Communication concerning the care one wishes to receive at the end of life (EOL) is central to ensuring that wishes are honored. Many studies have examined doctor-patient or doctor-family EOL communication. However, relatively few studies have focused on the occurrence of EOL care discussions among family members. This is an important topic, as research suggests that advance directives (ADs) are ineffective if patients have not involved surrogate decision-makers, most of whom are family members. This study examined EOL care discussions among family members. It used quantitative and qualitative data from a diverse sample of older adults from West Central Florida collected for the purpose of this examination. The quantitative and qualitative data were analyzed separately and together. This study employed the Transtheoretical Model, which proposes that individuals are in varying behavioral “stages of change” and that bringing about a behavioral change requires understanding their particular stage and adapting interventions appropriately. Statistical analysis of the quantitative data (N=364) using multinomial logistic regression showed that participants were in distinct stages that were associated with several factors, including family involvement with health care decision-making and communications with doctors. Racial and ethnic differences were not found in controlled analysis, though Hispanics were less likely to be in more advanced EOL care discussion stages in unadjusted analyses. Several themes were found in qualitative analysis of focus groups (n=36) drawn from the larger sample. Findings suggested that those who engaged in family EOL care discussions were more careful planners overall, more accepting of death, and able to manage complex family dynamics. They also had greater knowledge of EOL matters, largely related to knowledge of loved ones EOL wishes. The quantitative-qualitative (mixed-methods) study reinforced the role of family relationships in general in whether EOL care discussions occurred. It also highlighted the role of being proactive and having EOL care knowledge. All three studies – the quantitative, qualitative, and mixed methods showed the potential for doctors and other health professionals to help families with EOL care discussions and ACP overall.

Because of the expense associated with hospital admissions, the use of observation status has grown. One of the most consistently measured outcomes in observation is the patient length of stay (LOS). Research supports the positive impact that nurse practitioners (NP) have on LOS when added to other service lines that could be applied to observation. Banner Desert Medical Center (BDMC) is currently attempting to decrease their observation LOS. Adding acute care nurse practitioners (ACNP) to the care delivery model is a potential intervention. The purpose of this project was to develop an executive summary to inform staff of current evidence that supports the addition of ACNPs to observation. Then, via a survey, the project aimed to determine the level of staff support by identifying the Transtheoretical Model of Change (TTM) Stage of Change and to recommend appropriate stage-matched interventions for staff based on TTM processes of change. The 10 Likert scale survey questions were adapted from two validated TTM surveys. The final question asked for the pros and cons of the intervention to determine the Decisional Balance (DB). The registered nurse (RN) cohort demonstrated consistently strong support for the proposed intervention with an average mean response of 6.57 on affirmative questions and a correspondingly low average mean of 2.2 on negative questions. When compared to the RN cohort, the physician cohort had lower mean responses with an average of 4.29 on every affirmative, a higher average mean response of 3.85 on the negatively worded questions. The DB for RNs was 19 pros to two cons. The DB for physicians was eight cons to three pros. These finding reflect that nurses are in the Preparation Stage of Change and are ready to move forward with adding ACNPs. An appropriate stage-matched intervention for registered nurses would be the development of change teams. In contrast, the physician cohort is in the Precontemplation stage and is not ready to proceed with adding ACNPs. Appropriate stage-matched interventions for physicians would include facilitating consciousness-raising activities such as an open forum to communicating information about the proposed change and to explore concerns and questions regarding the intervention.

A review of literature indicates limited effort to understand and explain employees' acclimation to, and adoption of, new behaviors required by organization change initiatives. Psychological theories of individual behavior change have, in restricted instances, been applied into organizational environments. The transtheoretical model of change (TTM) offers a comprehensive explanation of behavior change uniting multiple theories of individual change. TTM describes change as a series of stages that individual progress through before arriving at the decision to implement a change in behavior. Movement through the stages is facilitated by processes which increase the probability of a behavior change effort's success. The present research investigated the potential applicability of TTM for explaining individual level change within a new context, specifically, an organizational environment. To examine if individual change in the context of an organization occurs in the fashion described by TTM, measures of core TTM constructs were delivered to employees in a water department of a city in the American southwest. The water department was immersed in an organization change initiative necessitating individual behavior change by its employees. Results of TTM core construct measures and their relationships with each other and the stages of change were examined. Initial findings are indicative of TTM's potential applicability as a description of behavior change within an organizational context. Implications of these findings, potential applications, imitations of the current research, and recommendations for future research are discussed.

