Theses and Dissertations at Montana State University (MSU)
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Item Use of a protocol to improve exam standardization and clinical support for SANE practitioners in Montana(Montana State University - Bozeman, College of Nursing, 2024) McKinney, Elizabeth Anne; Chairperson, Graduate Committee: Carrie W. Miller; This is a manuscript style paper that includes co-authored chapters.Statement of Problem: Sexual assault is a common occurrence throughout the United States with significant side effects. Reporting shows that one in every six women, one out of thirty- three men, one in nine girls, and one in 20 boys are victims of sexual assault. These rates are greater among Native Americans, incarcerated individuals, military members, and those who identify as LGBTQ+IA. Side effects are many and include physical, psychological, and financial repercussions. Research suggests that sexual assault nurse examiners (SANEs) improve not only the judicial outcomes but improve patient's sense of well-being and reduce secondary traumatization. A needs survey administered to a Southeast Montana hospital SANE program indicated provider confusion when training to do the SANE exam due to a lack of standardization among how providers completed the exam. Methods: A needs survey administered to a Southeast Montana hospital SANE program indicated provider confusion when training to do the SANE exam due to a lack of standardization among how providers completed the exam. Using recommendations provided by the National SANE Protocol, a quality improvement plan was created to evaluate the implementation of an adult/adolescent exam protocol, and a flowchart based on the protocol. Participants completed a pre-and post-survey to determine whether the protocol improved exam standardization, exam clarity, staff awareness of exam policy and procedures, quality of exam, confidence in practice, and clinical support of SANEs. Results: Survey respondents were primarily novice and advanced beginners to the SANE role. Prior to the intervention They had low confidence, low levels of clarity surrounding exam requirements, and a poor sense of clinical support. They report collecting high quality evidence and completing exams in line with policies and procedures. Following the intervention all survey elements increased in level agreement whether there was high agreement pre - intervention. Conclusion: The availability of standardized clinical tools increases confidence, clarity, and support among SANE providers, which we theorize will improve retention of SANEs and evidence quality.Item SBAR in long-term care: a quality improvement initiative(Montana State University - Bozeman, College of Nursing, 2024) van Houte, Alyshia Grace; Chairperson, Graduate Committee: Jamie M. Besel; This is a manuscript style paper that includes co-authored chapters.Background: The Situation-Background-Assessment-Recommendation (SBAR) tool was adapted by hospitals from the United States Navy in the late 1990s to improve communication during critical situations. SBAR is regularly used in the hospital setting, but its applicability to long-term care is often underutilized. Local Problem: At a 135-bed long-term care facility, there is no institutionally endorsed standard of communication between nurses and providers. Providers receive instant-messaging style communications from nursing staff that often lack structure and pertinent clinical information. An incomplete clinical picture increases the need for clarification, causing delays to patient care. Communication barriers serve as a source of frustration for nurses and providers. Methods: An interdisciplinary approach was used to develop an educational template that was incorporated into the facility's nursing orientation material. Attendance at staff huddles and face-to-face discussions with floor nurses provided education and introduced SBAR as the standard for nurse-provider communication. The Jefferson Scale of Attitudes Towards Nurse and Physician Collaboration (JSAPNC) measured staff satisfaction regarding interdisciplinary collaboration. SBAR utilization was monitored through regular audits of patient progress notes. Results: No statistically significant change was found in JSAPNC scores pre- and post-intervention; post-intervention rates did not meet the long-term goal of 75% utilization of SBAR for nurse-provider communication. Conclusion: Introductory and regularly interval education fosters high-fidelity use of SBAR, but the impact of SBAR utilization on nurse and provider satisfaction with interdisciplinary communication was indeterminate and requires further study.Item Improving new patient cancer treatment education: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Wilcox, Jamie Michelle; Chairperson, Graduate Committee: Elizabeth A. JohnsonBackground: A cancer diagnosis invokes high levels of uncertainty and anxiety. Healthcare professionals task themselves with providing appropriate education to help patients traverse their cancer treatment experience. Effective communication and educational interventions help patients acquire appropriate coping strategies to manage the disease process and reduce uncertainty. Purpose: This project aimed to improve patient satisfaction and decrease anxiety and uncertainty through an enhanced patient education process. The project took place in a rural outpatient oncology center. Participants included newly diagnosed oncology patients receiving intravenous (IV) chemotherapy/immunotherapy and clinic staff. Method: This project used the Demming Cycle quality improvement method. The education components drew on the guidance of literature reviewed for best practices and national guidelines for patient education and teaching techniques. Data obtained through surveys from patients and RNs, observations from the project lead, and additional feedback from staff informed the development of the education visit components. Intervention: A nurse education visit was scheduled the week before IV treatment started and included a learning needs assessment, clinic tour, education on port-a-cath care, regimen-specific side effects and self-management, and how and when to contact the healthcare team. Nurses provided content using the teach-back method. Results: Patient and staff completed surveys over six weeks of implementation. Sixteen patients completed surveys. 