Nursing School Theses, Dissertations, and Doctoral Papers

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How Older Adult Caregivers Manage Wound Care Procedures, Resources Needed, and Public Policy Implications
(2022-10) Swartzell, Kristen Leigh; Fulton, Janet S.; von Gaudecker, Jane R.; Bartlett Ellis, Rebecca J.; Huber, Lesa
As healthcare increasingly shifts to home and community-based settings, informal caregiver responsibilities are increasing beyond assistance with activities of daily living to include complex care procedures previously performed by licensed caregivers in clinical settings. With an aging population, increasing numbers of older adults are assuming a caregiving role, a trend that is projected to continue into the foreseeable future. These older caregivers performing complex care procedures such as wound care. The purpose of this dissertation study was to understand how older adult caregivers manage complex wound care procedures. Aims were to 1) develop a theory for how caregivers manage; 2) identify themes related to resources needed, and 3) determine resources available through the existing Medicaid 1915(c) waivers program. Aims 1 and 2 were achieved using qualitative analysis of interviews with 18 older adult caregivers aged 65 and older who were performing wound care in the home for a care recipient. Grounded theory methods were used to develop a theoretical framework describing the process of how the participants managed caregiving. The resultant theory, Pushing Through, consisted of five phases: 1) accepting the role, 2) lacking confidence, 3) creating a system, 4) trusting in self, 5) owning the outcomes. Secondary analysis of the interview data used thematic analysis methods to identify resources used or needed for the caregiver role. The resultant themes were (a) connection to a healthcare professional, (b) written instructions, (c) access to wound care supplies, (d) access to durable medical equipment, (e) financial resources, (f) personal care coverage, and (g) socialization and emotional support. Aim 3 used descriptive analysis of Medicaid 1915(c) home- and community-based services waivers for adults aged 65 and older for all 50 states plus the District of Columbia to identify the frequency and type of waiver services available for supporting caregivers. Results revealed that the number of services offered by state Medicaid waiver programs varied greatly across the country. Respite in varying forms was the most frequently available service. Findings from this dissertation will contribute to the development of evidence-based strategies to sustain older adult caregivers within their caregiving role.
Hospital Transfers: Perspectives of Nursing Home Residents and Nurses
(2022-05) Ahmetovic, Alma; Hickman, Susan E.; Draucker, Claire Burke; Huber, Lesa; Unroe, Kathleen T.
Between 1 million and 2.2 million nursing home residents are transferred to a hospital emergency department each year. These transfers are costly, have negative health outcomes, and can increase the morbidity and mortality of residents. Few studies, however, have provided in-depth descriptions of transfer experiences. The purpose of this study was to examine the transfer process between the nursing home and the hospital from the perspectives of nursing home residents and nurses, focusing on how decisions were made to transfer residents. Using a qualitative descriptive method, 22 participants (10 residents and 12 nurses) were recruited from four nursing homes located in rural Indiana. Purposive sampling, semi-structured interviews, and conventional content analysis were used to collect and analyze narratives obtained from residents and nurses about their experiences with a recent transfer and to develop four in-depth case descriptions of these transfers. The participants described four aspects of the transfer process: transfer decisions, transport experiences, hospital stays, and returns to the nursing home. The most common reason for transfers was an acute exacerbation of a chronic condition, and the decision to transfer was often made by a nurse. Most participants found aspects of the transfer, including their hospital stay, to be aversive or upsetting. The return to the nursing home was typically welcomed but often challenging due to problems with mobility, medication adjustments, and cognitive changes. Participants also provided several recommendations for avoiding potentially preventable transfers including adding “in-house” diagnostic testing and treatment equipment, improving staff competencies in managing acute exacerbations, increasing staffing, improving communication among staff, and increasing staff familiarity with resident histories and preferences. The findings have several clinical and policy implications for preventing or decreasing the negative effects of hospital transfers.
Identification, Quantification, and Characterization of Nursing Home Resident Pain Trajectories
(2022-05) Cole, Connie Sue; Hickman, Susan; Blackburn, Justin; Carpenter, Janet S.; Chen, Chen X.
