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... ADDRESSING CRNA STUDENT CLINICAL ORIENTATION Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2024 Addressing CRNA Student Clinical Orientation through Needs Assessment and Education Implementation Morgan M. Jarvis & Sara R. Starr Marian University Leighton School of Nursing Chair: Dr. Lee Ranalli, DNP, CRNA (Signature) Committee members: Date of Submission: April 28, 2024 April 23, 2024 (Date) Dr. Bradley Stelflug, DrAP, MBA, CRNA 1 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION Table of Contents Abstract ................................................................................................................................4 Introduction .........................................................................................................................5 Background ....................................................................................................................5 Problem Statement .........................................................................................................6 Needs Assessment and Gap Analysis ............................................................................8 Review of the Literature ......................................................................................................9 Benefits of a Structured Orientation ............................................................................10 Impact on Lowering Stress and Improving Confidence .............................................11 Impact on Level of Preparedness ................................................................................13 Impact on Satisfaction in Transitioning to Professional Role .....13 Theoretical Framework .....................14 Project Aims and Objectives ..............................................................................................17 SWOT Analysis .................................................................................................................18 Project Design/Methods 20 Project Site and Population ..........................................................................................20 Measurement Instrument(s) ........................................................................................21 Data Collection Procedure ..........................................................................................22 Ethical Considerations/Protection of Human Subjects ...23 Data Analysis and Results..23 Data Analysis ...............................................................................................................23 Results ..........................................................................................................................24 Pre-test Survey .............................................................................................................25 Post-test Survey ...........................................................................................................25 2 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION Data Analysis and Results..27 Strengths and Limitations ............................................................................................28 Conclusion ........................................................................................................................29 References ..........................................................................................................................31 Appendices ....34 Appendix A ..................................................................................................................34 Appendix B ..................................................................................................................38 Appendix C ..................................................................................................................39 Appendix D ..................................................................................................................40 Appendix E ..................................................................................................................41 Appendix F...................................................................................................................49 3 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION Abstract Background: Orientation programs are crucial for introducing individuals to educational institutions, internships, residencies, and workplaces, providing insight into expectations and operational procedures. However, at Marian University, there was a notable absence of a formalized orientation program for nurse anesthesia students before their immersion into the clinical setting. Purpose: This Doctor of Nursing Practice (DNP) project assessed the impact of a structured, student-led clinical orientation program on enhancing student preparedness in clinical environments. As part of this initiative, clinical site handbooks were developed to give students site-specific expectations, guidelines, and vital information pertinent to each clinical setting before their clinical immersion. Methods: Quantitative data were collected using electronic pre- and post-educational surveys using a 5-point Likert scale. Essential information for clinical site navigation was disseminated through handbooks created and posted on a dedicated Canvas page. Implementation: A convenience sample of 10 Marian University Student Registered Nurse Anesthesia (SRNA) students participated in this project. Before the educational orientation, pretest surveys were provided to students to identify any practice or knowledge gaps among the participants and any additional information needed before their initial clinical rotation. Conclusion: Overall, the findings indicate a significant increase in student preparedness (p< 0.001) post-implementation of the clinical orientation program. Clinical site handbooks were found notably beneficial (p<0.05), and the adopted teaching methods were deemed significantly advantageous (p<0.001). Keywords: Nurse Anesthesia, Curriculum Development, Orientation Program, SRNA 4 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 5 Addressing CRNA Student Clinical Orientation through Needs Assessment and Education Implementation This project was submitted to the faculty of Marian University Leighton School of Nursing as a partial fulfillment of degree requirements for the Doctor of Nursing Practice, Nurse Anesthesia track. Preparing for the first clinical rotation as a student registered nurse anesthetist (SRNA) was cited as one of anesthesia school's most overwhelming and stressful experiences (Chipas et al., 2012). For many, the transition from didactic education to clinical reality comes with a spectrum of emotions filled with change and challenges. One way to reduce the stress and anxiety experienced by SRNAs was through the use of an orientation program to the clinical environment. Background More than 8,500 student nurse anesthetists are enrolled in 128 accredited nurse anesthesia programs throughout the United States (National Board of Certification & Recertification for Nurse Anesthetists, 2022). Nurse anesthesia schooling has been documented as one of the most arduous academic pursuits, characterized by demanding classroom requirements and rigorous clinical residencies (Mesisca & Mainwaring, 2021). The substantial classroom workload significantly elevates stress levels for students, a burden compounded by the addition of clinical residencies (Chu et al., 2013). Typically, students enrolled in front-loaded programs, where the bulk of didactic coursework occurs early in the program, embark on their clinical training component in their second year of anesthesia school. The transition from classroom student to resident trainee is inherently stressful, underscoring the necessity for students to feel adequately equipped with the knowledge and tools essential for clinical success. Establishing a seamless ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 6 transition from classroom instruction to clinical practice, complete with transparent guidelines and expectations, is pivotal in reducing stress levels and enhancing clinical performance. A formalized orientation involves organized induction and planned learning activities aimed to generate explicit, structured knowledge and skills designed for the profession (Wiese, 2022, p. 6). Providing clear guidelines through a formalized orientation enhances student preparedness and alleviates stress levels as they transition into the clinical setting. The expressed concerns regarding unpreparedness among current students in a small, Midwestern nurse anesthesia program prompted the formulation of the following PICO question: Among doctoratelevel nurse anesthesia students, would the implementation of a formalized student-led clinical orientation program improve preparedness for the clinical setting within the initial two months compared to the absence of such a program? Problem Statement The primary goal of this educational initiative was to address the challenges encountered by SRNAs during their initial clinical rotation by creating and executing an evidence-based orientation program. To achieve this goal, the project team identified gaps in the existing orientation process and designed a comprehensive orientation program that aimed to facilitate the transition from didactic instruction to practical application within the clinical environment. The orientation program encompassed a detailed introduction to the clinical tracking database Medatrax and furnished site-specific insights pertinent to clinical rotations. Additionally, it offered guidance on various aspects of clinical readiness, including essential drug conversions and other pertinent information aimed at bolstering students confidence and preparedness for the clinical environment. ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 7 Additionally, specific clinical sites were incorporated into this standardized process to extend structured orientation to the clinical facilities. A clinical rotation handbook tailored to each site was created for students to refer to before and throughout their rotation. The clinical rotation handbook included information such as site expectations, technology and access information, logistics of the site (parking, breakrooms, and out-of-suite locations), supplies specific to the clinical site (anesthesia machines used and airway equipment available for use), and site-specific onboarding requirements (background check, health screen, and hospital orientation). The primary goal was to provide students with the necessary information to adjust to their new surroundings, reduce stress and anxiety, enhance communication, boost confidence, and promote success in this pivotal time of the anesthesia program. Currently, some clinical sites provide pertinent information, while others provide little to none. The clinical rotation handbooks are a convenient resource, granting students and the program easy access to essential information. By ensuring that students are equipped with all necessary resources and support, these handbooks serve as an additional tool in fostering an environment conducive to excellence throughout their clinical rotations. The preliminary plan for creating an orientation program involved gathering feedback from second and third-year students at Marian University to ascertain what information they felt was lacking before embarking on the clinical phase of their training. Subsequently, that feedback was organized and consolidated into a student-led orientation session, which was then presented between the spring and summer semesters of 2023. During this orientation program, summer clinical requirements were clearly delineated and discussed. Additionally, supplementary materials, including PowerPoint presentations detailing instructions for completing care plans and face sheets prior to clinical, were made available. ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 8 Upon completing this comprehensive orientation, SRNAs were equipped with the necessary knowledge and readiness to engage in clinical practice at any assigned location. The envisioned outcomes of these interventions included heightened levels of preparedness among students, reduced stress and anxiety levels, and a smoother transition into clinical rotations. By shifting the focus away from logistical concerns, unclear expectations, and resource availability, the aim was to expedite the transition into performing anesthesia and ensuring safe patient care. Needs Assessment and Gap Analysis The inconsistency nurse anesthesia students encounter as they transition from student to resident and move between clinical facilities poses a significant challenge. Students have expressed that the variations among clinical sites contribute to heightened stress levels, leaving them feeling unprepared and frustrated. For instance, while some clinical sites offer a structured day-long orientation encompassing hospital and surgery center tours, introductions to clinical preceptors, insights into operating room protocols, and clear expectations for the rotation, others provide minimal information or lack any orientation altogether. This disparity leaves students feeling overwhelmed and unsure of what to expect and adds to the anxiety and stress experienced by novice providers entering their clinical residencies. Thus, establishing a standardized format for clinical site-specific information, documented in individual clinical site handbooks accessible to students before each rotation, can effectively bridge this gap and alleviate the challenges encountered by many students. Guaranteeing students access to consistent and comprehensive information will likely foster confidence, enhance preparedness, and mitigate stress levels as they embark on their clinical rotations. Furthermore, nurse anesthesia students have articulated feelings of unpreparedness regarding specific expectations required for clinical rotations. They have stressed the need for a ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 9 more structured clinical orientation preceding their practicum, emphasizing the necessity for clear expectations and requirements. Several key themes voiced by nurse anesthesia students include the need for a comprehensive explanation and understanding of Medatrax, clarity on preceptor expectations, addressing microaggressions in the clinical environment, strategies for navigating direct questioning by preceptors, and understanding care plan requirements for the clinical semester. A student-led formalized orientation is poised to significantly reduce stress levels and equip students with the essential tools for success in their initial clinical rotation. Moreover, a site-specific information handbook will give students the necessary knowledge to be wellprepared on their first day of clinical and subsequent rotations. This comprehensive handbook will include details such as contact information and hospital maps, available case types and experiential opportunities, orientation and preceptor expectations, operating room protocols, the perioperative workflow, parking information, necessary supplies and their locations, useful lodging options, and any other pertinent information aimed at ensuring students success in the clinical setting. Both elements of this project will help enhance students' overall clinical experience by reducing stress and bolstering feelings of preparedness, confidence, and perceived competence in the clinical environment. By performing a needs assessment and literature review on how an orientation to the clinical environment and site-specific clinical handbooks could enhance student preparedness, this study demonstrated that by incorporating a formalized orientation to the clinical environment before starting clinical residency enhanced confidence, perceived competence in the clinical setting, while reducing overall stress among Marian SRNAs. Review of the Literature ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 10 A computerized systematic literature search was conducted through the Marian University library portal to identify, appraise, select, and synthesize all high-quality research evidence relevant to formalized orientation programs specific to SRNAs. This review was conducted from October 2022 to December 2022 using Medline-Ovid and Cumulative Index to Nursing and Allied Health Literature (CINAHL). The database searches were performed using the keywords and mesh terms orientation, nurse anesthesia, curriculum development, orientation program, education, and SRNA. The database searches were performed using the BOOLEAN phrases nurse anesthesia OR SRNA AND orientation program AND curriculum development. The following criteria were applied: articles published 2016-Present and academic peer-reviewed journals in English. The database search resulted in zero studies for review. Google Scholar was then used to hand-search relevant studies, resulting in seven pertinent studies conducted in the United States, Australia, Ireland, and Israel from 2011-2022. These articles are included in the literature matrix found in Appendix A. Benefits of a Structured Orientation The significance of a structured orientation cannot be overstated, as studies indicate that introducing new students to clinical sites can temporarily elevate mortality rates and medication errors (Wiese & Bennett, 2022). Therefore, a comprehensive orientation program is imperative for students embarking on clinical rotations to bolster their success and enhance patient safety (Wiese & Bennett, 2022). In a study conducted in Ireland, Wiese and Bennett (2022) interviewed fifteen medical consultants using the ready-set-go model, employing a constructivist grounded theory methodology to explore the significance of orientation in a new clinical environment. This study underscored the advantages of informal and formal orientation programs in improving clinical preparedness and patient safety (Wiese & Bennett, 2022). ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 11 To facilitate the transition from student to practicing clinician, the University of Maryland Medical Center implemented a formalized orientation program for nurse practitioner students (Bahouth & Esposito-Herr, 2009). This comprehensive program included both simulation and didactic critical care education while also emphasizing the availability of formalized resources. By preparing new practitioners for potential clinical scenarios and clarifying the expectations of their advanced provider role, this initiative aimed to equip them for success in their professional endeavors (Bahouth & Esposito-Herr, 2009). Furthermore, Messiah University, a private institution located in Pennsylvania, conducted a quality improvement initiative involving 32 advanced practice providers at the National Institute of Health (NIH) (Ebenezer, 2021). A tailored onboarding toolkit was developed under the premise that a structured orientation process would enhance the role transition and integration of advanced practice providers within the clinical environment. Both quantitative and qualitative data corroborated the necessity for a comprehensive onboarding procedure. Notably, statistically significant improvements were observed in perceived clinical, professional, and organizational competencies (Ebenezer, 2021). Hence, these findings suggest that the implementation of an onboarding toolkit can effectively enhance role transition for advanced practice providers. Impact on Lowering Stress and Improving Confidence Several studies have highlighted the association between the commencement of clinical residency and heightened levels of anxiety and stress (Watt et al., 2016). In their research, Watt et al. (2016) examined 118 registered nursing students enrolled at an Australian metropolitan university who participated in a structured three-day learning program preceding their clinical rotations. The study's primary objective was to evaluate the impact of this pre-clinical learning ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 12 program on mitigating anxiety and enhancing self-efficacy among the participants. Utilizing the General Self-Efficacy Scale (GSES-12) and the Hospital Anxiety and Depression Scale (HAD), the researchers evaluated self-efficacy and anxiety levels, respectively (Watt et al., 2016). The results demonstrated a significant reduction in anxiety levels following participation in the structured learning program, indicating its efficacy in alleviating preclinical apprehensions (Watt et al., 2016). Moreover, Watt et al. (2016) emphasized the correlation between the introduction to a new clinical environment and a decline in self-efficacy. However, they noted that structured orientation programs, characterized by clear expectations and guidelines, have been shown to boost confidence levels. The GSES-12 and HAD scales quantitatively evaluated self-efficacy and anxiety levels in the same cohort of 118 registered nursing students (Watt et al., 2016). The results unveiled a noteworthy increase in self-efficacy levels post-participation in the program, underscoring the potential benefits of structured learning initiatives before students enter the clinical arena (Watt et al., 2016). In a subsequent study, Tracy (2017) conducted interviews with fifteen Certified Registered Nurse Anesthetists (CRNAs) to explore the crucial factors contributing to a successful transition from student to provider. A recurring theme highlighted by CRNAs was the pivotal role of self-efficacy and confidence in the anesthesia profession (Tracy, 2017). Furthermore, the study underscored that a lack of orientation hindered role transition, exacerbating feelings of anxiety and stress among CRNAs (Tracy, 2017). Conversely, formalized orientation programs were reported to have a positive impact on facilitating role transition (Tracy, 2017). Additionally, CRNAs emphasized the importance of allowing students to ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 13 familiarize themselves with equipment and personnel during the orientation process (Tracy, 2017). Impact on Level of Preparedness Goldschmidt et al. (2011) conducted a survey involving seven advanced nurse practitioners at the Childrens Hospital of Philadelphia to evaluate the effectiveness of the hospitals onboarding process. Over 50% of the respondents expressed satisfaction with the preparation they received during onboarding, perceiving it as sufficient for success in their new roles (Goldschmidt et al., 2011). A prevalent theme among all participants highlighted the necessity for an onboarding process explicitly tailored to acute care areas. Moreover, the participants emphasized the crucial role of orientation in establishing clarity of roles and adequate preparation for their responsibilities (Goldschmidt et al., 2011). In a separate investigation, Chu et al. (2013) conducted a study involving twenty-two anesthesia residents at Stanford University who participated in a 10-month program called Successful Transition to Anesthesia Residency Training (START) before commencing their clinical residencies. The program's primary objective was to enhance the perceived level of preparedness among interns before they began their clinical rotations (Chu et al., 2013). The findings revealed that the implementation of a 10-month program specifically designed to facilitate clinical preparation significantly augmented interns subjective assessment of their readiness to embark on an anesthesiology residency (Chu et al., 2013). Impact on Satisfaction Transitioning to Professional Roles In Israel, a cross-sectional survey encompassing 79 graduate nurses from four institutions was conducted by Strauss et al. (2016). The objective was to assess the perceived effectiveness of a structured orientation program in facilitating students' transition into their professional roles. ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 14 The findings indicated that graduate nurses who underwent a formalized orientation reported higher satisfaction levels than those who did not (Strauss et al., 2016). These results underscore the association between formalized orientation programs and heightened learner satisfaction. Literature Review Conclusion This literature review focused on scrutinizing and assessing the orientation procedures implemented in various SRNA programs across the United States. It encompassed an analysis of the orientation processes tailored for SRNAs, medical students, registered nurses, and medical residents. Upon thorough examination of the literature, it was discerned that research specifically targeting SRNA orientation programs was limited. However, abundant data existed concerning orientation initiatives tailored to medical students, registered nurses, and residents. Consequently, it was deduced that there exists a pressing need for a formalized orientation process tailored specifically for SRNAs as they embark on their clinical journey. Theoretical Framework The Keller Attention, Relevance, Confidence, and Satisfaction (ARCS) Model of Instructional Design served as the guiding framework for the development of a formalized student-led orientation. Appendix B represents the current conceptual illustration and representation of this theory. Developed by John Keller, the ARCS model aims to stimulate and sustain learning motivation (Cai et al., 2022). This method was devised to comprehensively grasp the primary influencers of motivation within the learning process (Laurens-Arredondo, 2022). The model delineates four key conceptual pillars: attention, relevance, confidence, and satisfaction, each playing a crucial role in informing various learning strategies. Attention is widely regarded as the cornerstone of effective learning (Liu et al., 2020). Studies have consistently demonstrated that actively engaged and focused learners exhibit ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 15 greater retention and integration of acquired knowledge (Liu et al., 2020). According to Keller, three motivational strategies, perceptual arousal, inquiry arousal, and variability, play pivotal roles in capturing attention (Liu et al., 2020). In developing the student-led orientation program, both auditory and visual techniques were integrated to pique learner interest, ensuring that the information was presented in an engaging manner conducive to knowledge retention. Relevance pertains to the significance and appropriateness of the acquired information, focusing on its alignment with the learners existing knowledge, needs, and goals. Learners are inherently more motivated when they perceive that the knowledge, they acquire will directly contribute to achieving their future goals (Liu et al., 2020). Keller identified several motivational strategies, including goal orientation, motive matching, and familiarity, to establish relevance to the learner (Liu et al., 2020). These strategies underscore the practical applicability and personal significance of the learned material, thereby enhancing motivation and engagement (Liu et al., 2020). Confidence was established through various successful learning experiences, such as engaging with video or audio media, hands-on practice sessions, or teach-back methods (Liu et al., 2020). These activities enabled learners to develop a sense of self-assurance, knowing they had acquired the necessary knowledge to perform tasks proficiently and competently. To enhance confidence, motivational strategies focused on identifying learning requirements, offering opportunities for achievement, and empowering learners with a sense of personal control over their learning process (Liu et al., 2020). By aligning learning objectives with individual needs, providing avenues for success, and fostering autonomy, learners were better equipped to approach their tasks confidently and effectively. Satisfaction was attained upon the culmination of the learning journey, characterized by ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 16 learners positive outlook on the newly acquired knowledge and the milestones achieved during the process. Motivational strategies aimed at fostering learner satisfaction encompassed intrinsic reinforcement, extrinsic rewards, and equity considerations (Liu et al., 2020). Studies have correlated higher satisfaction scores with well-designed projects featuring challenging tasks and prompt feedback mechanisms (Liu et al., 2020). These four elements within the ARCS model formed the foundation for motivational learning initiatives. Liu et al. (2020) introduced the ARCS model as a framework for designing an interactive EKG-focused e-book and assessing its impact on nursing students EKG-related learning outcomes, contrasting it with conventional learning materials. Building upon this approach, the Keller ARCS model was harnessed to shape the development of a student-led clinical orientation program for junior student nurse anesthetists before embarking on their clinical residency rotations. Moreover, the ARCS model served as a blueprint for crafting a clinical rotation handbook aimed at preparing students before starting their clinical rotations, allowing for subsequent comparison of its impact on students who lacked such a handbook in the preceding year. A PowerPoint presentation with audio recordings was employed to capture learners' attention, enabling students to revisit the information as needed. Feedback from students emphasized the need for comprehensive information prior to starting clinical rotations to facilitate a smooth transition and ensure a successful start. Many students identified existing gaps in the current process, indicating a high level of engagement with the topic and eliciting perceptual arousal. Project Aims and Objectives Project Aims ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 17 This quality improvement project aimed to provide junior SRNAs with a structured student-led orientation and a comprehensive clinical rotation handbook prior to their first clinical rotation. The project delineated four specific aims: Identify and address gaps in the existing faculty-led orientation process through feedback and assessment from second and third-year SRNAs. Develop a formalized student-led orientation program and produce a clinical rotation handbook tailored to the needs of first-year SRNAs preparing for their initial clinical rotation. Equip SRNAs with essential guidelines, expectations, and foundational knowledge to facilitate a smooth transition from didactic learning to clinical practice, thereby promoting clinical success. Evaluate the project's impact on student self-efficacy and stress levels by measuring changes in preparedness and competence before and after the formalized orientation program. Project Objectives The project outcomes are outlined as follows: Gather feedback from second and third-year SRNAs via anonymous Qualtrics surveys to identify deficiencies in the orientation process and inform the development of the student-led orientation program for first-year SRNAs. Develop a structured student-led orientation program utilizing the Keller ARCS Model, tailored specifically for student nurse anesthetists. ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 18 Create clinical rotation handbooks containing site-specific information to aid students during their assigned rotations, outlining expectations, resources, and essential details for success. Employ the General Self-Efficacy Scale to assess changes in students self-efficacy levels before and after the formalized orientation, utilizing Qualtrics survey software during the Summer 2023 semester. Analyze the disparity between pre-test and post-test scores, comparing results with those of previous cohorts. This project was designed to facilitate a seamless transition from didactic coursework to clinical practice within the nurse anesthesia program. Integrating an orientation program into the curriculum aimed to enhance the competence, confidence, and comfort of SRNAs, thus facilitating a smoother transition into clinical rotations while reducing stress and anxiety commonly experienced during this phase of the program. SWOT Analysis A comprehensive SWOT analysis was instrumental in identifying the strengths, weaknesses, opportunities, and threats associated with the development of a formalized studentled orientation program for student nurse anesthetists embarking on clinical residency, as detailed in Appendix C. The strengths of this project stem from the invaluable support of university faculty, clinical residency sites, and clinical site coordinators. Both the university and clinical sites approved project implementation, underscoring their endorsement of this project. Participation in this project encompassed cohorts from 2023, 2024, and 2025, thereby ensuring a comprehensive perspective and representation across multiple years of the program. Notably, this project incurred no additional costs for the institution or clinical sites, demonstrating its ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 19 efficiency and resourcefulness. This project established instructional materials to equip upcoming students for success in their first clinical rotations. Information was easily accessible through the required Canvas courses and recorded PowerPoint presentations. Furthermore, sitespecific clinical rotation handbooks were readily accessible via a faculty-managed Canvas page, ensuring easy access for Marian University SRNAs. While this project showcased numerous strengths, it also faced several challenges. One significant obstacle was the scarcity of research on existing clinical orientation processes, compounded by an even more limited body of research concerning the initiation of an institutions start-up orientation. Additionally, the narrow timeframe for implementing this project to facilitate the comparison of pre-and post-orientation results and to evaluate stress levels and preparedness required expedited action to ensure timely completion and achieve project objectives. Furthermore, one of the primary objectives of this project relied on the participation of existing clinical sites. However, the decision of several facilities to stop taking Marian University SRNAs in the past year presented a substantial challenge during the implementation phase of this project. Although this project was tailored to a specific academic program, the approach was designed to be flexible and transferable to other nurse anesthesia programs, representing a significant opportunity for broader implementation and impact. Additional opportunities afforded by this project include improved student motivation and confidence, enhancing the clinical experiences of SRNAs while mitigating stress levels in their future rotations. Threats to the project encompass the fluctuating landscape of clinical sites, where there is a risk of sites being either added or lost, alongside the potential resistance from faculty towards adopting a new ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 20 orientation process. Furthermore, there is the looming possibility of an institutional facility altering their support for the project during the implementation phase. Project Design/Methods Drawing from the ARCS theoretical framework, an educational initiative was crafted to formulate and implement a structured orientation program. The 2025 cohort of student nurse anesthetists participated in pre- and post-orientation surveys aimed at gathering both quantitative and qualitative data, enabling a comprehensive assessment of their confidence levels before and after the intervention. Analysis of this data informed the refinement and execution of a formal orientation program, with the dual objectives of enhancing preparedness and mitigating stress among SRNAs as they transition into clinical residency. A clinical site handbook template was also developed and disseminated to clinical site coordinators. These handbooks serve as valuable resources, offering pertinent information for students to consult during their clinical rotations. Accessibility was ensured through integration into the Nurse Anesthesia Program Canvas page, facilitating easy reference and utilization by students and faculty alike. Project Site and Population The study involved participants enrolled in a doctoral Nurse Anesthesia program at a small, privately funded Midwestern University. Selection criteria were based on enrollment in the program, spanning three distinct cohorts. The needs assessment sample comprised 12 thirdyear SRNAs and 20 second-year SRNAs. Pre and post-tests were administered to 33 students from the 2025 cohort of first-year SRNAs. The recruitment of participants was facilitated through email communication, which outlined the studys purpose and instructions for completing the pre-survey. To ensure ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 21 anonymity, participant identities were protected by utilizing only the last four digits of their student identification numbers. Importantly, participation in the student survey was entirely voluntary, with no inducements or compensations offered for involvement. It is important to note that participants were not influenced by external incentives or rewards, ensuring the integrity and authenticity of their responses. The student-led formal orientation was conducted at the university with permission granted by the program director, as outlined in Appendix D. Inclusion criteria had to be met to participate in this project, including current Nurse Anesthesia students and those willing to participate in this study voluntarily. However, students who failed to participate within the stipulated deadline outlined in the email communication, or those who did not complete both pre and post-test surveys, were excluded from the data collection process. Measurement Instruments To measure the outcomes and effectiveness of this DNP project, the following instruments were utilized: a needs assessment survey and a pre-and post-test survey featuring questions rated on a five-point Likert scale. Questions using the Likert scale gauged participants perceived self-efficacy regarding clinical residency, with responses ranging from 1 for strong disagreement to 5 for strong agreement. Participants responses to both surveys were meticulously analyzed before and after the implementation of the orientation program. Scores derived from the surveys were subjected to analysis, ensuring the anonymity of individual participants. An examination of overall categorical responses from the pre-and post-orientation program surveys across each Likert category was conducted to discern any significant changes. Additionally, we integrated qualitative questions, including both select all that apply and free- ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 22 text formats, to identify recurring themes among participants. This qualitative data facilitated the customization of the orientation presentation to better align with the needs and preferences of the participants. The needs assessment survey and the pre-and post-test survey questionnaires, outlined in Appendix E, were created using Qualtrics computer software. Subsequently, these surveys were distributed to participants via their Marian University email addresses, utilizing a Qualtrics link to ensure efficient and seamless data collection. Data Collection Procedures Data collection was streamlined through the use of Qualtrics, an online survey software platform that facilitated the design, distribution, and analysis of the survey questionnaires. Initially, an email containing a survey link was sent to the 2023 and 2024 cohorts, inviting them to identify any gaps in the current orientation process and highlight challenges or areas for improvement. Participants were given 2.5 weeks to complete the survey, with reminder emails sent twice during this period to encourage participation. Following this, the data collected was utilized to structure a pre-test survey, which was then emailed to the 2025 cohort. This survey sought insights into any knowledge gaps or areas requiring additional information or practice during the clinical orientation week. Participants were given three weeks to complete the survey, with reminder emails sent two weeks after the initial invitation and on the final day of the survey period to maximum participation. The data gathered from the pre-test survey was instrumental in shaping the structure and content of the formal student-led clinical orientation conducted during the clinical orientation week. Subsequently, a post-test survey was distributed to the 2025 cohort via email link six weeks following the student-led clinical orientation. Participants were allotted two weeks to ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 23 complete the survey, with a reminder email dispatched after one week to encourage timely response. Ethical Considerations/Protection of Human Subjects Approval from the Marian Internal Review Board (IRB) was obtained prior to initiating this project, as documented in Appendix F. Given that the project was confined to a single institution and entailed an educational endeavor, it posed minimal risk to the participants. Participant confidentiality remained uncompromised as the study did not require access to protected personal health information. All data utilized to assess the projects impact were aggregated and devoid of any identifying details. To uphold confidentiality, participants were anonymized using only the last four digits of their student identification numbers. Furthermore, electronic files containing identifiable information were safeguarded with passwords, accessible solely to designated project coordinators. Once data was collected, student identifiers were deleted to protect participant anonymity. Participants were duly informed of the potential risks through an information letter that was emailed alongside project invitations. Engagement in this project was voluntary, with implicit consent assumed upon participation. Data Analysis and Results Data Analysis The data collected for this DNP project underwent a careful analysis aimed at extracting valuable insights and evaluating the efficacy of implementing a student-led formal orientation program alongside the development of site-specific clinical handbooks. Before delving into the analysis, a thorough data-cleaning process was conducted to uphold accuracy and reliability. ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 24 This process entailed identifying and addressing any inconsistencies, missing values, or outliers that could potentially skew the results. After completing the data-cleaning process, both one-sample t-tests and paired t-tests were utilized to analyze the quantitative data. Statistical analysis was conducted using IBM Statistical Package of Social Science (SPSS) software provided by Marian University. All analyses were performed by evaluating significance, with a p-value < 0.05 considered statistically significant. In addition to quantitative data, qualitative data was collected to offer insights for future enhancements to the clinical orientation process. This qualitative information provided valuable context and potential areas for improvement, complementing the quantitative findings. Results A combined total of 32 students participated in the needs assessment survey, with 12 students from the 2023 cohort and 20 students from the 2024 cohort contributing valuable insights. Among these participants, seventeen felt unprepared to begin clinical rotations. When asked where the majority of pertinent clinical information was obtained, twenty-three students indicated upperclassmen, previous cohorts, or fellow students, while only one selected Marian University faculty. Additionally, eighteen students felt unprepared to input essential clinical information into Medatrax before starting clinical rotations. Regarding the components deemed essential for a formalized clinical orientation, the survey revealed strong preferences: Medatrax (30 participants), care plans (21 participants), first-day preparedness (30 participants), stress management (19 participants), microaggression (22 participants), expectations (29 participants), and preoperative interviewing (24 participants). Furthermore, twenty-seven participants indicated ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 25 that access to a clinical site handbook would be highly or somewhat helpful before commencing clinical rotations. Additionally, 33 participants from the 2025 cohort were eligible to participate in this project. Among these eligible participants, 21 students engaged in the pre-test survey. However, only ten participants from the 2025 cohort elected to participate in both the pre and post-test surveys. Pre-test Survey Seventeen participants emphasized preceptor uncertainty as a significant source of pressure before embarking on clinical rotations, while eighteen participants identified knowledge gaps as another notable stressor. Among the respondents, seventeen felt somewhat prepared to conduct preoperative interviews, with three expressing a neutral stance. Additionally, seventeen participants admitted to feeling either somewhat or highly unconfident in their ability to draft detailed anesthesia plans and backup plans. Participants highlighted the need for additional information on various aspects, including clinical expectations, first-day preparedness, and examples of questions form preceptors. Furthermore, twenty-one participants believed that a formalized clinical orientation would either highly or somewhat alleviate their concerns before starting their first clinical rotation. In comparison, nineteen participants viewed a question-andanswer session during clinical orientation as highly or somewhat beneficial in reducing stress levels. Finally, twenty-one participants indicated that having access to a clinical site handbook would be highly or somewhat helpful before commencing clinical rotations. Post-test Survey Ten participants reported that the information provided during clinical orientation significantly enhanced their preparedness before embarking on their first clinical rotation. ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 26 Among them, eight participants found the clinical site handbooks to be either highly or somewhat helpful. However, two participants noted the absence of clinical site handbooks tailored to their specific site. Additionally, eight participants expressed feeling either highly or somewhat prepared to input clinical and case information into Medatrax following the instructional sessions during clinical orientation. Furthermore, nine participants indicated feeling highly confident in their ability to develop anesthesia care plans and backup care plans for their patients. A paired T-test was employed to compare pre-and post-test survey results regarding participants confidence in developing anesthesia care plans and backup plans for specific patients. Before clinical orientation, nine out of ten participants expressed feeling unconfident about this task. However, nine out of ten participants reported feeling confident in their ability to develop detailed care plans and backup plans after clinical orientation. The paired T-test, conducted at a 95% confidence interval, produced a two-sided p-value of .004, indicating a statistically significant improvement in participants confidence levels regarding anesthesia care plan development and backup planning. Further statistical details are outlined in Table 1. Table 1 Paired Sample T-Test (Level of Preparedness for Care Plan Development) PreIntervention Mean Std. Deviation Std. Error Mean .9000 .73786 .23333 95% Confidence Interval of the Difference Lower Upper .37216 1.42784 t df p 3.857 9 .004 Post Intervention Note. t = ratio; df = degrees of freedom. A one-sample T-test was conducted to assess students' preparedness to input case information into Medatrax following clinical orientation instruction. Eight participants reported ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 27 feeling highly prepared, while two expressed a neutral reaction. The analysis, conducted with a 99% confidence interval, revealed a p-value of less than .001, indicating a significant level of preparedness. Detailed results are presented in Table 2. Table 2 One-Sample T-Test (Medatrax Database Entry) PostIntervention Mean Std. Deviation 1.40 .843 99% Confidence Interval of the Difference Lower Upper .53 2.27 t df p 5.250 9 <.001 Note. t = ratio; df = degrees of freedom. Furthermore, students emphasized the necessity of a structured orientation before commencing clinical. Subsequently, a paired T-test was employed to conducted to evaluate the efficacy of the teaching methods employed. While nine participants found the methods highly beneficial, one deemed them somewhat helpful. The paired T-test, conducted with a 95% confidence interval, yielded a two-sided p-value of <.001, indicating a significant effectiveness of the teaching methods. Comprehensive results are presented in Table 3. Table 3 Paired Sample T-Test (Teaching Methods) PreIntervention Mean Std. Deviation Std. Error Mean -.9000 .31623 .10000 95% Confidence Interval of the Difference Lower Upper -1.12622 -.67378 t df p -9.0000 9 <.001 Post Intervention Note. t = ratio; df = degrees of freedom. Additionally, a one-sample T-test was utilized to evaluate the impact of the intervention on students preparedness before their first clinical rotation. All ten participants reported a ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 28 noticeable improvement in preparedness attributed to the structured clinical orientation. Analyzed with a 99% confidence interval, the one-sample T-test yielded a p-value of <.001, demonstrating a substantial elevation in preparedness levels following the formalized clinical orientation. Detailed findings are presented in Table 4. Table 4 One-Sample T-Test (Clinical Orientation) PostIntervention Mean Std. Deviation 1.10 .316 99% Confidence Interval of the Difference Lower Upper .78 1.42 t df p 11 9 <.001 Note. t = ratio; df = degrees of freedom. Finally, a paired T-test was conducted to compare pre- and post-test survey responses regarding the effectiveness of clinical site-specific handbooks. Eight participants found the handbooks highly helpful, while two indicated that they were not created for their specific site. Analyzed with a 95% confidence interval, the paired T-test yielded a two-sided p-value of .05, denoting the significant value of the clinical site handbooks in preparing for clinical rotations. Refer to Table 5 for detailed statistical information. Table 5 Paired Sample T-Test (Clinical Site Handbooks) PreIntervention Mean Std. Deviation Std. Error Mean -.6000 .84327 .26667 Post Intervention Note. t = ratio; df = degrees of freedom. 95% Confidence Interval of the Difference Lower Upper -1.20324 .00324 t df p -2.250 9 .051 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 29 Discussion Based on the needs assessment and the pre-test surveys, it was decided to conduct a comprehensive three-and-a-half-hour presentation during the clinical orientation week for the 2025 SRNA cohort. Using Microsoft PowerPoint, a detailed presentation was developed and delivered, with a total of thirty-three participants from the 2025 cohort in attendance. The presentation covered various topics related to Medatrax, including data entry, clinical case entry, DNP project hour tracking, daily preceptor evaluations, and summative evaluations. Participants received instructions on creating anesthesia care plans and backup strategies for patients, with examples and review provided during the session. Furthermore, detailed instructions were provided on conducting thorough preoperative interviews. A dedicated segment addressed strategies for managing microaggressions in the operating room. To bolster participants understanding, preceptor-style questions were provided to simulate scenarios encountered during clinical rotations. Additionally, the presentation delved into essential areas such as clinical expectations, first-day preparedness, stress and time management, as well as academic support and mental health services available through Marian University. The presentation concluded with a question-and-answer session, and all materials, examples, and handouts were distributed to participants for reference following the session. Strengths and Limitations It is important to acknowledge this project's limitations. The relatively small sample size raises concerns regarding the replicability of the results if this project were to be repeated. Although 21 participants completed the pre-test survey and 17 completed the post-test survey, only 10 participants completed both surveys, resulting in a reduction in the projects sample size. Despite sending several email reminders for pre- and post-test surveys, survey participation ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 30 remained voluntary and may have contributed to the lack of completion. Additionally, the failure to consistently use the same four-digit code number for both surveys may have further hindered participation. The creation of site-specific clinical handbooks also posed significant challenges for this project. Unfortunately, despite efforts to engage clinical coordinators, a notable portion of them did not respond to the authors emails soliciting their support for the project or assistance in compiling handbook information. Out of the 37 clinical sites, only eight clinical site handbooks were successfully created. Three clinical sites declined to participate in the DNP project altogether. This limited number stemmed from various factors, including challenges in contacting clinical site coordinators, the loss of clinical sites and clinical coordinators during the project timeframe, and instances of clinical sites voluntarily opting out. Despite these limitations, the results underscore the importance of implementing a formalized clinical orientation to enhance the preparedness of SRNA students as they embark on clinical rotations. Moving forward, future efforts include further development and customization of the formalized clinical orientation program to cater to the needs of incoming SRNA cohorts. Furthermore, ensuring the accuracy and currency of handbook content due to the dynamic nature of clinical environments is imperative to students' success. Policies, procedures, personnel, and facilities change regularly, necessitating ongoing maintenance and updates to the handbooks. Additionally, adding or removing clinical sites from the program can significantly impact the creation and maintenance of site-specific handbooks. Therefore, establishing clear lines of responsibility for creating, maintaining, and updating these handbooks will be essential to prevent inconsistencies or oversights in information and updates. Conclusion ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 31 Overall, the results of this project provide valuable insights into the effectiveness of a student-led formal clinical orientation program in enhancing participants confidence and level of preparedness while reducing stress and anxiety levels. Providing a structured framework for students to familiarize themselves with the expectations, guidelines, and operational procedures specific to the clinical setting enhances their sense of readiness and ability to navigate complex healthcare scenarios with confidence. Additionally, the creation of clinical site-specific handbooks serves as an invaluable tool in alleviating the stress and anxiety often experienced by SRNAs as they transition between various hospital rotations. These handbooks offer a centralized resource containing essential information tailored to each clinical site, including facility protocols, contact details, and key personnel, streamlining the adaptation process for SRNAs. By providing access to pertinent information in advance, these handbooks empower SRNAs to navigate their rotations more efficiently, enabling them to focus their energy on delivering quality patient care rather than grappling with logistical uncertainties and apprehension. Thus, the combination of a formalized student-led orientation program and the provision of clinical site-specific handbooks not only enhances the confidence and preparedness of SRNAs but ultimately enhances their educational experience and professional development. ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 32 References Bahouth, M. N., & Esposito-Herr, M. (2009). Orientation program for hospital-based nurse practitioners. AACN Advanced Critical Care, 20(1), 8290. https://doi.org/10.1097/nci.0b013e3181945422 Cai, X., Li, Z., Zhang, J., Peng, M., Yang, S., Tian, X., Yang, Q., & Yan, F. (2022). Effects of ARCS model-based motivational teaching strategies in community nursing: A mixedmethods intervention study. Nurse Education Today, 119, 105583. https://doi.org/10.1016/j.nedt.2022.105583 Chipas, A., Cordrey, D., Floyd, D., Grubbs, L., Miller, S., & Tyre, B. (2012). Stress: Perceptions, manifestations, and coping mechanisms of student registered nurse anesthetists. AANA Journal, 80(4), S4955. Chu, L. F., Ngai, L. K., Young, C. A., Pearl, R. G., Macario, A., & Harrison, T. (2013). Preparing interns for anesthesiology residency training: Development and assessment of the successful transition to anesthesia residency training (START) e-learning curriculum. Journal of Graduate Medical Education, 5(1), 125129. https://doi.org/10.4300/jgme-d12-00121.1 Ebenezer, L. (2021). Improving onboarding and role transition for advanced practice providers (31) [Doctoral dissertation, Messiah University]. Nursing (graduate) Student Scholarship. https://mosaic.messiah.edu/cgi/viewcontent.cgi?article=1030&context=grnu rse_st Goldschmidt, K., Rust, D., Torowicz, D., & Kolb, S. (2011). Onboarding advanced practice nurses: Development of an orientation program in a cardiac center. JONA: The Journal of Nursing Administration, 41(1), 3640. https://doi.org/10.1097/nna.0b013e3182002a36 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 33 Laurens-Arredondo, L. (2022). Mobile augmented reality adapted to the ARCS model of motivation: A case study during the COVID-19 pandemic. Education and Information Technologies, 27(6), 79277946. https://doi.org/10.1007/s10639-022-10933-9 Liu, Y., Chou, P.-L., & Lee, B.-O. (2020). Effect of an interactive e-book on nursing students' electrocardiogram-related learning achievement: A quasi-experimental design. Nurse Education Today, 90, 104427. https://doi.org/10.1016/j.nedt.2020.104427 Mesisca, J., & Mainwaring, J. (2021). Stress, anxiety, and well-being in nurse anesthesia doctoral students. AANA Journal, 89(5), 396402. National Board of Certification & Recertification. (2022). NBCRNA certification. Retrieved October 25, 2022, from https://www.nbcrna.com/initial-certification/nbcrna-certification Robinson, C. (2021). Development of an orientation program for new certified registered nurse anesthetists at Einstein Medical Center Philadelphia (28864061) [Doctoral dissertation, Wilmington University]. ProQuest Dissertations Publishing. https://www.proquest.com/openview/46b8353961e14b074637963905e49421/1?pqorigsite=gscholar&cbl=18750&diss=y Strauss, E., Ovnat, C., Gonen, A., Lev-Ari, L., & Mizrahi, A. (2016). Do orientation programs help new graduates? Nurse Education Today, 36, 422426. https://doi.org/10.1016/j.nedt.2015.09.002 Tracy, A. (2017). Perceptions of certified registered nurse anesthetists on factors affecting their transition from student. AANA Journal, 85(6), 438-444. Watt, E., Murphy, M., MacDonald, L., Pascoe, E., Storen, H., & Scanlon, A. (2016). An evaluation of a structured learning program as a component of the clinical practicum in ADDRESSING CRNA STUDENT CLINICAL ORIENTATION undergraduate nurse education: A repeated measures analysis. Nurse Education Today, 36, 172177. https://doi.org/10.1016/j.nedt.2015.09.008 Wiese, A., & Bennett, D. (2022). Orientation of medical trainees to a new clinical environment (the ready-steady-go model): A constructivist grounded theory study. BMC Medical Education, 22(37), 19. https://doi.org/10.1186/s12909-022-03105-3 34 35 Appendix A Literature Review Matrix Citation Chu et al. (2013) Ebenezer (2021) Research Design & Level of Evidence Longitudinal study; Level VI Theoretical / Conceptual Framework N/A Qualitative and Quantitative Study; Level VI Meleis transition theory and the Ottawa Model of Research use Purpose / Aim To determine if an e-learning curriculum would increase interns preparedness for the transition to the first year of clinical anesthesiology training and reduce stress by improving confidence and perceived competence in performing professional responsibilities. To improve the integration and engagement of advanced practice providers (APPs) within the National Institutes of Health (NIH), thereby enhancing their Population / Sample size n=x N= 22 interns Major Variables Instruments / Data collection Results 10-month Elearning curriculum Survey: a repeatedmeasures analysis of variance (ANOVA) was computed, with time as the repeated measure, followed by the Student-NewmanKeuls test for post hoc comparisons After participating in START, each interns selfassessed preparedness score improved from baseline by an average (SD) of 72% (114%). Participation in the 10month e-learning curriculum and virtual mentorship program improved interns impression of their residency program and significantly increased interns subjective assessment of their preparedness to begin anesthesiology residency. N= 32 advanced practice providers Orientation and role transition into practice versus no orientation Survey: Qualitative and quantitative questions using Qualtrics Comprehensive onboarding programs for improving role transitions for APPs. ADDRESSING CRNA STUDENT CLINICAL ORIENTATION Goldschmidt et al. (2011) Qualitative; Level VI Role Implementing Strategies Strauss et al. (2016) Cross-sectional Study; Level IV N/A Tracy (2017) Qualitative, descriptive, phenomenographic design; Level VI Meleis and colleagues Transitions Theory practice, creating more substantial teams, and enhancing patient care. To evaluate the achievement of the program goals and identify opportunities for improvement 36 N= 7 APN Onboarding and achievement of program goals Survey; 5-point Likert Scale To determine whether the graduates' transition into their workplace included a structured orientation program and to assess the program's effectiveness from the graduate's perspective. N= 100 graduate nurses from four different institutions in Israel Structured orientation program and satisfaction Cross-sectional survey; evaluated for internal consistency by standardized Cronbach's alpha coefficients To examine and describe the factors affecting CRNAs during N= 15 CRNAs Factors affecting transition Semi-structural online interviews using the Internet communication software audio-video conferencing (Skype, Developing a solid onboarding and orientation process is critical for the new APN for role clarity and preparation, credentialing, and feeling connected to their peers. A formalized orientation process led by an orientation coordinator provides additional support for the APN. Positive significant correlations between having a structured orientation program to the adaptation of the graduate nurses to the ward satisfaction of the graduates on the ward. Positive correlations were also found between the graduates' support and their satisfaction on the ward. Retention on the ward was highly correlated with having a program, satisfaction, adaptation, and support. Several community-based transition conditions or factors were identified as facilitating and inhibiting CRNA role transition. ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 37 their role transition. Watt et al. (2016) Repeated Measures Design; Level IV N/A To evaluate the duration of the effect of a three-day structured learning program within the clinical placement on final-year Bachelor of Nursing students' reports of anxiety and self-efficacy. N= 118 Final year Bachelor of Nursing Students Three-day structured learning program, anxiety, and self-efficacy Wiese & Bennett (2022) Qualitative Study; Level VI Constructivist Grounded Theory To conceptualize the strategies consultants, use in the early stages of working with new trainees that will be useful for future faculty development in this area. N= 20 consultants Informal versus formal orientation strategies Microsoft Corp) and recording software (Evaer, Evaer Technology). Verbatim transcripts were analyzed through inductive content analysis. A 30-point questionnaire, an anxiety subscale of The Hospital Anxiety & Depression Scale (The HAD), and the General Self-Efficacy Scale (GSES-12). The questionnaire was completed at three time points: on day one of the clinical placement, upon completion of the three-day structured clinical program, and upon completion of the clinical placement on day 18. Data were collected between February and December 2019. An inperson semi-structured interview with each participant at their workplace. Interviews ranged between 60 and 120 minutes, were audio-recorded, and transcribed verbatim. There was a statistically significant effect in reducing anxiety over time: F (1.73,74.46) = 25.20, p b 0.001 and increasing selfefficacy over time F (1.32,41.04) = 7.72, p b 0.004. The model of orientation constructed could be a valuable tool to support faculty development initiatives, the reflective learning practice of clinical supervisors, and curriculum design. This model suggests that a program of collective, individual, formal, and informal interactions and experiences may be needed to integrate trainees ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 38 successfully into a new clinical environment. 39 Appendix B Keller Attention, Relevance, Confidence, and Satisfaction (ARCS) Model of Instructional Design Goal Orientation The need to be successful at clinical (Provide clinical site manual) Motive Matching This information will be provided shortly before clinical starts Familiarity Incorporate information from didactic courses into the presentation Perceptual Arousal Advertise to students that important clinical information will be the topic Inquiry Arousal State the benefits that the information will provide to the student Variability Use both visual (PowerPoint) and audio media to present information Learning Requirements Question and answer session Learning Activities Will lower stress levels on the first day of clinical rotation Success Attributions Student will feel prepared for clinical residency Attention Relevance Confidence Satisfaction Self-Reinforcement Using teach-back methods, surveys, or question/answer opportunities Extrinsic Rewards Positive preceptor evaluations Equity Provide a survey and self-efficacy assessment a month after beginning clinical rotations ADDRESSING CRNA STUDENT CLINICAL ORIENTATION Appendix C SWOT Analysis 40 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION Appendix D Site Permission Letter 41 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION Appendix E Needs Assessment Survey 42 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 43 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 44 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 45 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION Pre-Test Survey 46 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 47 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 48 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION Post-Test Survey 49 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION Appendix F IRB Approval Letter 50  ...

