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Background: Work in palliative care can be a rewarding experience in helping those suffering with complicated illnesses, it can also expose those involved to significant work stress, potentially leading to burnout. Palliative medicine is a medical specialty wherein clinicians provide care for the medical, psychosocial and spiritual needs of seriously ill patients, and facilitate their understanding and coping skills through the illness progression. These clinicians are especially vulnerable to frequent exposure to traumatic situations due to the high density of complicated patients under their care, placing them at risk for burnout.
Objective: The objective of this quality improvement project was to better understand burnout levels in palliative nurse practitioners and nurses in a large inpatient, academic hospital system and to determine the feasibility and effectiveness of implementing mindfulness meditation to reduce burnout levels.
Design: The Maslach Burnout Inventory (MBI) was used to assess burnout pre and post implementation of a brief, self-guided mindfulness intervention via smartphone application. The intervention was performed individually, remotely, and asynchronously with volunteers.
Setting/participants: A total of 12 palliative care nurse practitioners and nurses volunteered from an inpatient palliative care group within a large healthcare system in North Carolina. Results: MBI domains analysis revealed a statistically significant decrease in emotional exhaustion (Pre: 2.2; Post: 1.5; p=.016). The depersonalization domain (emotional disconnect) score did not show a statistically significant decrease in the post-intervention score, but a numerical decrease was reported (Pre: 0.82; Post: 0.65). The personal accomplishment domain score did not show any significant change (Pre: 4.6; Post: 4.5). The reflective questions indicated that many participants felt the mindfulness exercise was feasible, tended to feel calmer, were more relaxed, and were satisfied with the intervention. This correlates to the statistically significant result on the emotional exhaustion subscale, leading to the conclusion that the mindfulness intervention was valuable to those who participated and had efficacious results.
Conclusion: The information gained from this project is vital to better understanding burnout in palliative clinicians given its consequences are detrimental to healthcare systems, patient care and clinicians themselves. By developing evidence-based interventions and training, burnout could be prevented, thereby promoting longevity and satisfaction of clinicians in palliative care. If burnout can be eased, seasoned clinicians can be retained, leading to reduced financial burden on the healthcare system and improved patient care and satisfaction.
This dissertation explores the cybersecurity risk disclosure and the information an organization signals via disclosure contents. Extant literature acknowledges the ability of the cybersecurity risk disclosure to predict subsequent related outcome (i.e., realization of breach incident). However, little research has addressed whether the disclosure signals important information about the IT Risk Culture governing the organization. To fill this gap, I examine cybersecurity risk disclosures using textual analysis and clustering techniques to analyze the IT Risk Culture of a sample of organizations between the years 2011 – 2019. Three classifications of IT Risk Culture are identified. I find that a certain IT Risk Culture, evidenced by the vulnerability and the propensity for risk transfer (i.e. cybersecurity insurance) expressed in the cybersecurity risk disclosure, is associated with subsequent cybersecurity breach. Additionally, the disclosure of Corporate Social Responsibility activity is found to be associated with a second classification of IT Risk Culture, one in which there is no significant association with subsequent cybersecurity breach. This dissertation contributes to holistic risk management literature by employing a systems perspective of IT Risk Culture to analyze related disclosures. Findings contribute greatly to the understanding of IT Risk Culture classification, predominant risk response behavior and the likelihood of subsequent related outcomes.
