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... PAIN MEDICATION USE AFTER CAESAREAN SECTION Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2023 A Retrospective Study on the Use of Rescue Pain Medication in Patients Who Receive Transabdominal Plane Blocks Post Caesarean Sections Nicholas Ramey Marian University Leighton School of Nursing Chair: Dr. Derrianne Monteiro *U*HUULDQQH3RQWHLUR -
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 (Signature) Committee Member: Dr. Ryan Sorrell (Signature) Date of Submission: 1 PAIN MEDICATION USE AFTER CAESAREAN SECTION 2 Table of Contents $EVWUDFW4 ,QWURGXFWLRQ5 %DFNJURXQG5 Problem 6WDWHPHQW7 *DS$QDO\VLV8 5HYLHZRI/LWHUDWXUH8 7$3%ORFNVZLWK6SLQDOV9 $QHVWKHVLDZLWKRXW7$3%ORFNV9 ThHRUHWLFDO)UDPHZRUN..10 Goals, Objectives, Expected Outcomes1 3URMHFW'HVLJQDQG0HWKRGV 11 3URMHFW6LWHDQG3RSXODWLRQ1 Measurement InstrumenWV2 'DWD&ROOHFWLRQ3URFHGXUHV2 (WKLFDO&RQVLGHUDWLRQV3 5HVXOWV 3DUWLFLSDQWV Post Operative Rescue Medication Use 'LVFXVVLRQ &RQFOXVLRQ 5HIHUHQFHV6 $SSHQGLFHV20 PAIN MEDICATION USE AFTER CAESAREAN SECTION 3 Appendix $20 $SSHQGL[%4 $SSHQGL[& PAIN MEDICATION USE AFTER CAESAREAN SECTION 4 Abstract Background and Review of Literature: Caesarean sections are one of the most performed procedures in the operating room. Managing pain for these patients is vital to ensure a positive birthing experience for mothers and facilitating bonding post-surgery. Regional anesthesia, specifically transabdominal plane (TAP) blocks, have shown to improve pain perception and reduce the need for opioid pain medications. Purpose: This DNP project was designed to validate that performing TAP blocks on patients who have a caesarean section reduce the need for rescue pain medications. Reducing the need for these medications negates the side effects they have and promotes a positive birthing experience. Methods: This DNP project will be retrospective chart review on patients who required a caesarean section and the use of rescue opioid medications. Charts will be reviewed in a 4-week period in the Spring of 2023 at a Midwest community hospital. Implementation Plan/Procedure: Charts reviewed will be divided into two groups who received a caesarean section. Group 1 will be those who did not receive a TAP block. Group 2 ZLOOEHWKRVHZKRGLGUHFHLYHD7$3EORFN%RWKJURXSVFKDUWVZLOOEHUHYLHZHGIRUXVHRI rescue medications and compared to one another using a Chi-Square Test. Implications/Conclusions: This study concluded that there was no statistical reduction in the use of rescue opioid pain medications in the 24 hours following a caesarean section when a TAP block was performed. Keywords: TAP BLOCK, OPIOID USE, CAESAREAN SECTION PAIN MEDICATION USE AFTER CAESAREAN SECTION 5 A Retrospective Study on the Use of Rescue Pain Medication in Patients Who Receive Transabdominal Plane Blocks Post Caesarean Sections 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, Certified Registered Nurse Anesthetist track. The development of anesthetic procedures, specifically regional anesthesia, has grown vastly in the last 20 years. With advances in technology related to ultrasound, medication preparation, and techniques used, regional anesthesia has become much safer and easier to perform. However, many providers choose not to perform regional adjuncts to their anesthetics due to a multitude of reasons including time constraints, lack of knowledge, misleading information, and many others. Regional anesthesia has a place in many areas of surgical populations, to help minimize and/or negate opioid use for post operative pain. Obstetrics is one population where the utilization of regional anesthesia is lacking, specifically in women undergoing caesarean sections. Cesarean sections represented eight percent of all operating room procedures and were the most frequent operating room procedure in 2018 (McDermott & Liang, 2021). On top of this statistic, cesarean deliveries account for 32% of all births in the North America, which equilibrates to 1.2 million deliveries via cesarean per year (Betran et al, 2016). Implementing regional block into a protocol into this population could affect millions via reduced use of rescue pain medications (roxycodone) and benefit patient satisfaction levels in a hospital system. Background A commonly provided anesthetic for a patient undergoing a cesarean section includes spinal anesthesia. As of 2017, more than 60% of women in the US receive some type of neuraxial procedure during their labor (Meng & Smiley, 2017). For cesarean sections PAIN MEDICATION USE AFTER CAESAREAN SECTION 6 specifically, a spinal needle is inserted into the subarachnoid space, and after confirming placement with positive cerebral spinal fluid flow through the nHHGOHDSURYLGHUVSUHIHUHQWLDO mixture of local anesthetics, opioids, and other medications are injected. This solution can provide adequate pain relief for the procedure while allowing the mother to be conscious during the birth. The benefit of a spinal anesthetic, depending on the local anesthetic and addition of other medications, is it has a low duration of action. The drawback is the same as the benefit, the spinal anesthesia duration of action is quick and provides comfort during the procedure, but once it wears off the mother will experience pain if no other intervention is made. There are many ways of treating post operative pain for this population. In the clinical setting, it is not uncommon for post partem women who have had a caesarean section to not receive regional anesthesia. However, it is not best practice for them to receive a regional anesthetic block either. For this population, the regional anesthesia provided to the patients is called a transabdominal plane block, otherwise known as a 7$3EORFN7KLVW\SHRIEORFNLV performed via bilateral injections of local anesthetic into the facial plane between the internal oblique muscle and the transversus abdominis muscle. This areas skin and muscle nerve supply is through spinal nerves which originated for the T6 to L2 spinal levels (Meng & Smiley, 2017). It is important to note that this type of anesthetic does not provide visceral coverage. The benefits of local anesthetic include providing pain relief with minimal side effects. While opioids can treat post operative cesarean pain, they also cause pruritus (itching), drowsiness, constipation, nausea/vomiting, and respiratory depression (Sadiq et. al., 2022). These side effects FDQGHFUHDVHWKHSDWLHQWVVDWLVIDFWLRQZLWKWKHLUKRVSLWDOstay and reduce the quality of bonding time with their new child. PAIN MEDICATION USE AFTER CAESAREAN SECTION 7 A study that occurred in Oslo University Hospital in Norway concluded that at the 24hour mark post caesarean section, incidence of a pain score of t4 was 68% of the included participant (Bjrnstad & Rder, 2020). In this same study, the median dose of oxycodone for 56% of the participants was 40 milligrams within that same 24 hour period (Bjornstad & Raeder, 2020). The National Institute of Health suggests dosing oxycodone five to fifteen milligrams every four to six hours meaning while 40 milligrams is within the dosing guidelines, it is still at the higher end (Sadiq et. al., 2022). There is little information that can validate the implementation of TAP blocks into best practice methods for post operative caesarean section pain. While traditionally, a pain score is used to gage the pain level one is in, this can be subjective based on the healthcare professional asking, and each patients response can vary widely. Therefore, the use of rescue medication to judge pain level is used as a common variable to access the adequacy of pain relief after the TAP block in comparison to those who do not receive the block. Problem Statement This project sought to validate that regional anesthesia, specifically the TAP block, in the obstetric population who underwent caesarean sections reduced the use of rescue pain medications in the 24-hour period after the procedure. This retrospective review of patients took place at a community hospital in the Midwest region of the United States and was conducted during a four-week period in the Spring of 2023. Standard practice was a TAP block is suggested on an as needed basis per patient undergoing a caesarean section, however, there is not much to support it is validity to patients from the anesthesia provider. Furthermore, this data could be used to implement the use of TAP blocks at other facilities. Data gathered from this project will support the confidence of patients in anesthesia providers who perform the TAP blocks. PAIN MEDICATION USE AFTER CAESAREAN SECTION 8 Implementation of this data during consent to the block will allow patients to make a more informed decision regarding the choice of receiving the TAP block. Needs Assessment & Gap Analysis Beacon Memorial hospital delivers more babies than any other hospital in the Beacon Hospital System at an average of 400 babies per year (Beacon, 2022). That is an average of one to two babies delivered per day. Current practice at the site is to utilize TAP blocks on an as needed basis for every caesarean section performed, however there is little evidence that can be provided to patients to support the use of them. Utilizing data collected through a retrospective review at Beacon Memorial Hospital, this project will be able to validate the use of TAP blocks with factual statistics for patients considering the procedure to assist with post-operative pain. Review of Literature A review of literature was performed to address the population, intervention, comparison, and outcomes (PICO) question of7KLVSURMHFWVHHNVWRYDOLGDWHLIUHJLRQDODQHVWKHVLD specifically the TAP block, in the obstetric population who undergo caesarean sections reduces the use of rescue pain medications in comparison with spinal anesthesia alone in the 24-hour SHULRGDIWHUWKHSURFHGXUH'DWDEDVHVLQFOXGLQJ&,1$+/3XE0HG0HGOLQH Ebsco were used for article collection. Search criteria for the review of literature included phrases and the following keywords in combination: TAP block, transabdominal plane, cesarean, cesarean section, post. Search criteria included articles published within the last five years, availability of the article in the English language, human subject involvement, and full texts. For the article to be included in the review of literature, the article must demonstrate the use of regional anesthesia, specifically TAP block or a variation, and rating of pain after cesarean section. Articles that did not meet these described criteria were omitted for the review of literature. PAIN MEDICATION USE AFTER CAESAREAN SECTION 9 This search elicited 29 articles related to the PICO question, of which 14 were duplicates. 