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... Identification of North American Azalea Species at Taylor University Rylie Boezeman and Kaitlin Stewart College of Arts and Sciences, Marian University Indianapolis 3200 Cold Spring Rd, Indianapolis, IN 46222 BACKGROUND The primary objective of this study is to identify North American azaleas present in the Whipple Azalea Garden on Taylor Universitys campus (Dr. Justice, 2024). The North American azalea is a subspecies of the Rhododendron genus. In this study, we will analyze three different samples of azaleas. Sample DNA profiles can only be obtained via DNA barcoding. DNA barcoding uses a segment of the complete genome to identify a species (DeSalle & Goldstein, 2019). The DNA barcoding method is necessary to identify azalea subspecies as they cannot be differentiated based solely on phenotype. By comparing the DNA profiles of the samples to known North American azalea genome sequences, we aim to confirm the identification of the azalea subspecies in the garden. We will use information from the genetic reference database established through Rhododendron taxonomy to aid in the identification of samples (Liu et al., 2021). We seek to not only identify North American azalea samples at Taylor University but also contribute to the broader understanding of Rhododendron biodiversity and conservation. FINDING 1: GEL ELECTROPHORESIS Gel Electrophoresis was utilized to confirm that the expected DNA was extracted and sufficiently amplified using the selected primers. Once adequate amplified DNA was confirmed, sample DNA was sent to GENEWIZ for DNA sequencing. Figure 3. Gel 1 displays amplified DNA of all three samples synthesized by primers ITS and matK. Figure 4. Gel 2 displays amplified DNA of all three samples synthesized by primers psbA-trnH. Sample 280 Sample 282 (R. calendulaceum) (R. calendulaceum) PsbA-trnH Figure 2. North American azaleas in Whipple Azalea Garden HYPOTHESIS Primer psbA-trnH effectively identifies whether the sample is of the rhododendron genus. However, psbAtrnH is ineffective for use in identifying North American rhododendron subspecies as there are no sequences deposited into the NCBI database. Primer ITS effectively determines whether the samples are Asiatic or North American species. FINDING 2: DNA SEQUENCING Figure 1. Whipple Azalea Garden at Taylor University in Upland, IN CONCLUSIONS ITS matK Sample 380 (R. alabamense) Rhododendron genus Rhododendron genus Rhododendron genus ERROR North American North American R. calendulaceum R. calendulaceum R. alabamense Primer matK best identifies precise Rhododendron subspecies considering limited North American azalea genome sequences in the NCBI database. A more extensive and diverse North American rhododendron genome sequence database would be beneficial in most accurately identifying subspecies of the Rhododendron genus. LITERATURE CITED DeSalle, R., & Goldstein, P. (2019). Review and interpretation of trends in DNA barcoding. Frontiers in Ecology and Evolution, 7, 302. Liu, Y., Zhang, M., Chen, X., Chen, X., Hu, Y., Gao, J., Pan, W., Xin, Y., Wu, J., Du, Y., & Zhang, X. (2021). Developing an efficient DNA barcoding system to differentiate between Lilium species. BMC Plant Biology, 21, 1-13. National Center for Biotechnology Information (NCBI)[Internet]. Bethesda (MD): National Library of Medicine (US), National Center for Biotechnology Information; [1988] [cited 2017 Apr 06]. Available from: https://www.ncbi.nlm.nih.gov/ DNA barcodes, with the use of three DNA primers (psbA-trnH, ITS, matK), can be used to identify subspecies of the North American azalea species (Yan et al., 2014). Spatiotemporal Evolution of the Global Species Diversity of Rhododendron Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/figure/Phylogenetic-relationships-and-divergencetime-estimates-of-Rhododendron-based-on-the_fig1_355805267 [accessed 19 Apr, 2024] MATERIALS AND METHODS Yan, L. J., Liu, J., Mller, M., Zhang, L., Zhang, X. M., Li, D. Z., & Gao, L. M. (2015). DNA barcoding of Rhododendron (Ericaceae), the largest Chinese plant genus in biodiversity hotspots of the HimalayaHengduan Mountains. Molecular ecology resources, 15(4), 932-944. Qiagen Inc. (2019). DNeasy Plant Pro Kit Handbook. Giagen Inc. 1. DNA extraction (DNeasy Plant Pro Kit Handbook: Purification of Total DNA from Plant Tissue Procedure) 2. Polymerase chain reaction: 94 C 60 sec; [40 cycles: 94C 60 s; 52C 90 s; 72C 90 s]; 72C 10 min 3. Gel electrophoresis 4. DNA sequencing (GENEWIZ) 5. Data analysis ACKNOWLEDGMENTS Figure 5. Phylogenetic relationships and divergence time estimates of Rhododendron based on the concatenated alignment of CDS sequences of 3,437 OGs. The 11 sections are noted above the branches and around the tree by numbers 1-11. Flower photographs are not to scale. The lowercase letters (a-ak) following the species names correspond to the photographs of these species around the tree. Geological time scales are shown as light-gray/white concentric rings. Special thanks to Dr. Sarah Justice and associated researchers for providing foundational sample DNA and to Cameron Morgan for ordering supplies.  ...

... Cinnamon: Food or Medicine Walter Brown, Maya Mundy, Jayden Francis and Oliver Russell College of Arts and Sciences, Marian University Indianapolis 3200 Cold Spring Rd, Indianapolis, IN 46222 INTRODUCTION RESULTS Cinnamon is one of the most common spices and food flavoring additives.. The National Library of Medicine states that "Cinnamon possesses antibacterial and antifungal properties" (Vasconcelos, 2018). During the last two decades, growing evidence shows that cinnamon is a strong antimicrobial agent that may act as antibacterial and antifungal system (Vasconcelos, 2018). The increased number of antibiotic-resistant bacteria calls for a new solution. This study aims to determine the effectiveness of cinnamon against two common bacterial strains, Staphylococcus aureus (S. aureus) and Eschericihia Coli (E.coli) on an agar plate. This culminates in the question: does cinnamon have the antimicrobial properties to serve as an alternative treatment for drug resistant bacterial infections caused by E.coli and S. aureus? Figure 1. Cinnamon extract is a concentrated liquid that is made by soaking cinnamon bark in alcohol and then straining out any remaining solids. It has an intense cinnamon flavor and is more concentrated than ground cinnamon After further experimentation on the antibiotic properties of cinnamon extract, the results are as followed. Cinnamon showed inhibition to both S. aureus and E. Coli, averaging a zone of inhibition of 30.167 mm towards S. aureus and 21.5 mm in response to E. Coli. These zone of inhibitions prove rather significant, due to the antibiotic disk of Ciprofloxacin's zones of inhibition being rather similar in value. DISCUSSION CONCLUSIONS MATERIALS AND METHODS Essential Oils Cassia Cinnamon (Cinnamomum aromaticum)100% Pure Therapeutic Grade Essential Oil was purchased from Healing Solutions LLC (Scottsdale, Arizona, USA) Bacterial Strains Escherichia coli (E. coli) and Staphylococcus aureus (S. aureus) were obtained from Carolina Biologicals(Burlington, North Carolina, USA) Materials Cinnamon has been proven to be sensitive from the zone of inhibition being greater than 21 mm for both E-coli and S.aureus. From this research cinnamon can be used as antibacterial and antifungal agent within common household items. In conclusion, cinnamon proved to be an effective antimicrobial agent it was seen to be sensitive to be the bacteria of S. aureus and E. coli. Knowing this, we can deduce that cinnamon can be a strong anti-microbial agent for bacteria disinfectant in household items. E-coli Figure 6. Cinnamon can be mixed with white vinegar and other essential oils to make an all-natural disinfectant household cleaner S.aureus 1 BBL Blank Paper Discs (6mm) were purchased from Benton, Dickinson and Company (Sparks,Maryland, USA) and were sterilized by autoclave. Ciprofloxacin 5g discs were purchased from Oxoid Ltd. (UK).Tryptic Soy Broth was purchased from Sigma Aldrich (St. Louis, Missouri, USA). MullerHinton Agar was purchased from Sigma Aldrich (St. Louis, Missouri, USA). Sodium Chloride was purchased from Carolina Biologicals (Burlington, North Carolina, USA) Inoculated Mueller Hinton agar plates by lawn method. LITERATURE CITED 1. Vasconcelos, N. G., Croda, J., & Simionatto, S. (2018). Antibacterial mechanisms of cinnamon and its constituents: A review. Microbial Pathogenesis, 120, 198203. https://doi.org/10.1016/j.micpath.2018.04.036 El Atki, Y., Aouam, I., El Kamari, F., Taroq, A., Nayme, K., Timinouni, M., Lyoussi, B., & Abdellaoui, A. (2019). Antibacterial activity of cinnamon essential oils and their synergistic potential with antibiotics. Journal of Advanced Pharmaceutical Technology & Research, 10(2), 63. https://doi.org/10.4103/japtr.japtr_366_18 3. Julianti, E., Rajah, K. K., & Fidrianny, I. (2017). Antibacterial Activity of Ethanolic Extract of Cinnamon Bark, Honey, and Their Combination Effects against Acne-Causing Bacteria. Scientia Pharmaceutica, 85(2), 19. https://doi.org/10.3390/scipharm85020019 Transferred four paper disc and one sterile Cipro disc, onto the agar plate. Then the Cinnamon essential oil was applied to three paper disc and water to the remaining disc as a control. ACKNOWLEDGMENTS Within five days of being in a 37-degree C incubator the zone of inhibition are measured and multiplied by 2. E-coli 2 S.aureus 2 We appreciate Carmela Marciano and Dr. Karla Kinkade for their support and expertise throughout this project. Their contributions have been essential to its success.  ...

... El fuego: una explosin del deseo Daniela Ochoa y Sarah Getman College of Arts and Sciences, Marian University Indianapolis 3200 Cold Spring Rd, Indianapolis, IN 46222 INTRODUCCIN LAS ROSAS Y GERTRUDIS La pelcula Como agua para chocolate enfoca en una familia mexicana durante la revolucin, y en temas de las mujeres de la familia y la tradicin. La historia enfoca en Tita, la hija menor de la familia que siente presin bajo la expectativa de su mam. Mientras ella se queda (en su mayora) obediente, sus deseos verdaderos estn expresados en el fuego, un elemento del realismo mgico de la pelcula. Finnegan, escribi en su artculo At Boiling Point: Like Water for Chocolate and the Boundaries of Mexican Identity que su interpretacin del ttulo de la pelcula es una pasin sexual como cuando el agua est a punto de hervir (Finnegan 15). En esta presentacin, analizamos el amor entre Tita y Pedro, el uso del incendio y la metfora de la caja de los cerillos en la pelcula. Tita cocina una comida tan rica con los ptalos de rosas, con eso Gertrudis siente la pasin adentro su cuerpo, y causa un fuego, que atrae a un revolucionario que la toma. La cocina de Tita abre paso para Gertrudis a ms libertad sexual y social. Los deseos de Tita, expresados en su cocina, tienen el poder de cambiar las vidas de sus amables. LA TESIS En Como Agua Para Chocolate, Tita encuentra que sus emociones y sus deseos eran tan fuertes y no puede restringirlos. Ella est, como dice en el ttulo, estar a punto de hervir y como un fuego, sus deseos consumen a Tita hasta que terminan con su vida. LOS PERSONAJES Y LA TRAMA La pelcula comienza con la narradora, la sobrina nieta de Tita. La narradora tiene un libro de las recetas de la familia y de Tita. La trama enfoca en el amor prohibido de Tita y Pedro. Cuando eran jvenes, Tita y Pedro se enamoraron, pero no pudieron casarse porque la tradicin en la familia es que la hija ms joven se encargue de la madre. Para estar cerca de Tita, Pedro se casa con la hermana de Tita, Rosaura. Tita tiene un conflicto entre su responsabilidad a su familia y sus deseos para ella misma. Gertrudis is successful not only in escaping the preordained female domesticity demanded by society, but she also achieves success in the male world, where might makes right, as she rapidly distinguishes herself as a generala of the Revolution and commands a regiment of men" (Dobrian 63). LA CAJA DE LOS CERILLOS - Una metfora introducida por John cuando Tita est recuperndose - Cada persona tiene una caja de cerillos en su mismo como el centro de la persona (la pasin y el amor): y necesita alguien o algo para encenderlos. - Mientras John describe esto, Tita recuerda sus memorias con Pedro. - El peligro de encender todos los cerillos al mismo tiempo regresar a los orgenes divinos. - Porque el fuego est situado como el centro de la persona y la felicidad, significa que la pasin (simbolizada por el fuego) dirige la vida humana. - Con esta importancia, las explosiones violentas del fuego son una expresin de la pasin y el deseo reprimidos. LA ESCENA FINAL Tita swallows matches in an attempt to reignite the couples love (Ching et al. 288). Despus de la boda de Esperanza, Pedro y Tita estn juntos por fin, pero en este momento, Pedro fallece en la cama. Tita se come una caja entera de los cerillos, y con cada cerillo hay una imagen de Pedro. Finalmente, ella se suicida para estar con l, y ella se incendia (y tambin el resto del rancho). Puede ser que la liberacin de todas las emociones que haban aguantado por mucho tiempo haya causado sus muertes. Hay un contraste interesante con las expectativas del mundo: usualmente, el fuego es un smbolo del infierno. Pero, aqu, es la cosa que conduce a Pedro y Tita a sus orgenes divinos," y la satisfaccin o la finalizacin de su amor. CONCLUSIN - Mientras Tita tiene maneras de expresar sus deseos creativamente, como en su cocina y tejido, la pasin es demasiada fuerte para guardar. - Por eso, sus deseos tambin estn expresados en una manera incontrolable: por el fuego. - The book revolves around the central premise that women experience love promised and not fulfilled, making them forever like water for chocolate (Ching et al. 295). - El texto implica que los medios de expresin tradicionales para las mujeres no son suficientes para expresar los deseos de las mujeres: los deseos necesitan estar libres o resulta en una explosin de algo incontrolable. FUENTES Ching, Erick, et al. Film Foray: Como Agua Para Chocolate (Like Water for Chocolate). Reframing Latin America, University of Texas Press, 2007, pp. 286305. JSTOR, http://www.jstor.org/stable/10.7560/709331.20. Accessed 25 Mar. 2024. Dobrian, Susan Lucas. Romancing the Cook: Parodic Consumption of Popular Romance Myths in Como Agua Para Chocolate. Latin American Literary Review, vol. 24, no. 48, 1996, pp. 5666. JSTOR, http://www.jstor.org/stable/20119730. Accessed 25 Mar. 2024. Finnegan, N. At Boiling Point: Like Water for Chocolate and the Boundaries of Mexican Identity. Bulletin of Latin American Research, vol. 18, no. 3, 1999, pp. 31126. JSTOR, http://www.jstor.org/stable/3339168. Accessed 30 Jan. 2024.  ...