... Casos de violencia sexual en Colombia versus Estados Unidos Ashley Durnil, Selena Glaze, Cristina Avello, Marie DiPaola College of Arts and Sciences, Marian University Indianapolis 3200 Cold Spring Rd, Indianapolis, IN 46222 ABSTRACTO - El tema principal es que, independientemente de dnde vivamos en el mundo, la agresin sexual ocurre. - La idea detrs de esta presentacin es que debemos escuchar cuando las mujeres hablan sobre sus experiencias con la violencia sexual. INTRODUCIN El 30% de las mujeres son agredidas sexualmente en el mundo cada ao. (BBC News Mundo, 2004). Vamos a estar hablando de dos casos que tienen que ver con violencia sexual. uno sera de colombia y el otro sera de america EL CASO DE BEDOYA Bedoya era periodista de investigacin en Colombia y durante una de sus investigaciones se sinti insegura. Habla con personas en posiciones de poder pidiendo proteccin. Se le neg esta proteccin. RECURSOS Nadie escuch a ninguna de las mujeres, pero finalmente sus voces fueron escuchadas. Le dijeron que estara bien. Bedoya tard cuatro aos en conseguir finalmente justicia. Poco despus fue agredida sexualmente y violada en mltiples ocasiones. En el caso de las gimnastas, fueron siete aos. Ahora Bedoya trabaja para apoyar a otras vctimas de agresin sexual y ha creado una organizacia por apoyo. Figure 1. Jineth Bedyoa Es mucho tiempo para esperar por la justicia, pero es crucial para un mundo en el que las mujeres puedan sentirse seguras y protegidas. CONCLUSIONS EL CASO DE NASSAR Larry Nassar era un entrenador de atletismo de la gimnasia deportiva de Estados Unidos que agredi sexualmente a ms de 500 gimnastas Los gimnastas estadounidenses (Simone Biles, Aly Raisman, y McKayla Maroney) decidieron encubrir a larry Nassar a pesar de que muchos gimnastas se haban presentado y haban hablado por s mismos. Los gimnastas de EE.UU. Lo mantuvieron bajo las envolturas porque no queran perder dinero, o estar en medio de esta situacin. . VOCES DE MUJERES Larry fue capaz de salirse con la suya con las gimnsistas que agrededi sexualmente, incluyendo a Simone Biles y tantas gimnastas ms famosos de EE.UU. Porque muchas personas de mayor poder no escucharn a estas mujeres cuando hablan por s mismas. La violencia sexual es un problema grande, no importa donde vayas. Las dos historias y las estadsticas son ejemplos de violencia sexual en el mundo. Especficamente en los estados unidos y en colombia podemos ver que la violencia fue por mucho tiempo, porque los pases no queran hacer gran cosa entonces las personas no pudieron ayuda. Figure 2: Demuestra ejemplos de violencia sexual. Es una lista para reconocer y ver las tendencias de la violencia. 1-800-800-5556 es el numero para violencia sexual. Si usted o alguien que conoce es vctima de agresin sexual, es importante recordar que no est solo y que hay ayuda disponible. Es importante que las vctimas de agresin sexual hablen y se unan para encarcelar a los perpetradores. Si no hablamos, slo permitiremos que agredan a ms mujeres. Ser vctima de agresin sexual no es nada de qu avergonzarse. Numeros de telfono para ayuda: 1-800-656-4673 LITERATURE CITED Figure 3: Larry Nassar El Caso de Jineth Bedoya, La Vctima de Violencia Sexual Durante El Conflicto Armado En Colombia Que Llev al Estado Ante UN Tribunal Internacional. BBC News Mundo, BBC, www.bbc.com/mundo/noticias-56491673. Accessed 17 Mar. 2024. Larry Nassar - Documentary, Wife & Crimes - Biography. Www.biography.com, 23 June 2020, www.biography.com/crimefigure/larry-nassar. Yeung, Peter. Facing High Rates of Sexual Violence, Colombia Turns to Salsa as Therapy. Al Jazeera, Al Jazeera, 5 Jan. 2024, www.aljazeera.com/features/2024/1/5/facing-high-rates-ofsexual-violence-colombia-turns-to-salsa-as-therapy. Waechter, Randall, and Van Ma. Sexual Violence in America: Public Funding and Social Priority. American Journal of Public Health, U.S. National Library of Medicine, Dec. 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4638240/.  ...

... Impact of Humans on Captive Red Kangaroo Behavior Bethanie Majewski and Piper Yockelson College of Arts and Sciences, Marian University Indianapolis 3200 Cold Spring Rd, Indianapolis, IN 46222 INTRODUCTION MATERIALS AND METHODS CONTINUED Do captive red kangaroos exhibit increased vigilance (awareness of potential threats) in the presence of large crowds of people? How does the presence of visitors in close proximity impact the interaction of red kangaroos? The average amount of time an individual kangaroo spends being vigilant is known to decrease as group sizes increase. (Carter et al. 2009). Vigilance is an integral component of antipredator behaviors in animals (Edwards et al. 2013). Many species exhibit fear responses, or vigilant behaviors, towards humans (Ciuti et al. 2012) However, some species do not as a result of the Human Shields hypothesis (Sarmento, Wesley). Research has found that in areas of a free-range exhibit in a zoo where there were more humans, kangaroos were much more vigilant (Sherwen et al. 2015). Sherwen et al. (2015) also identified that visitor effects on animals can be intensified in free-range zoo habits. Group size can influence the degree and amount of time red kangaroos exhibit vigilant behaviors in the wild (Favreau et al. 2010). The effects of visitor proximity and effects on red kangaroos behaviors are relatively understudied in captivity (Jones et al. 2021) so it is currently unknown how the stress of these animals relates to human presence, the levels of vigilance, or if humans are an enrichment to the captive kangaroo environment, among other notions. Two ethograms of behavior were utilized. One depicted the red kangaroos behaviors by Sherwen et al. (2015), while Jones et al. (2021) depicted the red kangaroo's distance to the path. We performed scan samples from an area of the enclosure where most kangaroos were visible. After each scan, there was a two-minute break until the next scan. We analyzed the data utilizing Microsoft Excel software to form scatter plots and bar charts. RESULTS CONTINUED Figure 1. Jones et al. (2021) path distance determinants. Figure 4. The percentage of time certain behaviors were observed compared to the amount of people in the enclosure is shown, as well as the standard deviations for each bar. DISCUSSION Figure 2. Sherwen et al. (2015) ethogram. The scatterplot depicting Number of People vs. Total % Vigilant Behavior showed that the number of people does not seem to play a large factor in the amount of time the kangaroos spend doing vigilant behaviors. This disagrees with research by Sherwen et. al (2015) that found when more humans were present, captive kangaroos were more vigilant. The bar graph analyzing % Time vs. Behaviors highlights that a medium amount of humans (26-37 people) appear to evoke the most vigilance in the red kangaroos. A small amount of humans (5-25 people) seems to lead to the most time spent foraging, while a large amount of humans (38-89 people) leads to the most time resting. Carter et al. (2009) identified that the larger a kangaroo mob, the less time the kangaroos will spend doing vigilant behaviors. The number of kangaroos was consistent with only human amounts changing. When more kangaroos live at the Indianapolis Zoo, further research could bridge this gap in data. Hume et al. (2019) found that kangaroos were much more vigilant in urban areas than in rural due to the higher human density, however our data disagrees with this finding as both visitor directed, and general vigilance were highest with a medium (26-37) amount of people rather than a large amount (38-89). RED KANGAROO (MACROPUS RUFUS) We observed 6 males and 13 females of varying ages, from joey to adult, red kangaroos (Macropus rufus) in the Indianapolis Zoo. Red kangaroos are the largest living marsupials in the world, which makes them a novelty in numerous zoos in the world (Jones et al. 2021). Red kangaroos are endemic to Australia (Zdun et al. 2023) and found in arid zones of Australia that typically have lower areas of cover available (Blumstein et al. 2003). Red kangaroos are likely to display changes in behavior in the presence of visitors in a free-range zoo exhibit. They are more likely to show an increase in visitor-directed vigilance and locomotion, and a decreased amount of time resting (Sherwen et al. 2015). RESULTS LITERATURE CITED MATERIALS AND METHODS Two dozen red kangaroos (Macropus rufus) at the Indianapolis Zoo were monitored for ten, one-hour sessions consisting of twenty instantaneous scan samplings that lasted one minute with inspiration derived from Sherwen et al. (2015). Email pyockelson261@marian.edu or bmajewski101@marian.edu for the full literature cited. Figure 3. R^2 value is 0.001, which shows a low correlation between the number of people and the total percentage of time the red kangaroos displayed vigilant behavior. ACKNOWLEDGMENTS We would like to thank Dr. David Benson for his assistance with this project.  ...

... Lets Get to the Root of Ginger! Addison Turnock, Olivia Stunkel, Freissa Martinez, Natalia Guerrero-Alonso, and Nikayla Willis College of Arts and Sciences, Marian University Indianapolis 3200 Cold Spring Rd, Indianapolis, IN 46222 INTRODUCTION Many experience problems with bloating that may be caused by food spoilage. This study aims to use ginger as a solution. Ginger has been shown to have properties that benefit our normal gastrointestinal flora (1). It has been shown to boost metabolism, reduce inflammatory effects on the body, and improve gastrointestinal health (1). Ginger has been shown to inhibit the growth of certain bacteria including Escherichia coli (E.coli) and Staphylococcus aureus (S.aureus) (1). If ginger has antimicrobial effects, then it may decrease bloating caused by bacterial induced food spoilage. Figure 1. This figure shows the embedding of 3 disks with 10L of ginger, and one of distilled water. Also shown is one Ciprofloxacin disk that is one of the control discs. RESULTS The antimicrobial activity of ginger essential oil against Staphylococcus aureus (S. aureus) and Escherichia coli (E. coli) was determined by measuring the zone of inhibition. For the bacteria to be sensitive, its zone of inhibition must measure >21 millimeters. If it is 16-20 millimeters, then it is intermediate and resistant is <15 millimeters (2). S. aureus was sensitive to ciprofloxacin (30 mm), and resistant to ginger (15 mm). E. coli was intermediate to ciprofloxacin (20 mm), and resistant to ginger (10 mm). We hypothesized that ginger would be an effective antimicrobial agent against S. aureus and E. coli. This hypothesis was disproven as ginger did not have a strong antimicrobial effect so it may have a weak to no effect on bloating. Essential Oils Using therapeutic Grade Essential Oil Ginger (Zingiber officinale) 100% Pure and Natural purchased from Huiqili Supply Chain Technology Co. Ltd. (Guangzhou, China. Bacterial Strains The essential oils were examined for their effectiveness against Escherichia coli (E. coli) and Staphylococcus aureus (S. aureus) that were obtained from Carolina Biologicals (Burlington, North Carolina, USA). Materials Figure 2. This Figure shows our results. (L) Escherichia coli (R) Staphylococcus aureus. Procedure for determining antimicrobial susceptibility The spice used was Ginger (Zingiber officinale) 100% Pure and Natural Therapeutic Grade Essential Oil which was purchased from Huiqili Supply Chain Technology Co. Ltd. (Guangzhou, China). After inoculation, the plates were incubated at 37 C, for a total of 5 days. After the incubation period, the zone of inhibition was measured with a metric ruler in millimeters. Escherichia coli was intermediate to ciprofloxacin (20 mm) and resistant to ginger (10 mm). Staphylococcus aureus was sensitive to ciprofloxacin (30 mm) and resistant to ginger (15 mm). This displays that ciprofloxacin had a greater effect on combatting both bacteria, S. aureus and E. coli, than the use of ginger essential oil. Our results indicate that ginger may be an ineffective antimicrobial agent against Staphylococcus aureus and Escherichia coli. Future research could consist of using a larger volume of ginger essential oil to observe if the zone of inhibition is increased. LITERATURE CITED Two Meller-Hinton plates were inoculated using a sterile swab. One plate was Escherichia coli , the other Staphylococcus aureus . This was repeated for a total of four plates, two Escherichia coli and two Staphylococcus aureus. The lawn method was used for inoculation. Four BBL Sensi-Discs were placed aseptically with tweezers. Tapping each disk down gently with the tweezers to ensure good contact with the plate surface and repeated with sterile tweezers each time until all plates had the same pattern of antimicrobial discs on them. Each plate had 3 disks embedded with 10L of ginger, 2 control disks: one with ciprofloxacin and the other with 10L of distilled water. Graph 1. Average measurements of the zones of inhibition of each plates paper discs. DISCUSSION MATERIALS AND METHODS BBL Blank Paper Discs (6mm) were purchased from Benton, Dickinson and Company (Sparks, Maryland, USA) and were sterilized by autoclave. Ciprofloxacin 5mg discs were purchased from Oxoid Ltd. (UK). Muller-Hinton Agar was purchased from Sigma Aldrich (St. Louis, Missouri, USA) DATA 1. Nadifah, F., & Sari, R. M. (2016). The effect of ginger (Zingiber officinale) and green tea (Camellia sinensis) against bacteria growth on soymilk. 2. Finazzo, S., & Obenauf, S. (2022). Laboratory Manual for Microbiology Fundamentals: A Clinical Approach. McGraw-Hill Education. ACKNOWLEDGMENTS Table 1. Collective data from S. aureus and E. coli and average of the zones of inhibition. We would like to thank Professor Marciano for providing the materials and guidance to perform this experiment.  ...

... The Observation of Captive Orangutans and their Behavior Tyler Prichard and Aaron Hunter College of Arts and Sciences, Marian University Indianapolis 3200 Cold Spring Rd, Indianapolis, IN 46222 MATERIALS & METHODS INTRODUCTION Animals in captivity show heightened levels of anxiety, stress, boredom, and suppression of natural instincts typically displayed in wild (Fyock 2017) Zoos strive to provide enriching environments to accommodate for the animals umwelt If not provided for properly Orangutans have suffered from obesity which in turn can lead to other health problems (Ting 2011) Captive Orangutans have been known to predominantly show more resting behaviors (Fyock 2017) We hypothesized that the orangutans would have heavily altered behavioral patterns in comparison to Wild orangutans. Figure 1. Captive Orangutan- Rocky Figure 2. Captive Orangutan Katy Experiment conducted at Simon Skjodt Center of Indianapolis Zoo Ethogram used to track behaviors Individual Focal Sampling was conducted; observation of one member of a species over an allotted amount of time Length of time the orangutan spent displaying the behavior was recorded Observed for 1-hour periods at a specified time of day (15 mins ON & 5 min break) Live on the islands of Borneo and Sumatra in Southeast Asia. Wild orangutans typically display high activity levels in early and later hours (6-8AM & 4-6PM) of the day. (Ting 2011) Most Wild Orangutan physical activity consists of foraging behaviors (Morrogh-Bernard, 2009) In nature, this species is arboreal or tree-dwelling Naturally live isolated from other members unless mating or childbearing Home ranges of orangutans vary by the sex. Females typically have 3.5-mile range. Males can have anywhere up to 15 miles. Behavior Name Description Feeding Anytime an animal is seen holding and/or ingesting food, as well as actively foraging for food. Resting Sitting or lying at rest, no obvious activity Groom Picking, prodding, pulling, or scratching at hair Sleep Sleeping will be marked if the animal has been laying down for an extended period and appears to have eyes closed Climb When an animal is either climbing a structure, a fence, or anything else, swinging or hanging is included. Locomotion When the animal is moving at any pace other than just standing in one place. Play Interaction with stimulus in the environment in a toyish manner. Species Interaction When animals come near one another, or make physical contact with another orangutan. Manipulate Any sort of interaction with non-food object in environment Interaction with visitor Anytime an animal shows any sort of reaction to visitor presence Not visible Animal has moved out of sight in the exhibit Ethogram modeled after: Fyock, K. (2017). (Fig. A) Fig A Majority of time was spent resting in early hours of day. Little to no physical activity. Highest prevalence of feeding behavior. (Fig. B) Figure 3. Main Exhibit CAPTIVE VS. WILD ORANGUTAN DAILY ACTIVITY a Figure a. - Represents the total daytime activity of both Rocky and Katy during observational hours ETHOGRAM TIME OF DAY IMPACT ON BEHAVIOR Fig B Large spike in Activity Levels. Highest percentage of physical activity during day, especially in Manipulation and Climbing behaviors. (Fig. C) Fig C Orangutan show peak in visitor interaction behaviors in the later afternoon. Regression back to resting behaviors and fading of physical activity behaviors. b Figure b. Displays the total daytime activities of wild orangutans in the Tanjung Puting National Park in Indonesia (MorroghBernard, 2009) Wild orangutans devote just about half of their daily activity to foraging for food and feeding (Fig. b). This is in sharp contrast to our results (Fig. a). We found that only about (~6%) of Captive Orangutan activity involved foraging and feeding and that their main activities (61%) were resting and interacting with visitors. Captive Orangutans don't have to search for their meals as they are provided by the Zookeepers The amount of time spent resting was one of the few similarities between captive and wild Orangutans with both spending about (~30-35%) of their time resting Rocky and Katy displayed visitor interaction by tapping on the wall of the exhibit, baring teeth, putting face directly against barrier. During our time observing they mostly reacted to rings, tattoos, our notebooks, and purses. Higher levels of species interaction in Captive Orangutans as they are sometimes placed in same exhibit as another member CONCLUSIONS From our time observing and collecting data we were able to draw some conclusions about the behavior of these captive orangutans. First, the literature that we found regarding decreased levels of activity in captive animals (Prince 1999) did not seem to apply to the orangutans we observed. The Captive orangutans showed only a slight increase in resting behaviors in comparison to their wild counterparts. So, despite the two groups being in very different environments their levels of relative activity were similar. Our other conclusion, revealed that time of day played a large role into the activity levels of captive orangutans. Their daily activity pattern had clear distinctions from the daily patterns of wild orangutans. LITERATURE CITED -Fyock, K. (2017). Determining the Effect of Visitor Group Size and Other Variables on the Behavior of Orangutans at the Oregon Zoo as a Measure of Welfare. -Morrogh-Bernard, H. C., Husson, S. J., Knott, C. D., Wich, S. A., van Schaik, C. P., van Noordwijk, M. A., ... & bin Sakong, R. (2009). Orangutan activity budgets and diet. Orangutans: Geographic variation in behavioral ecology and conservation, 119-133. -TING, C. Y. (2011). ORANGUTAN BEHAVIOUR IN CAPTIVITY: ACTIVITY BUDGETS, ENCLOSURE USE & THE VISITOR EFFECT. ACKNOWLEDGMENTS We want to thank Dr. Benson for all his help during the semester to bring this project to completion. We would also like to thank the Zookeepers at the Indianapolis Zoo for being a huge source of knowledge for us to use.  ...

... Socio-Linguistic Situation of Quebec, Canada Randy Schneider and Noah Sherman, and Finn Walker College of Arts and Sciences, Marian University Indianapolis 3200 Cold Spring Rd, Indianapolis, IN 46222 AB S T R A C T La situation socio-linguistique au Qubec est trs intressante, car les deux langues, l'anglais et le franais, coexistent. Cette situation a cr des situations uniques pour le Qubec. ST R U C T U R E L D U C A T IO N LIN G U IS T IQ U E E T L E F R A N A IS HISTOIRE DU FRANAIS A QUEBEC DANS LES TRAVAILS 1535 Lenseignement se donne en franais dans les classes maternelles, dans les coles primaires et secondaires, sous rserve des exceptions prvues la prsente section. (Charte de la langue franaise, de <>) 1603 Au Qubec, dans les travaux, il est ncessaire pour les employeurs d'offrir l'emploi ceux qui parlent franais seulement. 1608 1701 France vs Qubec [] [] [o] [o] [] [] [] [] [] [a] [i] [i] [u] [u] [y] [y] [a] [a ] [e] [e] [o] [ ] [] [ ] [w] [wa] 1760 SITUATION LINGUISTIQUE - Langue Officielle: Le franais - Autre Langues: Langlais, le mandarin, le punjabi 1867 CONCLUSIONS Pour conclure, notre exploration du franais qubcois et du franais parisien a rvl leurs charmes uniques. Entre la prononciation, le vocabulaire et la grammaire, chaque varit de franais porte les empreintes de sa culture. Les dictons qubcois que nous avons partags tmoignent de cette richesse culturelle. Ce projet nous a permis de comprendre que le franais, bien que commun, s'adapte aux couleurs locales de ses utilisateurs. C'est une clbration de la diversit de la langue franaise et de son volution continue. QUELQUES TRAITS DE GRAMMAIRE :LAUXILIAIRE Substitution de lauxiliaire avoir par tre Ex : Franais parisien : "Elle est alle au march." Franais qubcois (informel) : "Elle a alle au march." Soir. Utilisation d'auxiliaires dans des expressions idiomatiques Ex: Franais parisien : "J'ai froid." Franais qubcois (moins courant) : "Je suis froid." 1825 Jaques Cartier, un cartographe et un explorateur, est venu le long de la Saint-Laurent avec vingt les hommes. Samuel de Champlain tait le premier Europen l'le de Quebec. La colonie de Qubec a t fonde par Samuel de Champlain avec trente-deux colons. Champlain et huit des colons ont survcu, et en juin, plus de colons sont arrivs. Les Indiens d'Amrique et les Franais ont sign la Paix de Montral, mettant fin une centaine d'annes de guerre entre ces deux peuples et ouvrant le commerce de la fourrure. Montral a capitul devant la Grande-Bretagne, et avec le Trait de Paris en 1763, la Nouvelle-France a officiellement cd la Grande-Bretagne. La Banque de Montral a t fonde et le Canal de Lachine a t construit, en raison du dveloppement conomique. Le Canada a obtenu son indpendance de l'Angleterre. LIT E R A T U R E CIT E D La population bilingue Au Qubec, la plupart des gens sont bilingues, le Qubec ayant 59,2 % de la population bilingue du Canada. (Census of Population, 2021 (3901), de Statistique Canada) De La Statistique Du Qubec, Institut. Population and Age and Sex Structure Qubec. Institut De La Statistique Du Qubec, statistique.quebec.ca/en/document/population-and-age-and sex-structure-quebec. Qubcois French Vs Parisian French: Whats the Difference? www.lingualinx.com/blog/why-is-qu%C3%A9b%C3%A9cois-french-different from-parisian-french. Gendreau, Andre. Qubec City, Now and Then: A Review Essay. The Public Historian, vol. 31, no. 1, University of California Press, Jan. 2009, pp. 11016. https://doi.org/10.1525/tph.2009.31.1.110. Point. 4 Differences to Note Between Quebec French and France French. POINT3, point3.com/en/blog/4-differences-to-note-between quebec-french-and-france-french. Heritage, Canadian. Statistics on Official Languages in Canada. Canada.ca, 26 Nov. 2019, www.canada.ca/en/canadian heritage/services/official-languages-bilingualism/publications/statistics.html. REFLECTION Pour le Qubec, il y a une grande diversit en raison de ses langues. Cette diversit a aid manifester l'individualit des gens, rvlant ainsi la dignit de chaque individu.  ...