Pain prevalence in nursing home (NH) residents is high. Studies report up to 85.0% of NH residents experience pain and up to 58.0% experience persistent pain. Pain in NH residents can lead to decreased happiness, quality of life, and life satisfaction. Traditionally, pain has been studied in relation to specific comorbid conditions or pain subtypes (nociceptive, neuropathic) with little consideration for the dynamic (temporal) nature of pain. Current pain subtypes are clinically linked to recommended pain treatments and provide insight into underlying mechanisms. However, current pain subtypes are limited by their focus on pain origin, do not include severity or duration of the pain experience, and do not illustrate how the course or trajectory of pain changes over time. Understanding the trajectory of pain experience can provide opportunities to alter the course of pain experience, improve residents’ quality of life and prevent adverse outcomes. This dissertation provides the first evidence of four distinct pain trajectories among NH residents including persistent pain which was associated with several resident characteristics and clinically relevant diagnosis. Using residents’ characteristics associated with persistent pain, such as a history of fracture or contracture, may improve care planning based on early identification or risk stratification and can improve mitigation of persistent pain. To identify and characterize pain trajectories in NH residents, the following activities were completed (1) systematic review of the literature related to prevalence of pain and associated factors in NH residents, (2) cross-sectional analysis of secondary data to examine prevalence of pain, persistent pain, and factors associated with pain in NH residents, and (3) a longitudinal retrospective analysis of secondary data using group-based trajectory modeling to identify, quantify, and characterize NH pain trajectories. The findings from this study highlight the prevalence and complexity of pain in NH residents.
Exploring Mentoring Relationships Among Novice Nurse Faculty: A Grounded Theory
(2021-07) Busby, Katie Ruth; Reising, Deanna L.; DeMeester, Deborah; Seybold, Peter J.; Draucker, Claire Burke
The growing and aging population has created an increased demand for health care, resulting in a need for hundreds of thousands more nurses across the United States. As a result, additional nurse faculty are needed to teach the next generation of nurses. However, nurses who enter the faculty role in academia often come from various professional backgrounds with different educational preparation that may not equate to success with the tripartite faculty role of teaching, scholarship, and service. As a way to retain and develop novice faculty, mentoring relationships and programs are promoted as an intervention for career and psychosocial development within academia. Mentoring is an interpersonal process built on mutual trust and friendship to create a professional and personal bond. Mentoring relationships can help develop self-confidence, productivity, and career satisfaction among nurse faculty members. Effective mentoring relationships can ease the transition into academia and provide a vital foundation for productive academic careers. However, the interpersonal process that is the hallmark of mentoring can differ between a mentor and protégé, leading to vast differences in quality and effectiveness. Although mentoring is widely recommended, little is known about the process of mentoring relationships in academia or how novice nurse faculty utilize mentoring to transition into academia. The purpose of this qualitative grounded theory study is to uncover a theoretical framework that describes how mentoring relationships, as experienced by novice nurse faculty, unfold. Charmaz's method of grounded theory was used to interview full-time novice nurse faculty (N = 21) with three years or less in the faculty role from nursing programs across the United States. The grounded theory theoretical framework, Creating Mentorship Pathways to Navigate Academia captures the process of mentoring as experienced by novice nurse faculty within academia. The theoretical framework contains five main phases as described by novice nurse faculty being assigned a formal mentor, not having mentoring needs met, seeking an informal mentor, connecting with mentor, and doing the work of mentoring. Participants created mentorship pathways through both formal and informal mentoring relationships to navigate academia by acquiring knowledge, meeting expectations, and functioning in the role as a faculty member.