15 articles were reviewed, and five articles were omitted for no relevance to the PICO question. Refer to Appendix A for the full literature review matrix. TAP Blocks with Spinal Anesthesia TAP blocks have been associated as an adjunct to spinal anesthesia and in many cases with a shown reduction in postoperative caesarean section rescue opioid pain medication requirement (Habib et al, 2021; Jadon et al., 2018; Nedeljkovic et al., 2020; Staker et al., 2018). With the use of TAP blocks in conjuncture with spinal anesthesia has added benefits of reduced pruritus, more favorable safety profile, and better overall pain relief on post operative day one (Aga et al., 2021; Habib et al, 2021; Nedeljkovic et al., 2020). The use of TAP blocks has been shown a 59% reduction in the use of rescue pain medication in the first 24 hours in one study in comparison with spinal anesthesia alone (Staker et al., 2018). With the majority of studies showing a reduction in rescue pain medication, Yu et al. (2021) and Borys et al. (2019) observed little benefit of TAP blocks when compared to a multimodal oral analgesic regimen. Another study showed the use of intrathecal morphine in a spinal in comparison with a spinal with local anesthetic and TAP blocks were clinically similar with pain relief in the post operative period (Kwikiriza et al., 2019). Anesthesia without TAP Blocks Spinal anesthesia solely is associated with increase postoperative opioid use in those patients undergoing caesarean sections (Nedeljkovic et al., 2020). Nedeljkovic et al. (2020) observed that those who did not receive TAP blocks required 51.6% more opioids in the 72 hours post caesarean sections. In one study involved the use of epidural for post operative pain management, it was shown that that epidural group required less opioids in the 24 hour post PAIN MEDICATION USE AFTER CAESAREAN SECTION 10 operative period than those who received a spinal anesthetic with TAP blocks (Canakci et al., 2018). Theorical Framework The Symptom Management Theory (SMT) helps organize relevant concepts for research and practice in the form of a nursing framework (Bender et. al., 2018). The SMT is used to eliminate or minimize the extent of an issue or problem in health whether it be physical, mental, or social functioning. There are three components to SMT that include symptom experience, symptom management strategies, and outcomes (Bender et. al., 2018). The change that is being made in the illness or symptom is the most important part of the theory. Symptom experience is how the patient conceptualizes their understanding of their symptoms. This experience is measured from their baseline normal to the introduction of the new stimulus, which in this project would be their pain following a caesarean section (Bender et. al., 2018). Symptom management strategies includes any inWHUYHQWLRQPDGHWRDOWHURQHVSHUFHSWLRQ to the stimulus, delay its onset, or negate the symptom experiences entirely. In the case of this project, it would be the implementation of the transabdominal plane (TAP) block to intervene to prevent and/or minimize the symptom experience for the patient. The last component to this theorical framework is the outcome. Symptom outcomes should be clear and measurable (Bender et. al., 2018). This project will compare the symptom experience between two groups, both having a caesarean section, with one group having the intervention of symptom management strategy of receiving a TAP blocks. The outcome will assess the differences in pain perception within the first 24 hours post procedure, and the amount of rescue pain medication needed. Project Aims, Objectives, and Expected Outcomes PAIN MEDICATION USE AFTER CAESAREAN SECTION 11 The purpose for this project was to validate that TAP blocks performed on post cesarean section patients reduces the need for rescue pain medication within the first 24 hours. This data could be used at other locations to implement a post cesarean section protocol to help with post operative pain without the use of additional narcotics. The main objective for how this project was to achieve the aim through the data collected by anesthesia personal at Beacon Memorial Hospital. Data collected includes use of rescue pain medication, pain level, overall experience, and if the patient has issue with mobilization. The primary variable that was used was the use of rescue pain medication for those who received TAP blocks in comparison to those who did not receive one. The efficacy of TAP blocks was determined through this data and used to either prove or disprove the use of them in this patient population. Project Design and Methods The idea behind this scholarly project was to validate that TAP blocks for caesarean sections reduce the use to opioids in the parturient population. This validation will allow providers to have credible data to support the use of TAP blocks when presenting the anesthetic plan to the patients. The project has identified two groups, TAP block recipients and those who opt out and compare the need for rescue pain medication in the 24-hour period after a caesarean section. Project Site and Population The location for this retrospective review is an obstetric and neonatal level 3 perinatal hospital with an average of 400 births per year (Beacon, 2022). The hospital is a public facility in the Midwest region of the United States. The community is made up of multiple ethnicities and has a wide range of socioeconomic patients. PAIN MEDICATION USE AFTER CAESAREAN SECTION 12 The population for this project is women who have received a scheduled caesarean section from March 1, 2023, to March 31, 2022. The exclusion criteria for this project are emergent situations, and those who are unable to provide consent for the procedure. Measurement Instruments For this retrospective study, a tool has been developed to summarize the data into quantitative data. This tool can be referred to in Appendix B. The tool summarizes the data collected from patients. The quantitative data that will be complied into the spread sheet includes the following parameters: did the patient receive a TAP block in addition to spinal anesthesia, and did the patient require additional rescue medication in the first 24 post operatively. This tool has been developed to compare the two groups of those who did receive TAP blocks and those who did not. The parameter of if the patient required rescue pain medication was used to objectively view the efficacy of the TAP blocks and if they reduce opioid consumption post operatively. Data Collection Procedures Upon DSSURYDOIURP%HDFRQ+HDOWKV,QVWLWXWLRQDO5HYLHZ%RDUG ,5% WKLVSURMHFW divided the participants into two groups: those who received TAP blocks with spinal anesthesia and those who solely received spinal anesthesia for caesarean section. The data was collected for both groups of those who required rescue pain medication in the first 24 hour post caesarean section. Using this objective data to evaluate pain, the project either invalidate or validate whether TAP blocks reduce the number of opioids needed. This data will in turn be used to help providers explaining their anesthetic plan to patients in the future. Ethical Considerations PAIN MEDICATION USE AFTER CAESAREAN SECTION 13 Internal Review Board (IRB) approval was obtained prior to initiating this DNP project. The project notified ERWK0DULDQ8QLYHUVLW\V,5%RIWKHSURMHFWDQGBeacon +HDOWKV,5% and received exemption status from both, see Appendix C. No personal data was collected for the project. There will be no demographics, or identifiable traits that would identify any participants. All information acquired for this project was stored on an encrypted password protected computer that only the facilitator of the project had access too. An addition, a password was added to the Microsoft Excel file. Information will be stored for two years after completion of this project, and then destroyed. Results Participants A total of 40 patients electronic medical records (EMR) were reviewed and used in this study. 20 patients were placed in and met requirements for the control group, while the remaining 20 were placed into the experimental group. The experimental group were those who received a spinal anesthetic without narcotic and the addition of a TAP block for post operative pain. The TAP block consisted of a total of 60 mL of 0.5 percent bupivacaine, spilt equally bilaterally. Both groups EMR were reviewed 24 hours post operatively to evaluate use of opioid pain medication. Post Operative Rescue Medication Use To determine if TAP blocks are effective in reducing the consumption of post operative rescue pain medication, the experimental group was compared to the control group. A ChiSquare Test was utilized to evaluate if there was a statistical difference between the groups. It was concluded that there was not a statistical difference in the reduction of opioid rescue pain medication 24 hours post operatively for those who received a TAP block. The Chi-Square Test PAIN MEDICATION USE AFTER CAESAREAN SECTION 14 of Independence established a P value of 0.1138462, meaning there was a lack of statistical significance between the two groups. Discussion This DNP project sought to find if the addition of a TAP block would reduce the use of rescue pain medication in the 24 hour period post operatively after a caesarean section. The project consisted of two groups, an experimental group who received a TAP block in place of added narcotic to the spinal anesthetic. The control group solely received a spinal anesthetic with narcotics. The study concluded that there was not a statistical difference between the two groups, implying that TAP blocks do not reduce the need for rescue opioid pain medications in the 24 hours after a caesarean section. The results of the study did not correlate with previous studies such as Jadon et al. (2018). This study showed a reduction in the use of opioids post operatively. The limitation of these studies were the omission of if the patients were on any kind of multimodal pain regiments. A limitation of this study was the sample size. If this study could be repeated at an institution where TAP blocks were used in higher volume, it would be interesting to see the correlation with the addition of them. Another limitation of the study was the retrospective review of charts. The investigator had to rely on other providers charting and there was a question of standardization between providers. A prospective study with an increased