Sue & Bill Gross School of Nursing

Survival-to-hospital discharge rates remain low for outside-hospital cardiac arrest (OHCA) in the U.S. largely due to delays in activating the American Heart Association (AHA)’s chain of survival for adult OHCAs. There is a growing need to equip non-medical volunteers in parish communities to respond effectively to medical emergencies during worship services. Literature indicates that bystander-initiated CPR achieves outcomes comparable to physician-initiated CPR. Chest-compression only CPR for bystanders has been shown to yield similar survival rates to conventional CPR with ventilation, making it a viable alternative for bystanders. The project was guided by the Johns Hopkins Evidence-Based Practice Model/Framework. The project occurred at a local non-denominational church in Southern California. Sixteen volunteers included adult and adolescent (12+) Parish volunteers. The intervention included a 2-hour in-person didactic and hands-on practice session provided by a registered nurse, utilizing the American Heart Association’s Hands-Only CPR and AED training with a live feedback mannikin device. Pre- and post-intervention surveys measuring willingness and knowledge of CPR-AED use were collected before and immediately after using the validated Factors Influencing Community Willingness to Perform Cardiopulmonary Resuscitation and Use AED (FIXED) questionnaire. Sixteen participants (n=6 males and n=10 females) of which two (12.5%) are students, four (25%) are working in healthcare-related careers, ten (62.5%) are working in non-healthcare related careers. A 20% increase in pre- and post-intervention surveys was shown in the willingness domain, specifically for the slightly more, moderately, and extremely confident points of the FIXED questionnaire tool utilized. There is also an increase in intention to conduct CPR in a stranger, elderly, child, and family member. A total score of ≥14 (out of 18 questions) is reflective of a participant's “good” grasp of CPR-AED use knowledge defined as ≥75%. The pre-intervention participants’ “good” knowledge score was 0% (0 of 16 participants), whereas the post-intervention “good” knowledge score was achieved by 81.25% (13 of 16) of the participants. Overall, the primary and secondary outcomes were achieved as evidenced by the overall improved willingness and knowledge of CPR/AED use. The project site acknowledges the positive outcomes and has agreed to continue bi-annual comprehensive CPR/AED training to encourage knowledge retention and continual improvement of willingness to conduct bystander CPR/AED during a cardiac arrest emergency. Future data will be collected from the 6-month intervention training.

Purpose: This Doctor of Nursing Practice (DNP) quality-improvement (QI) project evaluated the impact of a peer-led certification workshop on the perceived value of specialty certification among medical-surgical and telemetry (MST) nurses and assessed certification engagement and barriers. Background: Specialty certification for registered nurses (RNs) is associated with improved patient outcomes, professional satisfaction, and career advancement. Despite these benefits, certification rates remain <1% among MST nurses at an acute care community hospital, compared to the average 51% in Magnet hospitals and 34% in non-Magnet hospitals. Barriers such as lack of time, limited confidence, and insufficient access to resources persist despite institutional support, including books, certification reimbursement, and a $500 incentive. Methods: This pre-post QI project was conducted at a community hospital in California. MST nurses were invited to attend a 1-hour Zoom workshop covering test-taking strategies, test anxiety management, and practice questions facilitated by volunteer peer staff nurses. Pre- and post-intervention surveys assessed certification interest, confidence, barriers, and the validated Perceived Value of Certification Tool (PVCT). An 8-week follow-up survey evaluated engagement towards certification. Results: Mean PVCT scores increased from 36.7 (pre, n=16) to 41.6 (post, n=11) (p = 0.01, Hedges’ g = 1.14). Common pre-intervention barriers included lack of time (69%) and fear of failure (50%). All post-intervention participants (n=11) reported the workshop as useful and were satisfied with the peer-led format. At 8-week follow-up (n = 7), all participants reported plans to pursue certification within six months and engaged in certification-related activities, including obtaining study materials (100%), researching eligibility (80%), enrolling in a review class (80%), joining a study group (60%), and meeting with a mentor (20%), reflecting progression from intention to action. Conclusion: The peer-led certification workshop increased the perceived value of certification and promoted engagement in certification activities. Peer-led educational interventions represent a scalable strategy to enhance certification readiness, but should be accompanied by complementary organizational efforts to address system-level barriers.