... The Antibiotic Effects of Basil on E. Coli and S. Aureus Sophie Krueger, Libby Bex, Alex Chavarria, Marie Dipaola College of Arts and Sciences, Marian University Indianapolis 3200 Cold Spring Rd, Indianapolis, IN 46222 BACTERIAL STRAINS AND MATERIALS INTRODUCTION Many spices hold natural qualities that help provide immunity against certain infections. In this experiment, our investigation group wants to address the antibiotic support of basil on various infections such as S. aureus and E. coli. Basil's aerial parts contain antimicrobial properties that our group will test on Agar disks for S. aureus and E. coli. When we add basil to the infection on Agar, we will see diminished growth as the basil has helped kill off some of the microbes METHODS Part 1: Aseptically transfer the bacteria from the broth culture to each of three Mueller Hinton agar plates using a sterile swab by dipping the swab into the broth culture and streaking the agar plates to create a confluent lawn of bacteria. Use a new sterile swab for each plate. You should create three Mueller Hinton lawns of E. coli and three Mueller Hinton lawns of S. aureus. Use sterile forceps to aseptically place 4 sterile 6mm blank paper discs onto each of the bacterial lawns. To one blank disc on each plate, add 10 ml of sterile water. To each of the three blank paper discs on each plate, add 10 ml of basil essential oil. Aseptically, place one Ciprofloxin 5mg disc onto the bacterial lawn, which will serve as the positive control for growth inhibition. Incubate all of the plates at 37C for 24 h, then transfer and store the plates to 4C. Examine the plates for zones of inhibition. Measure the diameter of each zone of inhibition in millimeters. If the diameter cannot be measured directly, measure the radius of the zone of inhibition and multiply by 2. Part 2: After the 24 hrs were up, we observed the results from both E.coli and S.aureus. When measuring the zones of inhibition we measured from the center of the disc to the outer ring where it ended (radius). Each measurement was made in millimeters . Once the results were gathered, we then put the information into graphs. After observing, the Muller-Hinton Agar plates were placed into a biohazard bag to be thrown out. Bacterial Strains: Escherichia coli (E. coli) in Tryptic Soy Broth Staphylococcus aureus (S. aureus) in Tryptic Soy Broth Materials: Autoclaved BBL Blank Paper Discs (6mm) Ciprofloxin 5mg discs Muller-Hinton Agar plates Sterile water Basil Essential Oil S. Aureus Water 0 mm 0 mm CIP- 5 12.0 mm 11.0 mm Basil 1 23.0 mm 19.0 mm Basil 2 6.0 mm 4.0 mm Basil 3 11.0 mm 10.0 mm Table 2 Disk E. Coli S. Aureus Water 0 mm 0 mm CIP - 5 12.0 mm 11.0 mm Basil 32.67 mm 11.0 mm Average 14.89 mm 14.666 mm From the first experiment, our aseptic technique led to complications within our tests. Both in E. coli and S.aureus. This could have been caused due to our aseptic technique. We originally started with 10 microliters of basil, water, and ciprofloxin. To fix this, we decided to use 5 microliters instead. With this change, our results next time around were way more successful. Another way to ensure success is to submerge each designated disk with basil, water, or the ciprofloxin. While making sure the field is sterile and materials are sterile. CONCLUSIONS Table 1 E. Coli EXPERIMENT RESULTS E. Coli S. Aureus 2ND EXPERIMENT RESULTS Disk ST 1 As a whole, our experiment with Basil was ultimately a success. The antibiotic effect of basil ended up working better than we thought based on the zone of inhibition from the measurements made during the experiment. As a group, we also improved or skills in the lab and gained knowledge on how basil, water, and ciprofloxin can be substituted as a antibiotic on certain bacterias or illnesses. Despite, our mistake with our first two agar plates, we changed the technique and it led to success. From the given results, we did not expect the basil to work as well as he did. Overall the experiment was a success and are very happy with our results. Table 3 Averages Disk Basil E. Coli 32.67 mm S. Aureus 11.0 mm Graph Summary Average zones for Basil = 32.67 mm for E.coli and 11.0 mm for S.aureus. The summarized data for all discs was 0 for water and 12.0 on e.coli and 11.0 mm on S.Aureus. LITERATURE CITED Liu, Q., Meng, X., Li, Y., Zhao, C.-N., Tang, G.-Y., & Li, H.-B. (2017). Antibacterial and antifungal activities of spices. International Journal of Molecular Sciences, 18(6) Kaya, I., Yigit, N., & Benli, M. (2008). Antimicrobial Activity of Various Extracts of Ocimum Basilicum L. And Observation of the Inhibition Effect on Bacterial Cells by Use of Scanning Electron Microscopy. African Journal of Traditional, Complementary, and Alternative Medicines, 5(4), 363-369. Shafique, M. & Khan, S.J. & Khan, N.H.. (2011). Study of antioxidant and antimicrobial activity of sweet basil (Ocimum basilicum) essential oil. Pharmacologyonline. 1. 105-111  ...

... Social Hierarchy of Miniature Cattle Cash Nelson College of Arts and Sciences, Marian University Indianapolis 3200 Cold Spring Rd, Indianapolis, IN 46222 QUESTION ACTIVITY BUDGET BY HIERARCHY ETHOGRAM Behavior Description Behavior Description Walking Walking more than 5ft Cleaning themselves Licking themselves INTRODUCTION Laying down Lying in 1 place for 1 min Cleaning another cow Licking another cow For cattle, a hierarchy is established and maintained by social interactions. It is most obvious when cattle are closely confined, when individuals will be seen to differ in whether they move out of the way of other individuals. The hierarchy is based on the dominancesubordination relationships that exist between each animal, and each other individual in the herd (Hall, 2009). The herd gets food from three sources, grain, hay, and grass. Understanding where each individual get most of their food is beneficial because it affects the size of each cow and how they make it through the winter. I hypothesize that lower individuals will spend more time grazing in the pasture, similar to what was found by Arave and Albright (1981). The hierarchy structure in relationship to grooming aims to answer one of two possible hypotheses. The Grooming-for-Commodity hypothesis posits that allogrooming is directed from low-ranking animals towards higher-ranking cows in exchange for tolerance and other favors. The Grooming-for-Stability hypothesis predicts that allogrooming is performed by high-ranking animals down the hierarchy in order to perpetuate the stability of the social structure (Val-Laillet et al. 2009) Understanding the social hierarchy of the herd of miniature cattle will help the rancher. This information is helpful when determining who to give more feed to. It also helps when sorting cattle to know which cows to sort together and which ones to keep apart to avoid fighting. Eating grass Eating only grass for 30 sec Scratch an itch Rubbing part of their body on an object Eating hay Eating only hay for 30 sec Flick their tail Flicking their tail from side to side Chewing cud Chewing cud for 30 sec Throw their head Shaking their head at another cow Investigating an object Sniff an object for 5 sec or more Forcing another cow out Uses their head to push another cow. Drinking water Drink water for 5 sec Loafing Stands in the same place for 1 min How does social hierarchy impact access to feed in the pasture? MINIATURE CATTLE (BOS TAURUS) Cattle are the descendants of aurochs, which were domesticated around 9000 years ago in western Asia, Africa, China, and India. There are two distinct subspecies of cattle, zebu which are characterized by their shoulder hump, and taurine which are hump less (Hall, 2002). Miniature cattle are just like full-size cattle in every way other than their size. Their height ranges from 36 inches to 42 inches. Their weight can range from 500-700 pounds depending on breed. (Boden, 2008) The herd used in the study is of the Western Heritage bloodline. This bloodline was started in Iowa by Dustin Pillard. The goal of the bloodline was for small colorful cattle. MATERIALS AND METHODS The herd consists of 18 female miniature cattle at the Lazy N Ranch in Morgantown, IN U.S.A., which was studied and observed. The study area was a 2-acre pasture. The pasture has a ditch for water as well as a water tank. There are 3 hay feeders throughout the pasture. There is an enclosed pen that serves as the area where the cattle are fed grain. I observed the herd at various times of the day including early morning, afternoon, before and after feeding, and evening. For 10 hours, instantaneous behavior scans were performed every 5 minutes and behaviors based on the ethogram were recorded. Between scans, bouts of grooming were recorded when observed. I also filmed the cattle during grain feeding time to observe how long they spent eating. Four separate feedings were recorded. DETERMINING THE HIERARCHY Hierarchy by Grain Eating Time (sec) Hierarchy by Weight Average Hierarchy 2.0 1429 MJ 575 2.0 1 2.0 2.0 MJ 1294 2.0 550 MJ 2 MJ MJ Mirage 1279 Ren 500 Mirage 3 Mirage Mirage Caitlyn 1025 Deuces 500 Star 4 Georgia 1011 Mirage 475 Phoenix 5 Ren Storm Bubbles 985 Storm 425 Storm 6 Deuces Ren Storm 955 Phoenix 350 Caitlyn 7 Star Star Tiger 830 Caitlyn 275 Ren 8 Phoenix Phoenix CC 790 Kitley 275 Deuces 9 Caitlyn Caitlyn Kitley 785 Star 250 Kitley 10 Julia 780 Georgia 225 Georgia 11 Georgia Georgia Star 745 Tiger 200 CC 12 Tiger CC Deuces 735 CC 150 Hazel 13 CC Hazel Hazel 670 Julia 150 Julia 14 Hazel Julia Snow 570 Snow 150 Delta 15 Julia Delta Ren 435 Hazel 125 Tiger 16 Delta 355 Delta 125 Snow 17 Snow Snow Phoenix 315 Bubbles 80 Bubbles 18 Bubbles Bubbles Hierarchy by Rank High Middle Low Storm Kitley Delta Hierarchy by Rancher High Middle Low Deuces Kitley Tiger TOTAL HERD ACTIVITY BUDGET On average, the herd spend half (51.4%) of their time eating while in the pasture. The rest of their time was spent in various activities (48.6%). The next highest were low energy activities like loafing 15.9%, laying down 11.2%, and chewing cud 8.3%. The most dominant group spent 47.8% of time feeding vs. 53.2% and 53.1% for lower groups The dominant group also spent more time eating the higher-quality feed (hay; 30.5%) vs. 17.6% and 20.6% for the lower ranking groups Lower ranking groups spent more time eating low quality feed (grass; 35.6% and 32.5%) than the higher-ranking individuals 17.3%. GROOMING I observed 22 bouts of grooming during the course of the study Allogrooming occurred most (20 times) between members of the same group in the hierarchy. Top ranking cows had the most grooming bouts (15), middle ranking (4), and bottom (3). CONCLUSION The hierarchy determined was nearly identical to what the rancher predicted. I found that individuals that where higher ranking spent less time eating hay and grass because they were receiving more grain. This is similar to what was found by Arave and Albright (1981). Lower ranking individuals had to spend more time grazing in the pasture to make up for lost grain. These individuals are also blocked from eating the higher quality hay. This is important information for the rancher because grain and hay are expensive. Therefore, the rancher would want a move even distribution of the food, so it is more cost effective. After eating, the most common activities were low energy activities. This is similar to findings by Hall (2009), in which cattle that receive supplementary feed will cut down on grazing behavior and instead spend this time laying or resting behaviors. When is comes to grooming, neither grooming hypothesis, Grooming-for-Stability and Grooming-for-Commodity, were supported. Rather the hypothesis by Arave and Albright (1981) was supported, which is that cows typically groom other closely ranked cows. The cows also seemed to have grooming partners. After once cow finished grooming the other cow would reciprocate the grooming some time after. Further research can be done on the affects of grooming. Is it done to maintain social status or is it a stress releaser? LITERATURE CITED For references, please email Cash Nelson at cnelson713@marian.edu ACKNOWLEDGMENTS I want to thank the rancher, my dad, for helping me collect data and knowledge about the cattle. I also want to thank Dr. Benson for inspiration and helping me improve my study. Finally, I want to thank the cows for being so fascinating. Also, for being so adorable.  ...

... The Impact of Internalized Thin Ideals and Empathy on Victim-Blaming Behavior on Social Media Profiles Katie Koger and Harper Ring Predictions Abstract People often look for social and emotional support from online communities and social media platforms. Unfortunately, often social media comments are hurtful and negative. The current study sought to investigate the factors that lead to negative and positive comments in online spaces. Results hint at how the physical features of the target (e.g., the person soliciting support on social media) and internalized ideals of the respondent (e.g., the person replying to social media posts) interact to predict the negative or positive responses in online spaces. Hypothesis 1: We predict a main effect of profile type such that respondents will rate the thin target more favorably than the heavy target. Hypothesis 2: We predict a main effect of empathy on ratings such that respondents high in empathy will rate the target more favorably than those low in empathy. Hypothesis 3: Interaction effect between profile type and internalized thin ideal such that those with high levels of internalized thin ideal will express the least favorable ratings toward the heavy target. Methods Background This study investigates the complex relationships between internalized thin ideals, empathy levels, and victim-blaming behavior on social media profiles. The purpose of this study is to deeper an understanding of how societal beauty standards impact social attitudes and behaviors, particularly within the context of online interactions. Our research found studies that investigated the effects of social media and problematic social media use on feelings toward body image and body satisfaction. Research on the effect of internalized thin ideals. However, we found a gap in the literature on how specifically individuals perceive others in online spaces based on body type. Research Design Participants were recruited from university campuses and willingly participated in our study. Participants were randomly assigned to one of two experimental groups. Each group was presented with an online survey presenting a manipulated social media profile that depicted either a thin or heavier individual, both experiencing a hypothetical breakup. After viewing the assigned image participants were asked to leave a comment on the post and share their attitudes towards the woman; rating her based on positive characteristics (i.e., kindness). Participants then completed self-report measures of the THINNA assessment and an empathy scale to create the baselines for analysis. Results To start the participants completed demographic questionnaires covering age, gender identity, race, and marital/relationship status. Next, they were randomly assigned a social media post to view and asked to engage with it by commenting as if they were a regular user. Participants completed the Internalized Thin Ideal Scale questionnaire which measured individuals' societal standards of thinness and their attitudes toward body shape and weight concerning these ideals. After viewing the post participants were asked to rate how well the woman in the profile depicted positive characteristics (i.e., kind, beautiful, confident, etc.) Lastly, there was The Empathy scale, which was a self-report questionnaire, used to give a baseline measure an individual's level of empathy. Condition Images Fig. 1. Respondents were randomly assigned to see a fictitious profile where a woman was posting about a recent breakup. The only difference between the two conditions was whether the post appeared with the photo on the left (thin target) or the right (heavy target). A factorial ANOVA analysis supported our hypothesis that those with higher levels of internalized thin ideal rated the thinner individuals more favorably and those with lower levels of internalized thin ideal rated the heavier target more favorably. There was no main effect of empathy, although there was a slight positive correlation with age (older participants were higher in empathy levels). The results of our research have a societal impact as it furthers the understanding of online judgment and the impact of societal beauty standards. References Harper, B., Tiggemann, M. The Effect of Thin Ideal Media Images on Womens Self-Objectification, Mood, and Body Image. Sex Roles 58, 649657 (2008). https://doi.org/10.1007/s11199-007-9379-x Maartje Boer, Gonneke W.J.M. Stevens, Catrin Finkenauer, Margaretha E. de Looze, Regina J.J.M. van den Eijnden, Social media use intensity, social media use problems, and mental health among adolescents: Investigating directionality and mediating processes, Computers in Human Behavior, Volume 116, 2021, 106645, ISSN 0747-5632, https://doi.org/10.1016/j.chb.2020.106645 Nadia A.J.D. Bij de Vaate, Jolanda Veldhuis, Elly A. Konijn, The impact of seeing and posting photos on mental health and body satisfaction: A panel study among Dutch and Japanese adolescents, Computers in Human Behavior, Volume 148, 2023, 107906, ISSN 0747-5632, https://doi.org/10.1016/j.chb.2023.107906  ...