The online delivery of higher education courses and programs continues to expand across academic disciplines at colleges and universities. This expansion of online education has been precipitated by, among other things, (a) the rise in personal computer ownership, (b) the ease of access to the Internet, (c) the availability and continuous improvement in technology for the delivery of online courses, and (d) the increase in demand for online courses by both traditional and nontraditional students. However, the proliferation of online education has not been enthusiastically supported by all constituents of higher education. Specifically, some faculty members remain resistant to the shift to online course delivery. This article applies the Transtheoretical Model of Change to the process of gaining faculty support for, and involvement in, online learning. After briefly reviewing current issues in online education and making a case for its adoption, we describe sources of faculty resistance and offer recommendations for interventions that may be applied to transforming faculty resistance to support and eventually to active participation.

The online delivery of higher education courses and programs continues to expand across academic disciplines at colleges and universities. This expansion of online education has been precipitated by, among other things, (a) the rise in personal computer ownership, (b) the ease of access to the Internet, (c) the availability and continuous improvement in technology for the delivery of online courses, and (d) the increase in demand for online courses by both traditional and nontraditional students. However, the proliferation of online education has not been enthusiastically supported by all constituents of higher education. Specifically, some faculty members remain resistant to the shift to online course delivery. This article applies the Transtheoretical Model of Change to the process of gaining faculty support for, and involvement in, online learning. After briefly reviewing current issues in online education and making a case for its adoption, we describe sources of faculty resistance and offer recommendations for interventions that may be applied to transforming faculty resistance to support and eventually to active participation.

Women ages 20–39 years old have seen the most dramatic increase in obesity levels in the United States over the last 2 decades. Researchers have indicated the need for studies to increase motivation in women to promote daily exercise. There is a gap in the literature about what motivational factors are most effective with increasing exercise in daily life. Using the transtheoretical model of change (TM) as the grounding theory, this study measured daily exercise adherence. A selective sampling of women ages 20–39 years old in the United States were recruited to complete an online survey. The online survey included two sections: one to screen participants with informed consent, and the survey itself, including 4 original questions to obtain further information about type of exercise, access to social support, readiness for change, and exercise adherence. A full version of the Exercise Motivations Inventory–2 (EMI-2) was also administered to determine exercise motivation. In total, 105 women were surveyed in the full study and multiple regression was used to assess the findings. Results of the study confirm prior research findings that women engage in exercise due to positive health, ill-health avoidance, and to control weight. In addition, women in the present study indicated positive social support affects daily exercise adherence. The results of this study may contribute to positive social change by furthering our understanding of what contributes to exercise adherence in the United States.

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Organizational readiness for implementation (ORI) is a critical barrier to successfully implementing evidence-based practices (EBPs) that support the recovery of people with severe mental illnesses (SMI). Despite the importance of ORI, to date, no approach for enhancing readiness across an organization has been developed. The two studies conducted as part of this dissertation aimed to identify, organize, and confirm potential strategies to support ORI enhancement in community mental health (CMH) services. Study findings may inform the development of practices to increase ORI, and thus optimize implementation of evidence-based practices in the CMH services. The first study aimed to develop a typology of pre-implementation strategies focused on ORI enhancement. A panel of implementation experts participated in a modified Delphi process to classify pre-implementation strategies into stages of organizational readiness. The experts selected strategies from a well-accepted compilation of 73 implementation strategies, developed as part of the Expert Recommendations for Implementing Change (ERIC) project. The Transtheoretical Model of behavioral change guided the experts in choosing strategies relevant during pre-implementation and classifying them into three readiness stages: Pre-contemplation, Contemplation, and Preparation. The experts identified 48 of the ERIC strategies as relevant to pre-implementation readiness enhancement and agreed on their classification into the three ORI stages. Several strategies were identified as relevant to more than one stage. The purpose of the second study was to confirm and expand the expert-based typology based on empirical data relevant to the implementation of mental health evidence-based practices. The study employed qualitative methods to learn about the experiences of various CMH stakeholders who participated in a recent implementation project. Participants’ feedback about the use of different ORI strategies was compared with the expert-based typology to identify consistencies and discrepancies. Two-thirds of the strategies and their ORI stage designation suggested by the experts were congruent with the second study participants' experiences. Participants also assigned several strategies to different stages than those indicated by the experts and mentioned additional strategies not included in the expert-based typology. The second study highlighted the applicability of the expert-based typology to the CMH field and offered suggestions for potential expansions. Together, these two studies provide an essential step towards conceptualizing and operationalizing the construct of ORI and the strategies for enhancing it in the CMH context. The high congruence between experts and implementers suggests the applicability of the Transtheoretical model for organizing the strategies associated with each stage. This dissertation provides a promising foundation for the future development of a systematic approach to ORI enhancement at various levels of readiness for a practice change. Direct targeting of ORI enhancement could increase the uptake of EBPs and ensure that more people with SMI benefit from state-of-the-art interventions supporting their recovery. / 2023-05-14T00:00:00Z

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