Background: A national intravenous fluid (IV) shortage prompted our institution to implement fluid conservation measures in the perioperative setting. Results from a preliminary survey conducted during the restriction period revealed that most anesthesia providers did not adhere to the restriction guideline, with nearly half opposing its implementation. There was a noticeable increase in anecdotal reports of postoperative nausea and vomiting (PONV) and hypotension in the postoperative anesthesia care unit (PACU). A multidisciplinary anesthesia team subsequently developed and implemented an updated preoperative IV fluid guideline concurrent with the replenishment of IV fluid supplies. This is particularly relevant given persistent gaps in national and local preparedness for supply chain disruptions driven by escalating natural disaster events. Objective: This QI project sought to evaluate improvements in provider reported adherence, workflow efficiency, and perceived utilization following the implementation of an updated, evidence-based guideline, with the goal of informing future planning in the event of an IV fluid shortage without compromising postoperative outcomes. Methods: This QI initiative was conducted within an urban anesthesia department at an academic Level I trauma center. A survey was distributed to 209 anesthesia providers within the department to evaluate an updated guideline, assess adherence, and examine provider perceptions. The Logic Model framework was employed to systematically identify and assess short and long term outcomes related to the guideline implementation. Results: A follow-up survey showed that while most providers reported low to moderate adherence, nearly twice as many providers chose to follow the updated guideline compared to the original (55% vs. 26%). Provider perceptions were more positive overall, with fewer expressing opposition. More providers felt that fluid waste was no longer a concern and believed the guideline did not cause delays or alterations in treatments or surgical start times. Although self reported on-time case rates did not improve, many providers reported increased satisfaction with having fluids prepared preoperatively. Sixty percent of respondents felt that 500 mL was sufficient for cases under two hours. The survey results identified certain procedural and surgical locations where reducing volumes to 250 mL was considered safe, as well as there was strong provider opposition to such reductions. The site of anesthesia delivery, patient acuity, and duration were identified as significant factors influencing providers’ perceptions of a safe initial IV fluid volume. Conclusion: When facing externally imposed fluid restrictions, a clear gap in practice was identified, in which no guidelines existed to drive clinical decision making. While provider acceptance improved, an adherence paradox emerged - support for the guideline increased, yet the proportion of providers who reported not following it rose, suggesting acceptance does not guarantee compliance. Additionally, under-resuscitation carries meaningful patient safety risks including PONV, hypotension, acute kidney injury, and myocardial infarction, reinforcing that fluid volumes must be tailored to patient acuity, surgical location, and case duration. There is a gap in the literature regarding fluid shortages and patient outcomes. Future studies should expand data collection to include patient outcomes, develop guidelines through expert feedback, and establish organizational policies to address IV supply chain disruptions, so that facilities have a clear basis for decision making.

OBJECTIVE: To determine the association between food insecurity and HIV infection with depression and anxiety among new tuberculosis (TB) patients. DESIGN: Our cross-sectional study assessed depression, anxiety and food insecurity with Patient Health Questionnaire (PHQ-9), Zung Anxiety Self-Assessment Scale (ZUNG) and Household Food Insecurity Access Scale, respectively. Poisson regression models with robust variance were used to examine correlates of depression (PHQ-9 ≥ 10) and anxiety (ZUNG ≥ 36). SETTING: Gaborone, Botswana. PARTICIPANTS: Patients who were newly diagnosed with TB. RESULTS: Between January and December 2019, we enrolled 180 TB patients from primary health clinics in Botswana. Overall, 99 (55·0 %) were HIV positive, 47 (26·1 %), 85 (47·2 %) and 69 (38·5 %) indicated depression, anxiety and moderate to severe food insecurity, respectively. After adjusting for potential confounders, food insecurity was associated with a higher prevalence of depression (adjusted prevalence ratio (aPR) = 2·30; 95 % CI 1·40, 3·78) and anxiety (aPR = 1·41; 95 % CI 1·05, 1·91). Prevalence of depression and anxiety was similar between HIV-infected and HIV-uninfected participants. Estimates remained comparable when restricted to HIV-infected participants. CONCLUSIONS: Mental disorders may be affected by food insecurity among new TB patients, regardless of HIV status.