Leadership Characteristics of Nurse Managers Associated with Implementation of Evidence-Based Practice
(2021-12) Noth-Matchett, Amanda Ann; Newhouse, Robin; Von Ah, Diane; Ellis, Rebecca Bartlett; Menachemi, Nir
The implementation of evidence into practice is a complex process. Estimates indicate that it takes seventeen years on average for research to be translated into practice. Delay in implementation of evidence-based practice (EBP) results in poor patient outcomes and negative impacts to healthcare systems. While many factors contribute to delayed implementation of evidence, organizational characteristics of healthcare institutions have a significant impact on implementation. Leaders play a critical role by influencing these organizational characteristics to support evidence-based practice implementation. A key leadership role within acute care healthcare organizations is that of the front-line nurse manager (NM). Front-line nurse managers have responsibility for nursing unit operations and clinical nurses who deliver patient care under the nurse managers supervision. The relationship between NM leadership competencies and implementation of EBP is not well understood. Therefore, there is a critical need to identify how NM leadership behaviors influence the implementation of EBP. This dissertation examined the relationship between NM leadership behaviors and implementation of EBP. Results link the role of the NM to evidence-based clinical practice, and describe competencies and education needed for NM development. With an understanding of the NM leadership behaviors associated with implementation of EBP, healthcare leaders can develop education, processes, and interventions to increase competencies on NM leadership behaviors. Better implementation support by NMs will result in an improvement in use of EBPs. To examine the NM leadership behaviors that are associated with implementation of EBP, the following activities were completed: (1) an integrative review of the literature related to NM competencies associated with implementation, (2) identification and description of nurse manager competencies associated with EBP implementation using the Delphi method, and (3) examination of NM leadership behaviors associated with implementation of EBP during the COVID-19 pandemic response through a multi-site descriptive correlational survey of NMs and their nursing staff. Results of these studies demonstrate the importance of NM leadership characteristics and behaviors on EBP implementation.
Activation in Persons with Opioid Use Disorders in Intenstive Outpatient Treatment
(2021-12) Keen, Alyson Yvonne; Lu, Yvonne; Draucker, Claire Burke; Oruche, Ukamaka; Mazurenko, Olena
Persons with opioid use disorder (OUD) often receive intensive outpatient treatment (IOT) but these programs are associated with low rates of completion and high rates of relapse. Enhancing patient activation - taking an active role in one’s healthcare - would likely improve outcomes for persons with OUD in IOT. The overarching purpose of this dissertation is to describe how persons with OUD experience IOT, especially regarding activation. The dissertation includes three components. The first is an integrative review of 29 studies of activation in persons with mental health disorders generally. Results revealed that activation was related to several heath and treatment-related factors and some interventions, most notably educational programs, increased activation. The second and third components were based on interviews with 14 persons who had been enrolled in an IOT program in academic health centers. The second component was a constructivist grounded theory study conducted to describe the process people undergo as they participate in an IOT program. Participants described a process of connecting and disconnecting that included eight stages: (1) connecting with drugs, (2) disconnecting from everyday life, (3) connecting with the IOT program, (4) connecting with others in the IOT program, (5) disconnecting from drugs, (6) reconnecting with others, (7) reconnecting with self, and (8) disconnecting from the IOT program. The third component was a qualitative descriptive study conducted to describe types of instances in which persons play an active role in their IOT (activation). Participants described six types of instances: (1) making and enacting one’s own treatment decisions, (2) actively engaging in treatment planning with staff, (3) choosing to actively engage in groups, (4) making a commitment to treatment, (5) taking responsibility for one’s own recovery, and (6) taking actions to avoid relapse. The results of this dissertation will inform the development of strategies to enhance activation among persons with OUD in IOT with the goal of improving engagement and program outcomes.