... Grooming Behavior and Social Hierarchy in Long-Tailed Macaques Andrew McDade and Hailey Ready College of Arts and Sciences, Marian University Indianapolis 3200 Cold Spring Rd, Indianapolis, IN 46222 INTRODUCTION Grooming is a common behavior observed in primates. For some primates, grooming might be performed according to ones social ranking, with middle-ranking individuals grooming more often than both high and low-ranking individuals (Xia, et al., 2021). In this hypothesis, individuals use grooming to establish rank within the social hierarchy. The steeper the social hierarchy is, the more time these middle-ranking individuals will spend grooming in an attempt to maintain their social rankingby grooming the lower-rankingor in an attempt to climb the hierarchyby grooming higherranking (Xia, et al., 2021). A second hypothesis explaining allogrooming regards grooming as a hygienic behavior with primates primarily grooming in locations on the body where the individual being groomed cannot reach themselves (Pfoh, et al., 2021). In long-tailed macaques, one study shows that female-to-female grooming interactions tended to be on the head or front, while male-to-male grooming interactions tended to be on the back or tail (Sonlanki, et al., 2020). In our study, we define the head and back as being hard to reach locations, while the tail, arms, legs and front are easy to reach locations. Using our definitions, this means that Sonlanki, et al. (2020) suggests both males and female perform allogrooming for hygiene (hard to reach locations) and for another reason (easy to reach locations). Our study was conducted on long-tailed macaques (Macaca fascicularis), using sex and size as a proxy for dominance. Since troops typically consider the largest male the most dominant individual (Hakim et al., 2023), larger individuals were considered more dominant than smaller individuals and males were considered the dominant sex. We predict intermediate-sized females will exhibit the most grooming behavior followed by medium-sized males. We also predict that intermediate-sized individuals will primarily groom individuals that are significantly larger or significantly smaller than themselves (Xia, et al., 2021), primarily focusing on areas that individuals find difficult to groom independently (Pfoh, et al., 2021). Additionally, while grooming, primates use their hands and mouth to move fur and pick skin, insects, and other parasites off of the individual being groomed. Other studies of primate handedness have found a tendency toward left-handed priority (Zhao, et al., 2012). In our study we also examined this tendency in Macaques. This study aims to enhance our understanding of social grooming among macaques and primates overall. This specific behavior is crucial for understanding macaques more deeply, as it can reveal insights into their relationships, hierarchy, and communication patterns. FIGURES CONCLUSIONS Figure 1 Time Spent Grooming with Dominant Hand Note. Instances where the location on the body of autogrooming would be extremely difficult to reach with the other hand (for example, grooming the left arm with the right hand) were omitted from these data. Figure 2 Groomed by Medium Time Proportionalized Note. The data was proportionalized via dividing each time collected by the equivalent value for each size population. Since large was the least common size, it was assigned a value of 1.00. There were 28 medium and 8 small, receiving 9.00 and 2.67 eq. respectively. This was done so each second was proportional to the number available LONG-TAILED MACAQUES Macaques are primates from Southeast Asia, with males ranging in size from about 16-25 in. and weighing 10.418.3 lbs. Females size ranges from about 15-19.8 in. and weigh 5.5-12.6 lbs. (Wisconsin National Primate Research Center). Troops are set up in a patriarchy, with one dominant (generally larger) male (Hakim et al., 2023). The group of macaques we are studying consists of a troop of a few dozen individuals with one dominant male (Indianapolis, 2021). Other studies have found that grooming behavior plays both a hygiene and social role in Macaques (Kanngiesser et al., 2010). Grooming behavior influences and indicates social status in many primates (Pfoh, et al., 2021). Factors like sex and size are a proxy for dominance and can therefore be associated with grooming behavior (Sonlanki, et al., 2020). Macaques are social animals and understanding their social behavior is a key factor in understanding their species. METHODS Long-tailed macaques, Macaca fascicularis, at the Indianapolis Zoo, were observed for a total of 10 hours. A few dozen were in an enclosure with two tall wooden structures and a raised wooden platform. Focal behavior sampling was used to observe grooming behaviors (Pfoh, et al., 2021) For every groomer and groomee, the data recorded included the length of time behavior was observed, sex and size of individuals involved, the location groomed, and what hand was used to do the grooming Size was defined as either small, medium, or large. Any juvenile macaque was considered small. There were only a few large macaques, who were noticeably larger than the others. The rest were considered medium-sized. The hand used for grooming was characterized by which was used for picking at the skin If an individual used both hands to pick at the skin, this was defined as both Social Hierarchy Hypothesis vs. Hygiene Hypothesis Our data did show hierarchy trends among the macaques. The hypothesis that medium sized macaques would disproportionally groom larger sized macaques was supported, as shown in Figure 2. This potentially could be to adhere to the social hierarchy or as a means to climb up it, as seen in (Xia, et al., 2021). However, the hypothesis that medium sized macaques would also groom smaller macaques at a higher rate was not supported. Proportionally, the medium macaques groomed the similar sized macaques at a higher rate than small macaques. The hygiene hypothesis was also confirmed in our data. During allogrooming, macaques had a much larger tendency to groom hard to reach places than easy, shown in Figure 3. Moreover, when autogrooming took place, the macaques essentially only groomed places deemed easy to reach (a staggering 98.2% as seen in Figure 4). These results greatly follow results from previous studies such as Pfoh, et al., 2021, which demonstrated allogrooming behavior primarily focused on hard-to-reach places. Unfortunately, we were unable to consistently identify the macaques sex during our observations, so grooming tendencies between sexes could not be studied. Handedness Hypothesis Our data did not show a significant handedness preference for the macaques during grooming. This does not align with previous studies that show nonhuman primates generally being left-handed (Zhao, et al., 2012). However, handedness is a difficult thing to test and measure as most primates use both hands for lots of the tasks they perform. Studies have also found that a handedness bias may exist for different behaviors within a population. For example, chimpanzees prefer to use their left hand to fish for termites, and they prefer to use their right hand for nut-cracking (Lonsdorf & Hopkins, 2005). In the future, we could look into handedness more by testing whether different tasks evoke different handedness behaviors in Macaques. LITERATURE CITED Figure 3 Groomer Grooming Groomee Note. This graph depicts the percentage of time hard and easy to reach spots were groomed during allogrooming. Figure 4 Groomer Grooming Self Note. This graph depicts the percentage of time hard and easy to reach spots were groomed during autogrooming. Hakim, R. R., Nasution, E. K., Rizaldi, Rukayah, S., & Riani, S. (2023). Daily behavior of alphamale compared with subordinate male in long-tailed macaque. The 7th International Conference On Basic Sciences 2021 (ICBS 2021). https://doi.org/10.1063/5.0111703 Kanngiesser, P., Sueur, C., Riedl, K., Grossmann, J., & Call, J. (2010). Grooming network cohesion and the role of individuals in a captive chimpanzee group. American Journal of Primatology, 73(8), 758767. https://doi.org/10.1002/ajp.20914 Long-tailed macaque. Wisconsin National Primate Research Center. (n.d.). https://primate.wisc.edu/primate-info-net/pin-factsheets/pin-factsheet-long-tailed-macaque/ Lonsdorf, E. V., & Hopkins, W. D. (2005). Wild chimpanzees show population-level handedness for tool use. Proceedings of the National Academy of Sciences, 102(35), 1263412638. https://doi.org/10.1073/pnas.0505806102 Pfoh, R., Tiddi, B., Di Bitetti, M. S., & Agostini, I. (2021). Grooming site preferences in black capuchin monkeys: Hygienic vs. social functions revisited. American journal of primatology, 83(12), e23336 https://onlinelibrary.wiley.com/doi/10.1002/ajp.23336 Solanki, G., Lalremruati, P. ., & K, L. (2020). Grooming pattern in captive Macaques: A comparative study. Environment Conservation Journal, 21(3), 127135. https://doi.org/10.36953/ECJ.2020.21315 Xia DP, Wang X, Garber PA, Sun BH, Sheeran LK, Sun L and Li JH (2021) Effects of Hierarchical Steepness on Grooming Patterns in Female Tibetan Macaques (Macaca thibetana). Front. Ecol. Evol. 9:631417. doi: 10.3389/fevo.2021.631417 https://www.frontiersin.org/articles/10.3389/fevo.2021.631417/full Zhou, J., Li, W., Wang, X., & Li, J. (2022). Seasonal Change in Activity Rhythms and Time Budgets of Tibetan Macaques. Biology, 11(9), 1260. https://doi.org/10.3390/biology11091260 Zhao, D., Hopkins, W. D., & Li, B. (2012). Handedness in nature: First evidence on manual laterality on Bimanual coordinated tube task in wild primates. American Journal of Physical Anthropology, 148(1), 3644. https://doi.org/10.1002/ajpa.22038 ACKNOWLEDGMENTS We would like to thank Dr. Benson for the support and for the guidance in our research. We would also like to thank the Chemistry department in the College of Arts and Sciences of Marian University.  ...

... The Effect of Parenting Styles on Individuals Dark Triad Scores M. Dumke, J. Ralph, & G. Pineda-Ramos Marian University Showcase of Scholarship Spring 2024 PSY250-MM02 Dr. Amanda C. Egan ABSTRACT Our study investigated the impact of parenting styles on a child's scores on the dark triad personality test. The way a child is parented directly impacts their growth and development from an early age. There are four parenting styles that are most often recognized including Authoritative, Authoritarian and Permissive/Neglectful. The review of previous literature found connections between lower quality parenting and increased levels of narcissism in children. RESULTS (cont.) Independent Samples T-Test The pearsons correlation test yielded results that showed significant correlations with permissive parenting and scores of Machiavellianism and Psychopathy at the p<.05 level. Authoritarian parenting also yielded positive correlation with Psychopathy at the p<.01 level. An independent samples T test was also performed to find significant effect of parenting type on an individual's scores on the sub scales of the dark triad. This test yielded a p value of 0.072 meaning there is a marginally significant effect on parenting type on the psychopathy sub score. BACKGROUND Parenting style refers to the pattern of approaches and behaviors that parents use when raising their child. The parenting styles investigated in this study include authoritarian, authoritative, and permissive. Authoritarian parenting involves parents that have one form of communication with strict rules they expect the child to follow (Sanvictores & Mendez, 2022). Authoritative parenting refers to parents that have a close and nurturing relationship with the child and set clear guidelines for their expectations while providing reasoning for those guidelines (Sanvictores & Mendez, 2022). Permissive parenting involves nurturing parents that have little or no expectations for their children (Sanvictores & Mendez, 2022). In recent years research has found that lower quality parenting and insecure relationships with ones caregivers can cause a child to develop antisocial personality traits found within the Dark Triad (Tajmirriyahi et al.,2021). PREDICTIONS H1: Respondents w/ Authoritative parenting style will report lower levels of machiavellianism than those whose parents used another parenting style. H2: Respondents w/ Authoritative parenting style will report lower levels of narcissism than those whose parents used another parenting style. H3: Respondents w/ Authoritative parenting style will report lower levels of psychopathy than those whose parents used another parenting style. METHODS RESULTS (cont.) Key Forty-five participants over the age of 18 (35 female, 10 male) took a Qualtrics survey that consisted of 57 questions. The first 30 questions were about the parenting style of which parent they selected. The next 27 were questions from the Short Dark Triad personality test. The survey also included demographic questions and questions regarding their parent's marital status and which parent they felt closest to growing up. REFERENCES Lyona, M., Brewer, G., Carter, L.C, (2020). Dark Triad traits and preference for partner parenting styles. ScienceDirect. https://www.sciencedirect.com/science/article/abs/pii/S0191886919305100 Sanvictores, T., & Mendez, M. D. (2022, September 18). Types of parenting styles and effects on children. StatPearls NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK568743/ Tajmirriyahi, M., Doerfler, S. M., Najafi, M., Hamidizadeh, K., & Ickes, W. (2021). Dark Triad traits, recalled and current quality of the parent-child relationship: A non-western replication and extension. Personality and Individual Differences, 180, 110949. https://doi.org/10.1016/j.paid.2021.110949 Red: negative correlation Purple: positive correlation White: no correlation Pearsons Correlation (r)  ...

... ONDANSETRON PRIOR TO SPINAL ANESTHESIA Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2024 Ondansetron Prior to Subarachnoid Anesthesia in Parturient Patients Undergoing Cesarean Section to Decrease Hypotension: A Practice Change Guideline Katie Holmer 1 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 2 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 3 Table of Contents Abstract...5 Ondansetron Prior to Spinal Anesthesia.6 Background..6 Problem Statement ..7 Gap Analysis8 Review of the Literature8 Dose.9 Timing10 Efficacy Evaluation....10 Literature Review Conclusion...11 Theoretical Framework...12 Project Aims and Objectives...12 Project Design/Methods...13 Project Site and Population...14 Measurement Instruments..14 Data Collection Procedure.15 Ethical Considerations/Protection of Human Subjects..15 Results...16 Participants.16 Pre-test...16 Knowledge Assessment.17 Willingness to Change...18 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 4 Chart Review.18 Discussion.19 Recommendations.20 Limitations.20 Conclusion20 References.....22 Appendix A Literature Matrix26 Appendix B Pre-test..30 Appendix C Post-test32 Appendix D Hospital IRB approval letter..33 Appendix E- Marian University IRB approval letter...35 Appendix F Pre-test Post-test Data Comparison...36 Appendix G Data Collection Tool...37 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 5 Abstract Background: Cesarean sections account for 31% of all births annually, with spinal anesthesia being the preferred method of anesthesia. The side effects from spinal anesthesia in the parturient include hypotension, bradycardia, and vasodilation. The medication ondansetron, when administered before spinal anesthesia, can help mitigate some side effects of spinal anesthesia. Purpose: This DNP project was developed to educate anesthesia providers on the benefits of administering ondansetron before spinal anesthesia in a parturient scheduled for a cesarean section. Methods: This DNP project collected quantitative and qualitative data through electronic pretests and post-tests. An evidence-based educational intervention was conducted with a retrospective chart review. Implementation: Five anesthesia providers at a rural hospital in northern Indiana participated in this project. The providers were given a pre-test and then, one-on-one, provided with education from a PowerPoint presentation. Following the presentation, a post-test was administered. Additionally, a retrospective chart review was conducted three months before and three months after the educational intervention to determine if a practice change had been made regarding the timing of ondansetron administration. Conclusion: The introduction of an educational intervention improved anesthesia providers' knowledge on the benefits of ondansetron before spinal anesthesia in parturients, with a statistically significant (p < 0.001) increase in pre-test to post-test scores. Additionally, a retrospective chart review indicated that before the educational intervention, ondansetron was given 0% of the time before spinal anesthesia in parturients, and following the educational intervention, it was increased to 50% of the time before spinal anesthesia. Keywords: Zofran, ondansetron, spinal, spinal anesthesia, neuraxial anesthesia, cesarean section, cesarean delivery, Bezold-Jarisch, and sympathectomy ONDANSETRON PRIOR TO SPINAL ANESTHESIA 6 Ondansetron Prior to Subarachnoid Anesthesia in Parturient Patients Undergoing Cesarean Section to Decrease Hypotension: A Practice Change Guideline This project is submitted to the faculty of Marian University Leighton School of Nursing as partial fulfillment of degree requirements for the Doctor of Nursing Practice, Certified Registered Nurse Anesthetist track. Cesarean sections (CS) comprise 31% of all deliveries annually. Researchers suggest that the best method of anesthesia for this patient population is spinal anesthesia. However, spinal anesthesia, though advantageous for its reduced medication transfer across the placenta to the fetus and the pain management for the mother, comes with some adverse side effects. Hypotension, bradycardia, nausea, and vomiting are the key side effects of spinal anesthesia. Current literature suggests using prophylactic interventions to decrease the risk of hypotension and, thus, nausea and vomiting associated with spinal anesthesia. Background According to the Centers for Disease Control and Prevention, there were 1,148,692 CS deliveries in 2020 in the United States, which account for 31.8% of all births (Osterman, 2022). Mothers having an elective CS can request the type of anesthesia they would like, whether general anesthesia, spinal anesthesia, or combined spinal/epidural anesthesia, as long as the choice is safe for the mother and baby. The American Society of Anesthesiologists, 2022 suggests that a spinal or epidural anesthetic plan best suits CS deliveries. This is because a onetime spinal injection or an epidural catheter that remains in place and can be dosed with stronger medications for the delivery both reduce the amount of medication to the fetus and allow the mother to remain awake and participate in the delivery (American Society of Anesthesiologists, 2022). ONDANSETRON PRIOR TO SPINAL ANESTHESIA 7 Even though spinal anesthesia is the preferred anesthetic for patients undergoing a CS, it does not come without risks or side effects. The primary concern with spinal anesthesia in the parturient is hypotension, affecting up to 90% of parturients receiving spinal anesthesia. Hypotension not only affects the mother but can also cause harm to the fetus due to uterine blood flow lacking autoregulation and being dependent on maternal blood pressure. In addition, hypotension commonly leads to dizziness with nausea and vomiting in the mother. Hypotension in the mother, however, can cause far more life-threatening concerns for the fetus, such as bradycardia, acidosis, and the potential for cardiovascular collapse. Additional maternal side effects include bradycardia and shivering (Fitzgerald et al., 2019). Researchers suggest that hypotension from spinal anesthesia is related to the BezoldJarisch reflex (BJR) (Arya et al., 2020). The inhibitory BJR happens when receptors in the epicardium of the left ventricle are stimulated by stretch, chemical