... The Paradoxical Rise in True Crime Media Consumption: A Gendered Psychological Perspective Maria Gropp & Dr. Noelany Pelc College of Arts and Sciences, Marian University Indianapolis 3200 Cold Spring Rd, Indianapolis, IN 46222 ABSTRACT The popularity of true crime in podcast, shows, movies, YouTube channels and books has greatly increased. The audience percentages show that women are twice as likely to be interested in true crime than men. Although there is no straightforward answer to this phenomenon, there are various reasons for why women may be the primary audience. RATIONALE PROVIDED BY WOMEN CONSUMERS Sociological Women are socialized to be empathetic Women are socialized to be vulnerable Women are socialized to be more easy targets Women are socialized to be Psychological Empathy toward victim & perpetrator Play "detective" or solve a puzzle Want to learn about "red flags" Learn about new precautions to take for safety POTENTIAL IMPLICATIONS Based on current data available, a number of possible implications include: Adrenaline and sense of control in listening to the content (Onque, 2023; Shrikant, 2023) Cons: Overrepresentation of violent experiences, perpetuation of harmful stereotypes and narratives around responsibility and victim-blaming. This culture us perpetuated through the use of misogynistic language and objectification of women. This disregards women's rights and safety (Southern Connecticut State University, 2022). Examples include: "She asked for it!", "Boys will be boys!", assuming only promiscuous women get raped or hurt, refusing to take sexual and violent crimes seriously. INTRODUCTION It is shown that 3 women are killed or attacked everyday by their intimate partner. The CDC points out that over half of women everywhere are victims of sexual violence. Women also make up of 70% of the victims of serial killers, (Sales, 2023). Figure 4. Indicates percentages of how women endorsed feeling after viewing true crime. Pros: Media can also shift awareness round violence against women, reduce stigma, increase representation of justice and accountability, and catalyze empowerment to work within the legal system or to make oneself safe in spaces FUTURE DIRECTIONS AND CONCLUSIONS Figure 1. Data shows that true crime is one of the most viewed podcasts. Figure 2. Data shows that women are more likely to view true crime than men. Figure 3. This chart shows the percentage of who regularly listens to true crime podcast. Figure 5. This table shows the rapid rise in demand for true crime content. BIOPSYCHOSOCIAL INTEGRATED FRAMEWORK SAMPLE QUOTES FROM VIEWERS There is no concrete statistical evidence concluding why women are intrigued by true crime. What we know is many women not only share in this curiosity, but also share their reasoning as to why they enjoy this specific genre. Women from different interview sources have shared similar answers about why they enjoy true crime. Overall, there are multiple conclusions to answer this question, that stem from psychological, sociological, and biological perspectives. "I've definitely picked up a few habits like locking my doors right when I get in the car and checking for tags on my things when I'm out by myself." (Perrett, 2022) "() part of the reason women might be more drawn to true crime than men is that women experience a different level of fear in their daily life than men do." (Hale, 2022) "()women like true crime because they can learn something from it." (Vicary, 2023) "Be learning how people end up a victim, they can keep it from happening themselves." (Vicary, 2023) Possible points of future exploration include additional polling data across representative samples. One point of study can include comparison data around how women feel before and after they consume true crime. Additionally, measures of internalized sexism, fear responses, traditional values, and locus of control may also provide greater insights into how motivations, beliefs, and values may be related to consumption patterns. Collecting data from women in higher crime rate areas could also be a meaningful comparison versus women who do not live in high crime areas. Given how true crime is can be portrayed in Hollywood depictions, studies could further examine this to see if this a potential reason for the increase in true crime viewership. Similar trends in the production and consumption of Hollywood biopics, documentaries and glamorized versions of true crime stories should be studied. LITERATURE CITED References available on supplementary handout.  ...

... Combating Contractures: Improving Rehabilitation Treatment for Patients with Chronic Spinal Cord Injuries to Regain Functional Movement and Improve Quality of Life Sadie Mauger Marian University College of Osteopathic Medicine Background NSCIS Fast Facts ~17,810 people are diagnosed with spinal cord injuries (SCI) every year, 78% in men since 2015 Most commonly caused by vehicular crashes, falls, acts of violence and sports Purpose Understand current standard of care and cost of SCI rehab. Identify successful methodologies for completing scientific research in SCI rehabilitation. Develop new strategies to more successful prevent and treat contractures that develop in patients with SCI that could hinder their rehabilitation treatment progression. SCI Impact on Daily Life Findings Standard of Care in Rehabilitation No optimal standard of care due to extensive multidisciplinary teams creating necessarily individualized treatment plans Future Directions Educating Caregivers Early identification and treatment of spasticity and contracture Teaching SCI caregivers how to actively stretch their patients to ensure they do not lose range of motion or develop contracture. Botulinum Toxin Injections Early identification of spasticity treated with Botox injections in affected muscles Temporarily paralyze the muscle preventing development of contracture from spasticity and inhibit further loss of range of motion. Injection Sites for Botulinum Toxin for Muscle Tightness After Hip Arthroplasty (Bhave et al. 2009). Biopsychosocial model of interacting factors for persons with SCI (2022). Importance of Rehabilitation Rehabilitation has proven to drastically improve the quality of life of SCI patients, however there is not a well-established standard of care. Rehabilitation of SCI is long, expensive, exhausting and can be further impacted by many secondary complications. Secondary complications are common including Pneumonia Bladder infections, UTI Pressure ulcers Deep vein thrombosis Depressive disorders Spasticity, contractures, muscle atrophy Complications are directly correlated with life expectancy and quality of life for patients with SCI. Osteopathic Neuromusculoskeletal Medicine Dependence levels for patients with SCI before (yellow) and after (blue) rehabilitation with one being total dependence (Turner-Stokes et al 2017). Bilchak et al. (2021) found repetitive exercise improves motor function after SCI by promoting synaptic plasticity via increasing formation or maintaining damaged synapses Recruiting sensory afferent and interneurons Spared supraspinal neurons Spasticity and Contractures Project Walk Boston and The Perfect Step Specialized paralysis recovery rehabilitation centers using innovative technology such as G-EO robotic walker Specialists at these facilities have identified muscle tone as a key limitation to their ability to progress patient rehabilitation treatments; preparing the body to move can often be the most cumbersome and time-consuming aspect of their sessions. Disruption of upper motor neuron inhibitory pathways can result in increased muscle tone, hyperactive reflexes, and rigidity which is termed spasticity. Increased spasticity may result in decreased range of motion of a joint leading to contracture in that joint. ~66% of SCI patients had at least one contracture within 1 year of injury (Diong et al. 2012). Utilize osteopathic manipulative treatment (OMT) to move patients muscles and joints with Stretching Gentle pressure Resistance Alignment Identify ideal manipulative techniques for treatment of contractures and improving range of motion Current and Future Research Case study with Project Walk Boston Studies exploring improved quality of life using retrospective analysis and surveys Proposal for studies to measure neutrophins in clients at these specialized paralysis recovery centers which promote neurogenesis, neuroregulation, synaptic regeneration, neuroprotection, and neuronal survival. References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Pie chart generated from data presented by Diong et al. 2012. G-EO Robotic Walker at The Perfect Step in Pomona, CA. Methods Literature Review among two databases: PubMed, Google Scholar Key Terms: SCI and rehabilitation, spasticity, contracture Data search was limited to publications after 1985, adults with chronic SCI. Initial title/abstract review with subsequent full text review was performed. Thirteen articles are included in this study. Contractures prevent patients ability to be active during rehabilitation which is integral to its success and higher activity promotes plasticity and better motor recovery. In 1985, Yarkoney et al. found a statistically significant relationship (at p < 0.01) between time before rehabilitation admission and increased numbers of contractures per patient. Research in Rehabilitation SCIRehab promotes a practice-based evidence methodology to identify most positive outcomes to improve clinical decision making and standard of care (Whiteneck et al 2009). 13. 14. Bhave, A., Zywiel, M. G., Ulrich, S. D., McGrath, M. S., Seyler, T. M., Marker, D. R., Delanois, R. E., & Mont, M. A. (2009). Botulinum toxin type A injections for the management of muscle tightness following total hip arthroplasty: A case series. Journal of Orthopaedic Surgery and Research, 4(1). https://doi.org/10.1186/1749-799x-4-34 Bilchak, J. N., Caron, G., & Ct, M.-P. (2021). Exercise-induced plasticity in signaling pathways involved in motor recovery after Spinal Cord Injury. International Journal of Molecular Sciences, 22(9), 4858. https://doi.org/10.3390/ijms22094858 BOTTE, M. J., NICKEL, V. L., & AKESON, W. H. (1988). Spasticity and contracture physiologic aspects of formation. Clinical Orthopaedics and Related Research, 233(NA;). https://doi.org/10.1097/00003086-198808000-00003 Budd, M. A., Gater, D. R., & Channell, I. (2022). Psychosocial consequences of Spinal Cord Injury: A narrative review. Journal of Personalized Medicine, 12(7), 1178. https://doi.org/10.3390/jpm12071178 Diong, J., Harvey, L. A., Kwah, L. K., Eyles, J., Ling, M. J., Ben, M., & Herbert, R. D. (2012). Incidence and predictors of contracture after spinal cord injurya prospective cohort study. Spinal Cord, 50(8), 579584. https://doi.org/10.1038/sc.2012.25 Harkema, S. J., Ferreira, C. K., van den Brand, R. J., & Krassioukov, A. V. (2008). Improvements in orthostatic instability with stand locomotor training in individuals with Spinal Cord Injury. Journal of Neurotrauma, 25(12), 14671475. https://doi.org/10.1089/neu.2008.0572 Harvey, L., & Herbert, R. (2002). Muscle stretching for treatment and prevention of contracture in people with Spinal Cord Injury. Spinal Cord, 40(1), 19. https://doi.org/10.1038/sj.sc.3101241 Nas, K. (2015). Rehabilitation of spinal cord injuries. World Journal of Orthopedics, 6(1), 8. https://doi.org/10.5312/wjo.v6.i1.8 Sadeghi, M., Mclvor, J., Finlayson, H., & Sawatzky, B. (2015). Static standing, dynamic standing and spasticity in individuals with Spinal Cord Injury. Spinal Cord, 54(5), 376382. https://doi.org/10.1038/sc.2015.160 Samejima, S., Henderson, R., Pradarelli, J., Mondello, S. E., & Moritz, C. T. (2022). Activity-dependent plasticity and spinal cord stimulation for motor recovery following Spinal Cord Injury. Experimental Neurology, 357, 114178. https://doi.org/10.1016/j.expneurol.2022.114178 Sezer, N., Akkus, S., & Uurlu, F. (2015). Chronic complications of Spinal Cord Injury. World Journal of Orthopedics, 6(1), 24. https://doi.org/10.5312/wjo.v6.i1.24 Turner-Stokes, L., Williams, H., Bill, A., Bassett, P., & Sephton, K. (2016). Cost-efficiency of specialist inpatient rehabilitation for working-aged adults with complex neurological disabilities: A multicentre cohort analysis of a National Clinical Data Set. BMJ Open, 6(2). https://doi.org/10.1136/bmjopen-2015-010238 Whiteneck, G., Cassaway, J., Dijkers, M., & Jha, A. (2009). New approach to study the contents and outcomes of Spinal Cord Injury Rehabilitation: The SCIREHAB project. The Journal of Spinal Cord Medicine, 32(3), 251259. https://doi.org/10.1080/10790268.2009.11760779 Yarkony, G. M., Bass, L. M., Keenan, V., & Meyer, P. R. (1985). Contractures complicating spinal cord injury: Incidence and comparison between spinal cord centre and General Hospital Acute Care. Spinal Cord, 23(5), 265271. https://doi.org/10.1038/sc.1985.43 Acknowledgements Thank you to The Perfect Step in Pomona, CA and Project Walk Boston in Stratham, NH for granting me access to your facilities, specialists, and managers to understand your process of rehabilitation and picking your brains about important factors of paralysis rehabilitation and how to improve it.  ...

... Virtual Simulation to Improve Self-Confidence in Clinical Decision-Making Kristen Richey Marian University, Leighton School of Nursing Doctor of Nursing Practice, Nurse Anesthesia December 19, 2023 2 Abstract Introduction: The didactic year in Marian University's Nurse Anesthesia program equips students with a comprehensive understanding of anesthesia's core concepts, including pathophysiology, pharmacology, and physics. The first year imparts essential knowledge and hones clinical skills through simulation-based training, covering fundamental procedures such as intubation, anesthesia machine checks, and bag-mask ventilation. The proficiency gained during this phase lays a robust foundation for the transition to clinical practice. However, the secondyear challenges student nurse anesthetists face in the operating room, requiring autonomous decision-making and a swift shift from bedside nursing to anesthesia practice, highlight the need for continued enhancement of their preparedness. Background: In anesthesia training, screen-based simulation stands out for its suitability in addressing knowledge-based learning objectives. While high-fidelity scenarios are generally preferred, the literature supports the idea that all levels of fidelity contribute to student learning when applied appropriately. Purpose: This project aims to deliberately integrate screen-based simulation into the didactic year of the nurse anesthesia program and assess its impact on perceived self-confidence among first-year students. Methods: This project used a quality improvement design. The modified Student Satisfaction and Self-Confidence in Learning tool was used as a pre and post-test survey to assess the implementation of screen-based simulation. Thirty first-year SRNAs participated in the survey during the spring semester of 2023. 3 Project Evaluation: The National League for Nursing Student Satisfaction and Self-Confidence in Learning tool was modified and used as both a pre-test and post-test. Utilizing Likert scale questions, the tool encompasses thirteen items, with five gauging student satisfaction and eight assessing confidence in learning. Participants completed identical surveys before and after the virtual simulation activity, and each question was analyzed independently. Student satisfaction and self-confidence scores were averaged to discern an overall trend. Conclusion: This project successfully integrated screen-based simulation into the didactic year of the nurse anesthesia program, demonstrating its potential to enhance student learning and confidence. The positive outcomes, as evidenced by high agreement in both pre-test and post-test surveys, contribute to the evolving discourse on innovative approaches in anesthesia education. Despite limitations such as small sample size and time constraints, the project underscores the efficacy of screen-based simulation as a supplementary educational strategy. Future research endeavors with larger and more diverse samples can provide deeper insights into the effectiveness of screen-based simulation. 4 Introduction Marian University's Nurse Anesthesia program is "front-loaded," meaning that the first year is entirely didactic education and simulation-based training. The didactic year introduces a breadth of knowledge and many clinical skills. Much of the curriculum is focused on core concepts of anesthesia: pathophysiology, pharmacology, and physics. Simulation-based training is also utilized to teach first-year students basic skills such as intubation, anesthesia machine check, and bag-mask ventilation. The knowledge and skill attained in the didactic year lay the foundation for clinical practice. Still, student nurse anesthetists face many challenges as they enter the operating room in the program's second year. There is pressure to perform well in clinical, demonstrate proficiency in basic anesthesia skills, make plan of care decisions autonomously, and quickly transition from bedside nurse to anesthesia provider. Many individual factors complicate role strain and competence in the clinical realm, but basic knowledge of anesthetic variety need not be one of them. Anesthetic considerations, patient comorbidities, and case variety can be integrated into simulated scenarios. This project aims to utilize screen-based simulation more intentionally within the didactic year of the nurse anesthesia program and to measure how it affects perceived self-confidence. Background Simulation-based training has been utilized in educational programs for decades to expose students to clinical scenarios without risks to patient safety. Much literature boasts of the benefits of simulation training in various professions, from aviation to medicine. In anesthesia training, simulation is a tool that can help students gain knowledge of case variety, anesthetic 5 implications, and improve confidence in handling real patient scenarios in the operating room. The accrediting body for nurse anesthesia programs has also supported simulation-based training in anesthesia education (Council on Accreditation, 2020). Several modalities of simulation-based training have proven to be effective in preparing students to enter the clinical realm (Fragapane et al., 2018). Modality in simulation refers to the methodology used. Standardized patients, smart mannequins, task trainers, and screen-based simulation are all separate modalities. Fidelity in simulation education refers to the extent of realism achieved (Kim et al., 2016). The equipment, scenario, and environment are all factors in achieving a realistic learning experience. For example, high-fidelity simulation (HFS) often involves a computerized mannequin that can demonstrate physiological responses to interventions (Kim et al., 2016). The setting may be a hospital or operating room complete with standard equipment and supplies, while an instructor typically controls the mannequin and bedside monitor from a neighboring room. The scenario's psychological, physical, and environmental aspects achieve a relatively high degree of realism. In contrast, low-fidelity simulations (LFS) may lack the components that create a realistic scenario. For example, task simulators such as an airway trainer for intubation would be considered low-fidelity. Likewise, screen-based simulation is considered low-fidelity but may be more beneficial for knowledge-based learning objectives (Fragapane et al., 2018). While students and instructors reportedly prefer high-fidelity scenarios, the literature supports that all levels of fidelity benefit the student when applied appropriately (Fragapane et al., 2018). Screen-based simulation provides an excellent adjunct to HFS and comes with benefits such as ease of accessibility, low cost, and the ability to repeat case scenarios. While HFS may offer an 6 enhanced level of clinical realism, screen-based simulation (SBS) may be beneficial to increase knowledge and student confidence. SBS are interactive, can simulate tasks, and still produce physiologic responses via scripts or mathematical models within the software (Swerdlow et al., 2020). The computerized mannequin may be superior for students to develop and practice psychomotor skills. However, SBS fosters cognitive skill development (Swerdlow et al., 2020). An application called Simpl was created with this in mind. The Simpl app is an adjustable patient monitor that is used for virtual simulation. This particular SBS program is inexpensive and can be used repeatedly by learners and educators. By utilizing a software program within the best-practice standards set by INACSL, first-year SRNAs have an opportunity to improve their cognitive skills, knowledge of case variety, and anesthetic considerations. Problem Statement Marian University's nurse anesthesia program provides access to HFS using a computerized mannequin in the setting of a simulation lab. The sim lab provides many highfidelity learning opportunities but lacks other forms of simulation modality. Because of the range of clinical skills needed in anesthesia practice, all simulation modalities should be utilized as much as possible before entering the clinical environment. LFS is underutilized in the didactic year and is arguably more accessible and cost-effective than the existing simulation within the curriculum (Wiggins et al., 2018; Yunoki & Sakai, 2018). This project aims to employ SBS training in the nurse anesthesia program's didactic year and improve the knowledge and selfconfidence of student nurse anesthetists. Gap Analysis 7 Currently, SBS is not utilized in Marian University's curriculum. An organizational framework should be used to improve SBS experiences for first-year SRNAs. The Jeffries Simulation Theory provides a straightforward framework for modeling simulation training (Jeffries, 2005). The International Nursing Association for Clinical Simulation and Learning (INACSL) also provides an evidence-based framework on which to model simulation design and facilitation (INACSL, 2016). The opportunities for SBS could be enhanced by providing software such as Simpl. Students may have access to screen-based simulations in and out of the classroom. If the appropriate framework is applied and the opportunities for LFS are multiplied, the learning experience for first-year students may be improved. This led to the following PICO question: For first-year SRNAs at Marian University, does the implementation of virtual case studies improve self-confidence and knowledge compared to the current simulation curriculum? Literature Review A literature review examined the evidence for virtual simulation in anesthesia education. This review was conducted from October 2022 to November 2022. The following electronic databases were searched: PubMed, CINAHL, MEDLINE, Google Scholar, and EBSCO. The search was conducted using the following phrases and keywords: anesthesia training, anesthesia education, simulation-based education, simulation-based training, virtual simulation, computer simulation, screen-based simulation, low-fidelity simulation, and anesthesia simulator. Only articles with full-text accessibility, peer-reviewed, and available in English were included. To fully grasp and understand how simulation-based training has evolved, the timeframe for these articles was not restricted to recent literature. Therefore, the dates of publishing range from 1994 to 2021. 