Det är därför viktigt att arbeta med dessa områden som ger arbetsglädje från flera håll för att underlätta anestesisjuksköterskans arbetsglädje. / Background: It has been established in earlier studies that the nurse's job satisfaction directly affects the level of nursing and that there are several factors that affect nurse’s job satisfaction. There is no research on what gives specialist educated nurse anaesthetist job satisfaction. Aim: The purpose of the study was to describe what creates and how nurse anaesthetist look at job satisfaction. Method: The study was conducted using qualitative design. The data was collected thru eight semi-structured interviews, data analysis is conducted through qualitative content analysis. Results: Eight areas relevant for nurse anesthetists was presented; psychosocial work environment, physical work environment, nursing care, skill development, management, independence, working hours and employee turnover. A ninth area, salary, was also investigated but was not found to be directly related to work satisfaction. Conclusion: Job satisfaction is an important factor for the anesthetist nurses to enjoy their work. It is therefore important to work with these areas that provide job satisfaction from several directions to facilitate the job satisfaction of the anesthetist nurse.

Bakgrund: Regional anestesi är en metod som blivit allt vanligare inom sjukvården. Metoden innebär att alla sinnesintryck temporärt elimineras från den valda kroppsdelen där kirurgin ska genomföras, detta görs genom att anlägga en nervblockad. Metoden möjliggör att patienten kan vara vaken under ett kirurgiskt ingrepp. Den högteknologiska operationsmiljön beskrivs många gånger som opersonlig, distanserad och kall, vilket kan medföra att patienterna upplever osäkerhet och sårbarhet. Således är det av vikt att undersöka patienters upplevelser för att anestesisjuksköterskan bättre ska kunna bemöta, vårda och stödja dem genom kirurgin. Syfte: Studiens syfte var att beskriva patienters upplevelser av att vara vaken under ett kirurgiskt ingrepp i regional anestesi. Metod: En strukturerad litteraturstudie med kvalitativ design, baserad på 13 vetenskapliga artiklar. De vetenskapliga artiklarna har analyserades med hjälp av Bettany-Saltikov och McSherrys dataextraktion. Resultat: I resultatet framkom tre huvudkategorier: Miljöns och kirurgins påverkan, Upplevelser av att överlämna sin kropp och Vårdpersonalens betydelse. Upplevelsen av att vara vaken under ett kirurgiskt ingrepp i regional anestesi kan upplevas både positivt och negativt. Vissa patienter upplevde delaktighet och kontroll medan andra upplevde motsatsen. Vidare kunde de uppleva smärta, rädsla, oro och obehag i samband med det kirurgiska ingreppet, trots detta var de generellt nöjda genom interaktionen de hade med vårdpersonalen. Slutsats: Anestesisjuksköterskan har en avgörande roll för patientens upplevelse av att vara vaken under kirurgi. Stöd, tröst och omtanke från anestesisjuksköterskan hjälpte patienten att överkomma sin oro och rädsla. En god kommunikation, information och närhet från vårdpersonalen kan stärka patientens välbefinnande och delaktighet.