substances, or medications (Arya et al., 2020). When enabled, the BJR increases parasympathetic activity, leading to hypotension, bradycardia, and vasodilation, and further inhibits sympathetic responses (Arya et al., 2020). The chemoreceptors and mechanoreceptors triggered during the BJR are sensitive to serotonin, also known as 5-HT3 (Arya et al., 2020). Ondansetron is a 5-HT3 receptor antagonist that blocks serotonin from initiating nerve signals on the chemoreceptors and mechanoreceptors, thus decreasing the response to the BJR (Aksoy et al., 2021). If the BJR can be blocked, the patient has a reduced risk of experiencing hypotension, bradycardia, nausea, and vomiting (Aksoy et al., 2021). Problem Statement With more than one million CS being performed every year, about 90% of mothers can be expected to experience hypotension from spinal anesthesia (Fitzgerald et al., 2019). ONDANSETRON PRIOR TO SPINAL ANESTHESIA 8 Researchers suggest the utilization of ondansetron prophylactically to help decrease hypotension before it occurs (Aksoy et al., 2021). Although there are guidelines from the American Association of Nurse Anesthesiology (AANA), 2022, for prophylactically giving ondansetron before spinal anesthesia, it is not always used. For example, 100% of providers at a rural hospital in northern Indiana have not adopted this practice. Therefore, the following PICO question was developed: Does an educational intervention change the current practice of anesthesia providers (at a rural hospital in northern Indiana) regarding the utilization of ondansetron prior to administering spinal anesthesia in parturients undergoing scheduled CS? Gap Analysis The investigator conducted an informal poll of anesthesia providers in the Summer of 2022 to evaluate the utilization of ondansetron in a rural anesthesia practice. The poll revealed that currently, ondansetron is not regularly administered prior to spinal anesthesia in laboring parturients. The anesthesia providers did not indicate awareness of this practice guideline. The practice of using ondansetron before spinal anesthesia is presently used by many certified registered nurse anesthetists (CRNAs) and is supported by the AANA with the most recent update to the obstetric guidelines in November of 2022 (American Association of Nurse Anesthesiology, 2022). The informal poll suggested a need for more knowledge surrounding the benefits of ondansetron and that an educational intervention could fill that knowledge gap. Review of Literature This literature review was conducted to evaluate articles discussing the use of ondansetron prior to spinal anesthesia in laboring parturients undergoing scheduled CS. The review search used the keywords Zofran, ondansetron, spinal, spinal anesthesia, neuraxial anesthesia, cesarean section, cesarean delivery, Bezold-Jarisch, and sympathectomy. This ONDANSETRON PRIOR TO SPINAL ANESTHESIA 9 literature review was conducted in October and November 2022 using PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases through the EBSCO interface. The databases were searched using the following BOOLEAN phrases: Zofran AND spinal anesthesia, ondansetron AND spinal anesthesia, spinal anesthesia AND Bezold-Jarisch, ondansetron AND neuraxial anesthesia AND Bezold-Jarisch. The inclusion criteria were adults, CS surgery, parturients, spinal anesthesia, studies in English or translated to English, and studies done on humans. The literature review search initially resulted in 211 articles. After applying inclusion and exclusion criteria, the literature review search was reduced to 23 articles. After full-text scanning, ten articles were selected for inclusion in the literature review. The literature review uncovered research studies that utilized different methods to evaluate the efficacy of ondansetron on spinal anesthesia-induced hypotension. The research focused on a few themes, such as the dose of ondansetron, the time of administration of the dose in relation to the placement of the spinal anesthesia, and the evaluation methods of efficacy. Dose Researchers have studied the best prophylactic dose of ondansetron to prevent hypotension. The recommended and studied doses ranged from four milligrams to eight milligrams. Of the 10 articles, four evaluated the use of four milligrams of ondansetron before the placement of spinal anesthesia (Shabana et al., 2018; Qian et al., 2020; Wahid et al., 2022; Xiao et al., 2020). Two of the 10 studies evaluated the use of eight milligrams of ondansetron (Aksoy et al., 2021; Karacaer et al., 2018). Three of the research studies compared the dose amounts of four, six, or eight milligrams of ondansetron to determine which dose would provide more benefit (Potdar et al., 2017; Samarah et al., 2020; Vashishth et al., 2022). Potdar et al. (2017) compared four milligrams of ondansetron to eight milligrams and determined that both ONDANSETRON PRIOR TO SPINAL ANESTHESIA 10 doses were beneficial in decreasing the severity of hypotension (P = 0.03); however, there was not a significant difference between the two doses. In sum, Xiao et al. (2020) and Shabana et al. (2018) indicate to give four milligrams of ondansetron. Furthermore, the AANA supports the indication of giving four milligrams of ondansetron before spinal anesthesia (American Association of Nurse Anesthesiology, 2022). Timing The appropriate timing of the dose of ondansetron with respect to the duration of effect of six hours varied among studies, and the dosing times ranged from five minutes to 20 minutes before the placement of spinal anesthesia. Five of the 10 articles gave ondansetron five minutes before administering spinal anesthesia (Aksoy et al., 2021; Karacaer et al., 2018; Potdar et al., 2017; Shabana et al., 2018; Vashishth et al., 2022). Three of the studies each gave ondansetron at varying times of 10 minutes (Xiao et al., 2020), 15 minutes (Wahid et al., 2022), and 20 minutes (Samarah et al., 2020). Qian et al. (2020) compared the administration of four milligrams of ondansetron five or 15 minutes before administering spinal anesthesia and found no significant statistical difference between the timing (P = 0.945). Based on the studies by Samarah et al. (2020), Wahid et al. (2022), and Xiao et al. (2022), it is efficacious to give ondansetron five to 20 minutes before administering spinal anesthesia. The current guidelines from the AANA do not indicate a dosing time in minutes but state that the dose should be administered before spinal anesthesia (American Association of Nurse Anesthesiology, 2022). Efficacy Evaluation There were two common benchmarks for the efficacy of giving ondansetron before spinal anesthesia in parturients to decrease hypotension. The two common assessment methods were monitoring for a decrease in the number of hypotensive or bradycardic episodes or assessing for ONDANSETRON PRIOR TO SPINAL ANESTHESIA 11 the quantity in milligrams or micrograms or the number of administrations of a vasopressor medication. Nine of the 10 studies utilized the amount of vasopressor used to treat hypotensive episodes to determine the efficacy of ondansetron in reducing hypotension from spinal anesthesia (Aksoy et al., 2021; Karacaer et al., 2018; Potdar et al., 2017; Qian et al., 2020; Samarah et al., 2020; Shabana et al., 2018; Vashishth et al., 2022; Wahid et al., 2022; Xiao et al., 2020). Additionally, three of the 10 research studies evaluated efficacy based on changes to the patient's blood pressure readings (Potdar et al., 2017; Shabana et al., 2018; Wahid et al., 2022). Furthermore, Shabana et al. (2018) determined that giving a patient four milligrams of ondansetron before spinal anesthesia significantly decreased the degree of decline in the patient's mean arterial pressure readings immediately following the spinal anesthesia placement. For example, the study group that received ondansetron had a mean arterial pressure of 76.4, and the control group had a mean arterial pressure of 68.4 (P = 0.007) (Shabana et al., 2018). Literature Review Conclusion The administration of ondansetron before spinal anesthesia in parturient patients scheduled for a CS is efficacious in decreasing the severity of hypotension and bradycardia and, thus, nausea and vomiting. Decreasing the severity of hypotension in the mother can promote possible better outcomes for the fetus. The most recent update to the AANA obstetrical care guidelines supports the administration of ondansetron prior to spinal anesthesia. The guideline states that four milligrams of ondansetron should be administered prior to the placement of spinal anesthesia in parturients but does not specify a timeframe for administration (American Association of Nurse Anesthesiology, 2022). ONDANSETRON PRIOR TO SPINAL ANESTHESIA 12 Theoretical Framework The theoretical framework that was utilized for this project was Lewins Theory of Change. The three main components of Lewins Theory of Change are unfreezing, change, and refreezing. Unfreezing takes place when people let go of an old practice. The component of change takes place when people can transform the way they think, feel, and act. Lastly, refreezing occurs when a person views the change as a new habit or standard of care (Lewins Change Theory Nursing Theory, 2020). For example, ondansetron is currently administered after the placement of spinal anesthesia at a rural hospital in northern Indiana. This project aimed to educate anesthesia providers on the benefits of administering ondansetron before spinal anesthesia. With the use of Lewins Theory of Change, hopefully, anesthesia providers will unfreeze, change, and refreeze their practice of administering ondansetron after spinal anesthesia to before spinal anesthesia after learning the evidence-based practice benefits of ondansetron. Project Aims and Objectives This quality improvement project aimed to increase the knowledge of anesthesia providers (at a rural hospital in northern Indiana) on the benefits of using ondansetron prior to spinal anesthesia in parturient patients scheduled for a CS to help reduce hypotension. In the case of a parturient, hypotension not only affects the mother but can affect the fetus also. Blood flow to the fetus is not autoregulated and is directly related to the mother's blood pressure; therefore, if the mother is hypotensive, this decreases the blood flow to the fetus, which could lead to fetal complications (Elisha & Terry, 2018). The objectives were as follows: -Include anesthesiologist physicians and CRNAs. -Provide an in-person pre-test to evaluate knowledge of current evidence-based practice regarding ondansetron. ONDANSETRON PRIOR TO SPINAL ANESTHESIA 13 - Provide an in-person educational intervention following the pre-test. -Provide a post-test in person following the educational intervention to assess knowledge gained from educational intervention and willingness to change practice. -Perform a retrospective chart review from three months prior to educational intervention to determine when ondansetron was administered. -Perform a retrospective chart review to determine when ondansetron was administered for three months following the educational intervention to determine if a practice change was made. Project Design/Methods This evidence-based practice quality improvement project was implemented utilizing an educational intervention to increase anesthesia providers awareness of the benefits of ondansetron when performing spinal anesthesia. First, a retrospective chart review of the previous three months was completed on all patients undergoing a scheduled CS with spinal anesthesia to evaluate if ondansetron was administered and, if so, if it was given before or after spinal anesthesia placement. Next, one-on-one in-person meetings were held throughout the day when each anesthesia provider was available before or between operating room cases. In the first five minutes of the educational presentation, an in-person pre-test using Qualtrics was administered to all anesthesiaproviding personnel at the facility, including CRNA staff and anesthesiologists. The pre-test included knowledge questions about ondansetron, the preferred method of anesthesia for a scheduled CS, whether ondansetron is administered, the timing of ondansetron, and the known benefits of the medication. Following the pre-test, a PowerPoint presentation was delivered in person utilizing information from evidence-based research. Following the educational intervention, an in-person ONDANSETRON PRIOR TO SPINAL ANESTHESIA 14 post-test was administered, which included knowledge-based questions to gauge learning of educational material. The pre-test and post-test were administered via Qualtrics. To ensure participants' anonymity, they were asked to create a four-digit code to provide on the Qualtrics surveys that could not be used to identify them. Participation was voluntary, and the participants pre-test and post-test performance remained anonymous. Participants were not rewarded or compensated for participating in the project. Lastly, a chart review of the three months following the educational intervention was completed to evaluate if the anesthesia providers changed their practice to administer ondansetron before spinal anesthesia for parturients undergoing a scheduled CS. Project Site and Population The project was implemented at a small rural hospital in northern Indiana. The hospital has four operating rooms. On average, the anesthesia providers perform anesthesia for 20 cesarean deliveries per month. The participants were recruited as a convenience sample of four anesthesiologists and one CRNA who jointly have many years of experience. Measurement Instruments Participants were administered a multiple-choice and fill-in-the-blank pre-test and posttest. The validity of the knowledge-based questions was confirmed by two community CRNA experts in obstetrical anesthesia. All information collected for this project was obtained from participants' pre-tests and post-tests. Please see Appendix B and Appendix C for copies of the pre-test and post-test. In addition, a retrospective chart review was completed and only looked at charts of patients who received spinal anesthesia for a scheduled CS and excluded patients undergoing an emergent CS. No identifying patient information was collected. A tool was developed to summarize the data into quantitative data for statistical analysis. This tool was ONDANSETRON PRIOR TO SPINAL ANESTHESIA 15 developed to compare the timing of ondansetron administration before and after the educational intervention. Please see Appendix F for a copy of the data collection tool. Data Collection Procedures Once approval was obtained from Ascension Hospital and Marian University Institutional Review Boards during the Fall semester of 2023, data collection was started. Participants were provided with an in-person pre-test, educational intervention, and post-test on a voluntary and anonymous basis. A chart review was completed for the three months before the educational intervention. Then, three months after the educational intervention, a chart review was completed during the Spring semester of 2024. Qualtrics was used to administer the pre-test and post-test and to help provide data analysis. Data was entered into Excel, and IBM software, SPSS, was used to perform statistical analysis of the data. Ethical Considerations/Protection of Human Subjects This DNP project was submitted to the Marian University Institutional Review Board as a practice change project. The DNP project was also submitted to Ascension Hospital's Institutional Review Board for approval. The DNP student did not collect demographic information from the participants (anesthesia providers), nor was patient information collected. All data from patient charts regarding ondansetron use was collected as binary, indicating before or after spinal anesthesia administration. No patient demographics, such as name, ethnicity, age, or weeks of gestation, were collected. Anesthesia participants were assured anonymity by choosing a random four-digit code on the day of education implementation. All participant data will be stored on the DNP student's laptop for two years following the project and will be password-protected to prevent access by unauthorized users. No patient data was obtained or stored. 16 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Results Five full-time employed anesthesia providers were eligible and participated in the project. The sample was a convenience sample. All five participants completed the pre-test, participated in the one-on-one educational PowerPoint, and then completed the post-test. Participants The only data collected on the participants was their years of practice in anesthesia. As the chart below shows, the providers have many years of experience. One provider, making up 20% of the group, has been in anesthesia for zero to five years. Two of the five providers had six to 10 years of experience, making up 40% of the population. Zero providers fell in the 11 to 19 years category. Lastly, making up 40% of the population, two of the five providers had 20 years or more of anesthesia experience. Years Practicing Anesthesia Valid 0-5 6-10 11-19 20+ Total Frequency 1 2 0 2 5 Percent Valid Percent 20.0 20.0 40.0 40.0 0 0 40.0 40.0 100.0 100.0 Cumulative Percent 20.0 60.0 0 40.0 100.0 Pre-test The pre-test consisted of 10 questions. One demographic question asked about years of anesthesia experience, four background information questions, and five knowledge assessment questions. The questions included selecting one, selecting two, selecting multiple, and filling in the blank. ONDANSETRON PRIOR TO SPINAL ANESTHESIA 17 To gauge the prevalence of a spinal anesthesia plan for scheduled CS, the question was asked, What is the primary anesthesia plan for scheduled CS patients at your facility? The response was that 100% of providers answered spinal anesthesia. Next, the providers were asked how often they experienced hemodynamic changes following spinal anesthesia. The responses were almost always (2 providers, 40%), Often (2 providers, 40%), Sometimes (1 provider, 20%), and Never (0%). This data helps to solidify the severity of the problem of hemodynamic changes following spinal anesthesia. Providers were then asked if they administered ondansetron when performing spinal anesthesia, and 100% of providers responded yes. They were also asked how many minutes before or after spinal anesthesia they administered ondansetron. The responses were zero to five minutes (0%), five to 10 minutes (0%), 10 to 15 minutes (1 provider, 20%), 15 to 20 minutes (1 provider, 20%), and 20 or more minutes (3 providers, 60%). Knowledge Assessment A knowledge assessment was completed comparing pre-test and post-test scores to assess the educational intervention's success. The same five questions were asked on both tests. Please see Appendix F for a comparison of responses. The tests were graded all or nothing regarding points for correct responses, with five points being the maximum points possible. The pre-test scores ranged from one to two out of five. Descriptive statistics were computed, and the pre-test had a mean of 1.60 with a standard deviation of 0.548. The post-test scores were much improved, and all participants scored a five out of five with a mean of five and a standard deviation of 0.000. A paired t-test was then performed using SPSS software, comparing the pre-test mean to the post-test mean, and determined that the results were significant (p < 0.001). 