FEATURED PHD DISSERTATIONS

Background: The prevalence and devastating effects of diagnostic error are not new; however, diagnostic errors are largely cognitive, making measurement and intervention difficult. The National Academy of Medicine proposed enhancing the diagnostic process for all healthcare professionals’ education and training as one method to improve diagnostic safety. Currently, most diagnostic reasoning is taught and learned within the clinical environment, where it is likely to be implicit, unstructured, and unpredictable. Simulation-based experiences (SBE) offer clinically and psychologically safe opportunities for learners to develop diagnostic reasoning skills. In addition, cognitive bias, which is a predictable reaction to information that may interfere with a provider’s diagnostic reasoning, can be introduced through purposely constructed simulation scenarios. Structured reflection is a multi-step process used for diagnostic verification following a provider’s initial intuited diagnosis. Of the many debiasing strategies, medical learners use of structured reflection has demonstrated the most consistent and statistically significant improvement of diagnostic accuracy. To date, few simulation studies have examined nurse practitioner students’ diagnostic reasoning competency or diagnosis accuracy, and no studies have examined nurse practitioner students’ use of structured reflection.

Purpose: The primary purpose of this mixed methods experimental study was the examination of the effect of structured reflection used during a simulated patient’s diagnostic workup on diagnostic reasoning competency. A secondary purpose was the examination of the effect of structured reflection used during a simulated patient’s diagnostic workup on diagnosis accuracy. A third purpose was to understand how the participants’ experience with cognitive bias and their perception of structured reflection’s utility helped explain any diagnostic reasoning competency and diagnosis accuracy changes. Running head: REFLECTION AND DIAGNOSTIC REASONING 11

Methods: Thirty-eight adult gerontology acute care nurse practitioner students completed a patient’s diagnostic workup during three SBE. Participants who were unaware of and blinded to the intervention, were randomized to either the intervention or to the control group. Intervention participants completed a structured reflection template at minute 20 of the SBE; control group participants completed a patient presentation template at minute 20 of the SBE. Blinded outcome raters reviewed the simulation recordings to assess diagnostic reasoning competency using the Diagnostic Reasoning Assessment (DRA), and diagnostic accuracy using a three-item accuracy scale. A series of open-ended questions explored the experience of cognitive bias and structured reflection or other debiasing strategies used by the participants. Responses were analyzed using qualitative description methods. The qualitative and quantitative data were integrated to offer a richer explanation and understanding of how the participants’ experience with cognitive bias and their perception of structured reflection’s utility affected diagnostic reasoning competency and accuracy.

Results: The mixed analysis of variance (ANOVA) on the DRA mean competency scores revealed no statistically significant interaction between structured reflection and time, F[2,62] = .431, p = .652, ηp2= .014). No statistically significant differences were found for the within groups ANOVA (F[2,62] = .259, p = .772, ηp2 = .008), or for the between groups ANOVA (F[1,31] = 1.195, p = .283, ηp2 = .037). Similarly, the Chi-square test for diagnostic reasoning competency categories did not find any statistical significance between groups for any of the three simulations. The Chi-square tests of diagnostic accuracy between the two groups were not statistically significant for any of the scenarios. Regardless of group, participants noted similar themes of nursing experience as why they were cognitively biased and changed their initially intuited diagnosis at similar rates. Structured reflection users noted the strategy’s utility was its organizational value and diagnostic verification; however, they expressed confusion for some of its components. Control group participants did not identify structured reflection as their debiasing strategy; however, they did note diagnostic verification for why they changed their initial diagnosis.

Implications: Nurse practitioner faculty can use these findings to build diagnostic reasoning educational content and application opportunities for structured reflection to ensure graduates can use this competently. Future simulation studies should include multiple scenarios to allow for more repetitive use of structured reflection and, subsequently, the collection of a mean diagnosis accuracy score and DRA scores. Additionally, to maintain intervention fidelity, comparator groups should be given an activity that is in line with the diagnostic workup of a patient but eliminates any opportunity for reflective thought.