Introduction: A high-functioning interdisciplinary team is needed to achieve optimal team and patient outcomes in the provision of care for intensive care patients. The difference between a high functioning and suboptimal interdisciplinary team manifest as variations in team outputs. Identification of key characteristics of high functioning teams can be used to assess and evaluate current interdisciplinary teams for potential areas of optimization. Methods: This study is a quality improvement needs assessment of the current interdisciplinary team performance in the neuroscience intensive care unit (NSICU) at a large academic medical center. This project employed a mixed method design, using quantitative methods for collected survey data and qualitative methods for thematic analysis of open-ended responses. Results: The survey had a 59.5% response rate, with 84 team members completing the survey. The majority of participants were registered nurses (n=51), followed by providers (n=21), and then other therapist members (n=12). Five themes were identified from open-ended responses regarding strengths and barriers to team effectiveness: structure, roles, the rounding processes, engagement, and team interactions. Within these themes, the needs of the team included: a shared decision-making model, improved engagement of staff members, improved team stability, clearly defined roles, interventions to improve the rounding process, and further evaluation of team interactions. Discussion: Assessment and diagnosis are the first steps in approaching optimization of the interdisciplinary team. Each interdisciplinary team is unique. Understanding the needs of the team is essential to creating a high functioning team. Key words: Interdisciplinary, Multidisciplinary, Team, Quality improvement, Team processes
More than 760,000 people have died from an opioid overdose since 1999. The opioid epidemic claimed more than 70,000 lives with over 1.6 million having an opioid use disorder in 2019. Literature suggests an association between increased opioid prescribing and increased opioid addiction and by limiting the number of opioid prescriptions written may reduce opioid addiction. There is variation in opioid prescribing practices among acute care providers and opioid prescribing education has been proven to be an effective strategy to optimize prescribing in the acute care setting. This quality improvement project sought to minimize the use of opioids for chronic non-cancer pain by adhering to the Centers for Disease Control Guideline for Prescribing Opioids for Chronic Pain.
Twenty-five acute-care providers including medical doctors, nurse practitioners, and physician assistants participated. This project included a pre-test to measure providers baseline pain management knowledge, an educational module, and then a post-test. Retrospective chart audits were performed on records of patients discharged from the acute care setting from July 2020 to August 2020 with an opioid for chronic non-cancer pain prior to implementation of educational intervention and again January 2021 to February 2021 post-implementation.
Comparison of the pre-and-post-test surveys revealed learning in several areas. Though not statistically significant, (Pre: 40.4; Post: 41.3, p=.276), efficacy of the educational session was evident by improved test scores, pre-test (M = 40.4, SD = 3.5) and post-test (M = 41.3, SD = 4.7). The average number of opioid prescriptions by provider decreased significantly in the post-intervention period (Pre: 3.4; Post: .24, p<.000). Results suggest that implementing opioid-prescribing guidelines can reduce sub-optimal opioid prescribing in the acute care setting, therefore reducing the number of available opioids in the community for diversion and abuse.
Approximately one in five high school student and 1 in 20 middle school students currently use e-cigarettes. The burgeoning number of e-cigarette users from 2017 to 2018, 1.5 million more, prompted the U.S. Surgeon General to declare an e-cigarette epidemic among teens. Serious health problems, such as bronchiolitis obliterans, DNA damage, increased risk for developing asthma and COPD, seizures, anoxic brain injury, elevated blood pressure, elevated heart rate, and myocardial infarction has been associated with exposure of toxic chemicals in the e-liquids that is heated to produce an aerosol and inhaled into the lungs. The long-term effects of e-cigarettes is unknown with research still in its infancy with only a little over 10 years since first introduced in the U.S. Despite a recent decline in the estimated users in 2020, adolescents and young adults continue to use e-cigarettes. The purpose of this scholarly project is to educate teens and young adults about the harmful effects of e-cigarettes in an effort to reduce e-cigarette use among current users. Objectives were to evaluate participants knowledge of perceived harms, implement e-cigarette education, and determine if the education encouraged a reduction in use or promote e-cigarette cessation. A quasi-experimental pre-posttest intervention quality improvement project was implemented at a rural family practice clinic in the southeastern region of the U. S. Participants were between the ages of 13 – 24 who vaped daily, randomized between an intervention group and control group, and administered 3 questionnaires (Initial Questionnaire, PESCDI, and E-cigarette Reasons for Use Scale). Intervention group viewed an educational video on the harms of e-cigarettes. PESCDI was administered as a posttest 2-4 weeks following appointment in the clinic. Initial Questionnaire results revealed that 76% of participants were female and the top 2 reasons for use were curiosity/peer-pressure/friends that use and flavors/tastes good. Majority believed that e-cigarettes were equally harmful (41%) and less harmful (41%) than tobacco cigarettes. Wilcoxon signed-rank test analysis of the PSECDI did not show that the educational intervention was statistically significant, however, median scores in the intervention group decreased indicating an overall decrease in nicotine dependency. Median scores in the control group did increase on posttest denoting a higher nicotine dependence on follow-up. Fisher’s exact tests compared pre and posttests according to categories, although not statistically significant, revealed that the intervention groups posttest PSECDI dependency decreased in the medium and low dependency categories and increased in the not dependent category representative of a clinically significant decline in nicotine dependency. One participant progressed from not dependent to low dependency. Limitations of the project include a small sample size due to small rural family practice and COVID-19 pandemic limiting the number of patients in the office. Future implications include replicating project at multiple sites for larger sample size to determine a statistical significance.