100% (n=16) were confident they could manage their symptoms at home after the education visit. Thematic findings from survey responses regarding the most valuable education piece included Theme 1, logistics of treatment; Theme 2, anticipated side effects and management; Theme 3, other value of knowledge and education regarding managing the disease process. Nine nurses were surveyed 17 times during the project, with each nurse completing 1 to 2 education sessions. 88% (n=17) of nurses surveyed felt the education visit improved from the previous system, and 71% (n=17) of nurses found the teach-back method was supportive of patient outcomes surrounding patient education. Conclusion: Providing a structured education visit for new oncology patients receiving chemotherapy/immunotherapy improved patient confidence in identifying and managing symptoms and side effects of therapy at home. The teach-back method reinforced the education content and demonstrated an understanding of the material.Item Implementing quantitative blood loss for cesarean section deliveries in a critical access hospital: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Donoven, Kristin Lee; Chairperson, Graduate Committee: Jamie M. Besel; This is a manuscript style paper that includes co-authored chapters.Background: The American College of Gynecologists (ACOG) and the Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN) strongly advocate the adoption of quantitative blood loss (QBL) measurement for all deliveries, as opposed to relying on traditional estimated blood loss reporting. This shift is crucial for the accurate detection of postpartum hemorrhage. In the United States, maternal morbidity due to maternal hemorrhage averages 11%, with up to 93% of postpartum hemorrhages being preventable. Objective: To enhance the awareness and recognition of postpartum hemorrhage during cesarean section deliveries (CSDs) among Operating Room (OR) Registered Nurses (RNs) thereby enabling early identification and intervention in a rural Montana critical-access hospital. Methods: Four electronic databases -- CatSearch, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Google Scholar, and Web of Science were accessed to retrieve peer-reviewed studies addressing the support and/or challenge of incorporating a quantitative blood loss program in an operative setting. All included studies were published between 2017 and 2023. After screening articles, 13 were eligible for inclusion. Results: To evaluate the feasibility and effectiveness of the project, a prospective 5-week Plan-Do-Study-Act (PDSA) cycle was implemented. Quantitative blood loss for all CSDs was assessed and documented. Additionally, EBL data was collected for comparison purposes. Using the QBL method, one CSD was identified as a PPH. Conclusions: The quality improvement project improved OR staff confidence in QBL assessment during CSDs. Consistent QBL application will further enhance accuracy and promptness in identifying and managing PPH, ensuring improved maternal outcomes guided by evidence-based practice recommendations. Implications for Practice: QBL precision enables healthcare providers to promptly identify a PPH and initiate timely interventions to mitigate adverse outcomes. By integrating QBL into CSD workflows, healthcare facilities can enhance patient safety, particularly in rural settings where access and resources may be limited. Overall, implementing QBL monitoring for CSDs represents a proactive approach to enhancing clinical practice, optimizing patient care, and reducing the burden of maternal morbidity and mortality.Item Medical flight handoff: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2023) Sunden, Peter Scott; Chairperson, Graduate Committee: Alice RunningBackground: Flight medicine, transporting patients from small facilities over long distances, is essential in rural areas. Providing pertinent patient information to receiving care teams is critical and evidence suggests that over half of the pertinent patient information is omitted. Problem: Incomplete patient information provided by the flight medicine community can negatively impact patient safety and receiving team care. Methods: This QI project intended to increase efficiency of patient handoff to receiving care teams by way of a "drop sheet". The drop sheet was developed using the Mechanism Injuries Signs/Symptoms Treatment (MIST) mnemonic. One carbon copy of the drop sheet was left with the receiving nurse; the flight crew retained the other. A QR code was printed at the bottom of the drop sheet linked to a Likert-type survey assessing the comfort, completeness, timeliness, and effectiveness of the flight crew's patient handoff. Interventions: Training on the drop sheet and survey coincided with the project roll-out January 10th, 2023. Flight crews were instructed to complete a drop sheet on every patient and to leave a copy of the drop sheet with staff on the receiving