8 Articles specific to virtual simulation in anesthesia education were very scarce. Due to the limited research on this topic, a broader selection of applicable papers was included. Very few randomized controlled trials have been published on SBS use in nurse anesthesia education; therefore, much of the literature included consists of other literature reviews and tangentially related simulation research. All articles were screened by title and abstract first. If the abstract discussed virtual simulation, fidelity in simulation, learner confidence, or a specific framework for simulation, the paper was tagged for full-text screening. Approximately 146 papers were considered, and 19 were utilized for this review. The major themes found in this literature are discussed below. Effectiveness of Simulation Decades of research have validated simulation as an effective tool in medical education. Simulation education allows the learner to hone clinical skills and knowledge without placing patients at risk, making it an integral part of modern educational programs (Hayden et al., 2014; Laschinger et al., 2008; Maran & Glavin, 2003; Massoth et al., 2019; Yunoki & Sakai, 2018). Several studies demonstrate that students participating in SBE have improved critical thinking, clinical competency, communication skills, and self-confidence (Al-Elq, 2010; Hayden et al., 2014; Okuda et al., 2009; Yunoki & Sakai, 2018). Five articles discuss the positive effect of simulation on student confidence and performance in the clinical setting compared to traditional education (Al-Elq, 2010; Chopra et al., 1994; Hayden et al., 2014; Nyssen et al., 2002; Wiggins et al., 2018). One longitudinal study found that for undergraduate nursing students, simulated experiences could replace actual clinical experiences with no adverse effects on clinical competency, critical thinking, or readiness for practice (Hayden et al., 2014). All articles discussing the benefits of SBE agree that the opportunity for students to practice skills repeatedly 9 improves knowledge and clinical performance (Al-Elq, 2010; Hayden et al., 2014; Laschinger et al., 2008; Massoth et al., 2019; Okuda et al., 2009; Yunoki & Sakai, 2018). Simulation in anesthesia education has been proven effective in teaching airway management, regional anesthesia, ultrasound-guided techniques, intravascular line placement, developing crisis management skills, and non-technical skills (Chopra et al., 1994; Erlinger et al., 2019; Liaw et al., 2014; Nyssen et al., 2002; Swerdlow et al., 2020; Wiggins et al., 2018). In addition, mannequin-based simulation experience is quite effective in developing psychomotor skills (Chopra et al., 1994; Kim et al., 2016; Maran & Glavin, 2003). However, there is disagreement in some literature about whether SBE translates into clinical practice. Some studies agree that skills and confidence gained in a simulated setting transfer to actual clinical practice (Al-Elq, 2010; Hayden et al., 2014; Wiggins et al., 2018). However, other studies remain skeptical that SBE effectively translates to clinical preparedness or improves patient outcomes (Laschinger et al., 2008; Massoth et al., 2019). Framework Several studies discuss the importance of using a framework for effective SBE (CannonBowers, 2008; Gordon et al., 2004; Pecka et al., 2014; Wiggins et al., 2018). Four articles discuss the importance of defining learning objectives prior to a simulated experience, stating that students will glean more from the scenario when clear objectives are provided (CannonBowers, 2008; Chopra et al., 1994; Gordon et al., 2004; Pecka et al., 2014). Prompt feedback and debriefing also aid the learner in achieving the learning objectives or identifying growth opportunities. Nine articles discuss feedback and debriefing as imperatives in SBE (Al-Elq, 2010; Cannon-Bowers, 2008; Chopra et al., 1994; Gordon et al., 2004; Liaw et al., 2014; Massoth et al., 2019; Pecka et al., 2014; Swerdlow et al., 2020; Wiggins et al., 2018). While 10 many different frameworks exist to design and implement SBE, the literature supports a few commonalities within these frameworks. First, a framework should be used when designing simulation scenarios or curricula (Cannon-Bowers, 2008; Chopra et al., 1994; Gordon et al., 2004; Pecka et al., 2014; Wiggins et al., 2018). The International Nursing Association for Clinical Simulation and Learning outlines the standards of best practice in SBE based on all available evidence in the current literature (Persico et al., 2021). As SBE grows, its facilitators must stay current with best practices to continue providing high-quality simulation that meets the needs of the learner. Finally, the simulation experiences must be evaluated regularly by both students and faculty to ensure that they continue to satisfy the overall learning objective effectively. This body of literature agrees that successful simulations have fundamental components such as clear learning objectives, a qualified facilitator, timely feedback, and debriefing (Cannon-Bowers, 2008; Gordon et al., 2004; Pecka et al., 2014; Persico et al., 2021; Wiggins et al., 2018). Fidelity Several articles discuss fidelity in simulation training, but the significance of fidelity in achieving specific learning objectives is unclear. Fidelity in SBE refers to the degree of realism achieved by the scenario. Specifically, fidelity is the extent to which the simulated scenario matches the system it simulates (Maran & Glavin, 2003). There is a distinction between psychological fidelity and physical fidelity that should be noted. Computerized mannequins or physical models such as an airway trainer offer a higher level of physical fidelity when compared to virtual simulation (Fragapane et al., 2018; Kim et al., 2016; Maran & Glavin, 2003). Students can develop psychomotor skills and gain a tactile understanding of specific tasks using these simulators. Psychological fidelity is the degree to which the learner feels in the simulation as 11 they would in the actual working environment (Maran & Glavin, 2003). Psychological fidelity may be achieved in any simulation modality if the scenario is appropriately designed. While there is pressure for education programs to provide high-fidelity SBE, much of the literature agrees that fidelity does not always equate to improved learning outcomes (Fragapane et al., 2018; Kim et al., 2016; Massoth et al., 2019; Maran & Glavin, 2003; Schwid et al., 2001; Swerdlow et al., 2020). When planning a simulation scenario, the type of task or learning objective should inform the level of fidelity required. Several articles discuss the effectiveness of LFS when the learning objective is a cognitive task (Fragapane et al., 2018; Kim et al., 2016; Massoth et al., 2019; Maran & Glavin, 2003; Schwid et al., 2001; Swerdlow et al., 2020). However, high-fidelity simulation has been proven more effective in developing psychomotor skills (Fragapane et al., 2018; Kim et al., 2016; Liaw et al., 2014). There are pros and cons to SBE deemed low-fidelity and high-fidelity, which are discussed repeatedly in the literature. Cost, maintenance of equipment, faculty resources, and accessibility are the most common factors that are considered when choosing the level of fidelity. In a meta-analysis of research on simulation in nursing education, Kim et al. synthesized the results of 40 studies according to the level of fidelity (2016). The effect sizes for high, medium, and low-fidelity simulations were measured to determine if high-fidelity scenarios were superior. The results showed that high-fidelity simulation has a large effect on psychomotor skills, but the effect size was not proportional to the level of fidelity (Kim et al., 2016). The difference in student outcomes between levels of fidelity was not significant (Kim et al., 2016). The meta-analysis is a unique article, yet much of this literature agrees with the conclusion that high-fidelity simulation is most effective for the development of psychomotor skills (Kim et al., 2016; Liaw et al., 2014; Maran & Glavin, 2003; Swerdlow et al., 2020). However, the literature 12 also agrees that LFS influences cognitive skill development and is often underutilized in educational programs (Kim et al., 2016; Liaw et al., 2014; Swerdlow et al., 2020). Modality Three studies compare simulation modalities, specifically virtual vs. mannequin-based, and the effect on learner performance. Liaw et al. compared student performance in mannequinbased and virtual simulation scenarios and found that the difference in student outcomes was insignificant (p = 0.17) (2014). This study also noted that virtual simulation offers an equally effective learning strategy without the resource requirements of high-fidelity mannequin-based simulation (Liaw et al., 2014). In a randomized controlled trial, Erlinger et al. compared virtual and mannequin-based simulation effects on student recognition of intraoperative myocardial infarction (2019). Both modalities were equally effective, and the difference in time to recognition between them was insignificant (p = 0.67) (Erlinger et al., 2019). In a comparison study on mannequin-based and computer-based simulation, Nyssen et al. evaluated student performance in a case of an intraoperative anaphylactic reaction (2002). There was no significant difference in recognition times between the two modalities (Nyssen et al., 2002). In a recent literature review, Swerdlow et al. examined the available evidence for SBS in anesthesia education (2020). This review considered 150 articles published between 1980 and 2020, and 33 were included for review (Swerdlow et al., 2020). SBS has advantages that include cost effectiveness, reduction of resource utilization, and less dependence on personnel (Swerdlow et al., 2020). SBS only requires a computer and allows the learner to practice at any time, in any location, and repeat simulations for maximum educational value (Swerdlow et al., 2020). Multiple studies have shown that SBS improves anesthesia students' cognitive and 13 teamwork skills (Swerdlow et al., 2020). According to much of the literature in this review, SBS is not an inferior modality to mannequin-based simulation if used correctly. Discussion Decades of literature demonstrate that simulation education can improve cognitive, psychomotor, teamwork, and communication skills across many disciplines. Substantial evidence supports the inclusion of SBE in health professions curricula. This group of literature defines fidelity as the degree of realism in a simulated scenario but reveals that it does not necessarily equate to improved learning outcomes. Many education programs have adopted HFS and spared no expense creating state-of-the-art simulation labs with high-fidelity computerized mannequins. Much of the existing research supports mannequin-based simulation, and evidence shows that it benefits students, especially in developing psychomotor skills. However, there are drawbacks to including and maintaining this simulation modality in university curricula, including the monetary expense and increased faculty workload. While there is very little research on virtual simulation in anesthesia education, we can look to SBS research in other disciplines. The existing literature supports SBS as an effective modality to develop cognitive skills specifically. Higher education programs likely underutilize it, and it is more cost-effective than the on-campus simulation labs. The virtual simulation also offers greater accessibility and opportunity for repetition that is unmatched by other modalities. Based on the findings in this review of literature, it is reasonable to hypothesize that students who utilize SBS software will improve their knowledge and confidence. Hopefully, implementing SBS in Marian University's curriculum will provide an additional tool for anesthesia students to help smooth the transition from didactic courses to the clinical environment. See Appendix A for a completed literature matrix. 14 Theoretical Framework The Jeffries Simulation Theory was presented in 2005 as a framework for designing, implementing, and evaluating simulation-based education (SBE) in nursing (Jeffries et al., 2005). The concepts of this theory include context, background, design, educational practices, simulation experience, and outcomes and will be briefly described. Context refers to the setting and purpose of the simulated experience (Jeffries et al., 2005). Simulation may take place in a lab, hospital setting, classroom, or virtually from any location. The intended purpose, whether for practice or evaluation, also affects the context of the experience. Background includes specific goals and expectations that may shape the simulation design (Jeffries et al., 2005). Time, resources, allocation of those resources, and how the simulation relates to the curriculum all influence the successful implementation of simulated learning experiences (Jeffries et al., 2005). The simulation design includes specific learning objectives that guide the simulated activities, scenarios, and complexity (Jeffries et al., 2005). While certain design elements may be changed throughout the implementation of a scenario, the level of fidelity, concepts, and equipment should be well established (Jeffries et al., 2005). Roles, scenario progression, and debriefing are all established in the simulation design. The simulation experience should be interactive, collaborative, and centered on the learner (Jeffries et al., 2005). A dynamic interaction between the facilitator and the participant makes the simulation experience successful. The facilitator and the learner must have established trust and buy-in to promote perceived fidelity and authenticity (Jeffries et al., 2005). The facilitator must possess the skill, knowledge, and preparation to guide the learners throughout the 15 scenario. Cues offered during the simulation and timely feedback or debriefing are essential to the success of the experience. Finally, simulation outcomes may be participant, patient, or system-focused (Jeffries et al., 2005). Most of the existing literature is focused on participant outcomes such as selfconfidence, improved knowledge, competency, and transfer of skills into the clinical environment. Some literature is geared toward patient outcomes after receiving treatment from clinicians trained in simulation modalities. System outcomes refer to organizational-level issues such as cost and quality improvement (Jeffries et al., 2005). The Jeffries Simulation Model will be used as a framework to design, implement, and evaluate this project. Each listed component will be considered as the new virtual simulation is developed. To see a visual representation of the Jeffries Simulation Model, please refer to Appendix F. Project Aims This project aims to utilize SBS software to improve the knowledge and self-confidence of first-year anesthesia students. The objectives are to enhance student knowledge of case variety, pharmacology, and confidence in decision-making before entering a real clinical setting. Project Design This project's design is a quality improvement initiative in the setting of graduate-level education. A new educational strategy was implemented within Marian University's current curriculum. Patient monitor simulation software was utilized for first-year anesthesia students to supplement their existing didactic learning objectives. Quantitative data was collected throughout the implementation stage for analysis. Data included student responses from the 16 modified Student Satisfaction and Self-Confidence in Learning tool. This project used a convenience sample of first-year nurse anesthesia students at Marian University. The SBS was implemented in the Spring 2023 semester before clinical rotations began. The expected outcome was that these students would have an enhanced learning experience and gain confidence prior to entering the clinical realm. In addition, INACSL best practices for simulation training were utilized. Methods Before this project was implemented, an exemption was obtained from Marian University's Institutional Review Board. Ten clinical scenarios were developed using the Jeffries Simulation Theory and INASCL standards for simulation with corresponding patient monitor adjustments. The project chair reviewed these scenarios and approved them for use in the virtual simulation. All students completed the same simulation scenarios and were not divided into control and experimental groups. Students first completed the Student Satisfaction and SelfConfidence in Learning tool that was modified for the purposes of this project. All questions were answered anonymously via a Qualtrics survey. Then, the virtual case scenarios were presented using the Simpl app. Students answered scenario questions in the Qualtrics survey while watching the patient monitor on their phones. The instructor adjusted the patient monitor to reflect each unique clinical scenario. Each question was multiple choice and focused on pharmacological interventions to be made according to the changes on the Simpl monitor. After completing the virtual scenarios, the students again completed the modified Student Satisfaction and Self-Confidence in Learning tool. 17 All data were collected via Qualtrics and analyzed for significance using SPSS statistical software. Thirty students completed the survey. No demographic information was collected as it was not relevant to the aim of this project. All participating students were first-year SRNAs, and this survey was administered in the spring semester of 2023. Project Evaluation An instrument developed by the National League for Nursing will be used to evaluate student confidence. This project administered the Student Satisfaction and Self-Confidence in Learning tool as a pre-test and post-test. This tool uses Likert scale questions to gauge student responses (NLN, n.d.). This instrument consists of thirteen questions with options ranging from "strongly disagree" to "strongly agree." Five questions measure student satisfaction with a learning activity, while the remaining eight measure students' confidence in learning (NLN, n.d.). Quantitative data was evaluated based on student responses to the SSCL tool and not on correctness within the simulated scenarios. The goal was not to test for correctness but to determine whether the learning strategy was effective. Student satisfaction and self-confidence scores range from 5 to 25 and 8 to 40, respectively. The average of these scores was used to determine an overall trend. To see the original tool, see Appendix B. To see the modified tool, see Appendix C. Data Collection All data for this project was collected in a singular Qualtrics survey. The link for the Qualtrics survey was given to the students via Webex chat. The ten virtual case scenario questions immediately followed the pre-test. Then, the post-test followed the virtual case scenarios. Students were given roughly five minutes to complete the pre-test. The case scenarios 18 were allowed two minutes each, and another five minutes were allowed for the post-test. All responses remained anonymous and confidential within the Qualtrics application. Ethical Considerations Marian University IRB approval for this project was received on February 16, 2023. The project was deemed exempt. Please see Appendix D to review the approval letter. It should be noted that the project's title changed slightly from the original IRB proposal, but the project's design, methods, and objectives remained identical. Because no demographic data or personal identifiers were used, and all data remained anonymous, minimal risk of student harm was assumed. Data Analysis The data were analyzed using descriptive statistics, including central tendency, frequency, and variability measures. All categorical and numerical data were evaluated in frequency tables. Frequencies and percentages were calculated for questions in the survey that were categorical variables. Mean, median, mode, and standard deviation were calculated for questions with continuous variables. IBM SPSS Statistics was used to perform all statistical analyses. Because the goal was to determine if virtual case simulations using the Simpl app were well received by the students, the answers to the case study questions were not analyzed for correctness. To see the virtual case scenarios presented, please see Appendix E. Only the SSCL tool survey questions were explored for the overall effect of the learning activity. Results Thirty-one first-year Marian University students participated in the virtual simulation activity. Demographic data was not relevant to the aim of the study and, therefore, not collected. 19 When this data was collected, all students were enrolled in the Nurse Anesthesia DNP program. In the pre and post-test survey, questions one through five aim to measure student satisfaction with their current learning. Questions six through thirteen aim to measure student self-confidence in learning. Students completed the same survey twice. Each of these questions was analyzed separately. In the pre-test survey, the distribution of the questions, or variables, is roughly symmetrical based on the closeness of their mean and median values. The median value for each question is 4. A rating of 4 in the survey correlates with an "agree" response on a scale of "strongly disagree to strongly agree." The mode is also consistently 4, indicating that it is the most common response to each question or statement in the survey. The pre-test survey's standard deviation and variance values are relatively low, indicating slight variation in the answers. In the post-test survey, the distribution appears to be generally symmetrical based on the proximity of the mean, median, and mode values. The mode value 5 indicates that "strongly agree" is the most common response to each post-test survey question. This demonstrates widespread agreement among students regarding their experience with the virtual learning activity. The mean and median values also have close proximity to each other, indicating that most students gave high ratings to each of the post-test survey questions. The standard deviation and variance values are comparatively higher than the pre-test, meaning greater response dispersion. The contingency tables below display the number of respondents and response distributions for both pre-test and post-test surveys. 20 Table 1 Pre-test Survey Measuring Satisfaction and Self-Confidence in Learning N Mean Median Mode Std. Deviation Variance Min. Maximum 1 29 4.14 4 4 0.58 0.34 3.00 5.00 2 29 4.14 4 4 0.69 0.48 2.00 5.00 3 29 4.24 4 4 0.58 0.33 3.00 5.00 4 29 4.07 4 4 0.59 0.35 3.00 5.00 5 29 4.21 4 4 0.62 0.38 3.00 5.00 Item Satisfaction Summed Satisfaction SelfConfidence 20.8 1 29 3.59 4 4 0.87 0.75 2.00 5.00 2 29 3.97 4 4 0.63 0.39 3.00 5.00 3 29 4.07 4 4 0.65 0.42 2.00 5.00 4 29 4.17 4 4 0.66 0.43 2.00 5.00 5 29 4.24 4 4 0.64 0.40 3.00 5.00 6 29 3.93 4 4 0.80 0.64 2.00 5.00 7 29 4.21 4 4 0.56 0.31 3.00 5.00 Summed Confidence 28.18 21 Table 2 Post-test Survey Measuring Satisfaction and Self-Confidence in Learning N Mean Median Mode Std. Deviation Variance Min. Maximum 1 31 4.32 5 5 0.87 0.76 2.00 5.00 2 30 4.53 5 5 0.73 0.53 2.00 5.00 3 30 4.57 5 5 0.63 0.39 3.00 5.00 4 30 4.50 5 5 0.78 0.60 2.00 5.00 5 30 4.53 5 5 0.63 0.40 3.00 5.00 Item Satisfaction Summed Satisfaction SelfConfidence 22.45 1 29 4.10 4 4 0.72 0.52 2.00 5.00 2 30 4.43 4 4 0.57 0.32 3.00 5.00 3 30 4.47 4.50 5 0.57 0.33 3.00 5.00 4 30 4.53 5 5 0.51 0.26 4.00 5.00 5 30 4.47 4 4 0.51 0.26 4.00 5.00 6 30 4.33 4.5 5 0.76 0.57 3.00 5.00 7 30 4.47 5 5 0.63 0.40 3.00 5.00 Summed Confidence 30.8 The t-value for each response was calculated to determine the significance of the mean difference compared to zero. A larger absolute t-value indicates a more significant difference. Smaller numbers signify higher levels of significance for the degrees of freedom, which represent the number of observations in the sample. The following table demonstrates the pre-test and posttest questions' t-values and 95% confidence intervals. 