Purpose:
The purpose of this educational project was to determine whether interprofessional team members who participate in a structured educational session demonstrate an increase in knowledge, confidence and self-efficacy in the care of adult brain tumor (ABT) patients. The aim was to evaluate baseline ABT knowledge of neuroscience registered nurses (RNs) and advanced practice providers (APPs) and to identify barriers associated with specialized educational programs.
Methods:
An evidence-based education program on ABT’s was developed and delivered to neuroscience interprofessional team members in a single institution in Charlotte, North Carolina. Three measurement tools were used for data collection. One tool was used to collect demographic information, one was used for a knowledge pre/post-intervention and one for the participants to rate their confidence level. RNs and APPs functioning in a neurosurgical, neurointensivist or neurohospitalist role were eligible to participate. Travel RNs were excluded.
Results:
Seventeen care providers participated in this project. Descriptive statistics were used to analyze the demographic characteristics of the participants, belief in supplemental education, and pre/post-intervention knowledge assessment items. McNemar’s test for paired binary data and StataCorp v.16 statistical software (2019) were used. Six participants recalled prior education specific to ABTs and 94% (n=16) believed additional education would be beneficial. A statistically significant increase in correct responses from the pre-posttest was seen in one question pertaining to histological grading classification system (p=.031). The lowest response recorded on the confidence survey was regarding the APP’s level of comfort in discussing treatment plans with patients and caregivers.
Implications:
The results of the project created a basis for understanding neuroscience team members level of knowledge and confidence. Further study is needed to determine effective educational strategies for the neuroscience team.
Keywords: brain neoplasm, clinical guidelines, specialized training
Though North Carolina is home to the 9th largest Indigenous population in America, as well as to the largest Tribe East of the Mississippi, North Carolina curriculum and schools often erode Indigenous histories from the classroom. Indigenous people are presented as forever constrained within antiquity, as savage, as docile, as stoic, and at worst – as nonexistent. This study centers Native students who traverse through these systems that perpetuate stereotypes of Indigenous barbarism, passivity, and erasure, with a focus on Native students living in urban areas of North Carolina. Similarly, non-Native teachers were interviewed for this study to discuss their role in this system as well as what they are doing to challenge it. Themes include problematic curriculum, anti-Indigeneity, erasure, White supremacy, and resistance and resilience.
Guidelines recommend prescribing four classifications of medications for individuals with heart failure with reduced ejection fraction (HFrEF). Individuals on guideline directed medical therapy (GDMT) have been shown to have reduced mortality and morbidity. If all eligible individuals were on GDMT, lives saved could be improved by 60% annually. The largest impact comes from prescribing GDMT with the lowest prescribing rates. Further evidence has confirmed there is a lack of guideline adherence in outpatient prescribing. Use of provider reminders with decision support improves adherence to guidelines.
Study Objectives: Determine the prescribing behaviors of advanced practice providers (APPs) and physicians before and after implementation of a provider reminder tool that offers decision support in outpatient prescribing.
Methods: This scholarly project occurred over two months in the fall of 2020. Eligibility criteria to have reminders placed in the chart included adults with HFrEF with a left ventricular ejection fraction (LVEF) less than 40%, seen by an APP or physician in an outpatient cardiology practice. When patients were seen in the office for their scheduled visit, providers had access to their electronic medical record (EMR) with the reminder tool sent as a provider communication note for all visit types. An additional paper reminder tool was handed to the provider for in-person visits. Following patient visits, prescribed medications were recorded to allow for pre-post comparisons. Analysis included descriptive statistics and McNemar’s test for paired nominal data using StataCorp v.16 statistical software (2019). Subgroup analysis was performed by provider type and visit type.