18 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Paired Samples Statistics Mean Pair 1 N Std. Deviation Std. Error Mean Pre-test Score 1.60 5 .548 .245 Post-test Score 5.00 5 .000 .000 Paired Samples Test Paired Differences Significance 95% Confidence Interval of the Mean Pair Pre-test Score 1 Post-test Score -3.400 Std. Std. Error Deviation Mean .548 .245 Difference Lower -4.080 Upper -2.720 t -13.880 df 4 One- Two- Sided p Sided p <.001 <.001 Willingness to Change Lastly, there was one question on the post-test that was not a knowledge assessment but rather an assessment of willingness to change. The question asked, When providing spinal anesthesia for scheduled CS patients, do you plan to administer a 5-HT3 antagonist before placing spinal anesthesia? All five providers (100%) responded that Yes they plan to administer ondansetron before spinal. This response shows a willingness to change their practice from administering ondansetron after spinal anesthesia to administering it before based on information received from the educational interventions. Chart Review A retrospective chart review was completed to assess anesthesia providers' timing of administering ondansetron in relation to spinal anesthesia in parturient patients receiving a scheduled CS. Please see Appendix G for the data collection tool used to compare the administration of ondansetron before and after the educational intervention. Data was collected 19 ONDANSETRON PRIOR TO SPINAL ANESTHESIA for three months before the educational intervention, which took place on January 18th, 2023. During those three months, 37 CS were performed; however, due to inclusion criteria, only 19 cases were included in this project. For the 19 cases included before the educational interventions, ondansetron was given 0% of the time before spinal anesthesia. In the three months following the educational intervention, 31 CS were performed, but only 14 of those met the inclusion criteria. Of the 14 cases included, ondansetron was given seven times before spinal anesthesia and seven times after spinal anesthesia, resulting in a 50% increase in practice change to administer before spinal anesthesia. Timing of Ondansetron Administration 8 7 6 5 4 3 2 1 0 OCT NOV DEC JAN 01-18 JAN19-31 Before Spinal FEB MARCH APRIL After Spinal Discussion The results from the knowledge assessment demonstrated that the providers gained critical knowledge on the value of using ondansetron. Additionally, when asked, 100% of providers answered yes that they plan to change their practice to administering ondansetron before spinal placement. The retrospective chart review showed an improvement from ondansetron never being given before spinal anesthesia to being given before in 50% of cases. ONDANSETRON PRIOR TO SPINAL ANESTHESIA 20 Recommendations Based on the results from the retrospective chart review, which indicated that only 50% of the time, providers changed their practice to reflect current guidelines, a recommendation is to continue education and implement a protocol. Limitations One limitation of this project was the small sample size of five anesthesia providers. However, all providers at the facility, including anesthesiologists and a CRNA, participated in all aspects of the project. Additionally, a t-test was performed to help account for the smaller sample size. A critical aspect of the project was the inclusion criteria. For instance, cases were omitted where the surgeon requested an epidural placement for a scheduled cesarean section instead of a spinal due to the anticipated length of the surgery. These cases, while significant, did not meet the specific criteria for the project. There are only two obstetricians performing CSs at this hospital, so this largely decreased the number of cases included in the project. Lastly, during the six months of data collection, the anesthesia department employed multiple traveling anesthesiologists to help cover staffing shortages. The traveling anesthesiologists did not receive the educational intervention. Therefore, the CSs performed by these anesthesiologists were omitted from the data collection, further decreasing the number of cases available for data analysis. Conclusion Hypotension from spinal anesthesia in the parturient patient can cause a cascade of negative outcomes. Administering ondansetron before placing spinal anesthesia can help mitigate some of the negative outcomes. This DNP project sought to determine whether ONDANSETRON PRIOR TO SPINAL ANESTHESIA 21 educating anesthesia providers on the benefits of ondansetron prior to placing spinal anesthesia would change the current practice of giving it after the procedure. This project's educational intervention was successful in increasing anesthesia providers' knowledge of the benefits of ondansetron prior to spinal anesthesia in parturients undergoing scheduled CS. When polled, providers were willing to change their practice, and the retrospective chart review indicated that providers were working to make a change with a 50% increase in ondansetron administration before spinal anesthesia. Practice change takes time, and with a willingness to change, a complete practice change is possible. ONDANSETRON PRIOR TO SPINAL ANESTHESIA 22 References American Association of Nurse Anesthesiology. (2022). Analgesia and anesthesia for the obstetric patient practice guidelines. In www.aana.com. Retrieved December 10, 2022, from https://www.aana.com/docs/default-source/practice-aana-com-web-documents(all)/professional-practice-manual/analgesia-and-anesthesia-for-the-obstetric-patient-novbod.pdf?sfvrsn=16ade2ec_8&utm_campaign=Essential%20Newsletter%20%202022&utm_medium=email&_h American Society of Anesthesiologists. (2022). C-Section: Surgery, risks & recovery made for this moment. Made for This Moment: Anesthesia, Pain Management & Surgery. https://www.asahq.org/madeforthismoment/preparing-for-surgery/procedures/csection/ Arya, S., Belwal, S., Uniyal, B., Tiwari, B., & Sharma, P. (2020). Bezold Jarisch reflex- new interest, old phenomenon. American Journal of Internal Medicine 8(1), 24. https://doi.org/10.11648/j.ajim.20200801.15 Aksoy, M., Dostbil, A., Aksoy, A. N., Ince, I., Bedir, Z., & Ozmen, O. (2021). Granisetron or ondansetron to prevent hypotension after spinal anesthesia for elective cesarean delivery: A randomized placebo-controlled trial. Journal of Clinical Anesthesia, 75, 110469. https://doi.org/10.1016/j.jclinane.2021.110469 Elisha, S., & Terry, K. L. (2018). Neonatal anesthesia. In J. J. Nagelhout & S. Elisha (Eds.), Nurse Anesthesia (6th ed., pp. 10921116). Elsevier. FastStats (n.d.). Births - method of delivery. Retrieved October 24, 2022, from https://www.cdc.gov/nchs/fastats/delivery.htm ONDANSETRON PRIOR TO SPINAL ANESTHESIA 23 Fitzgerald, J. P., Fedoruk, K. A., Jadin, S. M., Carvalho, B., & Halpern, S. H. (2019). Prevention of hypotension after spinal anesthesia for cesarean section: a systematic review and network metaanalysis of randomized controlled trials. Anaesthesia, 75(1), 109 121. https://doi.org/10.1111/anae.14841 Heesen, M., Klimek, M., Hoeks, S. E., & Rossaint, R. (2016). Prevention of spinal anesthesiainduced hypotension during cesarean delivery by 5-hydroxytryptamine-3 receptor antagonists. Anesthesia &Amp; Analgesia, 123(4), 977 988. https://doi.org/10.1213/ane.0000000000001511 Karacaer, F., Biricik, E., nal, L., Bykkurt, S., & nlgen, H. (2017). Does prophylactic ondansetron reduce norepinephrine consumption in patients undergoing cesarean section with spinal anesthesia? Journal of Anesthesia, 32(1), 90 97. https://doi.org/10.1007/s00540-017-2436-x Lewins Change Theory - Nursing Theory. (2020, July 19). Nursing Theory. https://nursingtheory.org/theories-and-models/lewin-change-theory.php Osterman, M. J. K. (2022). Changes in primary and repeat cesarean delivery: United States, 2016-2021. In U.S. Department of Health and Human Services, Center for Disease Control and Prevention (Report No. 21). U.S. Department of Health and Human Services. Retrieved October 8, 2022, from https://www.cdc.gov/nchs/data/vsrr/vsrr021.pdf Potdar, M., Kamat, L., Jha, T., Talnikar, A., Mahevi, Z., & Save, M. (2017). Effect of ondansetron in attenuation of post-spinal hypotension in caesarean section: A comparison of two different doses with placebo. Journal of Obstetric Anesthesia and Critical Care, 7(2), 69. https://doi.org/10.4103/joacc.joacc_7_16 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 24 Qian, J., Liu, L., Zheng, X., & Xiao, F. (2020). Does an earlier or late intravenous injection of ondansetron affect the dose of phenylephrine needed to prevent spinal anesthesia-induced hypotension in cesarean sections? Drug Design, Development, and Therapy, Volume 14, pp. 27892795. https://doi.org/10.2147/dddt.s257880 Samarah, W., Alghanem, S., Bsisu, I., Rahman, Z., Guzu, H., & Abufares, B. (2020). The effect of ondansetron administration 20 minutes prior to spinal anesthesia on hemodynamic status in patients undergoing elective caesarean section: A comparison between two different doses. Indian Journal of Anaesthesia, 64(11), 954. https://doi.org/10.4103/ija.ija_974_19 Shabana, A. A., Elkholy, N. I., Mohamed, A. M., & Abdel Hamid. A. I., (2018). Effect of ondansetron on hypotension and bradycardia associated with spinal anesthesia during cesarean section. Menoufia Medical Journal, 31(1), 12. https://doi.org/10.4103/11102098.234215 Vashishth, S., Lal, J., Bangarwa, N., Wadhwani, J., & Smriti, M. (2022). Efficacy of variable doses of prophylactic intravenous ondansetron in attenuating spinal induced hypotension in parturients undergoing caesarean delivery: A randomized control trial. Cureus. https://doi.org/10.7759/cureus.29440 Wahid, M., Ali, S., Yasin, B., Farhat, K., Noor, M., & Tassadaq Syed, F. (2022). Granisetron versus ondansetron: Comparison of 5HT3 antagonists in preventing spinal anesthesia induced hemodynamic instability in obstetric patients. Pakistan Journal of Medical Sciences, 38(7). https://doi.org/10.12669/pjms.38.7.5585\\ Xiao, F., Wei, C., Chang, X., Zhang, Y., Xue, L., Shen, H., Ngan Kee, W. D., & Chen, X. (2019). A prospective, randomized, double-blinded study of the effect of intravenous ONDANSETRON PRIOR TO SPINAL ANESTHESIA ondansetron on the effective dose in 50% of subjects of prophylactic phenylephrine infusions for preventing spinal anesthesiainduced hypotension during cesarean delivery. Anesthesia & Analgesia, 131(2), 564 569. https://doi.org/10.1213/ane.0000000000004534 25 26 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Appendix A Literature Matrix Citation Research Design Purpose / Aim Population / Sample size n=x Major Variables Instruments / Data collection Results Aksoy et al. (2021) Doubleblinded, randomized placebocontrolled trial To compare 8mg of Zofran to 3mg of Granisetran to a control of normal saline to determine if a 5HT3 antagonist will help decrease hypotension from spinal anesthesia in parturients To determine if a 5-HT3 antagonists decreases hypotension with spinal anesthesia Group I 8mg Zofran (n=40) 8mg of Zofran vs. 3mg of Granisetron vs. 10ml normal saline 5 minutes prior to spinal Number of doses of 6mg of ephedrine used for hypotension (30% decrease in SBP) Group I - 20 patients (50%), Group II 12 patients (30%), Group III 29 patients (72.5%) required ephedrine for hypotension (P = 0.001). Group III significantly higher than Group I (P = 0.033) and Group II (P <0.001). Group I ephedrine use compared to Group II was not statically significant (P = 0.055). Zofran doses ranging from 2 to 12mg, Granisetron, Vital signs, hypotension definition varied by research trial, vasopressor use A 5-HT3 antagonist prevented hypotension in obstetric and non-obstetric cases (p=0.003). Statistical significance for obstetric cases alone (p=0.1). To determine if Zofran decreased the incidence of hypotension, use of norepinephrine, and adverse effects of spinal anesthesia Group O 8mg Zofran (n=54) 8mg of Zofran vs. 4ml of normal saline 5 minutes prior to spinal anesthesia Incidence of hypotension, number of hypotensive episodes, total amount of norepinephrine uses, adverse effects that took place There was no significant difference in the incidence of hypotensive episode between Group O and Group S (p = 0.767). Number of hypotensive episodes greater for Group S than Group O and statistically significant (p = 0.009). Amount of norepinephrine used greater for Group S than Group O and was statistically significant (p= 0.009). Heesen et al. (2016) Karacaer et al. (2017) Systematic review, metaanalysis Prospective, randomized, doubleblinded control study Group II 3mg Granisetron (n=40) Group III 10ml normal saline (n=40) N=140 17 clinical trials (8 OB, 9 non-OB) N =1604 Group S - 4ml normal saline (n=54) N=108 27 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Potdar et al. (2017) Qian et al. (2020) Samarah et al. (2020) Prospective, randomized, doubleblinded placebo study Prospective randomized doubleblinded study Prospective, randomized, doubleblinded clinical trail To compare different doses of Zofran to 10ml of normal saline given prior to spinal anesthesia in parturients to compare vasopressor needs and incidence of nausea and vomiting To determine if the time the Zofran is administered before spinal anesthesia (SA) in parturients effects the amount of phenylephrine dose required To determine if the amount of Zofran given before spinal anesthesia in parturients decreased hypotension Group C 10ml normal saline (n=60) Group F 4mg Zofran (n=60) 10ml of normal saline vs. 4mg of Zofran vs. 8mg of Zofran 5 minutes prior to spinal anesthesia Incidence of hypotension, vasopressor requirements, incidence of nausea and vomiting Incidence of hypotension was less in Group F and Group E than Group C (p = 0.03). Ephedrine need for hypotension (SBP <90) was significantly higher in Group C compared to Group E and Group F (p= 0.03) No statical significance between Group E and Group F. 4mg of Zofran 5 minutes before SA vs. 4mg of Zofran 15 minutes before SA vs normal saline 15 minutes before SA Up-down drip allocation for phenylephrine, Effective dose( ED50) = no hypotension from time of SA to delivery of neonate Less hypotension in Group A and Group B compared to Group C (p <0.05). ED 50 Group A = 0.33mcg/kg/min, ED50 Group B = 0.36 mcg/kg/min, ED50 Group C = 0.41mcg/kg/min. This data indicates there is no benefit to giving Zofran earlier but there is benefit to giving it over normal saline. Zofran 4mg vs. 6mg vs. normal saline (control group) administered 15 to 20 minutes prior to spinal Amount of ephedrine in mg used to treat hypotension, episodes of hypotension Significantly more patients in Group C required higher doses of ephedrine compared to Group O4 and Group O6 (p= <0.001). The number of hypotensive episodes was not significant between the three groups (p=0.07). *Do not show a decrease in the number of hypotensive episodes between the groups but did show that Zofran decreased the severity of hypotension thus decreasing the amount ephedrine given. Group E 8mg Zofran (n=60) N=180 Group A 4mg Zofran 5 minutes (n=25) Group B 4mg Zofran 15 minutes (n=25) Group C normal saline 15 minutes (n=25) N=75 Group O4 4mg Zofran (n=51) Group O6 6mg Zofran (n=51) Group C normal saline (n=50) (N=151) 28 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Shabana et al. (2018) Vashishth et al. (2022) Prospective doubleblinded randomized control study Prospective, randomized, doubleblinded control study To evaluate the efficacy of Zofran given before SA in parturients at decreasing hypotension, N/V, and bradycardia. To determine the effectiveness of different doses of Zofran on hemodynamics in parturients receiving SA Group I 4mg Zofran (n=50) Group II normal saline (n=50) 4 mg Zofran vs. normal saline both given 5 minutes before SA Vital signs, episodes N/V, vasopressor requirements Group I required a significantly lower amounts of vasopressors (p=0.005). Bradycardia episodes were significantly lower in Group I than Group II (p=0.02). Drops in MAP were significantly lower in Group I than Group II (p=0.007). 4mg Zofran vs. 6mg Zofran vs. 8mg Zofran vs. normal saline all given 5 minutes before SA Vital signs, hypotension = drop in SBP more than 20% from baseline, N/V episodes, ephedrine requirements There was a significant decrease in hypotensive episodes amongst all Zofran groups (p<0.0001). Ephedrine requirements were significantly lower in all Zofran groups compared to normal saline (p<0.0001). 6mg and 8mg were more effective than 4mg at preventing drops in MAP. 4mg Zofran vs. 3mg Granisetron given 15 minutes before SA Vital signs, hypotension = SBP drop more than 20% below baseline, bradycardia = HR more than 20% below baseline, phenylephrine doses Group O and Group G both had statistically significant lower incidence of hypotension compared to Group N. Group O = (p=0.020) Group G = (p<0.001). Group O and Group G both had statistically significant decreased doses of phenylephrine compared to Group N. Group O = (p<0.001) Group G = (p<0.001). 4mg Zofran vs. normal saline 10 minutes prior to spinal Up-down sequential analysis for phenylephrine, vital signs, hypotension = SBP decrease to <80% of baseline, ED50 = no hypotensive ED50 was lower in Group O compared to Group C. Group O 0.24mcg/kg/min compared to Group C 0.32mcg/kg/min. Statistically significant (p<0.001) *Administration of Zofran is associated with a 26% reduction to the ED50 of phenylephrine drip infusion. N=100 Group O4 4mg Zofran (n=60) Group O6 6mg Zofran (n=60) Group O8 8mg Zofran (n=60) Group S normal saline (n=60) Wahid et al. (2022) Xiao et al. (2019) Prospective, randomized, study Parallelgroup, randomized, doubleblinded study To compare Zofran to Granisetron at preventing hemodynamic instability in parturients receiving SA To determine the ED50 dose of prophylactic phenylephrine in parturients receiving SA when given 4mg of Zofran N=240 Group N - Placebo (n=40) Group O 4mg Zofran (n=40) Group G 3mg Granisetron (n=40) N=120 Group O 4mg Zofran (n=30) Group C normal saline (n=30) N=60 29 ONDANSETRON PRIOR TO SPINAL ANESTHESIA compared to normal saline occurrence from time of starting drip to delivery of infant ONDANSETRON PRIOR TO SPINAL ANESTHESIA 30 Appendix B Pre-test Questionnaire 1. How many years have you been practicing anesthesia? a. SRNA b. 1-5 c. 6-10 d. 11-15 e. 16-20 f. 20 + 2. What is the primary anesthetic plan for scheduled C-section patients at your facility? a. General anesthesia b. Spinal anesthesia c. Epidural anesthesia d. Combined spinal/epidural 3. How often do you observe hemodynamic changes in your patient following spinal anesthesia? a. Almost always b. Often c. Sometimes d. Never 4. Which reflex is responsible for the hemodynamic changes following spinal anesthesia in parturients undergoing c-sections? (Fill in the blank) 5. Which TWO hemodynamic changes are most common following spinal anesthesia? (Select 2) a. Tachycardia b. Bradycardia c. Hypertension d. Hypotension 6. What is the most common indicator of hypotension following spinal anesthesia in the parturient? a. Shortness of breath b. Nausea and vomiting c. Headache d. Drowsiness 7. When providing spinal anesthesia for C-section patients, do you administer a 5-HT3 antagonist such as Zofran? a. Yes b. No ONDANSETRON PRIOR TO SPINAL ANESTHESIA 31 8. If yes, when is the best time to administer a 5-HT3 antagonist? a. Before spinal anesthesia administration b. After spinal anesthesia administration 9. How many minutes before or after spinal anesthesia administration do you typically give the 5-HT3 antagonist? a. 0-5 mins b. 5-10 mins c. 10-15 mins d. 15 20 mins e. 20 plus mins 10. What benefits does the administration of Zofran provide to the parturient undergoing spinal anesthesia? (Select all that apply) a. Decreased nausea b. Decreased vomiting c. Decreased pain d. Decreased degree of hypotension e. Decreased severity of bradycardia ONDANSETRON PRIOR TO SPINAL ANESTHESIA 32 Appendix C Post-test Questionnaire 1. Which reflex is responsible for the hemodynamic changes following spinal anesthesia in parturients undergoing c-sections? (Fill in the blank) 2. Which TWO hemodynamic changes are most common following spinal anesthesia? (Select 2) a. Tachycardia b. Bradycardia c. Hypertension d. Hypotension 3. What is the most common indicator of impending hypotension in the parturient following spinal anesthesia? a. Shortness of breath b. Nausea with or without vomiting c. Headache d. Drowsiness 4. When providing spinal anesthesia for scheduled C-section patients, do you plan to administer a 5-HT3 antagonist before placing spinal anesthesia? a. Yes b. No 5. When is the best time to administer a 5-HT3 antagonist? a. Before spinal anesthesia administration b. After spinal anesthesia administration 6. What benefits does the administration of Zofran provide