Understanding of Interprofessional Communication to Impact Patient Safety in the Operating Room: A Grounded Theory Study
(2021-11) McNealy, Kimberly Renee; Reising, Deanna L.; Draucker, Claire Burke; Wonder, Amy Hagedorn; Parrish-Sprowl, John
Intraoperative adverse events (IAEs) due to interprofessional miscommunication continue to occur despite implementation of surgical checklists and focused communication trainings. Much of the previous intraoperative communication research has focused on the content and quantity of interprofessional communication instead of its context and quality, and current communication interventions seem to have varying levels of engagement, effectiveness, and persistence. The purpose of this dissertation study was to explore the psychosocial processes involved during the establishment and maintenance of interprofessional communication surrounding IAEs or potential IAEs in the intraoperative environment and to identify the perceived facilitators and barriers to communication. Twenty surgical team members participated in semi-structured interviews and described their experiences with interprofessional communication during IAEs. Grounded theory methodology was used to identify the central process, Testing the Water, and two subprocesses, Reading the Room and Navigating Hierarchy. Testing the Water describes the situational nature of interprofessional communication as surgical team members navigate factors influencing the context and probable trajectories of surgical cases and the perceptions of professional rights and responsibilities within surgical teams. Participants in this study experienced Testing the Water differently based on their professional roles and tenure; findings were organized around three emerging groups identified as inexperienced nurses, experienced nurses, and surgeons. Interprofessional communication surrounding IAEs occurred for study participants in fluid, iterative phases identified as 1) Recognition, 2) Reconnaissance, 3) Rallying, 4) Reaction, and 5) Resolution. Participants recognized IAEs or potential IAEs, gathered information through reconnaissance, rallied other team members, reacted to stabilize patients, and resolved IAEs through individual or surgical team reflection. Study participants reported using strategies during communication to accomplish two psychosocial goals, preserving the flow of surgical cases, and protecting the ‘face’ of themselves and other surgical team members. Supporting these psychosocial goals through increased psychological safety for all surgical team members potentially leads to more effective, timely surgical team communication. More effective interprofessional communication facilitates the improved situational awareness, collective sensemaking, and integrated team mental models that are critical to coordinated responses to IAEs. The findings of this study suggest practical implications to increase the effectiveness of interprofessional communication in the intraoperative environment.
Evidence-Based Practive Sustainability and Nursing Professional Governance
(2021-10) Ferren, Melora Darlene; Newhouse, Robin; Von Ah, Diane; Ellis, Rebecca J. Bartlett; Menachemi, Nir
Patient care that is not based on evidence-based practice (EBP) could be considered malpractice, and it threatens patient safety, quality, and fiscal performance. EBP implementation is complex, and sustainment of these practices is such a persistent challenge that up to 70% of organizational change fails to be sustained. Sustainment of EBP decreases healthcare costs and improves patient outcomes. Professional attributes that influence sustainability are not well understood. Nursing professional governance (PG) is a framework of professional attributes that includes accountability, professional obligation, collateral relationships, and decision-making. This framework includes attributes that are necessary for professionals to effectively govern their profession and influence outcomes. Healthcare professionals are an important component of sustainability frameworks; however, the professional attributes that influence sustainability have not been validated by research. The purpose of this dissertation was to examine the influence of professional attributes on the sustainability of EBP and patient outcomes. This was accomplished through 1) an ethnographic qualitative study, 2) a cross-sectional study, and 3) a scoping review. The researcher used a qualitative study to described cultural characteristics, nurse values, and beliefs that influenced the sustainability of an EBP in the acute care setting. This was accomplished through a focused ethnographic approach with semi-structured interviews and observations. The study setting was a community hospital and the sample included registered nurses. In this study, nurses’ described experiences, beliefs, and values of an EBP intervention that influenced sustainability. The purpose of the cross-sectional study was to examine associations between professional governance attributes and unit-level central line-associated bloodstream infection outcomes. Secondary cross-sectional data were analyzed with independent-sample t-test, point-biserial correlation, and univariate logistic regression. The study setting included ninety-one inpatient units within eight acute care hospitals. In this study, results revealed possible connections between professional governance attributes and patient outcomes. Finally, a scoping review included 31 articles to provide an overview of evidence about sustainability and EBP champion responsibilities. The scoping review summarized literature on EBP champion responsibilities that influenced EBP sustainability. The findings of this dissertation can inform research, practice, and policy regarding professional attributes that enhanced or hindered EBP sustainability.