Results: A convenience sample of 120 consecutive provider-patient encounters was evaluated in a southeastern United States outpatient cardiology practice. Compliance with renin-angiotensin-aldosterone system (RAAS) inhibitors, beta blockers (BB), and hydralazine-isosorbide dinitrate (H-ISDN) were numerically improved, though not statistically significant. Compliance to aldosterone antagonists (MRA) showed significant improvement after the intervention for all patients (35.8% to 41.7%, p=.020), which continued after adjusting for contraindications by medication classification. Post intervention prescribing was improved in all visit types for all medication classes except RAAS inhibitors, beta blockers, and H-ISDN in virtual visit formats. Visit type influenced prescribing of RAAS inhibitors and MRAs. In-person RAAS inhibitor and MRA prescribing had significant improvement after the intervention (78.3% to 95.7%, p = .0455; 39.1% to 56.5%, p =.0455, respectively). Improvement in prescribing was noted for APPs and physicians, except for beta blockers among physicians. Subgroup analysis of provider type did not yield any statistical difference. Uptitration of medications were numerically increased for beta blockers and RASS inhibitors. Uptitration was significantly higher in heart failure providers for RAAS inhibitors as compared to non-heart failure providers (29%; 6.5%, p=.004). The opposite was true for beta blockers, with non-heart failure providers uptitrating more (19.2%), but it was not statistically significant.
Conclusions: This scholarly project demonstrated that an electronically delivered, paper generated provider reminder tool with decision support can clinically impact guideline adherence. With in-person visit type, the tool was statistically impactful. These findings are consistent with the literature. Given the uptake in the frequency of virtual visits following the coronavirus disease pandemic, virtual visit type reduced initiation of RAAS inhibitors and beta blockers, which require vital sign data. Provider type did not impact guideline prescribing. Being a heart failure specialist positively impacted prescribing.
ABSTRACT
ANDREW GARDNER. DACA Recipients Narratives: Pursuing Noncredit Occupational Training. (Under the direction of DR. MARK D’AMICO)
This adapted in-depth qualitative interview study explored and documented the lived experiences of four DACA recipients that pursued noncredit occupational training opportunities at a community college in North Carolina. The purpose was to understand what experiences led DACA recipients to enroll in noncredit occupational education in the community college setting, insight about their educational experiences in higher education, and how they used the education they gained through noncredit occupational education. Participant interviews styled after Seidman (2019) served as the primary means of data collection. Following Seidman (2019) protocols for an adapted in-depth qualitative interview, participants put their life into context, provided detailed accounts of certain critical life experiences, and reconstructed their experience within the framework of the study. Upon completion of all interviews and transcription, a detailed six phase thematic analysis guided by Braun and Clarke (2006) was completed. Though their experiences varied, four major themes were identified during the analysis process. Themes generated spoke to the personal, professional, and social experiences that shaped their journey and aspirations. The findings provided insight about each participant’s desperate path to pursue higher education and how noncredit occupational training provided them a “hidden” opportunity. Family played the greatest role in motivating and supporting participants during their journey. A high level of determination and perseverance was displayed. Participants combated obstacle after obstacle to enroll in postsecondary education and successfully leveraged it to embark on their professional career. Three conclusions were reached: (1) policies influence DACA students; (2) DACA students receive a lack of guidance; (3) DACA students leverage credentials.
The Institute of Medicine’s report “To Err is Human” remains relevant two decades later: medical error is the fourth leading cause of death in the United States and 40% of hospitalized children experience medical error. One obstacle to safer care is lack of error reporting. That omission denies the opportunity to learn from those events. Safety Culture describes a work environment conducive to reporting, and its properties are measurable using the Safety of Patients Survey (SOPS 1.0 TM). On a pediatric acute care unit in a children’s hospital in southeastern U. S., SOPS 1.0TM scores and error reporting fell well below agency benchmarks. The purpose of this quality improvement project was to improve error reporting and SOPS 1.0TM scores specific to reporting through a Safety Huddle Intervention. Marshall Ganz’s Change through Public Narrative Framework provided the theoretical design for this project: a story of self, a story of us, a story of now. The SOPS 1.0 TM was implemented before and after the six-week intervention on the project unit and a comparison unit and monthly error reporting was tracked before and after the intervention on those same units. The 5 composites of SOPS 1.0 TM purported to measure reporting culture showed no statistically significant differences after the intervention, or between the project and comparison units. Error reporting increased after the intervention on the project unit (p=0.0121) but not the comparison unit. Of note, this quality improvement project took place during the COVid 19 pandemic, and survey results revealed a preoccupation with staffing as an overriding concern for patient safety.