22 Table 3 Pre-test Survey T-values and Confidence Intervals Item T-value 95% Confidence Interval Satisfaction 1 38.361 3.917 4.3589 Satisfaction 2 32.153 3.8743 4.4015 Satisfaction 3 39.61 4.022 4.4607 Satisfaction 4 36.921 3.8432 4.2947 Satisfaction 5 36.548 3.9711 - 4.4427 Self-Confidence 1 22.282 3.2565 - 3.9159 Self-Confidence 2 34.124 3.7275 - 4.2036 Self-Confidence 3 33.665 3.8214 - 4.3165 Self-Confidence 4 34.127 3.9220 - 4.4229 Self-Confidence 5 35.937 3.9996 - 4.4831 Self-Confidence 6 26.504 3.6272 - 4.2348 Self-Confidence 7 40.506 3.9942 - 4.4196 23 Table 4 Post-test Survey T-values and Confidence Intervals Item t-value 95% Confidence Interval Satisfaction 1 27.623 4.003 - 4.6422 Satisfaction 2 34 4.2606 - 4.806 Satisfaction 3 34.952 4.3329 - 4.8004 Satisfaction 4 31.729 4.2099 - 4.7901 Satisfaction 5 39.487 4.2985 - 4.7681 Self-Confidence 1 30.509 3.8279 - 4.379 Self-Confidence 2 42.727 4.2211 - 4.6455 Self-Confidence 3 42.82 4.2533 - 4.68 Self-Confidence 4 48.934 4.3439 - 4.7228 Self-Confidence 5 48.215 4.2772 - 4.6561 Self-Confidence 6 31.308 4.0503 - 4.6164 Self-Confidence 7 38.907 4.2319 - 4.7015 A paired t-test was performed comparing values from the pre-test and post-test surveys to determine if the learning activity significantly improved student satisfaction and self-confidence in learning. Students reported their satisfaction with current learning on a 5-point scale ranging from 1 to 5. In the pre-test survey, students indicated they were satisfied with their current learning (Mean = 4.15, Median = 4, range = 2-5). In the post-test survey, students indicated increased satisfaction with current learning (Mean = 4.49, Median = 5, range = 2-5). The mean 24 results from both categories were compared between the pre-test and post-test. These results were statistically significant (p = 0.00042). Students reported their self-confidence in learning on a 5-point scale ranging from 1 to 5. In the pre-test survey, students indicated they felt confident in their current learning (Mean = 4.03, Median = 4, range = 2-5). In the post-test survey, students indicated that their selfconfidence in learning was increased (Mean = 4.4, Median 4.5, range = 2-5). The mean results from both categories were compared between the pre-test and post-test. These results were also statistically significant (p = 0.0004). Summary A total of 31 SRNAs participated in the virtual simulation learning activity. However, 29 students completed all questions in the pre-test and post-test survey, providing a completion rate of 94%. Overall, students reported being satisfied and self-confident in their current simulation learning. The pre-test results show a summed mean of 20.8 for satisfaction and 28.18 for selfconfidence in learning. However, after the virtual simulation activity, students reported even higher levels of satisfaction (Mean difference = +1.65) and self-confidence (Mean difference = +2.62). The post-test survey yields a summed mean of 22.45 for satisfaction and 30.8 for selfconfidence in learning. The increase in mean was statistically significant for satisfaction (p = 0.00042) and self-confidence (p=0.0004). Discussion While Marian University provides access to high-fidelity simulation in the sim lab and students are overall satisfied with their learning experience, screen-based simulation may offer improved opportunity and satisfaction among first-year SRNAs. As students prepare to enter the 25 clinical environment, a vast range of skills and critical thinking is required. All available simulation experiences and modalities should be utilized to maximize student self-confidence and clinical reasoning. This project aimed to employ SBS training in the nurse anesthesia program's didactic year and improve the knowledge and self-confidence of student nurse anesthetists. By utilizing the Simpl patient monitor app within the best-practice standards set by INACSL, first-year SRNAs had the opportunity to improve their cognitive skills, knowledge of case variety, and anesthetic considerations. The students participating in the virtual simulation learning activity reported improved satisfaction and self-confidence compared to the existing simulation curriculum. Overall, SRNAs were already widely satisfied with their simulation education. While the increase in means was significant after the virtual simulation, it is possible that students were unaware of LFS or SBS options available to them, and providing such an opportunity increased their satisfaction in learning. Virtual simulation activities offer additional value to the existing curriculum and are a cost-effective way to improve student engagement and satisfaction. Strengths and Limitations The strengths of this project are ease of participation, marginal costs, applicable technology, and faculty buy-in. The Simpl app is free and designed explicitly for healthcare professional students. Compared to other simulation modalities, the Simpl app is more costeffective and can be accessed anytime from the student's personal computer or smartphone. Faculty may incorporate the software into regular class time and facilitate virtual simulations, as was done in this project. Students may also promote their own learning by utilizing the app in group study settings. The opportunities for extension of this project are many. There is potential to enhance simulation education within Marian University's nurse anesthesia program. Virtual 26 simulation is not currently utilized regularly; therefore, no opposing factors exist. The ability to repeat case studies or scenarios may help to improve cognitive function and knowledge retention. The limitations of this project stem from using a convenience sample of first-year SRNAs at Marian. Due to the sampling method, the results cannot be generalized to all SRNAs. The small sample size for this project also limited the ability to run parametric statistics. Time was an additional limitation for the project. The virtual simulation was implemented in March 2023, and the students were scheduled to begin clinical in May 2023. In retrospect, implementing SBS throughout the entire first year of the program may yield superior outcomes for students. Finally, whoever facilitates the simulation must create the simulations and case scenarios. Creation, presentation, and evaluation of the simulations can be time-consuming. Therefore, successful utilization depends on faculty buy-in. Conclusion In conclusion, this project aimed to enhance the knowledge and self-confidence of firstyear anesthesia students using screen-based simulation. The project design incorporated a quality improvement initiative within a graduate-level education context, focusing on integrating patient monitor simulation software to augment existing learning objectives. The implementation of the SBS took place during the Spring 2023 semester, involving first-year SRNAs at Marian University. The methodology employed a well-structured approach, which involved developing and approving simulation scenarios, utilizing the Simpl app for case presentations, and administering a modified Student Satisfaction and Self-Confidence in Learning tool for data collection. The study measured student satisfaction and self-confidence before and after the virtual simulation 27 activities, using Likert scale questions and descriptive statistical analysis. Ethical considerations were appropriately addressed through Institutional Review Board approval, ensuring the privacy and anonymity of student data. The study's limitations included a relatively small sample size, time limitations, and lack of generalizability to all SRNAs. The results of the project indicated that the virtual simulation activity using the Simpl app was positively received by the participating students. Both pre-test and post-test surveys demonstrated a high level of agreement among students, with the post-test survey revealing increased satisfaction and confidence in their learning experience. The narrow proximity between mean, median, and mode values in the post-test survey demonstrates the consistent positive response from the students. While the standard deviation and variance values were somewhat higher in the post-test, indicating slightly greater response dispersion, the overall trend of enhanced satisfaction and confidence remained clear. This project's successful implementation of SBS as a supplemental educational strategy highlights its potential to effectively enhance student learning and confidence in anesthesia education. The positive outcomes observed in this study contribute to the broader discourse on innovative approaches to medical education and hold promise for the continued evolution of pedagogical methods in healthcare disciplines. Further research with larger and more diverse samples could provide deeper insights into the efficacy of SBS in various educational settings, ultimately advancing the quality of healthcare education and training. 28 References Al-Elq, A. H. (2010). Simulation-based medical teaching and learning. Journal of Family and Community Medicine, 17(1), 35-40. https://doi.org/10.4103/1319-1683.68787 Cannon-Bowers J. A. (2008). Recent advances in scenario-based training for medical education. Current Opinion in Anaesthesiology, 21(6), 784789. https://doi.org/10.1097/ACO.0b013e3283184435 Chopra, V., Gesink, B. J., de Jong, J., Bovill, J. G., Spierdijk, J., & Brand, R. (1994). Does training on an anaesthesia simulator lead to improvement in performance?. British Journal of Anaesthesia, 73(3), 293297. https://doi.org/10.1093/bja/73.3.293 Erlinger, L. R., Bartlett, A., & Perez, A. (2019). High-fidelity mannequin simulation versus virtual simulation for recognition of critical events by student registered nurse anesthetists. AANA Journal, 87(2), 105109. Retrieved from https://www.aana.com/docs/default-source/aana-journal-web-documents-1/high-fidelitymannequin-simulation-versus-virtual-simulation-for-recognition-of-critical-events-bystudent-registered-nurse-anesthetists-april-2019.pdf?sfvrsn=39513ada_6 Fragapane, L., Li, W., Khallouq, B., Cheng, Z. J., & Harris, D. M. (2018). Comparison of knowledge retention between high-fidelity patient simulation and read-only participants in undergraduate biomedical science education. Advances in Physiology Education, 42(4), 599604. https://doi.org/10.1152/advan.00091.2018 Gordon, J. A., Oriol, N. E., & Cooper, J. B. (2004). Bringing good teaching cases "to life": A simulator-based medical education service. Academic Medicine : Journal of the 29 Association of American Medical Colleges, 79(1), 2327. https://doi.org/10.1097/00001888-200401000-00007 Hayden, J., Smiley, R., Alexander, M., Kardong-Edgren, S., & Jeffries, P. (2014). The NCSBN national simulation study: A longitudinal, randomized controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation, 5(2). https://doi.org/10.1016/S2155-8256(15)30062-4 Healthcare Simulation Standards of Best Practice. (2016). Retrieved October 18, 2022, from https://www.inacsl.org/healthcare-simulation-standards INACSL Standards Committee, Hallmark, B., Brown, M., Peterson, D., Fey, M., Decker, S., Wells-Beede, E., Britt, T., Hardie, L., Shum, C., Arantes, H., Charnetski, M., & Morse, C. (2021). Healthcare simulation standards of best practice: Professional development. Clinical Simulation in Nursing, https://doi.org/10.1016/j.ecns.2021.08.007. Jeffries P. R. (2005). A framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nursing Education Perspectives, 26(2), 96103. Kim, J., Park, J. H., & Shin, S. (2016). Effectiveness of simulation-based nursing education depending on fidelity: Ameta-analysis. BMC Medical Education, 16, 152. https://doi.org/10.1186/s12909-016-0672-7 Laschinger, S., Medves, J., Pulling, C., McGraw, R., Waytuck, B., Harrison, M. B. & Gambeta, K. (2008). Effectiveness of simulation on health profession students' knowledge, skills, confidence and satisfaction. International Journal of Evidence-Based Healthcare, 6 (3), 278-302. https://doi.org/10.1111/j.1744-1609.2008.00108.x 30 Liaw, S. Y., Chan, S. W., Chen, F. G., Hooi, S. C., & Siau, C. (2014). Comparison of virtual patient simulation with mannequin-based simulation for improving clinical performances in assessing and managing clinical deterioration: Randomized controlled trial. Journal of Medical Internet Research, 16(9), 214. https://doi.org/10.2196/jmir.3322 Maran, N. J., & Glavin, R. J. (2003). Low- to high-fidelity simulation - a continuum of medical education?. Medical Education, 37(1), 2228. https://doi.org/10.1046/j.13652923.37.s1.9.x Massoth, C., Rder, H., Ohlenburg, H., Hessler, M., Zarbock, A., Ppping, D. M., & Wenk, M. (2019). High-fidelity is not superior to low-fidelity simulation but leads to overconfidence in medical students. BMC Medical Education, 19(1), 29. https://doi.org/10.1186/s12909-019-1464-7 Nyssen, A. S., Larbuisson, R., Janssens, M., Pendeville, P., & Mayn, A. (2002). A comparison of the training value of two types of anesthesia simulators: Computer screen-based and mannequin-based simulators. Anesthesia and Analgesia, 94(6),. https://doi.org/10.1097/00000539-200206000-00035 Okuda, Y., Bryson, E. O., DeMaria, S., Jr, Jacobson, L., Quinones, J., Shen, B., & Levine, A. I. (2009). The utility of simulation in medical education: What is the evidence?. The Mount Sinai Journal of Medicine, New York, 76(4), 330343. https://doi.org/10.1002/msj.20127 Pecka, S. L., Kotcherlakota, S., & Berger, A. M. (2014). Community of inquiry model: Advancing distance learning in nurse anesthesia education. AANA Journal, 82(3), 212 218. Retrieved from https://www.aana.com/docs/default-source/aana-journal-webdocuments-1/community-inquiry-0614-p212-218.pdf?sfvrsn=f4d848b1_8 31 Persico, L., Belle, A., DiGregorio, H., Wilson-Keates, B., & Shelton, C. (2021, September). Healthcare Simulation Standards of Best Practice Facilitation. Clinical Simulation in Nursing, 58, 2226. https://doi.org/10.1016/j.ecns.2021.08.010 Schwid, H. A., Rooke, G. A., Michalowski, P., & Ross, B. K. (2001). Screen-based anesthesia simulation with debriefing improves performance in a mannequin-based anesthesia simulator. Teaching and Learning in Medicine, 13(2), 9296. https://doi.org/10.1207/S15328015TLM1302_4 Swerdlow, B., Soelberg, J., & Osborne-Smith, L. (2020). Distance education in anesthesia using screen-based simulation - A brief integrative review. Advances in Medical Education and Practice, 11, 563567. https://doi.org/10.2147/AMEP.S266469 Wiggins, L., Morrison, S., Lutz, C., & O'Donnell, J. (2018). Using evidence-based best practices of simulation, checklists, deliberate practice, and debriefing to develop and improve a regional anesthesia training course. AANA Journal, 82(2), 119126. Retrieved from https://www.aana.com/docs/default-source/aana-journal-web-documents-1/usingevidence-based-best-practices-of-simulation-checklists-deliberate-practice-anddebriefing-to-develop-and-improve-a-regional-anesthesia-training-course-april2018.pdf?sfvrsn=c2505fb1_8 Yunoki, K., & Sakai, T. (2018). The role of simulation training in anesthesiology resident education. Journal of Anesthesia, 32(3), 425433. https://doi.org/10.1007/s00540-0182483-y 32 Appendix A Literature Review Matrix Citation Research Design Purpose / Aim Population / Sample size n=x Major Variables Instruments / Data collection Results (Al-Elq, 2010) Review of literature To demonstrate the value of simulation in undergraduate and postgraduate medical education programs. 40 articles A search of literature between 1990 and 2009 was conducted. PubMed and MEDLINE databases were used. Simulation training provides opportunities to improve students' confidence, competence, and patient safety. To explore simulation design and its influence on simulationbased education and training. N/A No data collected A framework is required for maximum benefit from simulation-based training. These frameworks should include learning objectives, performance measurement, and feedback or remediation. To determine if anesthesia simulation improves performance in recognizing anesthesia emergencies. To compare mannequin- 28 anesthesia students Literature review: Variables were clinical skills gained from simulation training Learning objectives, instruction al strategies, and feedback within simulation design. Choice of treatment and response time for anesthetic crises A scoring scheme was created to evaluate student performance within the simulation. High-fidelity anesthesia simulators do improve performance if used appropriately. Mannequi n-based Time to recognition of Students participating in the high-fidelity mannequin group Level I (Cannon-Bowers, 2008) Expert opinion Level VI (Chopra et al., 1994) Cohort study Level IV (Erlinger et al., 2019) RCT 39 students 33 Level I (Fragapane et al., 2018) Controlled clinical study Level III (Gordon et al., 2004) Case report Level V (Hayden et al., 2014) RCT Level I based simulation and virtual simulation on students' ability to recognize intraoperative myocardial infarction To compare learning outcomes for students participating in high-fidelity simulation or read-only materials. To explore the process of integrating simulation education into existing medical curriculum. To determine if simulation experience could replace clinical hours for undergraduate nursing students simulation vs. virtual simulation , recognitio n time critical event was recorded and analyzed between the two groups. had faster recognition times than the virtual simulation group. Third-year students were faster than second-year students, but this is attributed to more clinical experience. 135 undergraduat e students Highfidelity simulation scenario compared to readonly material Student performance was equal between intervention and control groups. Highfidelity simulation may not be superior to other methods. N/A N/A A series of quizzes to assess mastery of learning objectives were given to each group. Statistical analysis was performed. No data was collected The Creighton Competency Evaluation Instrument (CCEI), the New Graduate Nurse Performance Survey (NGNPS), and the Global Assessment of Clinical Competency There were no statistically significant differences in parameters of clinical competency, nursing knowledge, critical thinking, or readiness for practice between groups. Article was written about the simulation program at Havard Medical School. 666 students Students who had traditional clinical experienc e vs. students who had clinical hours replaced by simulation The article reports how Harvard Medical School implemented a simulationbased education program into their curriculum. The authors pose it as an example for how to approach simulation in healthcare education. 34 -based education (Kim et al., 2016) Meta analysis Level I (Laschinger et al., 2008) Metaanalysis Level I (Liaw et al., 2014) RCT Level I To determine the effectiveness of simulation-based education in nursing, and to compare the effect sizes between low and high-fidelity simulators. 40 studies included Highfidelity vs. low fidelity simulators To review best evidence on simulation-based training in health professions education. 23 studies included Anatomica l models either wholebody or part-body, with or without computer support. To compare mannequinbased simulation with virtual simulation effects on students' ability to recognize clinical deterioration 57 students Mannequi n-based simulation vs. virtual simulation and Readiness for Practice were the instruments used to assess student success. Fidelity level was coded and analyzed using Comprehensive Meta-Analysis software. Effect sizes on psychomotor, cognitive, and affective ability were calculated. Two independent reviewers extracted information from each paper. The Joanna Briggs Extraction tool was used for consistency. Post-tests immediately following each simulation and again 2.5 months after the simulation were completed High-fidelity simulation has a large effect size for psychomotor skills. However, the effect of simulation-based education was not proportional to fidelity level. Simulation training is a useful adjunct for clinical practice, but cannot replace clinical experience. Simulation experience may not translate into real-world skills. Virtual simulation and mannequin-based simulation were rated positively. There was no statistically significant difference in post-test scores. Both styles of simulation were effective in achieving the set learning outcomes. 35 (Maran & Glavin, 2003) Expert opinion Level VI (Massoth et al., 2019) RCT Level I (Nyssen et al., 2002) Comparis on Study Level IV (Okuda et al., 2009) Review of literature Level I (Pecka et al., 2014) Expert Opinion Level IV To discuss the use of different levels of simulation fidelity and modality in education.. N/A N/A No data was collected To evaluate the response to low fidelity vs high fidelity simulation and effect on confidence 135 medical students Highfidelity vs. low-fidelity simulation s To compare computer-based and mannequinbased simulators and the effect on learning outcomes for anesthesia residents 40 students To determine what evidence exists in favor of simulation training in medical education. To propose the use of the Community of Inquiry Model to 113 articles Computerbased vs. mannequi n simulators , treatment scores and diagnosis times Simulation training vs. standard training A 20-item multiple choice assessment and an 8-item Likert scale assessment were given pre and post participation in the simulation. A scoring tool was used to assess student performance and time to diagnosis. N/A N/A Many different types of simulators exist, and each has benefits and drawbacks. Levels of fidelity may serve to enhance cognitive ability or psychomotor skills. All levels of fidelity have value in education. High-fidelity simulation provided no advantage in learning compared to lowfidelity simulation. Highfidelity simulation overinflated self-confidence in the students' ability and knowledge. Screen-based simulators are useful in acquiring technical skills of patient management. The decision to use screenbased simulation or mannequin-based simulation should depend on cost and learning objectives. No data was collected Simulation improves knowledge, communication, teamwork, and performance compared to standard education. No data was collected The COI model serves as a framework to guide, evaluate, and research distance 36 (Schwid et al., 2001) RCT Level I (Swerdlow et al., 2020) Review of literature Level I (Wiggins et al., 2018) Quality Improvem ent Project Level IV (Yunoki & Sakai, 2018) Review of literature Level I evaluate distance learning strategies in nurse anesthesia education. To measure the effect of screenbased simulation on student response to critical events. To explore the evidence on screen-based simulation and how it may be utilized in anesthesia programs To determine the effectiveness of a regional anesthesia training course on improving knowledge, skill, and confidence in regional anesthesia administration To summarize the status of simulation education in anesthesia training, encourage more providers to get involved with learning techniques in nurse anesthesia programs. 31 anesthesia residents Screenbased simulation vs. traditional education Screenbased simulation vs. mannequi n-based simulators A quantitative scoring system was created to evaluate student responses 49 CRNAs Screenbased training and hands on experienc e Pre-test and post-test surveys were used to collect data on confidence levels 95 articles N/A No data was collected 150 articles No data was collected Simulation training proved to be more effective than written material. Students scored higher on evaluation in the screen-based simulation group. SBS is a viable and effective modality for anesthesia training programs. SBS offers unique advantages in comparison to mannequinbased simulation that may be especially useful for distance learning. Confidence levels and comfort with regional anesthesia improved after participation in the course Simulation has been effective in many aspects of anesthesia practice including airway management, regional, obstetric, and cardiac. Still, the optimal use of simulation in anesthesia education is unclear. 37 simulation education, and stimulate future research 38 Appendix B 39 Appendix C Modified NLN Tool Instructions: This questionnaire is a series of statements about your personal attitudes about the instruction you receive during your simulation activity. Each item represents a statement about your attitude toward your satisfaction with learning and self-confidence in obtaining the instruction you need. There are no right or wrong answers. You will probably agree with some statements and disagree with others. Please indicate your own personal feelings about each statement below by marking the numbers that best describe your attitude or beliefs. Please be truthful and describe your attitude as it really is, not what you would like for it to be. This is anonymous with the results being compiled as a group, not individually. Mark: 1 = STRONGLY DISAGREE with the statement 2 = DISAGREE with the statement 3 = UNDECIDED - you neither agree or disagree with the statement 4 = AGREE with the statement 5 = STRONGLY AGREE with the statement 40 National League for Nursing. (2005). Student Satisfaction and Self-confidence in Learning . Modified for purposes of this DNP project. 41 Appendix D 42 Appendix E Virtual Simulation Scenarios Your patient was recently induced followed by successful intubation of the trachea with an endotracheal tube. Based on the vital signs, which of the following would be the most appropriate intervention? A. Ephedrine 10 mg IV B. Epinephrine 10 mcg IV C. Phenylephrine 100 mcg IV D. Esmolol 50 mg IV Instructor scenario: Tachycardia, hypotension, decreased EtCO2 You successfully placed a spinal anesthetic for a patient undergoing cesarean delivery. Based on the vital signs, which of the following would be the most appropriate intervention? A. Ephedrine 10 mg IV B. Epinephrine 10 mcg IV C. Phenylephrine 100 mcg IV D. Esmolol 50 mg IV Instructor scenario: Bradycardia, hypotension, decreased EtCO2 The surgeon is conducting pneumoperitoneum for a laparoscopic cholecystectomy. Based on the vital signs, which of the following would be the most appropriate intervention? A. Labetalol 5 mg IV B. Nitroglycerin 50 mcg IV C. Hydralazine 10 mg IV D. Esmolol 50 mg IV Instructor scenario: Tachycardia, hypertension The surgeon is conducting pneumoperitoneum for a laparoscopic cholecystectomy. Based on the vital signs, which of the following would be the most appropriate initial intervention? A. Atropine 1 mg IV B. Epinephrine 10 mcg IV C. Ephedrine 10 mg IV 43 D. Advise the surgeon to stop and deflate the abdomen Instructor scenario: bradycardia, hypotension Vitals remain similar after deflation of the pneumoperitoneum. Based on the vital signs, which of the following would be the most appropriate pharmacologic intervention? E. Atropine 1 mg IV F. Glycopyrrolate 0.4 mg IV G. Epinephrine 10 mcg IV H. Ephedrine 10 mg IV Instructor scenario: bradycardia, hypotension Youve successfully induced your patient for a total shoulder arthroplasty. After the patient has been positioned, you notice these changes on the monitor. Which of the following is the most appropriate action? A. Phenylephrine 100 mcg IV B. Ephedrine 10 mg IV C. Glycopyrrolate 0.2 mg IV D. Epinephrine 10 mcg IV Instructor scenario: bradycardia, hypotension Which reflex is most likely responsible for the change in vital signs? A. Vasovagal reflex B. Bainbridge reflex C. Bezold-Jarisch reflex D. Baroreceptor reflex Instructor scenario: bradycardia, hypotension The surgeon is performing a craniotomy for tumor removal and has just tightened the Mayfield pins. Which of the following is the most appropriate action? A. Rocuronium 30 mg B. Propofol 50 mg 44 C. Hydromorphone 2 mg D. Titrate the gas to 1.2 MAC Instructor scenario: tachycardia, hypertension, increased respiratory rate During a sitting craniotomy, you notice a sudden change vital signs. What is the first action that should be taken? A. Increase FiO2 to 100% B. Alert the surgeon to flood the field with irrigation C. Call for help D. Auscultate with a precordial doppler Instructor scenario: low EtCO2, hypotension, tachycardia, ST depression Your patient is undergoing a robotic assisted hernia repair. Your preoperative evaluation revealed they are taking methadone, furosemide, and metoprolol. Based on the vital signs, what is the most appropriate action? A. Calcium chloride 1 g IV B. Epinephrine 1 mg IV C. Atropine 0.5 mg IV D. MgSO4 2 g IV Instructor scenario: hypotension, Torsades de Pointes, low EtCO2 45 Appendix F "Jeffries Simulation Model," by P. R. Jeffries, 2005, Nursing Education Perspectives, 26(2), 96103. (https://journals.lww.com/neponline/pages/articleviewer.aspx?year=2005&issue=03000&article= 00009&type=abstract) Copyright 2005 by National League for Nursing Inc.  ...