team. Results: At the projects conclusion, (03/10/2023), 64 flights were completed; drop sheets were used 67% of the time. Four surveys were completed during the data collection time. Conclusions: According to the literature, consistent information provided by flight crew handoffs can improve patient safety and report completeness to the receiving care team. Drop sheets were successfully utilized though receiving care team satisfaction with the process remains inconclusive.Item Development of an acuity scale for the inpatient hospice setting: a quality improvemtent project(Montana State University - Bozeman, College of Nursing, 2023) Blake, Angela Lynn; Chairperson, Graduate Committee: Sandra Benavides-VaelloBackground: Nurse burnout and care fatigue are troubling, prevalent issue within our medical community. Research has shown that high acuity and inequitable staffing assignments contribute to the problem. No streamline solutions have been proposed in the literature. Patient safety events such as falls, and medication errors have been shown to be interrelated to nurse burnout. Balancing workload and patient demands are essential in promoting safe care environments. A 21-bed hospice unit in North Idaho recognized this correlation and requested help in developing an acuity scale to promote nurse to patient staffing equitability thus lessening care burden. Method: A literature review reviled numerous articles promoting staffing balance to stave off care fatigue. Acuity scales are an efficient, concise way to quantify workload and promote balanced staffing assignments. Staff surveys were conducted prior to and post implementation of the tool to measure staff assignment satisfaction. Data was collected on fall rates and medication errors to detect correlation between the two factors. Intervention: Only one published hospice specific acuity scale was identified in the literature review done for this project, Mary Potter Hospice Acuity Tool. A unit specific tool was developed based of the framework provided by this published scale. The acuity tool was trialed on fifty new admissions into the hospice unit between February and March 2023. Results: Limited data was collected as the implementation phase of the project was delayed due to IRB approval and facility specific setbacks. The marginal data collected demonstrates nurse assignment satisfaction improved post intervention while fall rates and medication errors actually increased. Conclusion: This projects objectives were not fully realized due to the previously mentioned delays. The data collected was minimal and greatly impacted. This project provides a solid framework for future developments in unit specific acuity tool development. Future projects such as this one would benefit from a larger timeframe in which to revise the tool being developed and facilitate better impact on the metrics being studied.Item Impact of nurse residency programs on new graduate nurse retention outcomes: an integrative review(Montana State University - Bozeman, College of Nursing, 2023) Evans Nero, Tory Rose; Chairperson, Graduate Committee: Sandra KuntzProblem/Purpose: New graduate nurses are essential employees. Given the nationwide nursing shortage and the turmoil caused by the COVID-19 pandemic, there is a need to focus on new nurses' transition to practice. The transition from an academic setting into real-life practice is often stressful; therefore, nursing organizations have shifted their focus to emphasize new nurse satisfaction, support, and retention through the implementation of nurse residency programs. Nurse residency programs are hospital-implemented programs lasting about a year, and can vary in format, length, and structure. The programs aim to support new nurses' growth in essential skills like critical thinking, prioritization, and delegation. The purpose of this study was to conduct an integrative literature review to identify and evaluate the influence that nurse residency programs have on new graduate nurse attrition and retention outcomes. Procedure/Methods: Electronic database search of CINAHL, PubMed, and Web of Science discovered studies completed in the United States from 2017 to 2022. English-language articles were selected and reviewed for inclusion of registered nurses in an acute care setting that addressed new graduate nurses and intent to leave (attrition or retention) as a primary or secondary measure. Twelve articles met the inclusion criteria. The studies were evaluated for quality using Whittemore and Knafl's (2005) data analysis process. The application of Benner's Novice to Expert (1982) nursing theory provided the framework for the transitional experiences of new nurses. Results: Evidence supports new nurses participating in nurse residency programs experience positive outcomes, including increased confidence, social support, and decreased turnover rates. Workplace challenges and personal stressors were found to negatively impact turnover. Communication, recognition, rewards, and preceptor/mentor support positively influenced retention for at least a year, which provided hospitals with break-even to positive return on investment. Conclusions: New graduate nurses require time to grow and learn during the first year of practice. Three new phases of the novice nurse transition, supported by nurse residency programs, are proposed to enhance the expansion of Benner's theoretical model. The major thematic findings and improved retention rates demonstrate the need for resources and structured support encompassed within nurse residency programs.Item A registered nurse care manager's role in implementing a veteran obesity program(Montana State