to the parturient undergoing spinal anesthesia? (Select all that apply) a. Decreased nausea b. Decreased vomiting c. Decreased pain d. Decreased degree of hypotension e. Decreased severity of bradycardia ONDANSETRON PRIOR TO SPINAL ANESTHESIA Appendix D Ascension Health IRB Approval INSTITUTIONAL REVIEW BOARD NOT HUMAN SUBJECTS RESEARCH To: PANCHAPAKESAN HARAN cc: Katharine Holmer From: Ascension Health Institutional Review Board Date: October 6, 2023 On 10/6/2023, the IRB reviewed the following submission and determined that the proposed activity is not research involving human subjects as defined by DHHS/FDA regulations. Type of Review: Initial Study Title: Ondansetron Prior to Subarachnoid Anesthesia in Parturient Patients Undergoing Cesarean Section to Decrease Hypotension: A Practice Change Guideline Investigator: PANCHAPAKESAN HARAN IRB Study ID: RIN20230097 Funding: Name: 01Unfunded Documents Reviewed: See list at close of letter below signature line IRB review and approval by this organization is not required. This determination applies only to the activities described in the IRB submission and does not apply should any changes be made. If changes are made and there are questions about whether these activities are research involving humans in which the organization is engaged, please submit a new request to the IRB for a determination. You can create a modification by clicking Create Modification / CR within the study workspace in the Ascension eIRB system. Documents Reviewed for this Submission: Ascension QA-QI worksheet _Holmer.docx, Category: Other; Data points .docx, Category: Other; DNP consent .docx, Category: Recruitment Materials; Page 1 of 2 33 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Appendix D Ascension Health IRB Approval DNP IRB protocol.docx, Category: IRB Protocol; DNP ppt_Holmer.pptx, Category: Other; DNP Pre_Post Survey.docx, Category: Study Tools (Data Collection Sheet, Surveys, etc.); Page 2 of 2 34 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Appendix E Marian University IRB approval Institutional Review Board DATE: 11/28/2023 TO: Katherine Holmer & Lee Ranalli FROM: Institutional Review Board RE: S23.205 TITLE: SUBMISSION TYPE: Ondansetron prior to subarachnoid anesthesia in parturient patients undergoing cesarean section to decrease hypotension: A practice change New Project ACTION: Determination of Initial Review: Defer to Other Institutions IRB DECISION DATE: 11/21/2023 The Institutional Review Board at Marian University has reviewed your protocol and the supporting documents you submitted from the research partner site IRB. We defer to the decision reached by the partner IRB following review. As such, there will be no further review of your protocol by the Marian University IRB. Please inform us of any methodological changes, adverse outcomes experienced by participants, or changes in the approval granted by the partner sites IRB. The IRB also reminds the PIs to be mindful of all HIPPA guidelines when disseminating findings. __________________________________________ Christina Pepin, Ph.D., RN, CNE Chair, Marian University Institutional Review Board 35 36 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Appendix F Pre-test Post-test Data Comparison QUESTION ANSWERS n (PreTest) Which reflex is responsible for hemodynamic changes following Spinal Anesthesia? (Fill in the Blank) Two Most Common Hemodynamic Changes Following Spinal Anesthesia? Most Common Indicator of Hypotension? Cardiac Accelerators Bainbridge Sympathetic Bezold-Jarisch 3 1 1 0 0% 0 0 0 5 Tachycardia Bradycardia Hypertension Hypotension 0 5 0 5 100% 0 5 0 5 100% 0 3 1 1 0 5 60% 0 5 0 0 5 0 100% 5 3 1 0 0 0% 5 5 0 5 5 100% SOB N/V Headache Drowsiness When Is the Best Before Spinal Time to Administer After Spinal 5-HT3 Antagonist? Benefits of Decreased Nausea Administration of Decreased Vomiting Zofran (Select All Decreased Pain that Apply) Decreased HypoT Decreased Brady % Correct Responses 0% n (Posttest) % Correct Response s 100% 100% 37 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Appendix G Data Collection Tool Number of Cases Oct 18th-31st - 3 cases Number of Cases Nov 1st-30th 11 cases Number of Cases Dec 1st 31st 15 cases Number of Cases Jan 1st 18th 8 cases Educational Intervention Number of Cases Jan 19th-31st 3 cases Number of Cases Feb 1st 29th 9 cases Number of Cases March 1st -31st 14 cases Number of Cases April 1st 15th 5 cases Number of Cases Jan 19th- Feb 23rd: 8 Number of Scheduled Cesarean Section Cases Included in the Study Spinal Zofran Before Zofran After OCT NOV DEC Jan 1931 II I FEB March IIIIIII JAN 0118 IIIII IIII I IIIII III April 01-15 III II II IIIII II IIIII IIIIIII IIIII I III II I Reasons a case was omitted from the study: - One surgeon requests an epidural instead of a spinal due to the length of surgery. These cases were omitted because they did not meet the study's criteria. - Emergent cases were omitted because they did not meet the study's criteria. - Cases performed by traveling staff (not permanent) who did not receive educational intervention were omitted.  ...

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IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT The Effects of Impostor Phenomenon on the Minority CRNA Student Anissa Breland Marian University Leighton School of Nursing Team Member: Denise Ferrell, DNP, RN ________ (Signature) ______ 1 IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 2 Table of Contents Abstract Introduction Background Problem Statement Needs Assessment and Gap Analysis Project Aims and Objectives Theoretical or Conceptual Framework SWOT Analysis Literature Search Methodology Literature Review Synthesis of Information The Effects of Impostor Phenomenon Self-Determination Theory Small Group Discussions Project Design Population and Setting Measurement Instruments Data Collection Procedures Ethical Considerations Project Evaluation Plan Results Discussion Conclusion References Appendix A Appendix B Appendix C Appendix D Appendix E 3 4 5 7 7 8 8 9 10 11 11 12 13 14 14 15 16 16 17 17 19 23 25 30 30 31 34 36 IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 3 Abstract Imposter Phenomenon (IP), better known as Impostor Syndrome, may be defined as a state of fearing intellectual phoniness and an inability to internalize success. What was first discovered to appear in high-achieving women; now affects nearly 70% of the general population and is more prevalent in under-represented groups that includes racial, ethnic, gender, LGBTQ, religious, and other minorities. This project aimed to assess the impact of IP on the minority certified registered nurse anesthesia (CRNA) student, and the effectiveness of a small group discussion to minimize IP effects. The participants were enrolled in the graduating class of 2024, 2025, and 2026 of a CRNA program located in the Midwest. To implement this project, an online survey was administered using the survey software program Qualtrics. Qualtrics was utilized to deliver the survey link to respondent emails and collect responses electronically. The participants were required to complete the Clance Impostor Phenomenon scale pre-test to assess the personal impact of IP. Approximately 2 weeks following the initial survey, a brief PowerPoint presentation was presented via WebEx immediately followed by small group discussion including volunteers from the CRNA profession and a post-survey. It should be noted that information was only collected on the CRNA students and not the CRNA participants. The results of this project were limited because of the small sample size and additional research should be conducted. KEYWORDS: impostor syndrome, impostor phenomenon, nurse anesthesia students and impostor syndrome, nursing salons, Marie Manthey, fraud, coping with impostor syndrome IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 4 The Effects of Impostor Phenomenon on the Minority CRNA Student Introduction Impostor phenomenon (IP), also known as Impostor syndrome (IS) or impostorism, was first described by psychologists Clance and Imes (1978) as a state of fearing intellectual phoniness and an inability to internalize success in a group of high-achieving women. Impostor phenomenon is more frequently and incorrectly referred to as impostor syndrome. Because there is no official diagnosis in the Diagnostic and Statistical Manual (DSM) for mental health, it is more accurately referred to as impostor phenomenon (Arleo et al., 2021). With increasing recognition of IP, it has been estimated to affect 70% of the general population and appears to be more prevalent in individuals who identify with under-represented groups that included racial, ethnic, gender, LGBTQ, religious, and other minorities (Rivera et al., 2021). The effects of IP can lead to psychological and emotional distress resulting in anxiety, depression, substance abuse, and suicide (Rivera et al., 2021). Those suffering from IP constantly downplay their accomplishments which often leads to sabotaging their careers (Chrousos, 2020) and stifling their professional growth. At an organizational level, those who suffer from IP are less likely to apply for promotions for fear of failure and fear of being found out as a fraud leading to decreased diversity, especially in leadership positions (Rivera et al., 2021). Those suffering from impostor phenomenon have an innate fear of being discovered as a fraud or non-deserving professional, despite their demonstrated talent and achievements (Chrousos, 2020). Racial isolation may also contribute to feelings of IP. In college students belonging to racial minorities, mental health problems have been better predicted by impostor feelings than by the stress associated with their minority status" (Chrousos, 2020, p. 749). Perhaps unintentionally, white peers tend to pay less attention and give less credit to their black peers which further feed into IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 5 the feelings of fraudulence attributed to IP. Lack of recognition can limit opportunities for growth, decreases engagement and effort, undermines self-worth, and exacerbates attrition (Mhyre et al., 2022). Additionally, the feelings of self-doubt and not belonging to a particular group can lead to the feeling of being discovered as a fraud (Rivera et al., 2021). To effectively increase diversity, open discussions will help to increase the visibility of IP and to normalize these experiences instead of pathologizing them (Chrousos, 2020). Background The Association of American Medical Colleges (AAMC) recognized the need to improve physician diversity and began to recruit minority students in the 1960s, but progress has been slow even with the increasing engagement by the federal government in 1985 (Mhyre et al., 2022). The racial disparities in medical professions in relation to their numbers in the general population were defined as underrepresented in medicine (URiM) by the AAMC in 2003 (Mhyre et al., 2022). The ongoing need to increase a culturally diverse workforce to be a better reflection of the diverse populations served and to work to reduce health disparities also led to the acknowledgment of the need to increase the diversity among the doctoral-prepared underrepresented minority (URM) in nursing (Phillips et al., 2022). The lack of URM doctoral student application and success can be attributed in part to the self-perceived inadequacies symptoms of IP (Chrousos, 2020). IP for minority students leads to them questioning their ability and whether they truly belong in academia (Phillips et al., 2022). The presence of IP in URM doctoral students has specific implications requiring the sufferer to navigate racial isolation, microaggressions from their majority counterparts, and the need to prove themselves strictly because of their race (Phillips et al., 2022). An additional factor that plays into the IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 6 symptomology of IP includes the frequent dismissal of contributions and suggestions from the URM population (Chrousos, 2020). A chronic lack of acknowledgment and endorsement will fuel the deepening sense of unworthiness that is tied to IP (Chrousos, 2020). The key to changing the effects of IP in the URM population is to heighten the awareness of the phenomenon with persistent intervention and innovation, particularly amongst senior colleagues to junior colleagues, to help recognize, manage, and intervene when actions take place that may intensify the feelings of IP (Arleo et al., 2021). Awareness will help those experiencing IP realize the microaggressions they may experience has nothing to do with their abilities, qualifications, or the value of their thoughts and concepts (Chrousos, 2020). One way to increase self-awareness of the dynamics of IP for people who are experiencing it is through the sharing of information and insights in a comfortable setting where colleagues can gather conveniently (Chrousos, 2020). Marie Manthey is the creator of Nursing Salons. When creating Nursing Salons, Manthey wanted to create an informal environment where nurses from all walks of life could share, connect, and empower each other by discussing what was on the hearts and minds of the participants. Manthey says, "Salons are lively gatherings where people engage in big talk--talk that amuses, challenges, amazes, and is sometimes passionately acted upon. Most importantly, salons are gatherings where each participant forms and informs the conversation. Unlike formal meetings, they are opportunities where people can casually connect and share their experiences" (Sinkfield-Morey, 2019). In the spirit of Marie Manthey's Nursing Salon, the researcher hypothesizes that hosting an informal small group discussion in the academic setting may yield a similar impact. IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 7 Problem Statement Impostor phenomenon is an internalized feeling of not being good enough or viewing one's success as luck versus the results of hard work and dedication. Although many may be affected by impostor phenomenon, the underrepresented and marginalized populations often become stagnant in their goals due to these perceived feelings, and the fear of being discovered as a "fraud" decreases their willingness to be transparent and/or vulnerable to help identify the root of their feelings. Bringing awareness to IP and providing a safe and supportive environment to discuss these feelings may help to alleviate the psychological distress caused by those who are suffering in silence. This leads to the following question: Will attending an informal small group discussion for minority Student Registered Nurse Anesthetist (SRNA) and minority Certified Registered Nurse Anesthetist (CRNA) be a beneficial tool in helping individuals understand impostor phenomenon, allow them to assess the impact of its effects on their own lives, and providing them the opportunity to feel supported through their journey of personal success? Needs Assessment and Gap Analysis Although the modern nursing workforce is diverse, minority experts might be reluctant to contribute to their professional community because of the IP. While IP has been extensively covered in academic sources, further research is needed to assess its effects on minority healthcare providers (Chrousos, 2020; Holliday et al., 2019; Ogunyemi et al., 2021). Furthermore, efforts should be invested in detecting and elaborating on the strategies to address IP in minority CRNA student who may become the backbone of the national healthcare workforce. A repertoire of interventions should be put in place to convince minority CRNA students of the enormous potential they possess and engage them in advancing the national healthcare network for the sake of stakeholders well-being and prosperity. IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 8 Project Aims and Objectives The goal of this project is to determine if hosting small group discussions in the academic setting will help to expose and lessen the effects of Impostor Phenomenon in minority CRNA students. For this study, the term minority may include persons who identify with underrepresented racial/ethnic, cultural, religious, sexual orientation, and gender backgrounds. A virtual small group discussion comprised of volunteers from the current cohorts of CRNA students and minority representatives in the CRNA profession, will be facilitated by the researcher. The students will be given a survey before and after the small group session. The survey will be used to assess the volunteers knowledge of IP and its impact on how they view their success. A different survey will be offered post-intervention to determine the effectiveness of the small group session in identifying and alleviating the impact of IP in the academic setting. The projected timeline for completion of the intervention and the pre-and post-survey is Spring of 2024. An additional goal of this study is to increase the support and belongingness in the underrepresented groups. Theoretical or Conceptual Framework The theoretical framework used to guide this research is the self-determination theory (SDT). SDT focuses on motivation, development, and well-being based on the innate psychological needs, that include autonomy, competence, and relatedness (Deci & Ryan, 2009). According to Beck, the first component, "an autonomous being can make, and carry out, decisions to govern his/her actions", however, the feeling of autonomy is also impacted by the individual's environment. Therefore, an individual may have the ability to make their own decisions, but depending on their environment, they may perceive they lack the skills to do so (Beck, 2016). The second component, competence refers to perceived self-efficacy and self- IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 9 competence, and these perceptions play a significant role in autonomy which impacts one's motivation (Beck, 2016). The third component of SDT is relatedness which suggests that the sense of belongingness with positive and secure relationships will increase the internal motivation in individuals. The theory suggests that a person requires all these needs to be met to function at their best, feel more motivated, and experience better mental health. SDT is the chosen framework to guide this research because people who identify with IP may struggle with one or more of these three components. They may downplay their competence and sense of autonomy with luck, instead of feeling like they deserve their achievements. The third component of SDT, relatedness, may be impacted for many reasons. Individuals may tend to self-isolate for fear of their 'fraudulence' being identified, the lack of representation in students and faculty, the intentional and/or unintentional micro-aggressive behavior experienced by URM groups from peers and faculty, and the societal stigmas that have been engraved in both URM groups and their peers. SWOT Analysis Some of the strengths identified with this project include the increased ability of participants to acknowledge symptoms of IP and its impact on their life and increasing the sense of belongingness, value, and support for URM groups by using the social connection as an intervention. The small group session will be held virtually which will remove the need to find a physical location and increase the participants comfort levels and availability. This will also increase the likelihood that professional participants can participate from a distance. This project may present opportunities for the academic institution to identify barriers that members of URM groups face while matriculating through a graduate program. By identifying these barriers, academic institutions can ensure there are support services available to IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 10 meet the needs of all their students and help add value to marginalized communities. Additionally, the small group session will connect the minority CRNA student with CRNAs who may have shared similar experiences as them, allowing CRNAs to share their insights, and thereby, encourage networking and fostering collaborative