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BAG MASK VENTILATION 1 Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2024 BAG MASK VENTILATION 2 Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2024 Evidence-Based Bag Mask Ventilation Education in the Simulation Setting Cara Jammes & Miriam Rosenheck Marian University Leighton School of Nursing Chair: Dr. Goez____________ Project Team Members: Dr. Yant____________ Date of Submission: March 31, 2024 BAG MASK VENTILATION 3 Table of Contents Abstract ................................................................................................................................5 Introduction .........................................................................................................................7 Background ....................................................................................................................8 Problem Statement .......................................................................................................10 Organizational Gap Analysis of Project Site ............................................................10 Theoretical Framework/Evidence Based Practice Model/Conceptual Model12 Goals/Objectives/Expected Outcomes ..............................................................................11 Review of the Literature.15 Project Design/Methods 18 Project Site and Population ..........................................................................................20 Measurement Instrument(s) ........................................................................................22 Data Collection Procedure ..........................................................................................22 Ethical Considerations/Protection of Human Subjects ...23 Data Analysis and Results.24 Conclusion ........................................................................................................................25 References ..........................................................................................................................27 Appendices (Listed sequentially in order they appear in paper).31 Appendix A ..................................................................................................................31 Appendix B ..................................................................................................................32 Appendix C ..................................................................................................................33 Appendix D ..................................................................................................................34 Appendix E ..................................................................................................................35 BAG MASK VENTILATION Appendix F...................................................................................................................37 Appendix G ..................................................................................................................38 Appendix H ..................................................................................................................39 4 BAG MASK VENTILATION 5 Abstract Background and Review of Literature: Bag-mask ventilation (BMV) is a critical skill in the perioperative setting and is difficult to master for student registered nurse anesthetists (SRNAs). BMV has been shown to be the superior method of adequately pre-oxygenating patients prior to securing an airway. There is a growing body of evidence that all anesthesia providers including CRNAs, resident physicians, and attending physicians have lower levels of confidence with this skill in comparison to other, more invasive skills. Additionally, most providers prefer having access to annual BMV courses to refresh themselves on the latest BMV guidelines. Purpose: This study assessed changes in first year SRNA competence, knowledge, satisfaction, and confidence levels with BMV after implementing a BMV refresher simulation session prior to beginning clinical rotations. Methods: A systematic review of the literature was conducted using bag mask ventilation or bag valve mask. Inclusion criteria included text available in English, articles less than 5 years old, BMV as an intervention, and ventilation as an assessment. Exclusion criteria were laryngeal mask ventilation, passive oxygen insufflation, pilot studies, and unrelated research purposes. This resulted in 14 articles. The Marian University Internal Review Board (IRB) approval was obtained prior to initiating the DNP Project. First year SRNAs at Marian University Leighton School of Nursing were given a survey to assess their knowledge and confidence surrounding BMV prior to, and after attending a simulation session hosted by upper level SRNAs. The simulation session focused on the latest evidence based BMV techniques as well as indications to perform BMV and troubleshooting for patients who are difficult to ventilate. Paired t-tests were employed to compare pre and posttest scores. BAG MASK VENTILATION 6 Implementation Plan/Procedure: This prospective cohort study and systematic review assesses whether implementation of a hands on, evidence based BMV refresher course, in the simulation setting, improves first-year SRNA knowledge, satisfaction, confidence, and competence regarding BMV. The International Nursing Association of Clinical Simulation Learning (INASCL) standards of simulation education were upheld. Surveys were given prior to and after the simulation sessions on Qualtrics. Data was exported to Excel where statistical analysis was done. Implications/Conclusions: Eight first year SRNAs participated in the BMV simulation and completed the pre and posttests. There was a statistically significant improvement in SRNA confidence (p = 0.0084) and knowledge (p = 0.00058). This study underscores the importance of implementing BMV refresher courses to SRNAs. Additionally, this intervention should be considered by other anesthesia providers to increase confidence, knowledge, and competence surrounding BMV. BAG MASK VENTILATION 7 Evidence-Based Bag Mask Ventilation Education in the Simulation Setting Introduction 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, Nurse Anesthesia track. Effective bag-mask ventilation (BMV) is a critical skill in the peri-operative setting, providing adequate oxygenation upon induction for intubation, as well as providing adequate ventilation and airway management during times of crises. BMV is often a difficult skill to master among student registered nurse anesthetists (SRNAs) and novice anesthesia providers, accentuating the crucial need for proficient BMV education and mastery. Anesthesia providers provide BMV among individuals undergoing tracheal intubation to prevent severe hypoxemia and provide stability for ventilation in times of crises and implementing the latest evidence-based practice in BMV simulation can improve SRNA knowledge base and clinical skills. The purpose of this project was to implement the latest evidence based BMV practice in the simulation setting prior to first years entering the clinical environment, and then assess SRNA knowledge, satisfaction, and confidence levels pre and post-simulation. By implementing a BMV refresher course prior to clinical, we measured SRNA knowledge improvement and satisfaction due to said intervention. Not only did this intervention measure the effectiveness of evidence based BMV simulation as a refresher course, but this project also educated and prepared SRNAs for airway management success in the clinical setting. Background BAG MASK VENTILATION 8 BMV is a crucial skill in multiple facets of anesthesia care including preventing severe hypoxemia, establishing adequate ventilation when intubation is unsuccessful, and providing resuscitation due to adverse events. The relevance to patient safety illustrates the undeniable need for evidence based BMV education and anesthesia provider proficiency. Establishing effective ventilation in patients prevents severe hypoxemia upon induction. Severe hypoxemia can be defined as oxygen saturations less than 80% (Casey et al., 2019). Studies comparing BMV versus alternative methods upon induction incessantly prove BMV to be superior at providing adequate oxygenation in the perioperative setting (Casey et al., 2019; Semler et al., 2021). In fact, Casey et al. (2019) studied the differences in oxygen saturations among patients receiving BMV between induction and laryngoscopy and those not receiving BMV between induction and laryngoscopy. This study found patients receiving BMV during induction and laryngoscopy had higher oxygen saturations and lower rates of severe hypoxemia (oxygen saturation less than 80%) than those receiving no ventilation (Casey et al., 2019). Hypoxemia not only causes short-term ischemia to the body, but can also lead to cardiac arrest and death (Casey et al., 2019). Benditt (2019) further illustrates the necessity of effective BMV, especially among individuals with neuromuscular disorders as their decreased muscle strength predisposes them to severe hypoxemia and respiratory failure peri-operatively. More specifically, examples of at-risk populations include those with sleep apnea, hypoventilation disorders, muscular dystrophy, kyphoscoliosis, myasthenia gravis, Guillain Barre syndrome, sialorrhea, and ALS (Benditt, 2019). Not only are patients with neuromuscular diseases at risk, but other populations such as cigarette smokers, pediatrics, and obese patients (Dai et al., 2021). Similar to previous studies, Semler et al. (2019) studied the differences in oxygen saturation among patients receiving BMV between induction and laryngoscopy and those receiving apneic BAG MASK VENTILATION 9 oxygenation between induction and therapy. The patients receiving apneic oxygenation (receiving 100% oxygen at 15 L/min via nasal cannula) demonstrated lower oxygenation perioperatively than those receiving BMV (Semler et al., 2019). Multiple studies conclude the ample benefits of effective BMV when utilized during the induction phase of anesthesia. BMV is a fundamental skill learned in anesthesia school and effective ventilation continues to be a difficult skill to master in the field of anesthesia. Despite many educational efforts, this essential airway skill can be difficult to perform effectively, especially among inexperienced providers (Hart et al., 2020). The incidence of cannot intubate cannot ventilate (CICV) is estimated to be 1 in 10,000 cases (Fayed et al., 2022), and sufficient BMV can reduce the incidence of this dire complication. Fayed et al. (2022) assessed confidence levels among anesthesia providers regarding CICV management and found a high lack of experience and confidence in all provider roles (CRNAs, residents, and attendings). This highlights a need for more emergency airway teaching and training. In addition, results from Fayed et al. (2022) survey regarding preferred method of CICV teaching indicate the majority of respondents prefer an annual simulation training as an optimal teaching method. In recent years, new BMV research provides improved methods to adequately ventilate peri-operative patients. For instance, numerous studies have illustrated advantages of E-O hand technique over the E-C technique (Soleimanpour et al., 2018), and other studies have demonstrated the weight of utilizing STOP-bang questionnaire to identify risk factors for difficult BMV (Khan & Ahmed, 2021). The traditional E-C BMV technique includes forming a C with the index finger and thumb and applying downward pressure, while simultaneously creating an E with the third, fourth and fifth fingers, lifting the mandible upwards (Soleimannpour et al., 2018). The E-O technique involves placing the first and second fingers in BAG MASK VENTILATION 10 an O position around the mask entrance hole and the third, fourth, and fifth fingers placed surrounding the chin and mandible while simulating the same downward pressure and lifting of the jaw (Soleimanpour et al., 2018). The two-handed thenar eminence techniquein which the thenar eminences at the base of the thumbs press the mask to the face, while the other four fingers surround the mandible to lift the jawhas also shown to be more effective than E-C technique. However, data supports E-O technique to be superior compared to the other two (Soleimanpour et al., 2018). Furthermore, latest research has provided techniques for managing these difficult to ventilate patients, such as utilizing gel among bearded patients (Saqer et al., 2020). BMV research within the past five years guides practitioners to implement safe evidencebased practice. Problem Statement Despite efforts to teach proper BMV technique, new providers still require more robust teaching, as evidenced by (Fayed et al., 2022). Fayed et al. also shows that anesthesia providers are most receptive to in-person simulation workshops to learn and reinforce skills. The problem statement in PICOT format is: Does implementation of an evidence-based bag mask ventilation refresher course, in the simulation setting, improve SRNA knowledge, satisfaction, and selfconfidence, from pretest to posttest? Therefore, first-year Marian University SRNAs participated in a hands-on simulation workshop demonstrating the newest evidence-based techniques for providing effective bag-mask ventilation. Needs Assessment & Gap Analysis There is a need for more robust education in terms of BMV administration especially among new anesthesia providers, as evidenced by Fayed et al. 2022. Since this study took place at Henry Ford Hospital in Detroit Michigan, a large Midwest hospital, its findings are likely BAG MASK VENTILATION 11 generalizable to Marian University affiliate hospitals. This study showed that young anesthesia providers need more education when it comes to ventilation of difficult airways. Additionally, this study found that providers are most amenable to annual in-person simulation workshops. By instituting this adjunct pre-clinical workshop at Marian University, it will close the gap in knowledge, experience, and confidence among new anesthesia providers. Furthermore, recent evaluation has shown that Marian University offers a limited scope when teaching BMV techniques. Deficits include the evidence based, most effective BMV technique for inexperienced anesthesia providers, the E-O technique (Soleimanpour et al., 2018). Currently, at Marian University, educational standards of the bag mask ventilation skill include a shared simulation session among a small group of learners. About a week later, the skill is then checked by the simulation instructor, ensuring hand placement and adequate tidal volumes delivered for the manikin. This is helpful for foundational knowledge, and one can anticipate that fine-tuning techniques for application to real patient scenarios will be beneficial for students entering the clinical environment. The goal is for first year SRNAs to gain competency at all hand placements, including the E-O technique, two-handed thenar eminence technique, and mastery of STOP-bang under the close guidance of more experienced SRNAs. Project Aims and Objectives This projects aim was to educate pre-clinical Marian SRNAs how to effectively bagmask ventilate utilizing the latest evidence-based practice The hope was to improve SRNA knowledge, satisfaction, and confidence scores from pretest to posttest BAG MASK VENTILATION 12 Theoretical Framework Jeffries Simulation Theory The theoretical framework utilized to guide our project includes the Jeffries Simulation Theory developed by Pamela R. Jeffries, as displayed in Appendix A (Jeffries et al., 2015). This theory recognizes the significant research available supporting the efficacy of simulation-based education. The six core elements in this theory include context, background, design, educational practices, simulation experience, and outcomes (Jeffries et al., 2015). The background especially highlights the need for identifying learning expectation, overarching goals for the simulation, needed resources for simulation, and how this simulation supports the curriculum (Jeffries et al., 2015). In fact, implementing these strategies leads to improved patient outcomes, reduced cost, and improved processes within systems (Jeffries et al., 2015). Theory Guidance Jeffries Simulation Theory guided our project by identifying successful strategies to implement education in the clinical setting as well as methods to evaluate learned skills. For instance, Jeffries theory states commencing from an environment of trust on parts of both the facilitator and learner translates to being interactive, learner centric, experiential, and collaborative (Jeffries et al., 2015). In addition, steps of the simulation experience include having a pre-brief, simulation progression, cues, and debriefing (Jeffries et al., 2015). This theory is designed to promote favorable educational interventions by understanding factors influencing SRNA clinical behavior. For example, Jeffries theory provides guidance to promote a favorable bag mask ventilation simulation by including the following simulation design: Simulation should include specific learning objectives, desired fidelity, learner role assignments, simulation flow, and strategies for pre-briefing/debriefing (Jeffries et al., 2015). Creating, implementing, and BAG MASK VENTILATION 13 evaluating interventions influenced by Jeffries Simulation Theory provided insightful information regarding effectiveness of simulation and evidence-based bag mask ventilation education. SWOT Analysis SWOT stands for strengths, weaknesses, opportunities, and threats (Moran et al., 2019). See APPENDIX C for SWOT Analysis graphic. Strengths and weaknesses are intrinsic factors. The intrinsic strengths related to this project include having a reliable and valued team member to co-navigate this project, as well as being able to carry out this intervention in a familiar environmentin the simulated OR at Marian University. Technology and ease of data collection can be seen as a strength. However, technology can potentially land in the threats category as well, since all data stored in technology is at risk for being hacked, altered, and inaccessible. Anticipated intrinsic weaknesses involving this study are related to participation and ensuring adequate student involvement. Since there will likely not be a monetary or grade incentive to participate, busy students may not want to involve themselves in a time-consuming task. Unfamiliarity with Qualtrics could perhaps be a weakness as well. Opportunities to benefit the project would be if the teachers granted incentive to students for taking time to participate in the DNP projects. Additionally, there could be a change to the clinical environment to benefit the project and outcomes of patients. Threats, like opportunities, are external factors. The processes of the study, regarding a comparison of pretest vs. posttest knowledge results, requires the student to have internet and device access, which all these students have. However, a future change in access to devices and internet could truncate opportunity and threaten students ability to participate in the data collection. This external factor, along with environmental changes related to school simulation access, are situations in which there would be a negative impact on BAG MASK VENTILATION 14 project data and implementation. Potential threats to our project could have been a lack of participation from students, students not receiving the survey, or an issue with the Qualtrics website; if there is an update that wipes all the data and surveys. A contingency plan is in play: all surveys and resulting data will be saved on an alternative medium so that a crash or wipe of Qualtrics software would not be detrimental or cause us data loss. Additionally, encouragement of checking spam and junk email folders could fix the issue of students not receiving the survey. If necessary, the surveys will be filled out on paper. Another potential threat to the project was if the new methods of bag masking become standard in sim education, prior to conducting the project. In addition, the equipment must be readily available and in working function for proper project implementation. Lastly, a threat to the project could have been related to our school stakeholder no longer approving the conduction of this project or granting us simulation lab access. Search Methodology The search for pertinent sources regarding effective bag-mask ventilation was conducted September and October of 2022 utilizing PubMed database. The keywords and BOOLEAN phrases that were entered into PubMed include bag mask ventilation OR bag valve mask ventilation. The initial search resulted in 129 articles. Results older than five years old and not available in English language were filtered, as shown in a PRISMA flow chart (Appendix D). Duplicate articles were removed as well, resulted in 94 identified sources. Inclusion criteria for selected articles included text available in English articles less than 5 years old, bag mask ventilation as an intervention, and ventilation as an assessment. Upon screening the 94 identified articles, 62 results with the following criteria were excluded: laryngeal mask ventilation, passive oxygen insufflation, pilot studies, and unrelated research purposes. Final screening of sources BAG MASK VENTILATION 15 resulted in 13 articles. Additional review of reference lists from one systematic review did identify one additional relevant source, totaling the sources utilized in this literature review to 14. Literature Review Results The literature review search resulted in a final count of 14 relevant articles illustrating main points regarding effective bag mask ventilation. Multiple topics were covered among these articles including the relevance and dire need for effective BMV, key predictors for difficult BMV, and effective BMV strategies. Appendix F exhibits a literature review matrix detailing key points of each article. Relevance of Effective Bag Mask Ventilation Multiple articles accentuate the clinical significance and dire need to implement effective BMV among patients receiving anesthesia (Benditt, 2019; Casey et al., 2019; Fayed et al., 2022; Semler et al., 2021). Casey et al. (2019) especially emphasizes the clinical difference between patients undergoing tracheal intubation receiving bag mask ventilation and patients undergoing tracheal intubation receiving no bag mask ventilation between induction and laryngoscopy. In fact, this randomized controlled study found the difference in lowest oxygen saturation between the bag mask ventilation group and no bag mask ventilation group was an average of 8% (Casey et al., 2019). They also found more participants exhibiting an oxygen saturation of less than 70% in the no bag mask ventilation group (Casey et al., 2019). Similarly, Semler et al. (2019) studied the difference in oxygen saturations among patients receiving apneic oxygenation and patients receiving bag mask ventilation. This study found apneic oxygenation prior to intubation does not produce the same results as bag mask ventilation prior to intubation (Semler et al., 2019). More specifically, patients receiving apneic preoxygenation had lower arterial oxygen saturations BAG MASK VENTILATION 16 compared to those receiving bag mask ventilation prior to laryngoscopy (Semler et al., 2019). Not only is effective bag mask ventilation essential for patients undergoing surgery, but effective BMV is especially critical for those with neuromuscular diseases (Benditt, 2019). Benditt (2019) illustrates patients with neuromuscular diseases have decreased ventilatory muscle strength, a reduced vital capacity, as well as forced vital capacity (FVC) leading to rapid desaturations upon induction of anesthesia. Fayed et al., (2022) further illustrates the need for effective bag mask ventilation as well as effective bag mask ventilation education, according to his latest research. In Fayeds quasiexperimental study, anesthesia providers (CRNAs, anesthesia residents, and anesthesia attendings) participated in a cannot intubate cannot ventilate scenario (Fayed et al., 2022). Following the scenario, the participants reported a lack of experience and confidence in managing cannot intubate cannot ventilate scenarios (Fayed et al., 2022). This critical piece of information indicates the urgent need for additional training in cannot intubate cannot ventilate scenarios. Key Predictors for Difficult Bag Mask Ventilation Numerous articles highlighted key predictors for effective bag mask ventilation among patients in the surgical setting, citing both pathological indicators as well as physical indicators (Farid & Taman, 2020; Khan & Ahmed, 2021; Sager et al., 2020; Mouri et al., 2022). Regarding physical characteristics, Farid & Taman (2020) mention several physical characteristics predictive of difficult bag mask ventilation and these include: a short thyromental distance, macroglossia, presence of a beard, lack of teeth, and snoring. Sager et al. (2022) also lists beard and lack of teeth as predictors, as well as obese body habitus, and an increased neck circumference. Two other studies mention disease states associated with difficult bag mask BAG MASK VENTILATION 17 ventilation and those include asthma, pneumonia, chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea (OSA) (Farid & Taman, 2020; Khan & Ahmed, 2021). Effective Bag Mask Ventilation Strategies Numerous studies have been conducted illustrating effective bag mask ventilation strategies including specific hand positioning, addition of positive end expiratory pressure (PEEP), medications, and supplemental devices (Farid & Taman, 2020; Sager et al., 2020; Soleimanpour et al., 2018; Otten et al., 2019; Zweiker et al., 2018; Dai et al., 2021; Uhm & Kim, 2021; Benditt, 2019). Soleimanpour et al. (2019) compared the difference between E-C technique and O-C technique during bag mask ventilation. This study found that among novice providers, there was a significant difference in tidal volume between the E-C and O-C technique (P < 0.0001), meaning novices provided better bag mask ventilation utilizing the O-C technique compared to the traditional E-C technique (Soleimanpour et al., 2019). Also addressing hand placement, Otten et al., (2019) compared the two hand ventilation to one hand ventilation technique and found the two handed technique produced the greatest tidal volume among patients. Applying hand placement among pediatrics, Zweiker et al. (2018) also found the use of five fingers produced greater tidal volume delivery than the tradition two finger hold during bag mask ventilation. Three studies emphasized the implementation of PEEP to provide adequate bag mask ventilation (Farid & Taman, 2020; Dai et al., 2021; Uhm & Kim, 2021). In Dai et al.s randomized double-blind trial, the addition of PEEP during bag mask ventilation improved oxygen reserve and enhanced oxygenation among patients with hypoxia compared to patients receiving bag mask ventilation alone. Uhm & Kim (2021) found similar results stating positive pressure during bag mask ventilation is directly proportional to administered tidal volumes. In BAG MASK VENTILATION 18 fact, low positive pressures were associated with suboptimal tidal volumes (321 mL) and an average between 10-20 cm H2O resulted in adequate tidal volumes. On the contrary, positive pressures greater than 20 cm H2O resulted in adverse effects such as gastric insufflation and positive pressures greater than 40 cm H2O are associated with higher hospital mortality (Uhm & Kim, 2021). Finally, numerous studies found additional medical adjuncts to improve bag mask ventilation among patients. For example, Farid & Taman (2020) found sevoflurane to facilitate bag mask ventilation and provide better intubation conditions in comparison to propofol inductions. Additionally, among patients with beards, Sager et al. (2020) found gel applied to masks to significantly improve tidal volumes during bag mask ventilation. More specifically, mean tidal volumes during bag mask ventilation with gel was an average 467 mL, and mean tidal volumes during bag mask ventilation without gel was an average 283 mL (Sager et al., 2020). Sager et al. (2020) also mentions the implementation of airway devices (lubricated nasal airway for example) is advantageous among difficult bag mask ventilation. Lastly, Benditt (2019) mentions the application of a chin strap to provide the most effective seal during bag mask ventilation. Project Design/Methods Project Design The project design we implemented was an educational intervention among SRNAs at Marian University. This educational intervention included implementing the latest evidencebased research regarding bag mask ventilation in the simulation setting. The latest research included the E-O hand technique, two-handed thenar eminence technique, application of PEEP, BAG MASK VENTILATION 19 application of gel among bearded patients, utilization of mask straps for providers with small hands, implementation of oral/nasal airways among OSA patients, and the use of two handed bag mask ventilation among hard to ventilate patients. In addition, students were presented with key indicators for difficult bag mask ventilation. Key indicators for difficult bag mask include both physical characteristics and pathological diseases. Physical characteristics include a short thyromental distance, macroglossia, presence of a beard, edentulousness, snoring, obesity, and increased neck circumference. Pathological diseases include asthma, pneumonia, COPD, and OSA. Methods used to obtain data for the project included a pre-test and post test to compare knowledge before versus after the educational intervention. Knowledge questions were written, presented to committee to validate by content and face, and delivered to participants via Qualtrics surveying software. Quantitative methods were analyzed by way of descriptive statistics: mean, standard deviation, and frequency tables. Measurement methods from the National League for Nursing (NLN) tools for simulation activity, have two subsets for evaluation: satisfaction and self-confidence (Jeffries et al., 2015). These categories were assessed via Likert scale. This assessed the SRNAs confidence and satisfaction level of BMV presimulation and post-simulation. NLN tools are reliable and valid evaluation techniques. Reliability of the tools were tested using Cronbachs alpha, a measurement of reliability of a research instrument (Taber, 2018). Reliability of the satisfaction tool is 0.94, and reliability of the self-confidence tool is 0.87. See evaluation tool in Appendix E. Implementation of surveying and educating first-year students on BMV techniques occurred prior to their first clinical rotation. Moreover, the International Nursing Association of Clinical Simulation Learning (INASCL) standards of simulation education were upheld as they BAG MASK VENTILATION 20 fostered development and assisted in progression towards achieving objectives (McMahon et al., 2021). After the academic year of 2023 to 2024 concludes, the students manning this project will have graduated. The hope was for students and faculty to continue this educational simulation during the pre-clinical orientation week, prior to students embarking on their clinical component of the curriculum. As new evidence-based techniques come to light, this educational intervention may be adjusted. Population and Setting The setting of the project took place at Marian University in the simulation center. The necessary resources for the project included the simulation manikin and a bag masking device. The adjunct resources for the project included an oral and nasal airway, chin strap, and gel. The university stakeholder, represented by faculty, played a role requiring us to coordinate accordingly to use