University - Bozeman, College of Nursing, 2022) Fleming-Weiler, Denise Dawn; Chairperson, Graduate Committee: Denise RiveraAim: A link exists between obesity, hypertension, cardiovascular disease, diabetes, and numerous other comorbid conditions. Studies have shown that weight reduction has a positive effect on comorbid conditions. The aim is to develop an obesity management program that combats obesity in the veteran population by focusing on self-efficacy and the registered nurse (RN) care manager role. Design: Quality improvement project Methods: The databases searched include Montana State University: CatSearch, Google Scholar, ProQuest, CINAHL, MEDLINE, and EBSCO Web of Science. The study participants include adults who met the Center for Disease Control and Prevention's (CDC) definition of obesity, with a Body Max Index (BMI) greater than 30 kg/m 2. Results: Further research could yield better practices for successfully implementing weight management treatment and intervention plans if programs focus on self-efficacy and collaboration with established programs. Additionally, more research would help identify an obesity registered nurse care manager's impact in combating obesity in the veteran populationItem Increasing medication HCAHPS scores using a standardized, simplified process to educate patients on commonly prescribed new medications(Montana State University - Bozeman, College of Nursing, 2021) Wurz, Stephen; Chairperson, Graduate Committee: Margaret HammerslaBackground: An estimated 40% to 50% of patients do not understand their medications leading to 125,000 preventable deaths annually and $100 billion in preventable healthcare costs. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is used to measure patients' perspectives of their care with two of the questions explicitly related to new medication and side effects education. HCAHPS scores drive reimbursement to hospitals. Care that the patient perceives as positive improves outcomes and increases healthcare value. Aim: The aim of this project was to increase patient knowledge of new medications, develop a tool to guide nurse medication education, and improve medication HCAHPS scores. Methods: This project implemented a simple medication education tool which listed 8 common classes of medications, their uses, and most common side effects. This was done to increase patient understanding of prescribed medications on a telemetry floor at a large central Montana hospital. The tool was developed using evidence-based research, RN's were educated on its use, and it was placed at the patient bedside as a resource for patient medication education. Results: A total of 87% of unit RN's were educated on the tool and its expected use. To check for tool at the patient bedside, 6 rooms out of a total of 33 were audited twice weekly for four weeks. Two PDSA Cycles were completed after low rates of tool at the bedside were discovered. Scores improved after each PDSA Cycle with a score of 100% obtained at the beginning of Week 4 of implementation. HCAHPS data was not available at the time of writing. Conclusions: The development of a new medication and side effects education tool was placed at the bedside and used as a guide to educate patients on their prescribed medications. This was done to increase patient comprehension and thereby satisfaction of medication understanding as an attempt to increase HCAHPS scores in the medication education category.Item Development and implementation of a policy to reduce urinary catheter days(Montana State University - Bozeman, College of Nursing, 2022) Trystianson, Bowen Austin Stephen; Chairperson, Graduate Committee: Yoshiko Yamashita ColcloughUrinary catheters are useful medical tools for draining urine. These devices are often used for patients whose medical conditions make urination difficult or may limit their mobility, making toileting challenging. The use of urinary catheters is associated with risks such as trauma or infection. Therefore, medical research aims to limit the usage of urinary catheters only for patients who need intervention and also to reduce the duration of catheter usage. A hospital in central Montana had noted an increase in their overall urinary catheter use. To address this increase a project was started with the goal of revising an existing catheter policy and adding in the authorization for registered nurses to remove catheters when appropriate. To help guide the project, a literature review was undertaken. Research was sought out in the areas of urinary catheter guidelines, utilization of policies, implementation of policies, and sustaining change. Once the literature review was completed, an existing policy was checked against existing guidelines and a point was added to this policy to permit registered nurses to remove urinary catheters when deemed appropriate. Further, this policy was adopted by the facility. Training presentations were then developed and recorded to familiarize nurses with the new policy and the new nurse-driven urinary catheter removal process. An algorithm was developed to aid nurses' decision-making process for the removal of catheters. As there was considerable delay in the project implementation due to various factors, the end goal of achieving a reduction in urinary catheter days was not determined. Despite not achieving the ultimate goal within the specified time, this project is still of value to future quality improvement initiatives. The project identifies a number of potential pitfalls and recommends ways to overcome these obstacles. It also highlights the value of persevering the implementation process despite the associated difficulties and delays.