Factors Associated with Home Based Self-Collection for Human Papillomavirus (HPV) Testing
(2021-09) Biederman, Erika Brooke; Champion, Victoria; Zimet, Gregory; Draucker, Claire; Han, Jiali
Women who are medically underserved may be less likely to obtain provider-based cervical cancer screening because of structural and intrapersonal barriers. Self-collection for human papillomavirus (HPV) testing, a method for women to collect their own sample through a vaginal swab or urine collection, has accuracy comparable to provider-based cervico-vaginal HPV testing and may be useful in overcoming barriers to provider-based cervical cancer screening. The purpose of this dissertation study is to examine factors associated with self-collection for HPV testing, psychometrically test Diffusion of Innovations (DOI) instruments, and identify preferences for self-collection for HPV testing. Three distinct aims were developed: 1) factors (sociodemographic, health-related, and theoretical variables) associated with mailed return of vaginal self-collection for HPV testing, 2) psychometric examination of DOI ÷instruments (relative advantages and complexity), and 3) dimensions of self-collection and characteristic preferences to self-collection for HPV testing stratified by age cohorts. This dissertation involved two cross-sectional studies. In Chapters 2-3, data were collected from women (n=168) at food pantries and online. Women were eligible if they were: 1) female, 2) between the ages of 30-65, 3) could read and speak English, and 4) at 2019 federal poverty guidelines for income and family size as defined by the Department of Health and Human Services. Women were not eligible if they had a history of hysterectomy or were adherent to cervical cancer screening guidelines. Logistic regression analyses, item analysis, Cronbach’s alpha, exploratory factor analysis, and tests were used to analyze data. Chapter 4 involved collection of data from an online survey with a sample (n=878) provided by Dynata. Participants evaluated 9 scenarios that varied along 4 attributes: HPV self-collection kit type (vaginal swab or urine collection), HPV self-collection kit delivery (mail, pharmacy pick-up, or clinic pick-up), HPV self-collection kit return (mail, pharmacy drop-off, or clinic drop-off), and HPV test result communication (mail, phone call, or text message). Ratings-based conjoint analysis (RBCA) determined how each attribute influenced the ratings of each scenario.
"It's Hard!": Adolescents' School Experience and Self-Management of Psychogenic Nonepileptic Seizures
(2021-06) Tanner, Andrea Lynn; Miller, Wendy; Buelow, Janice; von Gaudecker, Jane; Decker, Janet R.
Adolescents with a type of conversion disorder called psychogenic nonepileptic seizures (PNES) experience many school, relationship, and health care struggles as they attempt to manage their mental health condition with PNES events that strikingly resemble epileptic seizures. Considered one of the top three neuropsychiatric problems, health care providers and school personnel remain ill-informed regarding how to care for adolescents with PNES. Because of the unique multidisciplinary approach needed to address adolescent PNES, school nurses are uniquely positioned to bridge health care and education systems. A review of literature examined the concept of school nurse selfmanagement support for PNES, existing school nurse-led mental health interventions, and the relationships between concepts for a conceptual framework guiding adolescent PNES research. This review of literature reveals an absence of adolescents’ perspective and school emphasis in PNES research. This study was designed to investigate adolescents’ experience attending school and self-managing PNES. This was accomplished through a qualitative content analysis of data generated from semi-structured interviews and magnitude coding of select quantifiable data. Data were obtained from 10 adolescents, 12 to 19 years of age, with current or recent in-person school attendance. The results indicate adolescents from the sample had school experiences that involved stress, bullying, accusations of faking seizures, and feelings of isolation or exclusion. Their mostly effective proactive selfmanagement activities included seeking protection, persevering in life despite PNES struggles, and progress monitoring through seizure tracking. Reactive activities of mixed effectiveness included coping responses to seizure warnings. School nurses, school personnel, family members, and peers served as both facilitators and barriers for PNES self-management. Adolescents also contributed information for three emerging themes— family-management, school-management, and illness representation. These findings reveal the difficulties of attending school and self-managing PNES and inform future PNES interventions to improve academic, mental health, and quality of life outcomes.

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