relationships with future colleagues. A noticeable weakness is the lack of research that has been conducted on IP and its effect of URM CRNA to guide the project. Another weakness is the potential for reluctance felt by volunteers to contribute their thoughts freely, resulting in a lack of transparency, vulnerability, and openness from all involved which could impact the results/effects of this project. Individuals dealing with IP already struggle with feeling fraudulent or inept. It will require some finesse to provide an environment where they feel safe to share their feelings. There is also the potential that the experienced CRNAs, themselves, are struggling with IP and will not be able to serve in the capacity that will be supportive to the minority CRNA student. URM groups are not heavily represented in the CRNA profession which may add to the difficulty of finding professional volunteers to connect with every student participating in the study. Potential threats to this research include not having enough participants to determine the effectiveness of the proposed intervention, and the lack of empathy and mutual respect for perceived feelings of IP that may inhibit an authentic interaction. Additionally, the researcher has limited knowledge in facilitating the small group session to ensure the group stays focused and utilizes the time together, appropriately. There is also the high risk of attrition for student volunteers based on their academic schedule. Literature Search Methodology This literature review was done to define impostor phenomenon (IP), examine its effects on underrepresented minority (URM) groups, and to determine if participating in a small group IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 11 discussion that includes URM CRNA student and URM CRNA will help to alleviate the symptoms of IP. Keywords such as impostor phenomenon, nursing salons, certified registered nurse anesthetist, student registered nurse anesthetist, graduate students, minorities, diversity, mental health, self-determination theory, stress, and wellness were used to research the literature. The literature review was conducted from September 2022 to December 2022. BOOLEAN phrases used for this literature review were impostor phenomenon AND minority graduate students, impostor syndrome AND Student Registered Nurse Anesthetist, minority AND graduate school, and impostor syndrome AND diversity. Exclusion criteria used during the search included articles greater than ten years, articles that were not related to impostor syndrome and its effects on graduate students, articles that were not in English, and articles that did not use small group discussions as an intervention. Inclusion criteria consisted of articles that were published within ten years, articles written in English, articles that used small group discussions as an intervention, URM groups that included gender, race/ethnicity, sexual orientation, culture, and religion, and articles that defined the impostor syndrome and its symptomology. Literature Review Synthesis of Information The Effects of Impostor Phenomenon Impostor phenomenon is characterized as chronic feelings of self-doubt and internalized fear of being exposed as an intellectual fraud. Sufferers are incapable of internalizing and taking ownership of their accomplishments, competencies, or skills. (Ogunyemi et al., 2021). To improve diversity among graduate students, institutions need to implement policies to acknowledge and combat the feelings of self-doubt (Chrousos, 2020). According to Chang et al., IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 12 "Unaddressed impostor feelings impede developing interest in science and self-efficacy and have a dispiriting effect that perpetuates unsatisfactory diversity in the health science workforce when such feelings are experienced more by those historically underrepresented in the workforce" (2022). Chrousos has found that IP occurs more frequently in high achievers, women, and underrepresented racial, ethnic, and religious minorities (2020). Additionally, research suggest that IP should be tackled on an organizational level to cultivate female mentors, role models, and encouraging leadership training (Holliday et al., 2019). Dr. Valerie Young, another expert on IP, has founded five "competence subtypes" or self-undermining, unrealistically idealized selfperception sub-types that those struggling with IP adopt that may hold them back from reaching their full potential which include: the perfectionist, the natural genius, the super-person, the expert, and the soloist (Ogunyemi et al., 2021) (See Appendix E). Self-doubt is also developed through the individual's ideas about mindset. A study suggests there are two mindsets: growth mindset and fixed mindset. Growth mindset believes ability is derived from acquired skills, continued practice, and experience, while a person with a fixed mindset believes they are born with their abilities, and they cannot be altered or developed (Chandra et al., 2019). Self-Determination Theory The self-determination theory (SDT) is a theory based on motivation, development, and well-being. According to the theory, the three basic needs of SDT are autonomy, competence, and relatedness, and these are necessary for one to feel psychologically at their best (Neufeld et al., 2022). To note, the theory suggests that for it to be effective, autonomy must first be met for the individual to then meet the needs of competence and relatedness (Beck, 2016). Furthermore, positive feedback also appears to play a role in perceptions of impostor phenomenon (IP). In fact, with IP, individuals falsely and incorrectly attribute their success to luck (autonomy), IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 13 discount their achievements (competence), and feel like a fake (relatedness) (Neufeld et al., 2022). Additionally, individuals with elevated IP levels tend to attribute their successes to external factors like luck, charm, or working harder than others, rather than having specific talents or skills (Vaughn et al., 2019). Interestingly, a study conducted on medical students suggested that those who are more self-determined and whose basic psychological needs are more supported in their medical program, will experience less frequent and severe IP symptoms (Neufeld et al., 2022). Moreover, the literature suggests that the increased prevalence of mental health issues related to IP could be directly related to the lowered well-being experienced by individuals who are not achieving their SDT needs (Beck, 2016). Small Group Discussions Open discussions about Impostor Phenomenon at the institutional level should put a name to these feelings and normalize them as common experiences rather than pathologizing them" (Chrousos, 2020, p. 750). Encouraging connectedness among peers can thwart feelings of isolation and increased relatedness concept of SDT. A study completed at Stanford University shown that small groups improved IP, connection with others, and allowed exposure and tolerance to diverse perspectives (Gold et al., 2020). Additionally, having open discussions about IP, can expose the negative ways it has unknowingly affected the lives of the individuals struggling with IP. Following a study on cohorts enrolled in medical education, participants' viewed IP as a source of stress, unfulfilled potential, and poor relationships (Ogunyemi et al., 2022). Taken together, this review points the way to the efficacy of small group participation on the topic of IP to address current or future feelings of IP. IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 14 Project Design The project design will consist of a pre- and post-survey that will include both quantitative and qualitative data with a PowerPoint presentation and a small group discussion being the intervention. All students in the CRNA program who self-identify with belonging to underrepresented minority (URM) groups will be invited to complete a pre-survey to assess to what degree they identify with IP and how it impacts their lives. Following the initial survey, there will be a virtual meeting that encompasses a brief PowerPoint presentation, small group discussion facilitated by the researcher with CRNA students and CRNA professionals from URM and a post-survey. The goal of the group discussion is to create a platform to allow students and professionals to engage in their experiences with IP and how they overcame them. Participants will be provided a link to be allowed to join the virtual meeting. The goal of this session is to correctly identify IP, unveil the effects of IP in the students personal and professional lives, and help them see the value and uniqueness they bring to the table. After the completion of the small group discussion, participants will complete the post-survey to determine the benefits of the intervention. Population and Setting The participants of this project will be students enrolled in the doctoral-prepared CRNA program, at a private, Catholic institution in the Midwest. The students will be from the graduating CRNA cohorts of 2024, 2025, and 2026. The surveys will be conducted via Qualtrics. The institution offers graduate Health Profession programs such as Nurse Anesthetist, Family Nurse Practitioner, Osteopathic Medicine. The small group discussion will be held virtually. CRNA students and CRNA professionals may log on from a location of their choosing. Participants will be provided a link to join the virtual session. CRNAs will be volunteers from IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 15 multiple locations. All participants are volunteers and may revoke participation at any time. Participants will consist of various ages and members of URM groups. Measurement Instruments The data collection portion of this project will be completed over the course of one month. Participants will complete a 25-question pre-survey. The survey will consist of 20 likert style questions from the Clance IP Scale (Appendix C) assessing IP's impact in their personal and professional lives, and 2 Yes/No/I don't know questions. The Yes/No/I Don't Know questions will include: Have you heard of impostor phenomenon? and Do you believe impostor phenomenon affects your life? Additionally, the pre-survey will include demographic questions to help determine if the participant identifies with an URM. Before completing the post-survey, participants will be expected to participate in a scheduled virtual Webex hosted by the researcher lasting approximately 30-60 minutes. During the Webex, there will be a brief PowerPoint presentation and an open dialogue about IP, the symptoms of IP, how IP has affected professional growth and development, its impact on self-worth/self-esteem, and how to cope with IP. The researcher's goal is to help facilitate the dialogue, time management, and ensure a safe environment to encourage participation in a judgement free manner. After the Webex is complete, a post-survey will be sent out via Qualtrics given to participants to assess the benefits of the intervention. The questions will include: In your own words, define impostor phenomenon, Name an intervention to lessen the impact of impostor phenomenon, Prior to this project, did you think impostor phenomenon impacted your life? After this project, do you think impostor phenomenon impacts your life? Do you think the group discussion was beneficial? and Would you like to have more group sessions on various topics that are important to you? If so, name a topic you would like to discuss. Results of the survey will be anonymous; CRNA student IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 16 will be asked to use the last 4 digits of their school identification for tracking purposes only. Demographic questions will include age, sexual orientation, race/ethnicity, gender, marital status, and religious affiliation. The purpose of the study was to determine if creating a bias-free social setting for open dialogue will alleviate the impact of impostor phenomenon. Data Collection Procedures The pre-and post-survey was completed via Qualtrics. Participants will use the last 4digits of their school identification card as an identifier. The survey will contain demographics data where participants may choose to self-identify with their chosen minority identifier. Exclusion to participate in the study based on minority status was left to the participants discretion. The use of the identifier will allow the researcher to match the pre- and post-survey responses for each participant, ensuring they are analyzing data from the same individuals. Qualtrics is a quick and efficient way to build, distribute and analyze data. Qualtrics also exports data into Excel documents. The qualitative data will be reviewed to see what common themes emerge from the data. The top 2 themes will be used for dissemination. Using the identifiers as trackers, Qualtrics will make it easy to quantify the pre-survey questions. Based on the data gathered and analyzed, the researcher will determine if the small group discussion helped to alleviate the impact of impostor phenomenon in the participants' lives. Ethical Considerations Before conducting the project, the researcher will seek approval from the institution IRB. Privacy will be maintained by using the last 4 digits of the participants' school identification for tracking purposes. Information will be stored in Qualtrics and only the researcher will be able to IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 17 access the information. Because there are no risks, consents are not required. Once dissemination is completed, all data will be deleted. Project Evaluation Plan Qualtrics allows for the data to be easily exported to SPSS. SPSS will be used to complete a statistical analysis of the data collected. Qualtrics will also allow for a visual representation of the results via a bar graph. The scoring system for Clance IP scale will determine the severity of IP for everyone. For the qualitative data, the themes that emerged from the data collected will be disseminated. Results Of the many candidates invited to participate in the study, there were 8 participants and 7 provided informed consent to fill out the survey form, which means the response rate was 87.5%. However, it is worth stressing that of 7 respondents who provided informed participation consent, only 5 responded to all survey questions. The researcher discovered this fact when analyzing the collected data. When analyzing the demographic characteristics of the cohort, most of the participants (75%) who chose to provide relevant data were ages between 31 and 35. Of participants who filled the demographic section of the survey, 75% were female, and 50% identified themselves as Hispanic or Latino. Half of the participants for whom English was not their first language reported Spanish as their mother tongue. Seventy-five percent of participants who elected to mention their sexual orientation identified themselves as heterosexual. Half of the respondents who decided to disclose their religion identified themselves as Christians, while 25% of respondents were affiliated with Judaism. IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 18 57% of participants agreed to discuss the representation of their ethnicity, culture, and religion in their graduate program. The researcher reported equal percentages of respondents who agreed and disagreed that those elements were well-represented in their graduate program (50% and 50%). As this finding is insightful, it is discussed further in this report. The participants responses to the survey questions are reported in the table below. Table 1. Participants responses to the survey questions. I have often succeeded on a test or task even though I was afraid that I would not do well before I undertook the task. I can give the impression that Im more competent than I really am I avoid evaluations if possible and have a dread of others evaluating me. When people praise me for something Ive accomplished, Im afraid I wont be able to live up to their expectations of me in the future. I sometimes think I obtained my present position or gained my present success because I happened to be in the right place at the right time or knew the right people. Im afraid people important to me may find out that Im not as capable as they think I am. I tend to remember the incidents in which I have not done my best more than those times I have done my best. I rarely do a project or task as well as Id like to do it. Sometimes I feel or believe that my success in my life or in my job has been the result of some kind of error. Its hard for me to accept compliments or praise about my intelligence or accomplishments At times, I feel my success has been due to some kind of luck. 1 (Not true at all) - 2 (Rarely) 3 (Sometimes) 4 (Often) 5 (Very true) 20% 20% 20% 50% 20% - 60% 20% - 20% 40% 40% - - - 40% 20% 40% - 40% 20% 20% - - 80% - 20% - - - 40% 20% 20% 20% 20% - 80% - - 60% - 40% - - - 40% 40% 20% - 40% 20% 20% - 20% IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT Im disappointed at times in my present accomplishments and think I should have accomplished much more. Sometimes Im afraid others will discover how much knowledge or ability I really lack. Im often afraid that I may fail at a new assignment or undertaking even though I generally do well at what I attempt. When Ive succeeded at something and received recognition for my accomplishments, I have doubts that I can keep repeating that success. If I receive a great deal of praise and recognition for something Ive accomplished, I tend to discount the importance of what Ive done. I often compare my ability to those around me and think they may be more intelligent than I am. I often worry about not succeeding with a project or examination, even though others around me have considerable confidence that I will do well. If Im going to receive a promotion or gain recognition of some kind, I hesitate to tell others until it is an accomplished fact. I feel bad and discouraged if Im not the best or at least very special in situations that involve achievement. 