sample size would be ideal with more precise regulations over the experimental group. Conclusion In conclusion, this study found that there was no additional benefit with the addition of TAP blocks in conjunction with spinal anesthesia in reducing the need for rescue pain medication in the following 24 hours after a caesarean section. Additional studies are needed to PAIN MEDICATION USE AFTER CAESAREAN SECTION 15 evaluate the effectiveness of TAP blocks and their place in the obstetric population with regards to improving the birthing experience. PAIN MEDICATION USE AFTER CAESAREAN SECTION 16 References Aga, A., Abrar, M., Ashebir, Z., Seifu, A., Zewdu, D., & Teshome, D. (2021). The use of perineural dexamethasone and transverse abdominal plane block for postoperative analgesia in cesarean section operations under spinal anesthesia: an observational study. BMC anesthesiology, 21(1), 292. https://doi.org/10.1186/s12871-021-01513-4 Bender, M.S., Janson, S.J., Franck, L.S., & Lee, K.A. (2018). Theory of symptom Management. Middle Range Theory for Nursing. p. 147-178. https://doi.org/10.1891/9780826159922.0008 Betran A.P., Ye, J., Moller A.B., Zhang, J., Glmezoglu, A.M., & Torloni MR. (2016). The increasing trend in caesarean section rates: global, regional and national estimates: 19902014. PLoS One. 11(2), e0148343. https://doi.org/10.1371/journal.pone.0148343 Borys, M., Potrec-Studzinska, B., Wiech, M., Piwowarczyk, P., Sysiak-6DZHFND-5\SXODN (*FD, T., Kwasniewska, A., & Czuczwar, M. (2019). Transversus abdominis plane block and quadratus lumborum block did not reduce the incidence or severity of chronic postsurgical pain following cesarean section: a prospective, observational study. Anaesthesiology Intensive Therapy, 51(4), 257261. https://doi.org/10.5114/ait.2019.88071 Bjornstad, J., & Raeder, J. (2020). Post-operative pain after caesarean section. Tidsskrift for den Norske laegeforening, 140(7). https://doi.org/10.4045/tidsskr.19.0506 PAIN MEDICATION USE AFTER CAESAREAN SECTION 17 Canakci, E., Gultekin, A., Cebeci, Z., Hanedan, B., & Kilinc, A. (2018). The Analgesic Efficacy of Transverse Abdominis Plane Block versus Epidural Block after Caesarean Delivery: Which One Is Effective? TAP Block? Epidural Block?. Pain research & management, 2018, 3562701. https://doi.org/10.1155/2018/3562701 %HDFRQ&KLOGUHQV+RVSLWDO  1HZERUQ,QWHQVLYH&DUH8QLW https://www.beaconhealthsystem.org/beacon-childrens-hospital/newborn-intensive-careunit-nicu/ Habib, A. S., Nedeljkovic, S. S., Horn, J. L., Smiley, R. M., Kett, A. G., Vallejo, M. C., Song, J., Scranton, R., & Bao, X. (2021). Randomized trial of transversus abdominis plane block with liposomal bupivacaine after cesarean delivery with or without intrathecal morphine. Journal of Clinical Anesthesia, 75, 110527. https://doi.org/10.1016/j.jclinane.2021.110527 Jadon, A., Jain, P., Chakraborty, S., Motaka, M., Parida, S. S., Sinha, N., Agrawal, A., & Pati, A. K. (2018). Role of ultrasound guided transversus abdominis plane block as a component of multimodal analgesic regimen for lower segment caesarean section: a randomized double blind clinical study. BMC Anesthesiology, 18(1), 53. https://doi.org/10.1186/s12871-018-0512-x PAIN MEDICATION USE AFTER CAESAREAN SECTION 18 Kwikiriza, A., Kiwanuka, J. K., Firth, P. G., Hoeft, M. A., Modest, V. E., & Ttendo, S. S. (2019). The analgesic effects of intrathecal morphine in comparison with ultrasoundguided transversus abdominis plane block after caesarean section: a randomized controlled trial at a Ugandan regional referral hospital. Anesthesia, 74(2), 167173. https://doi.org/10.1111/anae.14467 McDermott, K., & Liang, L. (2021). Overview of operating room procedures during inpatient stays in US hospitals, 2018. Healthcare Cost and Utilization Project. https://hcupus.ahrq.gov/reports/statbriefs/sb281-Operating-Room-Procedures-DuringHospitalization-2018.jsp Meng, M. L., & Smiley, R. (2017). Modern Neuraxial Anesthesia for Labor and Delivery. F1000Research, 6, 1211. https://doi.org/10.12688/f1000research.11130.1 Nedeljkovic, S. S., Kett, A., Vallejo, M. C., Horn, J. L., Carvalho, B., Bao, X., Cole, N. M., Renfro, L., Gadsden, J. C., Song, J., Yang, J., & Habib, A. S. (2020). Transversus Abdominis Plane Block With Liposomal Bupivacaine for Pain After Cesarean Delivery in a Multicenter, Randomized, Double-Blind, Controlled Trial. Anesthesia and analgesia, 131(6), 18301839. https://doi.org/10.1213/ANE.0000000000005075 Staker, J. J., Liu, D., Church, R., Carlson, D. J., Panahkhahi, M., Lim, A., & LeCong, T. (2018). A triple-blind, placebo-controlled randomized trial of the ilioinguinal-transversus PAIN MEDICATION USE AFTER CAESAREAN SECTION 19 abdominis plane (I-TAP) nerve block for elective caesarean section. Anaesthesia, 73(5), 594602. https://doi.org/10.1111/anae.14222 Sadiq, N.M., Dice, T.J., & Mead, T. (2022) Oxycodone. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482226/ Yu, Y., Gao, S., Yuen, V. M., Choi, S. W., & Xu, X. (2021). The analgesic efficacy of ultrasound-guided transversus abdominis plane (TAP) block combined with oral multimodal analgesia in comparison with oral multimodal analgesia after caesarean delivery: a randomized controlled trial. BMC anesthesiology, 21(1), 7. https://doi.org/10.1186/s12871-020-01223-3 PAIN MEDICATION USE AFTER CAESAREAN SECTION 20 Appendix A Literature Review Matrix Citation Aga, A., Abrar, M., Ashebir, Z., Seifu, A., Zewdu, D., & Teshome, D. (2021). The use of perineural dexamethasone and transverse abdominal plane block for postoperative analgesia in cesarean section operations under spinal anesthesia: an observational study. BMC anesthesiology, 21(1), 292. https://doi.org/10.1186/s12871-021-01513-4 Borys, 03RWU-6WXG]LVND%:LHFK0 Piwowarczyk, P., Sysiak-6DZHFND-5\SXODN (*FD7.ZDQLHZVND$ &]XF]ZDU0 (2019). Transversus abdominis plane block and quadratus lumborum block did not reduce the incidence or severity of chronic postsurgical pain following cesarean section: a prospective, observational study. Anaesthesiology intensive therapy, 51(4), 257261. https://doi.org/10.5114/ait.2019.88071 Research Design & Level of Evidence Prospective Population / Sample size n=x Major Variables Instruments / Data collection Results Patients undergoing elective cesarean section with spinal anesthesia. Sample size = 58 TAP blocks with dexamethasone and bupivacaine and TAP blocks with bupivacaine An additive agent of perineural dexamethasone at a dose of 8 mg during bilateral TAP block for elective CS operation under spinal anesthesia provided better pain relief on postoperative day 1. Prospective, observational study Women with singleton pregnancies above 18 years old, greater than 36 weeks, and undergoing cesarean section under spinal. Sample size = 233 TAP block, quadratus lumborum block The primary outcomes are the period for the first request of postoperative pain relief medication and the numerical rating scale (NRS) pain intensity scores at 2, 6, 12, and 24 h after surgery. The secondary outcomes are comparing the 24-h tramadol and diclofenac analgesic requirements and the incidences of side effects on postoperative day one The patients received either TAP block or QLB as the primary analgesia technique following cesarean section. The control group consisted of patients without any postsurgical plane block. The incidence and characteristics of chronic pain were evaluated using the Neuropathic Pain Chronic postsurgical pain is highly prevalent following cesarean section. The studied plane blocks did not reduce the incidence or severity of CPSP after cesarean section when compared to the standard analgesic regimen. PAIN MEDICATION USE AFTER CAESAREAN SECTION Canakci, E., Gultekin, A., Cebeci, Z., Hanedan, B., & Kilinc, A. (2018). The Analgesic Efficacy of Transverse Abdominis Plane Block versus Epidural Block after Caesarean Delivery: Which One Is Effective? TAP Block? Epidural Block?. Pain research & management. https://doi.org/10.1155/2018/3562701 Randomized Control Habib, A. S., Nedeljkovic, S. S., Horn, J. L., Smiley, R. M., Kett, A. G., Vallejo, M. C., Song, J., Scranton, R., & Bao, X. (2021). Randomized trial of transversus abdominis plane block with liposomal bupivacaine after cesarean delivery with or without intrathecal morphine. Journal of clinical anesthesia, 75, 110527. https://doi.org/10.1016/j.jclinane.2021.110527 Randomized Control Jadon, A., Jain, P., Chakraborty, S., Motaka, M., Parida, S. S., Sinha, N., Agrawal, A., & Pati, A. K. (2018). Role of ultrasound guided transversus abdominis plane block as a component of multimodal analgesic regimen for lower segment caesarean section: a randomized double blind clinical study. BMC anesthesiology, 18(1), 53. https://doi.org/10.1186/s12871-018-0512-x Randomized double blind clinical study 21 Patients in the ASA I-II risk group, undergone an elective Csection, were randomly assigned to the study. Sample Size = 80 Women with term pregnancy of 37 to 42 weeks scheduled for elective CD under spinal anesthesia. Sample Size = 153 Epidural group and TAP block with spinal group Patients undergoing caesarean delivery. Sample size = 139 TAP block with 0.375% ropivacaine group, TAP block with 20 ml saline Tap block with liposomal bupivacaine, intrathecal morphine, and tap block plus intrathecal morphine Symptom Inventory at the first, third, and sixth months after surgery. The amount (mg) of total analgesics received by the patients in the first 24 hours of the postoperative period The LB and LB + ITM groups were compared with the ITM group for all efficacy outcomes. Postsurgical opioid consumption in morphine milligram equivalents through 72 h was compared by assessing noninferiority before testing superiority. Postsurgical pruritus severity was assessed on an 11-point numerical rating scale. All the subjects received a standard spinal anesthetic and diclofenac was administered for postoperative pain. Breakthrough pain was treated with tramadol. Post-operatively, all the subjects were assessed at 0, 2, 4, 6, 8, 10, 12, The epidural anesthesia is still the golden standard to achieve a post caesarean analgesia. Epidural anesthesia is a considerably effective method in controlling the postoperative pain. LB TAP block with or without ITM resulted in statistically noninferior postsurgical opioid consumption through 72 h, reduced pruritus, and favorable safety compared with ITM in women undergoing CD. TAP block reduces pain, prolongs the duration of analgesia and decreases supplemental opioid consumption when used for multimodal analgesia for pain relief after caesarean section PAIN MEDICATION USE AFTER CAESAREAN SECTION