Background: Congenital heart disease (CHD) is the most common neonatal congenital defect, impacting approximately nine per 1000 live births, with about three per 1000 infants requiring surgical intervention in the neonatal period. As these children are now surviving well into adulthood, the focus for their healthcare has shifted to neurodevelopmental outcomes. Emerging research has identified that survivors of CHD are at high risk for neurodevelopmental delays and disabilities. Growth failure and malnutrition are common consequences of CHD, and poor oral feeding is implicated as a strong early contributor to the growth challenges seen within this population. Over 50% of neonates with complex CHD who required a surgical intervention during the neonatal period are discharged home with the inability to achieve full oral feeling. The etiology of oral feeding difficulties in neonates and infants with CHD remains unknown.

Aim: The aim of this study was to identify predictors of the inability to achieve full oral feeding by the time of discharge from the neonatal hospitalization in infants with CHD who have undergone palliative or corrective surgical intervention requiring cardiopulmonary bypass. Methodology: A secondary data analysis of a prospective cohort study of full-term neonates with complex CHD was conducted. Stepwise logistic regression was used for unbiased selection of independent variables that were then inputted into a predictive model, with the dichotomous dependent variable being oral feeding status at time of neonatal discharge.

Results: Fifty-eight percent of neonates (112/192) did not achieve full oral feeding by hospital discharge. In logistic regression analyses, duration of deep hypothermic circulatory arrest (DHCA) and number of endotracheal intubations were identified as significant predictors of the inability to achieve oral feeding. If full oral feeding was not achieved by postoperative day ten, only an additional 7.5% of neonates achieved full oral feeding by discharge. Brain maturation and acquired brain injury were not predictors of full oral feeding. Implications: Duration of DHCA over 40 minutes was a strong predictor of poor feeding after surgery, suggesting that if DHCA duration cannot remain under 40 minutes, alternative surgical perfusion strategies should be considered. Failure to reach full oral feeds by discharge was common, and prolonged hospitalization primarily for feeding dysfunction does not improve oral feeding.

Implications: Attainment of neurodevelopmental skills can be superior in the home environment when compared to the hospital environment. Therefore, preparing families for discharge before achievement of full oral feeding may positively contribute to neurodevelopment of neonates with complex CHD.

Background: Hospital-based nurses in all practice areas, including emergency, pediatric, medical-surgical, and critical care units, play a crucial role in safeguarding patients with sickle cell disease (SCD) from developing avoidable complications. Despite this, barriers in providing efficacious care to young adults with SCD exist. Multiple studies have demonstrated that in general, providers’ race/ethnicity contributes to their attitudes and perceptions of patients with SCD; however, the body of literature on patients with SCD lacks information specifically on medical-surgical nurses’ and nursing assistants’ attitudes and the relationship between these attitudes and care provided for the SCD population, particularly in the young adult SCD population.

Purpose: This study examined the relationship of age, race, years of experience among medical-surgical nurses and nursing assistants to their attitudes in caring for young adults with sickle cell disease (SCD) and identified barriers that influence care provided.

Design: An explanatory sequential mixed-methods study design was used. Methods: Fifty-six study participants completed the General Perceptions of Sickle Cell Patients (GPSCP) Scale-17 that assessed provider attitudes toward patients with SCD. The GPSCP-17 has four subscales: Negative Attitudes, Positive Attitudes, Concerning Raising Behaviors, and Red Flag Behaviors. Qualitative interviews were conducted with a subset of the quantitative sample to elucidate and provide meaning to the quantitative data.

Results: There was no relationship of age and years of experience to scores on GPSCP-17’s four subscales. White/Caucasian study participants scored higher on the Red Flag Behaviors subscale than participants from other ethnicities/races, (t = 2.45, p= 0.018) Cohen’s d 0.803, indicating that White/Caucasian participants had stronger beliefs than other ethnicities/races that certain PERCEPTIONS OF YOUNG ADULTS WITH SCD 3 behaviors exhibited by patients with SCD are concerning for drug-seeking behaviors. Themes generated from the analysis of the qualitative interview data were: 1) reflections on one’s own practice compared to others’ practice. 2) communication as a barrier or facilitator to providing care; 3) lack of accurate knowledge as a barrier to care resulting in care that is not evidence-based; and 4) adjunct staff are critical to facilitating holistic care.

Conclusions: Differences by race/ethnicity exist in medical-surgical nurse and nursing assistant attitudes related to patients with SCD. Poor communication and lack of national standards of care are barriers to high quality of care of young adults with SCD. Implications: Culturally sensitive nursing care that is based on current practice guidelines is needed for care for young adults with SCD in the medical-surgical setting.