The Veterans Health Administration (VHA) Office of Nursing Services (ONS) was an early adopter of Clinical Nurse Leader (CNL) practice, generating some of the earliest pilot data of CNL practice effectiveness. In 2011 the VHA ONS CNL Implementation & Evaluation Service (CNL I&E) piloted a curriculum to facilitate CNL transition to effective practice at local VHA settings. In 2015, the CNL I&E and local VHA setting stakeholders collaborated to refine the program, based on lessons learned at the national and local level. The workgroup reviewed the literature to identify theoretical frameworks for CNL practice and practice development. The workgroup selected Benner et al.'s Novice-to-Expert model as the defining framework for CNL practice development, and Bender et al.'s CNL Practice Model as the defining framework for CNL practice integration. The selected frameworks were cross-walked against existing curriculum elements to identify and clarify additional practice development needs. The work generated key insights into: core stages of transition to effective practice; CNL progress and expectations for each stage; and organizational support structures necessary for CNL success at each stage. The refined CNL development model is a robust tool that can be applied to support consistent and effective integration of CNL practice into care delivery.

AIMS: To determine the power of a conceptual clinical nurse leader practice model to explain the care model's enactment and trajectory in real world settings. BACKGROUND: How nursing, organised into specific models of care, functions as an organisational strategy for quality is not well specified. Clinical nurse leader integrated care delivery is one emerging model with growing adoption. A recently validated clinical nurse leader practice model conceptualizes the care model's characteristics and hypothesizes their mechanisms of action. METHODS: Pattern matching case study design and mixed methods were used to determine how the care model's constructs were operationalized in one regional United States health system that integrated clinical nurse leaders into their care delivery system in 2010. RESULTS: The findings confirmed the empirical presence of all clinical nurse leader practice model constructs and provided a rich description of how the health system operationalized the constructs in practice. The findings support the hypothesized model pathway from Clinical Nurse Leader structuring to Clinical Nurse Leader practice and outcomes. CONCLUSION: The findings indicate analytic generalizability of the clinical nurse leader practice model. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing practice organised to focus on microsystem care processes can catalyse multidisciplinary engagement with, and consistent enactment of, quality practices. The model has great potential for transferability across diverse health systems.

Background: Type 2 diabetes is a growing problem across the world. Diabetes leads to increased levels of hemoglobin A1c (A1C), and if left untreated, can lead to further chronic disease. This review examines the effectiveness of group-based diabetes self-management education (DSME) on lowering A1C levels and increasing diabetes knowledge.

Methods: Databases used for this review include PubMed, CINAHL, Google Scholar, and Web of Science. The three studies chosen for this review include two randomized controlled trials (RCT's) and one quasi-experimental study, which were peer-reviewed and published in the past 5 years.

Results: All studies demonstrated a slight decrease in A1C levels; however, one study found a significant decrease between pre-and-post intervention (p<0.0001). The two RCT's also reported a significant increase in diabetes knowledge.

Discussion: The strengths found across all studies were the study design used, fidelity of the intervention, and validity of the methods used to measure the primary outcome. All three studies took a different DSME approach; however, their end-goal was the same as they measured similar outcomes.

Conclusion: DSME is a feasible approach in improving diabetes education and attempting to reduce A1C levels. Further research is needed to develop a standardized curriculum that maximizes the benefits of DSME.

Sleep deprivation is a common problem in the intensive care unit because it can increase rates of delirium, impede proper recovery, lead to longer hospital stays, and increase health care costs. This study aims to review three randomized controlled trials that observe the effect of noise reduction methods in improving sleep quality among intensive care patients. One study compared rates of delirium among those use earplugs and those who do not. Two other studies found that interventions such as earplugs, eye masks, and melatonin have proven to improve sleep quality. While interventions such as earplugs may be uncomfortable for some patients, it is reasonable it to at least offer these products to those who may want it. This can in turn improve patient satisfaction rates, decrease hospital length of stays and reduce healthcare costs. Moreover, these interventions are safe, cost effective, and easy to implement.

Faculty advisor: Jill P Berg, Ph.D., Professor Emeritus (jpberg@uci.edu) - Program in Nursing Science

Interpretation of pain in infants - especially in the NICU - is difficult to assess due to their inabilities to communicate verbally or demonstrate their pain. Most often, healthcare providers rely on indicators such as facial activity, changes in muscle tone, and duration of sleep/wake states to assess the presence of pain. With the high incidence of painful procedures occurring in the NICU, it is essential to find effective methods to decrease the associated discomfort and assist infants in gaining short and long term benefits. While there are a variety of methods to treat and manage pain levels in the NICU, the focus of this paper will be on one: the administration of oral sucrose.

Faculty advisor: Yuqing Guo, Ph.D. (gyuqing@uci.edu) - Program in Nursing Science