19 - 80% 20% - - 40% 20% 40% - - 20% 20% 40% 20% - 20% 40% 40% - - 20% 20% 20% 40% - 20% 20% 60% - - 20% 20% 40% 20% - - 40% 40% 20% - 20% 20% 40% 20% - Discussion The collected data allowed the researcher to assume that the respondents acknowledge the amount of effort that they invest in their studies and careers. Only 20% of respondents attribute their accomplishments to luck or other external factors that are beyond their control. The respondents attitude toward their accomplishments is reflected in the chart below. Pic. 1. At times, I feel my success has been due to some kind of luck IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 20% 20 Not true at all 0% 40% rarely sometimes 20% often very true 20% The analysis of the participants responses makes it obvious they tend to acknowledge and praise the amount of personal effort invested to succeed in studies, career, or other domains. However, the respondents acknowledgement of their own worth does not make them immune to comparing their accomplishments with those of other people. In the study, 60% of respondents agreed that they used to compare their accomplishments with the accomplishments of other people and thought other people were more intelligent. Another noteworthy discovery is that the comparison of their performance with that of other people forced the respondents to focus on their failures rather than achievements. The participants approach to assessing their performance is reflected in the chart below. Pic. 2. When people praise me for something Ive accomplished, Im afraid I wont be able to live up to their expectations of me in the future IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 21 0% 0% Not true at all 40% 40% rarely sometimes often very true 20% The participants focus on their failures rather than success is believed to have several implications about their future performance in the selected field. First, the participants might have low morale if they believe they are underperforming in the selected field. The respondents attitude toward their ability to get the most out of available opportunities is shown in the graph below. Pic. 3. I often worry about not succeeding with a project or examination, even though others around me have considerable confidence that I will do well. 0% 20% 20% Not true at all rarely sometimes 20% 40% often very true IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 22 Second, respondents might be reluctant to cooperate with other people fearing those would discover their lack of competence. The participants attitude toward their performance and its potential effect on cooperating with other people is shown in the graph below. Pic. 4. Sometimes Im afraid others will discover how much knowledge or ability I really lack 0% 0% Not true at all 40% 40% rarely sometimes often very true 20% The last, but not the least significant, implication is that ongoing questioning of own effectiveness and reluctance to cooperate with others might stumble the minority CRNA student and the individuals sustainable development in the selected field. Such individuals might feel their accomplishments are insignificant or that they are not good enough to contribute to the field. This assumption is based on the fact that a considerable number of respondents tend to discount their accomplishments, as it is shown in the graph below. Pic. 5. If I receive a great deal of praise and recognition for something Ive accomplished, I tend to discount the importance of what Ive done IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 23 0% 20% not true at all rarely 40% sometimes 20% often very true 20% Noteworthy, the respondents were less susceptible to IP than it was hypothesized at the beginning of the data collection process. This positive trend can potentially be attributed to the fact that diversity has become an inalienable element of the modern educational environment. Half of the respondents who consented to share relevant information agreed their graduate programs represented their ethnicity, culture, and religion. Such culturally sensitive programs could empower the minority CRNA student to have an adequate assessment of their accomplishments and plan further contributions to their professional communities. The researcher, however, acknowledges that this study has several limitations that could potentially affect the accuracy of findings. First, the sample size was small to transfer the obtained findings to a larger group of minority CRNA students. Second, the response rate was comparatively small as only 5 out of 7 respondents replied to all survey questions. The low response rate could have potentially affected the accuracy of research findings. Conclusion In summary, IP can significantly undermine the minority CRNA students effectiveness in the anesthesia field due to the internalized feeling of not being good enough or viewing one's success as luck versus the results of hard work and dedication. The existing evidence suggests IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 24 that the IP is more prevalent in minority students who face racial disparities resulting in their being underrepresented in different fields, including anesthesia. IP can undermine the minority students morale and intention to contribute to their professional communities. This study surveyed a group of minority CRNA students to assess the prevalence of the IP in this population group and its effect on their decision-making. In contrast to the initial hypothesis, IP was less common among the sample size, and the respondents were used to acknowledgment and praise for the amount of personal effort invested in achieving academic or professional successes. However, the detected attitude did not make the participants immune to comparing themselves to other people and treating those people as more intelligent and worth promotion. Analyzing the collected responses, the study discovered implications of the IP for minority CRNA student. First, minority CRNA students might report an undermined morale caused by the belief they are underperforming. Second, ongoing comparison of own cognitive abilities and performance with the abilities and performance of other people might discourage the minority CRNA student from cooperating with peers in an extended professional network. Finally, the IP might discourage minority CRNA student from leaving their comfort zone and consider promotion even if they might deserve it. The researcher, however, acknowledges that the study has some limitations, including small sample size and low response rate, which might affect the accuracy of findings and makes it impossible to transfer them to a larger group of nursing students. A thought-provoking finding that requires further verification suggests that the integration of ethnical, cultural, and religious elements in the graduate program makes minority students less susceptible to the IP. However, IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 25 further research is needed to gain an in-depth understanding of how these programs should look, and how they might provide equal opportunities for all learners. IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 26 References Arleo, E., Wagner-Schuman, M., McGinty, G., Salazar, G., & Mayr, N. (2021). Tackling impostor syndrome: A multidisciplinary approach [Editorial]. Clinical Imaging, 74, 170 172. https://doi.org/10.1016/j.clinimag.2020.12.035 Avery-Desmarais, S., Revell, S., & McCurry, M. (2021). A theoretical framework to promote minority PhD and DNP stutdent success in nursing education. Journal of Professional Nursing, 37, 11491153. https://doi.org/10.1016/j.profnurs.2021.10.002 Baumann, N., Faulk, C., Vanderlan, J., Chen, J., & Bhayani, R. (2020). Small-group discussion sessions on impostor syndrome. MedEdPortal. https://doi.org/10.15766/mep_23748265.11004 Beck, M. F. (2016). Examining doctoral attrition: A self-determination theory approach. The Nebraska Educator: A Student Led Journal, 33(3), 519. https://doi.org/https://doi:10.13014/K2JW8BSG Chandra, S., Huebert, C., Crowley, E., & Das, A. (2019). Impostor syndrome: Could it be holding you or your mentees back? Chest, 156(1), 2632. https://doi.org/10.1016/j.chest.2019.02.325 Chang, S., Lee, H., Anderson, C., Lewis, K., Chakraverty, D., & Yates, M. (2022). Intervening on impostor phenomenon: Prospective evaluation of a workshop for health science students using a mixed-method design. BMC Med Educ, 22. https://doi.org/10.1186/s12909-022-03824-7 Chrousos, G. P. (2020). Imposter syndrome threatens diversity. Science, 367(6479), 749750. https://doi.org/10.1126/science.aba8039 IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 27 Clance, P. (1985). The impostor phenomenon: When success makes you fell like a fake. Bantam Books. Clance, P. R., & Imes, S. A. (1978). The impostor phenomenon in high achieving women: Dynamics and therapeutic intervention. Psychotherapy: Theory, Research, & Practice, 15(3), 241247. https://doi.org/10.1037/h0086006 Deci, E. L., & Ryan, R. M. (2009). The what and whyof goal pursuits: Human needs and the self-determination of behavior. An International Journal for the Advancement of Psychological Theory, 11(4), 227268. https://doi.org/10.1207/S15327965PLI1104_01 Gold, J., Bentzley, J., Franciscus, A., Forte, C., & De Golia, S. (2020). An intervention in social connection: Medical student reflection groups. Academic Psychiatry. https://doi.org/10.1007/s40596-019-01058-2 Holliday, A., Gheihman, G., Cooper, C., Sullivan, A., Ohyama, H., Leaf, D., & Leaf, R. (2019). High prevalence of imposterism among female harvard medical and dental students. Journal of General Internal Medicine, 35(8), 24993501. https://doi.org/10.1007/s11606019-05441-5 Levant, B., Villwock, J., & Mansard, A. (2020). Imposterism in third-year medical students: an item analysis using the Clance imposter phenomenon scale. Perspective Med Educ, 9, 8391. https://doi.org/10.1007/s40037-020-00562-8 Manthey, M. (n.d.). What is a nursing salon? https://mariesnursingsalon.wordpress.com/what-isa-nursing-salon/ McMannon, H. T. (2022). Tricking the imposter: Struggles and successes with imposter syndrome. Nurse Anesthesiology. IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 28 https://doi.org/https://nurseanesthesiology.aana.com/tricking-the-imposter-struggles-andsuccesses-with-imposter-syndrome Mhyre, J., Jackson, J., Lucero, J., & Goree, J. (2022). Workforce solutions to address health disparities. Current Opinion Anesthesiology, 35, 317325. https://doi.org/10.1097/ACO.0000000000001147 Neufeld, A., Babenko, O., Lai, H., Svrcek, C., & Malin, G. (2022). Why do we feel like intellectual frauds? A self-determination theory perspective on the imposter phenomenon in medical students. Teaching and Learning in Medicine. https://doi.org/10.1080/10401334.2022.2056741 Ogunyemi, D., Lee, T., Ma, M., Osuma, A., Eghbali, M., & Bouri, N. (2022). Improving wellness: Defeating imposter syndrome in medical education using an interactive reflective workshop. PLoS ONE, 17(8). https://doi.org/10.1371/journal.pone.0272496 Phillips, J., Julion, W., Dallas, C., Alexander, C., Burnett, G., Smith, C., & Maryland, M. (2022). Pursuing a doctorate in nursing: Implications for underrepresented minority nurses. Journal of Professional Nursing, 39, 117121. https://doi.org/10.1016/j.profnurs.2022.01.008 Rivera, N., Feldman, E., Augustin, D., Caceres, W., Gans, H., & Blankenburg, R. (2021). Do I belong here? Confronting imposter syndrome at an individual, peer, and institutional level in health professionals. MedEdPORTAL. https://doi.org/10.15766/mep_23748265.11166 Sinkfield-Morey, T. (2019). The nursing salon experience: A salon for nurses of color. Creative Nursing, 25(4), 308310. https://doi.org/https:10.1891/1078-4535.25.4.308 IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 29 Vaughn, A., Taasoobshirazi, G., & Johnson, M. (2019). Impostor phenomenon and motivation: Women in higher education. Studies in Higher Education. https://doi.org/10.1080.03075079.2019.1568976 30 Appendix A Gantt Chart TASK Oct PICOT x Proposal Nov Dec Jan Feb x x Mar Apr May x x x Draft 1 Proposal x Draft 2 Proposal x Draft 3 Informal Project Presentation IRB x Approval Final DNP Project x 31 Appendix B SWOT Analysis Strengths: Increase the participants ability to identify Weaknesses: Impostor Phenomenon, and its impact Increase the sense of belongingness and Lack of transparency and openness from participants Limited research on Impostor support for underrepresented minority Phenomenon and relation to CRNA groups students The ability to conduct a virtual small group session that may increase Inability to have representatives that meet the diverse needs of all participants availability of participants and remove the need to find a physical location Opportunities: Threats: The ability for academic institutions to Not enough participants become more aware of barriers Researchers lack of knowledge underrepresented minority groups face to ensure they receive adequate support facilitating small group discussions Participants lacking empathy and mutual Ability for CRNA students to networks respect for an individuals perceived and collaborate with future colleagues feelings Participant attrition Worsening survey results 32 Appendix C Clance IP Scale For each question, please circle the number that best indicates how true the statement is of you. It is best to give the first response that enters your mind rather than dwelling on each statement and thinking about it over and over. 1. I have often succeeded on a test or task even though I was afraid that I would not do well before I undertook the task. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 2. I can give the impression that Im more competent than I really am. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 3. I avoid evaluations if possible and have a dread of others evaluating me. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 4. When people praise me for something Ive accomplished, Im afraid I wont be able to live up to their expectations of me in the future. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 5. I sometimes think I obtained my present position or gained my present success because I happened to be in the right place at the right time or knew the right people. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 6. Im afraid people important to me may find out that Im not as capable as they think I am. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 7. I tend to remember the incidents in which I have not done my best more than those times I have done my best. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 8. I rarely do a project or task as well as Id like to do it. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 9. Sometimes I feel or believe that my success in my life or in my job has been the result of some kind of error. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 10. Its hard for me to accept compliments or praise about my intelligence or accomplishments. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 11. At times, I feel my success has been due to some kind of luck. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 12. Im disappointed at times in my present accomplishments and think I should have accomplished much more. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 33 13. Sometimes Im afraid others will discover how much knowledge or ability I really lack. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 14. Im often afraid that I may fail at a new assignment or undertaking even though I generally do well at what I attempt. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 15. When Ive succeeded at something and received recognition for my accomplishments, I have doubts that I can keep repeating that success. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 16. If I receive a great deal of praise and recognition for something Ive accomplished, I tend to discount the importance of what Ive done. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 17. I often compare my ability to those around me and think they may be more intelligent than I am. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 18. I often worry about not succeeding with a project or examination, even though others around me have considerable confidence that I will do well. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 19. If Im going to receive a promotion or gain recognition of some kind, I hesitate to tell others until it is an accomplished fact. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 20. I feel bad and discouraged if Im not the best or at least very special in situations that involve achievement. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) Scoring the Impostor Test The Impostor Test was developed to help individuals determine whether or not they have IP characteristics and, if so, to what extent they are suffering. After taking the Impostor Test, add together the numbers of the responses to each statement. If the total score is 40 or less, the respondent has few Impostor characteristics; if the score is between 41 and 60, the respondent has moderate IP experiences; a score between 61 and 80 means the respondent frequently has Impostor feelings; and a score higher than 80 means the respondent often has intense IP experiences. The higher the score, the more frequently and seriously the Impostor Phenomenon interferes in a persons life. Note. From The Impostor Phenomenon: When Success Makes You Feel Like A Fake (pp. 20-22), by P.R. Clance, 1985, Toronto: Bantam Books. Copyright 1985 by Pauline Rose Clance, Ph.D., ABPP. Reprinted by permission. Do not reproduce without permission from Pauline Rose Clance, drpaulinerose@comcast.net, www.paulineroseclance.com. 34 Appendix D Literature Review Matrix Citation (AveryDesmarais et al., 2021) Research Population/Sample Methods/Intervention Instruments/Data Design & Level Size (n=x) Collection of Evidence Theoretical N/A N/A Minority Doctoral framework/Case Student success study, Level V framework (Baumann et al., 2020) Cohort, Level IV Internal medicine residents, n=21 30-45min psychologist led interactive discussion Postsession survey (Beck, M. F., 2016) Systematic Review, Level IV N/A N/A N/A (Chandra et al., 2019) (Chang et al., 2022) Systematic Review, Level III Prospective mixed-method design, Level IV N/A N/A N/A College students in a 10-week summer research experience program, n=51 Interactive IP workshop (Chrousos, G., 2020 Expert opinion, Level V N/A N/A Reports of experience, preand post-survey, and growth mindset surveys N/A Results Minority student stressors is a systems problem and MDSS gives the framework for faculty and peer support 81% felt small group session was beneficial Correlation between SDT and IP and doctoral attrition rates Discussed the prevalence of IP Students found the interactive IP workshop to be beneficial Impostor phenomenon threatens diversity. Shed light on IP by peer and faculty open discussion to reduce its influence on diversifying educational settings 35 (Gold et al., 2020) Cohort, Level IV First and second year medical students, n=30 Biweekly support groups over 6 months; high attrition Emotional SelfAwareness Scale; modified Interpersonal Fulfillment Index; Revised UCLA Loneliness Scale Clance Impostor Phenomenon Scale; Burnout assessment (Levant et al., 2020) Cross-sectional, Level IV Third year medical students, n=127 Preclinical to clinical phase of training (Mhyre et al., 2022) Expert Review, Level V N/A N/A N/A (Neufield et al., 2022) Cross-sectional, Level IV Medical student from 3 Canadian institutions, n=1450 The effects of SelfDetermination Theory in relation to Impostor Syndrome Clance IP scale; General Causality Orientation Scale; Comprehensive Relative Autonomy Index; Basic Psychological Need Satisfaction at Work Scale (Ogunyemi et al., 2022) Retrospective cross-sectional, Level IV Medical education cohorts, n=198 Medical education cohort and interactive workshop Young Impostor Syndrome Scale Students benefited from support groups and connectedness Third year related more with items related to fear of failure, hesistance to share recognition before it is announced, and believing themselves less capable Barriers to increase diversity in medicine to address health disparities Students who are selfdetermined and basic needs are more supported in their medical program had less symptoms of IP Interactive workshop was beneficial in increasing awareness and knowledge regarding IP in faculty and students 36 (Phillips et al., 2022) Expert Opinion, Level V N/A N/A Doctoral Readiness Inventory (DRI) (Rivera et al., 2021) Cross-sectional, Level IV 3 Academic conferences, n=92 N/A Pre- and postsession survey (Vaughn et al., 2019) Cross-sectional, Level IV Academic women, n=1326 N/A Multiple online surveys Fostering mentorship to support URM and utilizing DRI to determine readiness to pursue doctoral degree Workshops effective means to discuss strategies to combat IP High IP levels in women correlate with success and motivation 37 Appendix E Impostor Syndrome Subtypes Subtype Characteristics Perfectionist Perceives competence as 100% perfection. Anything short of this is considered failure. This individual always focuses on how something could have been done better. Measures competence by how easily the achievement came to him/her. Hard work and perseverance are considered negative traits because this individual feels that success should have come more naturally to them. Perceives competence as the ability to juggle numerous roles and responsibilities simultaneously. Falling even slightly short in one role (parent, caregiver, researcher, etc.) constitutes overall failure even in the context of major successes. Measures competence by the volume of knowledge or skill. This individual fears being exposed as inexperienced because of lack of knowledge. Perceives competence only if an achievement was obtained completely on their own without the aid of additional resources. Asking for help is considered a sign of failure. Natural Genius Super-person Expert Soloist  ...