school resources. The student participants played the role of providing data to conduct the project; participation in the pretest, posttest, and education, were all required of the student participants. Inclusion criteria were as follows: first-year student of Marian Universitys CRNA program and in the didactic segment of the curriculum prior to clinical. Exclusion criteria: second or third-year student of Marian Universitys CRNA program, has experienced the clinical environment, and Marian University student outside the CRNA program. The project site was organized as the simulation center is already functioning prior to the start of this study. The simulation area of the school was located on the second floor of the health sciences building and the simulation chair was our contact for site personnel. If need be, other faculty had the ability to unlock the simulation center door and provide access. The hope was to BAG MASK VENTILATION 21 integrate this skill seamlessly into the first-year curriculum so that its maximally beneficial for the students, as well as for the project data collection. Resources and facilitators of this project were as mentioned above. Constraints and barriers that could have influenced the implementation of this DNP project were potential difficulty coordinating time in the simulation lab, technology and access to the pretest and posttest, as well as participation turn out of the first-year student body. The plan to overcome these barriers was to assist those needing help with the technology, utilize a surveying method that students are comfortable with, be well-organized and accessible in planning simulation, and communicate with first-year students to learn how to best supplement their curriculum. The plan of the project was to have the first-year participants fill out a qualitative pre-test about effective bag-mask ventilation strategies, to assess baseline knowledge. The educational intervention component was conducted after the pre-test. This educational intervention included implementing the latest evidence-based research regarding bag mask ventilation in the simulation setting. This included the E-O hand technique, two-handed thenar eminence technique, utilizing PEEP, gel among bearded patients, mask straps for providers with small hands, oral/nasal airways among OSA patients, and the use of two-handed bag mask ventilation among hard to ventilate patients. These methods were demonstrated and practiced. Additionally, students were presented with key indicators for difficult bag mask ventilation. After the educational intervention, the posttest was conducted. Results of pretest and posttest were compared and analyzed. The hypothesis and hope was that posttest results showed improved results compared to pretest results. BAG MASK VENTILATION 22 Measurement Instruments In order to measure and evaluate the outcomes and educational efficacy of this DNP project, a comparison of pretest and posttest results were conducted on the same day. The pretest results were obtained prior to the educational intervention, and the posttest results were obtained immediately following the educational intervention. These pretests and posttests were delivered via Qualtrics software online. Data will be saved for a minimum of two years, and a maximum of five years. To compare the pretest and posttest systematically, students were instructed to list the last four digits of their student ID number on the pretest and posttest. To maintain confidentiality, the surveyors had no way of identifying students with pre and post tests. Data Collection Procedures All steps of the project were planned, completed, checked, and acted upon, as is noted in the PDCA (Plan Do Check Act) framework (Isniah et al., 2020). The chronology of events were as listed above: the first-year participants fill out a qualitative pre-test about effective bag-mask ventilation strategies, to assess baseline knowledge. The educational intervention component was conducted after the pre-test. This educational intervention included implementing the latest evidence-based research regarding bag mask ventilation in the simulation setting. This included the E-O hand technique, two-handed thenar eminence technique, utilizing PEEP, gel among bearded patients, chin straps for providers with small hands, oral/nasal airways among OSA patients, and the use of two-handed bag mask ventilation among hard to ventilate patients. These methods were demonstrated and practiced. After the educational intervention, the qualitative posttest was then be conducted. NLN self-confidence and satisfaction surveys were also conducted by the student participants. The projected recruitment was done by the two students conducting the project by way of emailing and reaching out to first-years in a multimodal BAG MASK VENTILATION 23 fashion. The data was then synthesized. The steps in actualizing the intervention was as mentioned, in a pre-clinical seminar for first-year students, and the evaluation was a comparison of pretest and posttest surveys via Qualtrics website software. Ethical Considerations The Marian University Internal Review Board (IRB) approval was obtained prior to initiating the DNP Project. The official IRB Determination Form was submitted as soon as the proposal was approved. Thereafter, informed consents were drafted for participants. The Family Educational Rights and Privacy Act (FERPA) is a Federal law that protects the privacy of student education records (US Department of Education, 2021). Its ensured that participating students, along with their results, was protected. Their pretest and posttest results were not identifiable to person. A unique ID number was used, consistent with both pretest and posttest in order to compare results. However, project coordinators and anyone synthesizing data were not able to associate names and test results. All information collected as part of evaluating the impact of this project was aggregated data from the project participants and did not include student identifiers. Participant confidentiality was assured by coding the participants using their randomly assigned individual identification numbers. The results of the pretest and posttest were only accessible to the project coordinators, and was password protected. To comply with the rights and welfare of participating research subjects, our project was submitted and then approved by the Institutional Review Board (IRB) at Marian University. Project Evaluation Plan The ability to evaluate efficacy of the project depended on statistical tests analysis methods. This was crucial for trustworthiness, credibility, dependability, confirmability, and transferability of results. Data synthesis was carried out by way of a paired t-test, comparing the BAG MASK VENTILATION 24 two populations of pretest versus posttest knowledge. Descriptive statistics such as mean, standard deviation, and frequency tables, was analyzed to support efficacy of project. A t-test also compared the means of two samples. The p value in a t-test indicated the statistical significance of data (Greenland et al., 2016). The Likert scale NLN questionnaire on simulation satisfaction and self-confidence of student participants also synthesized by way of descriptive statistics. Data Analysis and Results Surveys in the form of pretest and posttest (Appendices D and E) were made available to the DNP students participating in the BMV simulation. There were a total of 8 participants, all completing the pretest, BMV simulation, and the posttest. Results of the pre and posttest were matched using the last four digits of the students ID number. Data was compiled and analyzed via Microsoft Excel. Confidence was analyzed via a Wilcoxon test to assess the SRNAs confidence levels from pre to post test. After conducting the Wilcoxon test, our p-value equated to 0.0084. Because our p-value was less than 0.05, we have statistically significant evidence to reject the null hypothesis (the two data sets are equal), and we can conclude the data assessing SRNA confidence level pretest differs from the data assessing SRNA confidence level posttest. A paired t-test (Table 1) was implemented to assess knowledge gain and to determine if knowledge improvement from pre-test to posttest was statistically significant. The mean of the SRNAs pretest was 60.9%, and the mean of the SRNAs posttest was 93.8%. After performing the paired t-test, the p-value was 0.00058, concluding the p-value was <0.05, and proving the improved test scores were statistically significant. BAG MASK VENTILATION 25 Table 1. At the end of the posttest, an NLN student satisfaction and self-confidence survey (Appendix D) was completed by the participants, and this survey is used to assess SRNA satisfaction with the educational approach and confidence to perform effective bag mask ventilation The NLN survey reflects an agree/disagree 5-point Likert scale. The mean scores for the NLN survey fall within the range of 4.625 and 4.5, correlating with a response between 4 (agree) and 5 (strongly agree). These results indicate a strong satisfaction for the simulation and a strong confidence in bag mask ventilation skills. See table 2, represented in Appendix G, for data from the validated NLN confidence and satisfaction survey. Conclusion Bag mask ventilation is an essential skill as an anesthesia provider in the perioperative setting, and the skills for mastery must be taught in preparation for clinical practice. This skill of BMV is often difficult to execute among SRNAs and novice providers, further accentuating the need for sufficient education. SRNAs learn this skill first in the textbooks, and this skill can be reinforced by implementing simulation training. SRNAs partaking in the BMV simulation acknowledge they are better prepared, confident, and knowledgeable implementing safe and effective bag mask ventilation. BAG MASK VENTILATION 26 Improvements for this study and further needs for further project projections include a multitude of factors. Reinforcing the idea of assessing first-year SRNAs could assess the students ability to perform BMV without any prior clinical experience. Including a larger sample size could further validate our results, and including SRNAs from other graduate schools can accomplish this larger sample size goal. Another improvement includes implementing a second posttest to assess retainment of BMV knowledge. This posttest could be given one month after the simulation. Strengths of this project includes involving SRNAs who have yet to enter the clinical setting. By educating and testing SRNAs prior to entering the clinical setting, we can limit any extraneous variables affecting SRNAs BMV skills and knowledge. Another strength includes having a strong pre-test prior to our simulation. Instead of retroactively assessing the SRNAs knowledge of BMV, we were able to assess a strong baseline prior to our intervention. Once again, BMV is an imminent skill any anesthesia provider must master and implementing effective educational BMV scenarios propels future anesthesia providers toward this goal. BMV education in the simulation setting has proven to be effective in improving student knowledge, and in parallel, has shown favorable satisfaction and confidence scores as a result. BAG MASK VENTILATION 27 References Benditt, J. O., (2019). Respiratory Care of Patients With Neuromuscular Disease. Respiratory Care, 64(6), 679-688. https://doi.org/10.4187/respcare.06827 Casey, J. D., Janz D. R., Russel, D. W., Vonderhaar, D. J., Joffe, A. M., Dischert, K. M., Brown, R. M., Zouk, A. N., Gulati, S., Heideman, B. E., Lester, M. G., Toporek, A. H., Bentov, I., Self, W. H., Rice, T. W., & Semler, M. W., (2019). Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults. New England Journal of Medicine, 380(9), 811-821. https://doi.org/10.1056/NEJMoa1812405 Dai, Y., Dai, J., Walline, J. H., Fu, Y., Zhu, H., Xu, J., & Xuezhong, Y., (2021). Can bag-valve mask ventilation with positive end-expiratory pressure reduce hypoxia during intubation? A prospective, randomized, double-blind trial. Trials. https:/doi.org/10.1186/s13063-02105413-3 Farid, A. M. & Taman, H. I. (2020). The Impact of Sevoflurane and Propofol Anesthetic Induction on Bag Mask Ventilation in Surgical Patients with High Body Mass Index Anesthesia: Essays and Resources, 14(4), 594-599. https://doi.org/10.4103/aer.aer_20_21 Fayed, M., Nowak, K., Angappan, S., Patel, N, Abdulkarim, F., Penning, D. H., & China, A. K., (2022). Emergent Surgical Airway Skills: Time to Re-evaluate the Competencies. Cureus, 14(3). https://doi.org/10.7758/cureus.23260 Greenland, S., Senn, S. J., Rothman, K. J., Carlin, J. B., Poole, C., Goodman, S. N., & Altman, D. G. (2016). Statistical tests, p values, confidence intervals, and power: A guide to misinterpretations. European Journal of Epidemiology, 31(4), 337350. https://doi.org/10.1007/s10654-016-0149 BAG MASK VENTILATION 28 Hart, D., Driver, B., Kartha, G., Reardon, R., & Miner, J., (2020). Efficacy of Laryngeal Tube versus Bag Mask Ventilation by Inexperienced Providers. West Journal Emergency Medicine, 21(3), 688-693. https://doi.org/10.5811/westjem.2020.3.45844 Isniah, S., Hardi Purba, H., & Debora, F. (2020). Plan do check action (PDCA) method: Literature Review and Research issues. Jurnal Sistem Dan Manajemen Industri, 4(1), 72 81. https://doi.org/10.30656/jsmi.v4i1.2186 Jeffries, P. M., Rodgers, B., & Adamson, K., (2015). NLN Jeffries simulation theory: brief narrative description. Nursing Education Perspectives, 36(5). Mouri, M., Krishnan, S., & Maani, C. V., (2022). Airway Assessment. StatPearls. Otten, D., Liao, M. M., Wolken, R., Douglas, I. S., Mishra, R., Kao, A., Barrett, W., Drasler, E., Byyny, R. L., & Haukoos, J. S., (2019). Comparison of bag-valve-mask hand-sealing techniques in a simulated model. Annual Emergency Medicine, 63(1), https://doi.org/10.1016/j.annemergmed.2013.07.014 Khan, M. N. & Ahmed, A., (2021). Accuracy of STOP-Bang Questionnaire in Predicting Difficult Mask Ventilation: An Observational Study. Cureus, 13(6). https://doi.org/10.7759/cureus.15955 McMahon, E., Jimenez, F. A., Lawrence, K., & Victor, J. (2021). Healthcare simulation standards of best PRACTICETM evaluation of Learning and Performance. Clinical Simulation in Nursing, 58, 5456. https://doi.org/10.1016/j.ecns.2021.08.016 Moran, K. J., Burson, R., & Conrad, D. (2019). The doctor of nursing practice project: A BAG MASK VENTILATION 29 framework for success: a framework for success. Jones & Bartlett Learning, LLC. Saqer, A. M., Mubarak, A. M., Alotaibi, R. N., Alharthi, M. Z., Aljanoubi, M. A., Alshabanat, & S., Mobrad, A. M., (2020). Using gel for difficult mask ventilation on the bearded patients: a simulation-based study. Internal Emergency Medicine, 16(4), 1043-1049. https://doi.org/10.1007/s11739-020-02547-1 Semler, M. W., Janz, D. R., Lentz, R. J., Matthews, D. T., Norman, B. C., Assad, T. R., Keriwala, R. D., Ferrel, B. A., Noto, M. J., McKown, A. C., Kocurek, E. G., Warren, M. A., Huerta, L. E., & Rice, T. W., (2021). Bag-Mask Ventilation Versus Apneic Oxygenation During Tracheal Intubation of the Critically Ill. American Journal of Respiratory and Critical Care Medicine, 193(3), 273-280. https://doi.org/10.1164/rccm.201507-1294OC Smith & Liehr., (2018). Middle Range Theory for Nursing (4th edition). Springer Publishing Company. Soleimanpour, M., Rahmani, F., Bagi, H., Ala, A., Mahmoodpoor, A., Hassani, F., Sharifi, S., Esfanjani, R. M., & Soleimanpour, Hassan, (2018). Comparison of Three Techniques on Facility of Bag-Mask Ventilation: Thenar Eminence, E-O, and E-C. Anesthesia and Pain Medicine, 8(4). https://doi.org/10.5812/aapm.74226 Taber, K. S. (2018). The use of Cronbachs alpha when developing and Reporting Research Instruments in science education. Research in Science Education, 48(6), 12731296. https://doi.org/10.1007/s11165-016-9602-2 Uhm, D., Kim, A., (2021). Tidal volume according to the 4-point sealing forces of a bag-valvemask: an adult respiratory arrest simulator-based prospective, descriptive study. BMC BAG MASK VENTILATION 30 Emergency Medicine, 21(1). https://doi.org/10.1186/s12873-021-00451-1 US Department of Education (ED). (2021, August 25). Family educational rights and privacy act (FERPA). Home. Retrieved February 5, 2023, from https://www2.ed.gov/policy/gen/guid/fpco/ferpa/index.html Zweiker, D., Schwaberger, H., Urlesberger, B., Mileder, L. P., Baik-SChneditz, N., Pichler, G., Schmolzer, G. M., & Schwaberger, B., (2018). Does the Number of Fingers on the Bag Influence Volume Delivery? A Randomized Model Study of Bag-Valve-Mask Ventilation in Infants. Children, 5(8), 132. https://doi.org/10.3390/children5100132 BAG MASK VENTILATION 31 Appendix A Jeffries Simulation Theory BAG MASK VENTILATION 32 Appendix B SWOT Analysis BAG MASK VENTILATION 33 Appendix C PRISMA Flow Chart BAG MASK VENTILATION 34 Appendix D NLN Satisfaction & Self-Confidence Tool Student Satisfaction and Self-Confidence in Learning Instructions: This questionnaire is a series of statements about your personal attitudes about the instruction you receive during your simulation activity. Each item represents a statement about your attitude toward your satisfaction with learning and self-confidence in obtaining the instruction you need. There are no right or wrong answers. You will probably agree with some of the statements and disagree with others. Please indicate your own personal feelings about each statement below by marking the numbers that best describe your attitude or beliefs. Please be truthful and describe your attitude as it really is, not what you would like for it to be. This is anonymous with the results being compiled as a group, not individually. Mark: 1 = STRONGLY DISAGREE with the statement 2 = DISAGREE with the statement 3 = UNDECIDED - you neither agree or disagree with the statement 4 = AGREE with the statement 5 = STRONGLY AGREE with the statement Satisfaction with Current Learning SD D UN A SA 1. The teaching methods used in this simulation were helpful and effective. 1 2 3 4 5 2. The simulation provided me with a variety of learning materials and activities to promote my learning the medical surgical curriculum. 1 2 3 4 5 3. I enjoyed how my instructor taught the simulation. 1 2 3 4 5 4. The teaching materials used in this simulation were motivating and helped me to learn. 1 2 3 4 5 5. The way my instructor(s) taught the simulation was suitable to the way I learn. 1 2 3 4 5 UN A SA Self-confidence in Learning SD D 6. I am confident that I am mastering the content of the simulation activity that my instructors presented to me. 1 2 3 4 5 7. I am confident that this simulation covered critical content necessary for the mastery of medical surgical curriculum. 1 2 3 4 5 8. I am confident that I am developing the skills and obtaining the required knowledge from this simulation to perform necessary tasks in a clinical setting 1 2 3 4 5 9. My instructors used helpful resources to teach the simulation. 1 2 3 4 5 10. It is my responsibility as the student to learn what I need to know from this simulation activity. 1 2 3 4 5 11. I know how to get help when I do not understand the concepts covered in the simulation. 1 2 3 4 5 12. I know how to use simulation activities to learn critical aspects of these skills. 1 2 3 4 5 13. It is the instructor's responsibility to tell me what I need to learn of the simulation activity content during class time.. 1 2 3 4 5 Copyright, National League for Nursing, 2005 Revised December 22, 2004 BAG MASK VENTILATION 35 APPENDIX E BAG MASK VENTILATION 36 BAG MASK VENTILATION 37 APPENDIX F PROJECT TEAM MEMBERSHIP Marian University Leighton School of Nursing Graduate Department Notice of DNP Project Team Membership Miriam Wallach & Cara Pepperman Name of DNP Student: _______________________________________________________________ Bag Mask Ventilation Education in the Simulation Setting Title of DNP Project:Evidence-Based _________________________________________________________________ I hereby agree to serve as the Chairperson of the DNP Project Committee for the above-named student. Signature: ______________________________ Printed/Typed Name Date: 09/30/2022 I hereby agree to serve as a Member of the DNP Project Committee for the above-named student. Signature: ______________________________ Printed/Typed Name Gregory Yant Date: 10/1/2022 Additional Members of the DNP Project Committee for above-named student (if needed). Signature: ______________________________ Date: Approval: Signature: ______________________________ Date: 10/03/2022 FNP or CRNA Program Director or Asst Program Directors or Graduate Chairperson Please Note: FNP DNP students will have a Chairperson (faculty) and an outside the university practice mentor (does not have to be doctorally prepared) on the committee. CRNA DNP students will have a Chairperson (faculty), PhD Project 1st Reader, and an outside the university practice mentor (does not have to be doctorally prepared). BAG MASK VENTILATION 38 APPENDIX G Table 2 Mean Median Mode Standard Deviation Sample Variance Minimum Maximum Count Confidence Level S1 4.625 5 5 0.517 S2 4.5 4.5 4 0.535 S3 4.625 5 5 0.518 S4 4.5 4.5 4 0.535 S5 4.5 4.5 4 0.535 C6 4.5 4.5 4 0.535 S7 4.5 4.5 4 0.535 C8 4.625 5 5 0.518 C9 4.625 5 5 0.518 C10 4.625 5 5 0.518 C11 4.625 5 5 0.518 0.268 0.268 0.268 0.286 0.286 0.286 0.286 0.268 0.268 0.268 0.268 4 5 8 0.433 4 5 8 0.447 4 5 8 0.433 4 5 8 0.447 4 5 8 0.447 4 5 8 0.447 4 5 8 0.447 4 5 8 0.433 4 5 8 0.433 4 5 8 0.433 4 5 8 0.433 Key: S = Satisfaction. C = Confidence. BAG MASK VENTILATION 39 Appendix H Literature Review Matrix Citation Benditt, J. O., (2019). Respiratory Care of Patients With Neuromuscular Disease. Respiratory Care, 64(6), 679-688. https://doi.org/10.4187/respcare.06827 Research Design & Level of Evidence QuasiExperimental; Level III Casey, J. D., Janz D. R., Russel, D. W., Vonderhaar, D. J., Joffe, A. M., Dischert, K. M., Brown, R. M., Zouk, A. N., Gulati, S., Heideman, B. E., Lester, M. G., Toporek, A. H., Bentov, I., Self, W. H., Rice, T. W., & Semler, M. W., (2019). Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults. New England Journal of Medicine, 380(9), 811-821. https://doi.org/10.1056/NEJMoa1812405 Randomized Controlled Trial; Level III Dai, Y., Dai, J., Walline, J. H., Fu, Y., Zhu, H., Xu, J., & Xuezhong, Y., (2021). Can bag-valve mask ventilation with positive end-expiratory pressure reduce hypoxia during intubation? A Prospective randomized double-blind trial; Level II Population / Sample size n=x Major Variables Instruments / Data collection Results Population: Patients with neuromuscular disease. Sample includes patient undergoing effective bag mask ventilation (n= 12), CPAP machines at night (n=35), and tracheostomy ventilation throughout the day (n = 20) Population: Critically ill patients. Sample includes undergoing tracheal intubation (n=401) Independent variables include intervention such as bag mask ventilation, CPAP machines, and tracheostomy ventilation. Dependent variables include oxygen saturation, cough function, and end tidal CO2. Vital capacity, ventilatory support, capnography, pulse oximetry. Patients with neuromuscular disease are especially weak and need extra assistance during ventilation. Extra considerations should be given to those with neuromuscular disease while bag mask ventilating. Independent variables include bag mask ventilation and no bag mask ventilation intervention. Dependent variables include oxygenation saturation. Independent variables: bag mask ventilation without PEEP, Laryngoscopy, pulse oximetry, bag mask Patients receiving NO bag mask ventilation prior to intubation had lower oxygen saturations compared to patients receiving bag mask ventilation. Ventilation device, respiratory, CO2, and O2 monitors Additional PEEP during bag mask ventilation improves oxygen reserve and Population: ED patients. Sample: patients requiring endotracheal BAG MASK VENTILATION 40 intubation for acute respiratory failure in the ED (n = 144) prospective, randomized, double-blind trial. Trials. https:/doi.org/10.1186/s13063-021-05413-3 Farid, A. M. & Taman, H. I. (2020). The Impact of Sevoflurane and Propofol Anesthetic Induction on Bag Mask Ventilation in Surgical Patients with High Body Mass Index Anesthesia: Essays and Resources, 14(4), 594-599. https://doi.org/10.4103/aer.aer_20_21 Quasiexperimental; Level III Fayed, M., Nowak, K., Angappan, S., Patel, N, Abdulkarim, F., Penning, D. H., & China, A. K., (2022). Emergent Surgical Airway Skills: Time to Re-evaluate the Competencies. Cureus, 14(3). https://doi.org/10.7758/cureus.23260 Quasiexperimental; Level III Hart, D., Driver, B., Kartha, G., Reardon, R., & Miner, J., (2020). Efficacy of Laryngeal Tube versus Bag Mask Ventilation by Inexperienced Providers. West Journal Emergency Medicine, 21(3), 688-693. https://doi.org/10.5811/westjem.2020.3.45844 Crossover study. Observational; Level III Population: Obese patients undergoing anesthesia Sample: pts undergoing sevoflurane induction (n = 100). Pts undergoing propofol induction (n=100) Population: Anesthesia providers. Sample: attendings (n=54), residents (n=44), CRNAs (n=21) Population: Inexperienced airway providers Sample: first year emergency medicine residents, third and fourth year bag mask ventilation with PEEP. Dependent variables: exhaled tidal volume, respiratory rate, exhaled oxygen concentration Independent variables: sevoflurane and propofol administration. Dependent variables: ease of bag mask ventilation Independent variables: cannot intubate cannot ventilate scenario. Dependent variables: providers confidence levels Independent variables: bag mask ventilation intervention and extraglottic device intervention. Dependent variables: tidal enhances oxygenation in patients with hypoxia compared to patients receiving bag mask ventilation alone. Propofol, sevoflurane, bag mask, pulse oximetry Sevo can facilitate BMV and provide better intubation conditions comparison to propofol induction. Online questionnaire Participants reported lack of experience and confidence in managing cannot intubate cannot ventilate scenarios. Indicators of difficult bag mask ventilation Extraglottic devices, bag mask, mannequins Inexperienced airway providers were able to provide higher ventilation volumes and peak pressures with extraglottic device compared to BMV in a manikin model BAG MASK VENTILATION 41 medical students (n=20) Khan, M. N. & Ahmed, A., (2021). Accuracy of STOP-Bang Questionnaire in Predicting Difficult Mask Ventilation: An Observational Study. Cureus, 13(6). https://doi.org/10.7759/cureus.15955 Prospective crosssectional observational study; Level III Mouri, M., Krishnan, S., & Maani, C. V., (2022). Airway Assessment. StatPearls. Retrospective chart review; Level III Otten, D., Liao, M. M., Wolken, R., Douglas, I. S., Mishra, R., Kao, A., Barrett, W., Drasler, E., Byyny, R. L., & Haukoos, J. S., (2019). Comparison of bag-valve-mask hand-sealing techniques in a simulated model. Annual Emergency Medicine, 63(1), https://doi.org/10.1016/j.annemergmed.2013.07.014 Prospective, crossover study; Level III Saqer, A. M., Mubarak, A. M., Alotaibi, R. N., Alharthi, M. Z., Aljanoubi, M. A., Alshabanat, & S., Mobrad, A. M., (2020). Using gel for difficult mask ventilation on the bearded patients: a simulation-based study. Internal Emergency Medicine, 16(4), 1043-1049. https://doi.org/10.1007/s11739-020-02547-1 Randomized crossover design; Level III Population: patients receiving general anesthesia for elective surgeries. Sample: patients (n=530) Population: patients receiving general anesthesia. Sample: Patients in outpatient center (n=130) Population: Healthcare providers. Sample: healthcare providers with greater than 5 or more emergency bag-valve-mask experiences (n=52) Population: respiratory therapists. Sample: male respiratory therapists (n=42) and female respiratory therapists (n=32) volumes and ventilation peak pressures Independent variables: STOPbang score. Dependent variables: ease of BMV STOP-bang questionnaire. Ease of mask ventilation assessment OSA is a strong predictor of difficult bag mask ventilation Independent variables: disease state, airway history. Dependent variables: assessment of difficult airway Independent variables: one handed BMV technique, two handed BMV technique. Dependent variable: Tidal volumes Bag mask ventilation device, TV, provider assessment Disease states such as asthma, pneumonia, and COPD have been associated with difficult ventilation and oxygenation Bag mask, inline monitor measuring tidal volume 2 handed mask ventilation technique resulted in higher tidal volumes than 1 handed technique. Independent variables: gel application before BMV. Dependent variables: TV Mannequin, bag mask, tidal volumes, survey Mean tidal volume during BMV without gel application was 283 mL. Mean tidal volume during BMV with gel was 467 mL. BAG MASK VENTILATION 42 Semler, M. W., Janz, D. R., Lentz, R. J., Matthews, D. T., Norman, B. C., Assad, T. R., Keriwala, R. D., Ferrel, B. A., Noto, M. J., McKown, A. C., Kocurek, E. G., Warren, M. A., Huerta, L. E., & Rice, T. W., (2021). BagMask Ventilation Versus Apneic Oxygenation During Tracheal Intubation of the Critically Ill. American Journal of Respiratory and Critical Care Medicine, 193(3), 273-280. https://doi.org/10.1164/rccm.2015071294OC Randomized open-label pragmatic trial; Level III Population: medical ICU patients. Sample: 150 ICU adult patients Independent variables: BMV, apneic oxygenation. Dependent variables: oxygen saturations Bag mask ventilation, pulse oximetry Apneic oxygenation does not improve lowest arterial oxygen saturation during endotracheal intubation. Findings do not support routine use of apneic oxygenation during endotracheal intubation of critically ill adults. Soleimanpour, M., Rahmani, F., Bagi, H., Ala, A., Mahmoodpoor, A., Hassani, F., Sharifi, S., Esfanjani, R. M., & Soleimanpour, Hassan, (2018). Comparison of Three Techniques on Facility of Bag-Mask Ventilation: Thenar Eminence, E-O, and E-C. Anesthesia and Pain Medicine, 8(4). https://doi.org/10.5812/aapm.74226 Quasiexperimental; Level III Population: Medical students and experienced anesthesia providers. Sample (n=100) Independent variables: E-C technique, E-O technique. Dependent variables: chest rise, ventilation quality Ventilation Assessment, mannequin, bag mask Uhm, D., Kim, A., (2021). Tidal volume according to the 4-point sealing forces of a bag-valve-mask: an adult respiratory arrest simulator-based prospective, descriptive study. BMC Emergency Medicine, 21(1). https://doi.org/10.1186/s12873021-00451-1 Prospective descriptive study; Level III Population: undergraduate students Sample: undergraduate paramedic students (n=125) Independent variables: sealing force. Dependent variables: peak pressure, tidal volume Self-reported questionnaire Among professionals, there was no significant difference between the E-O and E-C technique. However, among the novice providers, the E-O technique was performed better than the E-C technique The higher the peak pressure and apex sealing force, the greater the tidal volumes. Zweiker, D., Schwaberger, H., Urlesberger, B., Mileder, L. P., Baik-SChneditz, N., Pichler, G., Schmolzer, G. M., & Schwaberger, B., (2018). Does the Number of Fingers on the Bag Influence Volume Delivery? A Randomized Model Study of Bag-Valve-Mask Ventilation in Infants. Children, 5(8), 132. https://doi.org/10.3390/children5100132 Randomized crossover student; Level III Population: Healthcare professionals. Sample: Healthcare professionals trained in neonatal/pediatric Independent variables: 2 finger technique, 5 finger technique. Dependent variables: tidal volume Mannequin, ventilation device, respiratory function monitor Five-finger technique led to higher tidal volumes when compared to the twofinger technique among pediatric and neonate mannequins. BAG MASK VENTILATION 43 resuscitation (n=40)  ...