Kwikiriza, A., Kiwanuka, J. K., Firth, P. G., Hoeft, M. A., Modest, V. E., & Ttendo, S. S. (2019). The analgesic effects of intrathecal morphine in comparison with ultrasound-guided transversus abdominis plane block after caesarean section: a randomized controlled trial at a Ugandan regional referral hospital. Anaesthesia, 74(2), 167173. https://doi.org/10.1111/anae.14467 Prospective, Randomized controlled trial Nedeljkovic, S. S., Kett, A., Vallejo, M. C., Horn, J. L., Carvalho, B., Bao, X., Cole, N. M., Renfro, L., Gadsden, J. C., Song, J., Yang, J., & Habib, A. S. (2020). Transversus Abdominis Plane Block Randomized, Doubleblind, Women were eligible for enrolment if they fulfilled the following inclusion criteria: between the ages of 15 and 49; receiving spinal anesthetic without sedation for an uncomplicated caesarean delivery via a low, transverse abdominal incision (Pfannenstiel); in good health, with no major medical problems (ASA status 2); and able give informed consent. Sample size = 130 Women with term pregnancies undergoing 22 Intrathecal Morphine group, TAP block group Tap block with liposomal bupivacaine plus 18 & 24 h. The primary outcome was the time to first analgesic request The subjects were reviewed at 8 h, 16 h and 24 h following the placement of intrathecal morphine or TAP block by a research assistant, a qualified midwife trained in data collection. The primary end point was total postsurgical opioid consumption through 72 hours. Pain The study found that intrathecal morphine and TAP block provided clinically similar outcomes for pain relief after caesarean section TAP block using LB plus bupivacaine HCl as part of a multimodal analgesia protocol incorporating PAIN MEDICATION USE AFTER CAESAREAN SECTION With Liposomal Bupivacaine for Pain After Cesarean Delivery in a Multicenter, Randomized, Double-Blind, Controlled Trial. Anesthesia and analgesia, 131(6), 18301839. https://doi.org/10.1213/ANE.0000000000005075 controlled trial Staker, J. J., Liu, D., Church, R., Carlson, D. J., Panahkhahi, M., Lim, A., & LeCong, T. (2018). A triple-blind, placebo-controlled randomized trial of the ilioinguinal-transversus abdominis plane (ITAP) nerve block for elective caesarean section. Anaesthesia, 73(5), 594602. https://doi.org/10.1111/anae.14222 Triple blind, controlled randomized trial Yu, Y., Gao, S., Yuen, V. M., Choi, S. W., & Xu, X. (2021). The analgesic efficacy of ultrasoundguided transversus abdominis plane (TAP) block combined with oral multimodal analgesia in comparison with oral multimodal analgesia after caesarean delivery: a randomized controlled trial. BMC anesthesiology, 21(1), 7. https://doi.org/10.1186/s12871-020-01223-3 Randomized Control Trail elective cesarean delivery under spinal anesthesia Sample Size = 186 We recruited ZRPHQ \HDUVDQG kg who were scheduled for elective caesarean section with spinal anesthesia between February and July 2016. Sample size = 100 Parturient who were scheduled for elective caesarean delivery under spinal anesthesia Sample Size = 159 23 bupivacaine HCI, and tap block with bupivacaine HCI alone intensity was measured using a visual analog scale intrathecal morphine resulted in reduced opioid consumption after cesarean delivery I-TAP group, control group The primary outcome was total fentanyl consumption at 24 h. This trial demonstrated that the addition of the I-TAP block to a multi-modal analgesic regimen resulted in a 59% reduction in total PCA fentanyl dose over the first 24 h after elective caesarean section Placebo vs TAP block group All the parturient were evaluated for pain or related complications in the first 24 h after surgery. The primary outcome is the percentage of parturient who required oxycodone as a rescue analgesia. Bilateral single-shot of TAP blocks confer little additional benefit when a multimodal oral analgesic regimen is used for pain control after caesarean section under spinal anesthesia. PAIN MEDICATION USE AFTER CAESAREAN SECTION 24 Appendix B Data Collection Tool Patient Type of Anesthesia Received TAP Block? Required Rescue Pain Medication within 24 hours? Patient A General Yes No Patient B Spinal Yes No Patient C Spinal No Yes Patient D Spinal Yes No PAIN MEDICATION USE AFTER CAESAREAN SECTION Appendix C IRB Approval Institutional Review Board DATE: 05-02-2023 TO: Nicholas Ramey & Dr. Derrianne Monteiro FROM: Institutional Review Board RE: S23.165 TITLE: SUBMISSION TYPE: A Retrospective Study on the Use of Rescue Pain Medication in Patients Who Receive Transabdominal Plane Blocks Post Caesarean Sections New Project ACTION: Determination of EXEMPT Status DECISION DATE: 05-02-2023 The Institutional Review Board at Marian University has reviewed your protocol and has determined the procedures proposed are appropriate for exemption under the federal regulation. As such, there will be no further review of your protocol and you are cleared to proceed with your project. The protocol will remain on file with the Marian University IRB as a matter of record. Although researchers for exempt studies are not required to complete online CITI training for research involving human subjects, the IRB recommends that they do so, particularly as a learning exercise in the case of student researchers. Information on CITI training can be found on the IRBs website: http://www.marian.edu/academics/institutional-review-board. It is the responsibility of the PI (and, if applicable, the faculty supervisor) to inform the IRB if the procedures presented in this protocol are to be modified of if problems related to human research participants arise in connection with this project. Any procedural modifications must be evaluated by the IRB before being implemented, as some modifications may change the review status of this project. Please contact me if you are unsure whether your proposed modification requires review. Proposed modifications should be addressed in writing to the IRB. Please reference the above IRB protocol number in any communication to the IRB regarding this project. __________________________________________ Amanda C. Egan, Ph.D. Chair, Marian University Institutional Review Board 25 

 

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... Class of 2023 Graduation Speech Mario Perez Good evening, friends, family, faculty, staff, and, most importantly, the class of 2023. I want to thank everyone who is here and thank God for putting me in this position to speak to you all. To my fellow graduates, We Made it. The all-nighters, the long essays, the group projects. It has all paid off. We came to this institution in search of an education, yet as we depart its hallowed halls, we realize that our experience here has yielded far more than academic knowledge. I remember walking into my first college class unsure if I belonged. I sat there in Mrs. Singletons class playing images in my head of how my college experience would unfold. Stressing myself so early on if I was apt to be in high standards. To say the least, I was scared. As my journey progressed, I gradually came to embrace my individuality, buoyed by the affirmations of my educators. My path was not easy. It was filled with trials and tribulations but through this, there were 3 pieces of advice I received that served as a lighthouse. I want to share them with you as you embark on your new journeys. Number one. Dont be afraid to fail. Many successful people have faced failures along the way, but they persevered and learned from their mistakes. Failure is a valuable opportunity for growth and learning, and it is often a necessary step on the path to success. So don't be afraid to take risks. Pick up a new hobby, start a business, ask that person out. Try new things and make those mistakes. Embrace failure as a teacher and use it as motivation to push yourself even further. Remember, the only true failure is giving up on your dreams. Number two. Value your relationships I urge you to remember the importance of valuing relationships and not letting school define you. While academic achievements are undoubtedly important, they are not the only measure of success. It is equally important to cultivate meaningful relationships with the people in your life. These can provide you with the support, love, and guidance you need to succeed in all areas of your life. So, don't forget to take the time to nurture your connections, whether it's with your family, friends, or significant other. This graduation is just the beginning of your journey, so don't let school overshadow the people that will sustain you throughout your life. Number 3. Be Yourself College is a time of tremendous growth and self-discovery, and it's natural to feel pressure to conform to the expectations of others. However, I challenge you to resist that pressure and to embrace your true self. When you embrace who you truly are, you open yourself up to new experiences, new perspectives, and new relationships that will enrich your life in ways you never thought possible. Do not be afraid to express your unique talents, interests, and passions, even if they don't fit neatly into society's expectations. Remember that the world needs your unique gifts and that by being true to yourself, you inspire others to do the same. So, I impulse you to embrace your individuality and to be confident in your own skin. Now as we depart from this graduation into another chapter of our life. I urge you to take what you have learned here and use it as a springboard to soar to new heights. This moment marks the culmination of years of hard work, dedication, and sacrifice, and it is a testament to your perseverance and tenacity. As you step out into the world, remember that the journey does not end here. Instead, it is merely the beginning of a new chapter in your lives, one that is filled with endless possibilities and opportunities. Stay hungry, stay curious, and never lose sight of your dreams. Let the fire within you burn brightly and never allow the setbacks and challenges of life to extinguish it. Remember that every great achievement begins with a dream, and it is only through perseverance, hard work, and dedication that we can bring those goals to fruition. So, hold fast to your aspirations, remain focused on your goals, and let your passion drive you forward. And when you do finally achieve everything, youve ever wanted, do not forget the hard work and dedication it took to get there and use your success to inspire others to pursue their own dreams. Congratulations, class of 2023, go out there and create a better tomorrow for all. Mario Perez Associate in Science Exercise Science Class of 2023  ...

... ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students graduating in May 2023 Anatomage Table and Effects on Improving Clinical Anatomy Knowledge and Competence in Anesthesia Procedures and Assessment Chidimma N. Offiah and Precious Hogo Marian University Leighton School of Nursing Chair: Bradley Stelflug, DNAP, CRNA (Signature) Project Team Members: Dr. Erica Ausel _________________________ (Signature) Christina Pepin RN PhD CNE _________________________ (Signature) Date of Submission: March 7, 2023 1 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 2 Table of Contents Abstract ........................................................................................................................................... 4 Anatomage Table and Effects on Improving Clinical Anatomy Knowledge and Competence in Anesthesia Procedures and Assessment.......................................................................................... 6 Background ................................................................................................................................. 7 Problem Statement ...................................................................................................................... 9 Needs Assessment and Gap Analysis ......................................................................................... 9 Literature Review Methods....................................................................................................... 10 Review of the Literature ............................................................................................................... 12 Theoretical framework .................................................................................................................. 20 Aim ........................................................................................................................................... 22 Objectives ................................................................................................................................. 22 SWOT Analysis ........................................................................................................................ 22 Project Design / Methods .............................................................................................................. 24 Project Site and Population ....................................................................................................... 24 Measurement Instruments ......................................................................................................... 24 Data Collection Procedures....................................................................................................... 25 Ethical Considerations / Protection of Human Subjects ........................................................... 27 Project Evaluation Plan ............................................................................................................. 27 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 3 Data Analysis and Results ............................................................................................................ 28 Quantitative Results/Analysis ................................................................................................... 28 Qualitative Results/Analysis ..................................................................................................... 31 Quantitative Discussion ............................................................................................................ 36 Qualitative Discussion .............................................................................................................. 39 Conclusion .................................................................................................................................... 41 References ..................................................................................................................................... 43 Appendix A ............................................................................................................................... 49 Appendix B ............................................................................................................................... 62 Appendix C ............................................................................................................................... 63 Appendix D ............................................................................................................................... 64 Appendix E ............................................................................................................................... 65 Appendix F................................................................................................................................ 66 Appendix G ............................................................................................................................... 67 Appendix H ............................................................................................................................... 68 Appendix I ................................................................................................................................ 70 Appendix J ................................................................................................................................ 73 Appendix K ............................................................................................................................... 74 Appendix L ............................................................................................................................... 79 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 4 Abstract Background The Certified Registered Nurse Anesthetist (CRNA) profession is fast growing and at an all-time high, with over 56 thousand licensed professionals. Nurse Anesthetist programs are tasked with developing a high academic curriculum with a strong anatomy course at its core. In a hospital setting, CRNAs are considered the airway experts that respond to airway emergencies, called to perform Transesophageal Echocardiograms (TEEs), Point of Care Ultrasounds (POCUs) including high risk procedures such as Peripheral Nerve Blocks (PNB), spinals and epidurals. Hence, a sound working knowledge of anatomical structures and their relationship to surrounding structures is vital. To bridge the gap in knowledge and comprehension of anatomy, several curriculums are starting to employ the use of virtual reality or 3D technology as an adjunct to learning anatomy. The Anatomage Table (AT) is the first 3D virtual dissection table that allows users to visualize anatomy at the highest level of accuracy. The AT is a fairly new technology developed in 2004 with limited research published to address its usefulness in graduate/undergraduate nursing programs. No research was found that evaluates the effectiveness and impact of the AT in learning anatomy in the Nurse Anesthesia Program. Purpose: The purpose of this project is to evaluate the effectiveness and perceived benefits of the AT to improve the knowledge of clinical anatomy and enhance performance of point-of-care assessments and interventional anesthesia procedures in first year student registered nurse anesthetists (SRNA) during the 2021-2022 academic year. Methods: This was a two-part project, a sequential explanatory mixed methods design. Quantitative and qualitative data were evaluated using a pre and post-test, a self-efficacy tool, an open-ended questionnaire, and a PNB simulation exam. ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 5 Utilizing prebriefing video teaching airway anatomy and its innervations was published for students to view prior to attending a hands-on simulation. A pretest was given prior to the simulation experience followed by a posttest, a self-efficacy survey and an open-ended questionnaire. Subsequently, the AT was used as an adjunct to teach interscalene block prior to their PNB simulation exam. The previous cohort who received teaching using traditional methods (lecture, mannikin, cadaver) was used as a comparison group. Results: Mean knowledge scores increased from 9.40 2.46 in the pretest to 10.56 2.42 in the posttest (p=.052). p>0.05. However, students reported the AT as an effective teaching tool that enhanced their knowledge of anatomy, increased retention, and had a positive impact on clinical preparedness. Keywords: Virtual reality, Anatomy [Education], Anatomage, 3D Visualization, 3-dimensional education, three-dimensional image, or imaging, ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 6 Anatomage Table and Effects on Improving Clinical Anatomy Knowledge and Competence in Anesthesia Procedures and Assessment 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. Integrating 3D Anatomage Table into the nurse anesthesia curriculum shows promise to increase knowledge of clinical anatomy. A sound working knowledge of anatomy gained from Anatomage training will enhance the Students Registered Nurse Anesthetist (SRNA) performance of peripheral nerve blocks (PNBs), emergency cricothyroidotomy, and assessment of cranial nerve (CN) function during and after surgery. This DNP project seeks to assess students level of anatomy knowledge and competence gained from Anatomage training modules and live sessions on PNBs, laryngeal anatomy, and CN innervations. Performing a PNB involves the infiltration of local nerves that innervates a body region to be operated on with local anesthetics which then inhibits peripheral nerves from communicating with the central nervous system, thereby allowing the surgical procedure to take place without the patient feeling any pain (Hroux et al., 2019). The use of PNBs to facilitate surgical procedures is on the rise and presents tremendous benefits to patients in improving outcome and functional recovery. A significant 20% of upper extremity surgeries are carried out solely under PNBs while still rendering the body region immobile and/or painless, therefore eliminating the side effects of general anesthesia (Hroux et al., 2019). Side effects of general anesthesia include nausea and vomiting, sore throat, fatigue, and prolonged hospital stay (Hroux et al., 2019). According to Hroux et al. (2019) it has been established that the use of PNBs among the elderly population poses a greater advantage because studies have shown that it decreases the incidences of postoperative delirium that is otherwise rampant from the use of anesthetic agents. ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 7 Through technological advances neurologic injuries following PNB are rare (5 in every 10,000) with most being transient, PNBs is not without risk, hence devastating, and long-lasting complications could occur (Terracciano et al., 2019). The type of block and breaking the skin barrier with a needle places patients at risk for bleeding, infection, neuropathy, and damage to neighboring structures (Terracciano et al., 2019). Mechanical trauma from needle placements can be avoided through an in-depth knowledge of anatomy and anatomical variations in various populations. An advance knowledge of anatomy can be facilitated through the incorporation of the Anatomage Table in preparing SRNA's for clinical practice. Cadaver dissection has been the traditional teaching method for learning human anatomy, however, studies show enhanced learning experiences with the incorporation of 3D technology such as the Anatomage table. In a study conducted by Alasmari (2021), students preferred using 3D Anatomage as an adjunct tool to cadaver dissection in learning anatomy as it fostered interactive learning (Alasmari, 2021). Reports have shown that 89% of students agree that 3D Anatomage was instrumental to their understanding of the relationship between internal structures and visualizing the body system (Alasmari, 2021). Background Anatomy is the basis of all medical education. It is the fundamental basic knowledge to which healthcare providers build a solid background for clinical practice (Saverino, 2020). The practice of regional anesthesia such as PNBs particularly is inconceivable without a sound knowledge of the human anatomy. Hewson et al., (2018) highlighted a review article that reported that post-operative neurological symptoms suggestive of nerve injury after PNBs among anesthesiologist occur in 0-2.2% of patient in 3 months, 0-0.8% of patients in 6 months and 0-.2% of patient in 1 year. Several factors including nerve localization technique contribute to the ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 8 likelihood of nerve injury following a PNBs. The importance of a detailed knowledge of human anatomy in anesthesia education to ensure safe medical practices cannot be over emphasized. Trauma to the airway significantly contributes to patient morbidity and mortality. Moreover, airway injury constitutes 6% of the most common injuries leading to malpractice claims (Patwa & Shah, 2015). A sound knowledge of airway anatomy improves safety of the conduct of anesthesia, optimizes ventilation and airway patency (Patwa & Shah, 2015). Traditionally cadaver-based anatomical education has been the gold standard for hundreds of years. However, in recent years medical teaching institutions have looked to other modalities to enhance anatomy education due to limitations such as scarcity of cadavers, increasing costs in acquisition, maintenance, and time-consuming dissection-based instruction (Singal et al., 2020). Considering the covid 19 pandemic aftermath, cadavers are projected to become an even more rare commodity as body donors may be carriers or would have died of covid 19 and currently, no screening tests exist to rule out this infection in donors (Singal et al., 2020). Therefore, it is not advisable to accept body donations for the safety of students and faculty (Singal et al., 2020). Moreover, students have reported inadequate exposure to anatomy during clinical training, such that there is a growing concern that medical students are not competent in anatomy knowledge when they enter clinical practice (Ghosh, 2017). While human cadaveric based instruction is the preferred pedagogy, students still express varied reactions to this method, presenting with differing levels of anatomy self-efficacy (Langfield et al., 2018). Although no single teaching tool has been found to meet all curriculum requirements, the multimodal approach has been advocated as the best way to teach modern anatomy (Estai & Bunt, 2016). Integrating 3D visualization technologies in anatomy education is one of the ways being explored to this effect. ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 9 Integrating 3D interactive visual technology such as the use of an Anatomage Table into the existing anesthesia program curriculum at Marian University may Anatomage Table is an advanced 3D visualization system that allows students to interact with digital cadavers for anatomy and physiology education. This DNP project will develop, pilot, and evaluate the perceived benefits of Anatomage Table incorporated into the current anesthesia education at Marian University. Problem Statement Lack of confidence in performing peripheral nerve blocks, and low levels of anatomy self-efficacy can lead to unsafe practice that may lead to dangerous patient adverse outcomes. In the past Marian SRNAs have relied on pictorial images from textbooks, YouTube videos, and anatomy apps to enhance classroom anatomy education. The growing evidence that anatomical understanding can be enhanced with the use of 3D resources along with the positive outcomes of evidence based multimodal approaches to anatomy education, has led to a new approach in the curriculum resulting in the acquisition of an Anatomage Table. Does the use of an AnatomageTable increase knowledge of clinical anatomy and enhance performance of regional anesthesia procedures in CRNA students compared to current practice? Needs Assessment and Gap Analysis The CRNA program at Marian University currently utilizes traditional teaching modalities for anatomy and physiology learning. Current modalities of teaching include textbooks, research papers, videos, anatomy applications, simulation, and lectures. Current evidence identifies the Anatomage Table as beneficial in improving students' understanding of human anatomy and showcases anatomical variations and could be a valuable tool in anatomy identification in various populations (Baratz et al., 2019). This new technology recently became available to Marian ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 10 Universitys health science department and has not yet been added into the SRNAs curricula. In general, students are nervous or may have inconsistent experiences within the clinical environment in performing PNBs, emergency cricothyrotomy, identification of cranial nerve innervation and neurovascular assessment via train-of-four. According to research, twenty-first-century medical students are encaustic and engaged with learning anatomy utilizing technology, which can be instrumental in creating or improving both students and faculties learning experiences (Baratz et al., 2019). Baratz explored the effectiveness of learning gross anatomy of the same regions via traditional cadaveric dissection and using the Anatomage table and found quiz scores to be the same regardless of learning modality except in the musculoskeletal system where the Anatomage Table group had significantly higher average quiz score (Baratz et al., 2019). The Anatomage Table group also expressed a significantly higher degree of excitement, perceived degree of comfort and preparedness (Baratz et al., 2019). The importance of thorough knowledge and competence of anatomy to clinical application is irrefutable, and with the limitations of traditional teaching modalities and cadaveric dissection, research suggests that multimodal pedagogical methods are most effective at teaching students anatomy when used in a complementary manner (Baratz et al., 2019). The implementation of cutting-edge technology to improve students' understanding of anatomy can prove valuable as studies show a correlation with its use and a positive impact on students perceptions on academic success (Baratz et al., 2019). Literature Review Methods This review of the literature sought articles specific to the use of an Anatomage Table/virtual dissection table in anatomy education. The literature search was conducted in December 2021, in three databases under four platforms: MEDLINE-Ovid, MEDLINE-Ebsco, ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 11 CINAHL-Ebscohost, and Google Scholar. A comprehensive search utilizing: advance search, keywords, synonyms, Boolean/Phrase, and Medical Subject Headings [MeSH] terms were used. The database search was limited to articles published in the English language, conducted on humans, and classified as a Clinical Trial (CT) or Randomized Controlled Trial (RCT), cohort study and retrospective studies. Primary terms used to search MEDLINE-Ebsco, CINAHLEbscohost and MEDLINE-Ovid database were Anatomage, anatomy education, 3D visualization OR 3-d visualization, and virtual cadaver, virtual reality, anatomy [Education], anesth$, Anatomage, three-dimensional image or imaging, Three-Dimensional/, 3D visualization, 3dimensional, education. The following Boolean phrases were used to narrow our search results to our specific topic; anatomy education AND 3D visualization OR 3-d visualization, virtual reality/ AND anatomy[Education], anesth$ AND virtual reality/, three-dimensional image or imaging, Three-Dimensional/ OR 3D visualization OR 3-dimensional, three-dimensional image or imaging, Three-Dimensional/ OR 3D visualization OR 3-dimensional AND anatomy[Education], anesth$ AND three-dimensional image or imaging, Three-Dimensional/ OR 3D visualization OR 3-dimensional, education AND anesth$ AND three-dimensional image or imaging, Three-Dimensional/ OR 3D visualization OR 3-dimensional. All articles that resulted from searching the keyword Anatomage were reviewed for relevance to the research topic. Lastly, Google Scholar was searched using the Anatomage virtual dissection table as the search term and all 375 results were scanned for relevance to the research topic. Exclusion criteria included meta-analysis and systematic review articles, posters, books, and non-sentinel articles that are not within the last five years. Full-text articles were reviewed and excluded based on lack of pertinence to area of focus, wrong intervention, and population of interest (i.e., simulation-based learning, Anatomage software, 3D non virtual Anatomage/dissection table, or ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 12 Anatomage for diagnostics). From the initial search results of 695 articles, 20 met criteria for inclusion in this review of the literature. These comprise varied types of studies which includes but are not limited to randomized control trials, quasi experimental, retrospective studies, and cross-sectional descriptive studies (See appendix A for a list of literature reviewed and appendix B Prisma diagram). Review of the Literature Anatomage Table and Research Samples The effects/outcomes of the use of the AT as teaching pedagogy in learning anatomy was explored as a means of improving academic performance, knowledge, radiologic interpretation, as well as a 3D dissection tool, and as an effective teaching method. The literature reviewed provided quantitative and qualitative evidence of the pivotal role and impact of teaching and learning anatomy utilizing a 3D virtual anatomy table such as the Anatomage Table (AT) and Sectra Table (ST). The qualitative evidence evaluated students perceptions and opinions regarding student satisfaction, usefulness, and effectiveness of learning. There was no significant difference in terms of age, gender, cohort, prior anatomy knowledge, or experience with the AT, cadaveric dissection, or virtual scalpels. There was equivalent prerequisite course work among the groups of participants enrolled in this review of the literature (da Silveira et al., 2021; Afsharpour et al., 2018; Bhadoria, 2021; Boscolo-Berto et al., 2021; Kazoka & Pilmane, 2019). Impact on Scores The literature was unanimous in showing an increase in students knowledge and performance in Anatomy course work, with the implementation of these modern human sized digital touch-screen table technology (Narnaware & Neumeier, 2021; Bhadoria, 2021; BoscoloBerto et al., 2021; Whited et al., 2021). Employing the AT as a modality of teaching anatomy to ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 13 medical students in more complex topics showed an increase in test grades, pre-exposure to AT (50.381.17(SE) compared to post-exposure to AT (56.941.18(SE) (P < 0.001) (Bhadoria, 2021). Further, an increase was found in the grades of students who were classified as poor performers (failing grade <50). An increase in grades was noted based on performance on monthly tests (161.83(SE), when compared to students classified as good performers (scored grades 50) whose grades increased about 3 points (3.32.08 (SE), which was statistically significant (P < 0.001) (Bhadoria, 2021). In congruence with findings of improved academic performance with the use of an AT, the few studies conducted on nursing students demonstrated a positive impact on increased knowledge reflected through students examination scores and grade point average (GPA) (Narnaware & Neumeier, 2021; Bianchi et al., 2020). Narnaware and Neumeier found the mean class average at mid-term#1, mid-term#2, mid-term#3, and final exam grades of students taught with the AT showed a significant increase when compared to students taught without the AT (See table 1). Table 1. Scores on nursing exams in groups with and without exposure to the AT Table term1 term 2 term 3 final Without AT 67.4 3.4 63.8 2.6 62.9 1.4 64. 2.4 With AT 71.4 2.8 68.3 2.8 66.2 1.5 68.9 1.9 (Narnaware & Neumeier, 2021, p. 311) Students using the AT had an overall higher GPA (3.0 0.09), when compared to students taught without the AT (2.74 0.12) (P < 0.05) (Narnaware & Neumeier, 2021). Bianchi et al. sought to find out if the implementation of the AT would enhance students performance and ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 14 result in a decrease in anxiety and subsequently improve performance (2020). A State-Trait Anxiety Inventory (STAI) test was used to evaluate students state of anxiety related to the final exam, and this revealed that the mean STAI score of the groups of students who attended the AT laboratory session (46.5) were significantly lower in comparison to the students who only attended the mandatory lectures (52.3) (Bianchi et al., 2020). They also found that none of the students in the AT group failed the final exam, compared to seven failures in the group without the AT (p < 0.05) (Bianchi et al., 2020). Impact With Combined Methods Some studies compared different teaching methods employed in improving students learning of anatomy, such as the AT, plastinated specimens, cadavers, anatomical models, textbooks, and lectures (Abdulrahman et al., 2021; Afsharpour et al., 2018; Boscolo-Berto et al., 2021; da Silveira et al., 2021; Whited et al., 2021; Baratz et al., 2019; Anand & Singel, 2014; Kausar et al., 2020). Studies showed that the use of only one of the teaching methods, the AT or others, in learning anatomy during the practical laboratory secession was not as effective as a combined approach (Abdulrahman et al., 2021; Boscolo-Berto et al., 2021; da Silveira et al., 2021; Baratz et al., 2019). Abdulrahman et al. found that students scored lower in an anatomy practical exam instructed using the AT (184.4) or plastinated specimens (18.34.6) alone, than students instructed using a combination of both teaching strategies (20.45.6) (P = 0.0001) (2021). Whited et al. not only found that a combination of cadaveric specimens and AT increased students confidence and knowledge of pediatric anatomy in all five body systems (i.e., Head, Eyes, Ears, Nose and Throat [HEENT], cardiovascular, respiratory, musculoskeletal, and neurological) (2021). They also found that graduate nurse practice students experienced an additional benefit from pairing up after each laboratory session to utilize previously learned ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 15 health assessment skills, to immediately apply anatomical knowledge gained in the laboratory (Whited et al., 2021). An early study by Anand and Singel found no significant difference in students test scores (P = 0.0979) between the use of the AT versus traditional dissection method in teaching neuroanatomy (2014). Persistence of Impact A question arises concerning whether the effects of combined teaching methods are seen only in lab examinations or if it is also reflected in overall course performance. Interestingly, a particular study comparing three pedagogies in teaching gross anatomy using cadavers, anatomical models, and AT in three different Doctor of Chiropractic student cohorts enrolled in a lecture and laboratory anatomy course, found significant improvements in laboratory exam scores between cohorts (p < .001), but no significant differences were seen in lecture exam scores (Afsharpour et al., 2018). The average midterm and final laboratory exam scores between cohort 1, cohort 2 and cohort 3 showed a successive significant increase (mean= 76.1%, 81.4%, and 85.1% respectively) in learning with cadavers, anatomical models, and AT respectively, but the mean lecture exam scores (61.2%, 62.4% and 61.1%) remained consistent between cohorts (Afsharpour et al., 2018). Baratz et al. also compared the use of the AT to cadaveric dissections in teaching about the pelvis and perineum (P/P) and musculoskeletal system (MSK), they found the AT group had a significantly higher average quiz score in the MSK (p = 0.03), but no difference was found between the two modalities in P/P during the post-lab quizzes (2019). However, the practical exam results showed no significant difference when the mean exam scores of the AT and cadaver practical exams were compared in both the P/P (p = 0.83) and MSK (p = 0.41) anatomical regions (Baratz et al., 2019). ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 16 Impact on Radiologic and Surgical Skills Studies showed that the AT was useful as an educational radiologic imaging modality and as a dissection tool, as students were able to create incisions and cuts to remove and uncover different layers of organic tissues (Kazoka & Pilmane, 2019; Paech et al., 2017). Kazoka and Pilmane showed that the advantage of adding virtual scalpels to Human Anatomy course outweighed the disadvantages as students learned how to control the directions, length, and depth of all performed incisions, identify special anatomical structures, understand spatial relationships among organs and learned a variety of ways to better illustrate layer and topographical anatomy using 3D format (2019). Paech et al. evaluated three approaches to using radiologic anatomy (RA) in the teaching of general anatomy: group 1- included students training in RA seminar and cadaver CT scans on the AT; group 2 utilized RA seminar and group 3 had neither the seminar nor the CT cadaver/AT (2017). The AT and cadaver CT scan combination resulted in an average test score of 21.8 5.0, when compared to RA seminar group alone (18.3 5.0) and the group without any radiologic image interpretation training (17.1 4.7) (p < 0.001). Student Perception of the Anatomage Table Determining student perception of the AT teaching modality is integral to the impactful use of the modality. Qualitative data from questionnaires, free text responses and Likert -type responses were reported in several studies (Narnaware, & Neumeier, 2021; Tenaw, 2020; Kazoka & Pilmane, 2019; Paech et al., 2017; Boscolo-Berto et al., 2021). In this literature review, studies were assessed for student overall satisfaction, perception of usefulness of the AT technology, perception of usefulness compared to other teaching modalities, and student assessment of the AT contribution to learning. ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 17 Student Satisfaction Perception on student satisfaction with the use of AT was examined (Narnaware, & Neumeier, 2021; Tenaw, 2020; Kazoka & Pilmane, 2019; Paech et al., 2017; Boscolo-Berto et al., 2021) and most students in each study believed the implementation of the AT improved their comprehension of the human body. Students indicated they would recommend this teaching tool to other students and believed it provided a truer perception of the human body. However, there was less agreement as to the effectiveness of the AT when compared to other resources. Narnaware and Neumeier (2021) found that while 51.3% preferred the AT to the use of an actual human cadaver, 46.6% preferred a cadaver. Kazoka and Pilmane (2019) reported that 70% of the students were satisfied with the virtual dissection and/or their own prepared anatomical 3D models, but the students also highlighted the role and necessity of real dissection. A greater percentage however thought that use of virtual dissection with AT alone was enough to teach and study anatomy (45.25% students), while 24.75% preferred printed 3D anatomical models and the classical methods of learning and teaching anatomy (Kazoka & Pilmane, 2019). Students reported that the use of AT was a more engaging experience than studying textbooks and atlases (Boscolo-Berto et al., 2021). Boscolo-Berto et al. also reported that students cited advantages of performing procedures on life-size male or female virtual cadavers, viewed from different angles and tissue levels and were able to perform different types of cuts, create incisions, uncover different layers of tissue, reattach bones, muscles, blood vessels and back to the skin level (2021). Students enjoyed the virtual tools in the practical classes and said that they learned theoretical material better (Pilmane & Kaoka, 2019; Alasmari, 2021). ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 18 Anatomage Table Usefulness Usefulness of the AT expressed by students in the teaching and learning of human anatomy was reported by Tenaw (2020) and Kazoka and Pilmane (2017). Both research studies showed that students found the AT to be interesting and an effective learning tool for developing their knowledge and skills, collaborative learning, and learning anatomical language of the structures. The students who spent more time with the AT had a more positive perception (Tenaw, 2020; Kazoka & Pilmane, 2017; Fyfe et al., 2018). Students appreciated the active participation, the ability to manipulate the virtual cadaver, and the topographical relationship between anatomical structures to better understand relational anatomy and cross-sectional imaging (Kazoka & Pilmane, 2017). Student Perception of AT Compared with Other Teaching Methods When comparing the AT with other teaching modalities such as human cadaveric specimen, plastination specimen, as well as combination of modalities (multimodal approach), there were more positive attitudes from students in favor of a combined teaching model as opposed to a sole teaching modality (Abdulrahman et al., 2021; da Silveira et al., 2021; Alasmari, 2021; Kazoka & Pilmane 2019). The 3D Anatomage Table was preferred as an additional tool to cadaveric dissected specimens in learning anatomy. Kazoka and Pilmane (2019) reported that students gave preference to a combination of real and virtual dissection and printed 3D models, reinforcing their objective research finding that use of the combined methodology increased the students' learning experiences. When students reported that they were more excited and perceived a greater degree of learning while using the AT Table, they also showed objective improvement in test performance as reported above (Baratz, 2019). Students practical engagement was found to enhance active learning (Alasmari, (2021; Baratz, 2019; ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 19 Kazoka & Pilmane, 2017). Making sagittal, parasagittal, coronal, and transverse sections of the digital body in 3D AT boosted their understanding of relational anatomy (Alasmari, 2021). Taken together, the findings of these studies indicated that the addition of an AT to traditional teaching modalities has consistently been viewed as a positive enhancement to anatomy education. Student Perception of AT Effectiveness of Learning Anatomy Most of the students agreed that virtual dissection with AT deepened their understanding and improved their learning experience (Bhadoria, 2021; da Silveira et al., 2021; Anand & Singel, 2014; Custer & Michael, 2015). Students stated that it provided them with a threedimensional perspective of structures and helped them recall (Bhadoria, 2021). Students reported that learning took less time compared with traditional learning (da Silveira et al., 2021; Anand & Singel, 2014). Most students found the AT to be an effective teaching tool because it allowed them to visualize relative size of different parts of brain and spinal cord better, visualize relations of different parts better and enhanced overall classroom experience (Anand & Singel, 2014). Students also felt that they were better prepared to enter the health care profession (Custer & Michael, 2015). Student Perception of a Similar Virtual Anatomical Table Technology Like the AT are other 3D dissection tables for example, the Sectra Table and Sectra Board (Sectra Group, Linkping, Sweden) which have also been studied and yielded similar results of student satisfaction (Kausar et al., 2020; Whited et al., 2021; Bianchi et al., 2020). Student feedback from these studies revealed the perception of students regarding the use of Sectra. All the students showed strong positive responses towards the use of Sectra, and none responded negatively. Whited et al. (2021) reported qualitative data revealing many positive ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 20 themes in relation to the anatomy review experience. Most of the students reported that using the 3D Sectra Table and prosected cadavers was a beneficial experience (Whited et al., 2021). Overall, students reported that they had a much more in-depth understanding with Sectra than they had viewing images in a textbook. A student, identified as a visual learner, stated: It really helped connect where everything is located, and also why and how certain systems work (Whited et al., 2021, p. 350). Other students cited benefits that included interactivity, use of images from real patients instead of generic illustrations, and use of case studies in combination with the images and scans. Bianchi et al. (2020) reported that 100% of students indicated satisfying or very satisfying as their degree of interest in the subject, the quality of the AT and its useful application in their nursing education. All the students in the Bianchi study also described their level of knowledge as satisfying or very satisfying. In summary, qualitative data on the use of AT reported high levels of student satisfaction. Similar results were found for studies in which a similar table, the Sectra Table, was used. It appears that a high quality virtual anatomical teaching table, the AT, produces quantitative and qualitative improvements in anatomy education. The Sectra Table research also supports the use of the virtual anatomical teaching tool, although it is beyond the scope of this paper to determine if one table is preferable to the other. Theoretical framework The framework used to guide this project is Kolb's experiential learning theory. The theory is represented by a four-stage cycle which the learner must execute for an effective learning experience (Kolb & Kolb, 2009). The four stages of the model are as follows: Stage 1. having a concrete experience, followed by ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 21 Stage 2. an observation of and reflection on that experience which then leads to Stage 3. the formation of abstract concepts and that are in turn, finally used to test Stage 4. hypothesis resulting in new experiences. In addition to providing a process for experiential learning, Kolb emphasizes the concept of individual learning styles as well as an opportunity for each learner to acquire knowledge, based on their individual preferences (Kolb & Kolb, 2009). The learning styles are not addressed in this project. (See appendix C-Framework). Stage 1 Concrete Experience Students encountered a new experience by watching Anatomage Table instructional videos on navigating the virtual 3D human cadaver. These videos were aimed at enhancing base knowledge on the airway anatomy structures, muscles and Peripheral nerve innervation. Stage 2 Reflective Observation of the New Experience Reflective observation occurred during and after the simulation debriefing phase. Students were invited to give a review, reflections and feedback on the videos watched and the active participation experience with the Anatomage Table. The students human anatomy self-efficacy was evaluated using a self-efficacy instrument developed by Baldwin et al. (1999). Stage 3 Abstract Conceptualization The students were allowed to consider the relevance of the Anatomage Table experience and were also encouraged to consider new ideas to utilize the Anatomage Table. Stage 4 Active Experimentation ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 22 During the active experimentation phase, learners applied what was learned into practice. They navigated through the Anatomage table performing different activities and case studies. Aim The aim of this project was to develop, pilot, and evaluate the perceived benefits of an Anatomage table to improve the knowledge of clinical anatomy and enhance performance of pointof-care assessments and interventional anesthesia procedures. Objectives 1. Develop Anatomage Table instructional videos by March 2022 2. Provide guidance navigating Anatomage Table during the experimentation phase 3. Utilize a self-efficacy scale after the active experimentation phase 4. Utilize pretest-posttest design before and after active experimentation phase 5. Examine the differences in the pretest and posttest scores during summer of 2022 SWOT Analysis In conducting a Strength, Weakness, Opportunities, and Threats (SWOT) analysis to evaluate the overall project design highlighted several factors that will help in anticipating challenges and steer the project down a successful path. The application of technology in the field of medicine has grown over the years and is responsible for breakthrough medical advances and its role in understanding anatomy is evident. Twenty-first-century medical students enjoy learning anatomy with technology such as the Anatomage Table and report improved learning experiences (Baratz et al., 2019). The Anatomage Table is an expensive learning tool, and with one shared amongst the health science departments, it creates limited access for participants to practice training interventions. Successfully acquiring more and implementing the Anatomage Table would ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 23 strengthen the CRNA programs curriculum, potentially making it known as one of the best CRNA programs in the Midwest due to the potential for increased knowledge, confidence, and success in performing procedures that require a sound knowledge of anatomy in the community. And lastly a foreseen threat towards the project being implemented permanently within the CRNA's programs curriculum is lack of faculty training. With an already full curriculum in place, housing this project and finding a good fit for it within the curriculum could be a problem, thus making it a stand-alone tool that can be easily forgotten. (See appendix D- SWOT Analysis). ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 24 Project Design / Methods An educational intervention design was chosen to effectively answer our PICOT question and address this projects aims. To further explore this projects goals, a mixed methods design-specifically the sequential explanatory design type-- was used to obtain data for the project. A mixed methods design, combining quantitative and qualitative measures, provided a more complete and nuanced investigation of our PICOT question. The sequential explanatory design is preferred because it retains the exact order in which the quantitative and qualitative data will be collected for this project. We followed the requirements of the sequential explanatory design which typically first collects quantitative data by using a pre and post-test and result from a PNB simulation exam (interscalene), followed by qualitative data utilizing an open-ended questionnaire, a self-efficacy tool and lastly, a final explanation/analysis. Project Site and Population This DNP project was implemented at a private, liberal arts university in the Midwest. The target population was the first year Students Registered Nurse Anesthesia (SRNAs). There was equivalent prerequisite course work amongst participants, none having prior experiences with the AT. Inclusion criteria included first year Nurse Anesthesia Students and exclusion criteria included unwillingness to participate in the project and prior experience with the AT. Recruitment methods included an email sent out to the first year SRNAs to seek volunteers and another email sent out seeking participation from all SRNAs. Measurement Instruments A quantitative pre and post-test was utilized to measure baseline anatomical knowledge as well as knowledge change after pre-briefing videos and AT simulation teaching intervention. ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 25 The project team worked in collaboration to create the aforementioned tests and videos. The test consisted of 5 questions that were a combination of multiple choice, select all that apply, and matching questions see appendix E. The open-ended questioner consisted of 3 questions. See appendix F. For assessing educational process change, the Anatomy Self-efficacy instrument was used (Burgoon, 2012). This tool was originally developed by Baldwin in 1999 and called the Biology Self Efficacy Scale and has been subsequently modified by several other authors (Burgoon, 2012; Ainscough, 2016). The DNP project team made minor changes, with permission from the author to meet our specific needs but to maintaining the validity and reliability of the tool The Anatomical Self-Efficacy Instrument was incorporated into a survey and was filled after the AT intervention. The coefficient alpha for the anatomical self-efficacy instrument (composed of all 16 items) ranged from 0.90 to 0.96 depending on the survey administration, indicating the scale had a high degree of internal reliability (Ainscough et al., 2016; Burgoon et al., 2012). (See appendix G- Anatomical Self-Efficacy Instrument). Data Collection Procedures By implementing the AT as a teaching modality (intervention) we hoped to ascertain if students experience increased knowledge (outcome) and efficacy (outcome) to enhance their clinical performance of peripheral nerve blocks (PNBs) (outcome) as determined by the analysis of data collected pre and post implementation of interventions. To utilize the AT to properly ascertain the outcomes, this project used two pre-briefing videos demonstrating the use of the AT in learning two anatomical topics, followed by a simulation teaching session. To collect data to evaluate the effectiveness of our project, a pre-test was administered before participants viewed the pre-briefing videos, and prior to the simulation teaching sessions. After the simulation session a post-test, self-efficacy assessment and data from an open-ended questionnaire was ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 26 obtained to analyze the impact on knowledge and self-efficacy. See appendix H for the selfefficacy survey on PNB. In addition, data needed to assess enhanced performance on PNBs were collected by asking for volunteers from the sample population and providing them with a simulation teaching session after they have listened to the lecture portion of PNBs, and their traditional simulation teaching. No participant was denied access to the traditional teaching methods (lecture and simulation time). However, the volunteers received additional training on PNBs with the AT before the sample populations practical test out exam, to assess if volunteers from the sample population experienced enhanced performance during the test out. This process ensured an accurate measurement on the impact of the AT. This additional teaching with the AT was strictly voluntary to protect the integrity of this DNP project because the students willingly volunteered for this extra teaching modality. Students data from the test was de-identified by the simulation professor. This was done by assigning numbers instead of names to grades obtained before the data was made available to the designers of this project. The other prebriefing video (Laryngeal Airway anatomy and nerve innervation) and simulation teaching session was provided to the entire sample population but only knowledge and self-efficacy was evaluated. See appendix I for the self-efficacy survey on Laryngeal airway anatomy and nerve innervation Simulation. The project design takes guidance from recent reports from committees concerned with advanced nursing practice education. Incorporating recommendations from the Healthcare Simulation Standards of Best Practices, we provided pre-briefing videos to teach participants how to utilize the AT to learn three anatomy topics that are vital for an SRNA (INACSL, 2021). According to the International Nursing Association for Clinical Simulation and Learnings (INACSL) best practices, pre-briefing videos ensure that simulation participants were adequately ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 27 prepared for the educational content and are knowledgeable in the processes and procedures for the simulation experience(2021). Ethical Considerations / Protection of Human Subjects This DNP project was deemed exempt by the Marian University Internal Review board (see appendix J). Data from the participants were collected through pre and post-test and self-efficacy surveys provided via Canvas. In addition, data from the open-ended questionnaire was collected electronically and went through a de-identification process by the course faculty before it was made available to the designers of this project for statistical analysis. Access to data was limited to the course faculty and the designers of this project. No risks were identified. Consent was implied by the willingness to participate. participate in the AT training intervention had the opportunity extended to them after the data collection was completed. Project Evaluation Plan For the quantitative analysis of the data, a Wilcoxon signed ranked t-test was utilized to evaluate the effectiveness of the pre-briefing videos and AT simulation teaching intervention by determining if the difference between the pre and posttest were statistically significant. An independent samples t-test was utilized to analyze the PNB check off examination scores of the SRNAs who participated in the AT training intervention to those who did not participate in the AT intervention. To analyze the qualitative data, a structured analysis method was utilized where thematic analysis of the open-ended questionnaires was evaluated, identifying patterns of themes in the interview data. Lastly, descriptive statistics were utilized to analyze data from the Self Efficacy Instrument. ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 28 Data Analysis and Results Quantitative Results/Analysis Laryngeal airway anatomy and nerve innervation Simulation: Pre & Post test For the quantitative analysis of the data, a Wilcoxon t-test was utilized to evaluate the effectiveness of the pre-briefing videos and AT simulation teaching on laryngeal airway anatomy and its innervations. Overall, the SRNAs were able to achieve markedly higher scores in the airway anatomy knowledge posttest when compared to the pretest. In the sample size of 27 SRNAs, the mean of the test scores increased from 9.40 2.46 in the pretest to 10.56 2.42 in the posttest (see table 3). However, no statistically significant difference was found in the results (W = 93.000, z = -1.629, p = 0.052, r=-0.313) (see table 2). Table 2. Wilcoxon signed rank Paired Samples T-Test Measure 1 Pre Measure 2 - Post W z 93.000 -1.629 df p 0.052 Note. For all tests, the alternative hypothesis specifies that Pre is less than Post. Note. Wilcoxon signed-rank test. Table 3. Descriptive Statistics Pre-Test Median 10.000 Post-test 11.000 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION Mean 9.407 10.556 Std. Deviation 2.469 2.423 Minimum 3.000 5.000 Maximum 13.000 13.000 29 N =27 The self-efficacy posttest survey was given to assess the self-efficacy of students after participating in Laryngeal airway anatomy and nerve innervation AT training. The maximum score on all questions was a 5 (Totally confident) while Q12 and Q13 had a minimum score of 1 (Not at all) (see table 4). For frequency tables on Laryngeal airway anatomy and nerve innervation Simulation Self-Efficacy posttest survey questions please refer to appendix K. Table 4. Laryngeal airway anatomy and nerve innervation Simulation: Self-Efficacy posttest survey Descriptive Statistics Mean Std. Deviation Minimum Maximum Q1 3.727 0.761 2 5 Q2 3.636 0.699 2 5 Q3 4.03 0.684 3 5 Q4 3.667 0.645 2 5 Q5 4.03 0.684 3 5 Q6 3.879 0.6 3 5 Q7 3.939 0.659 3 5 Q8 3.818 0.808 2 5 Q9 3.727 0.719 2 5 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION Q10 3.788 0.696 2 5 Q11 3.97 0.728 2 5 Q12 3.545 0.905 1 5 Q13 3.364 0.895 1 5 Q14 3.788 0.696 2 5 Q15 3.697 0.684 2 5 Q16 3.879 0.65 3 5 N= 33 PNB Assessment Exam Results A total of 33 SRNAs participated in the PNB (interscalene) skills examination. An independent samples t-test was used to calculate the mean scores of participants who attended the Anatomage Table (AT) training prior to the check off examination (project group) and the mean scores of those that had no AT training prior to the check off examination (comparison group). No significant difference was found (t(31)= -0.536, p>0.05)(see table 5). The mean of the AT trained participants (M = 94.118, sd = 16.606), was not significantly different from the mean of those that did not have the AT training (M = 96.875, sd = 12.500) (see table 6). Table 5. Independent Samples T-Test 95% CI for Mean Difference Scores t df p Mean Difference SE Difference Lower Upper -0.536 31 0.596 -2.757 -13.244 7.730 Note. Students t-test 5.142 30 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 31 Table 6. Group Descriptives Scores Group N Mean SD SE Coefficient of variation AT training 17 94.118 16.605 4.027 0.176 No AT training 16 96.875 12.500 3.125 0.129 The self-efficacy posttest survey was given to assess the self-efficacy of students after participating in PNB training with the AT. The maximum score on all questions was a 5 (Totally confident) while Q13 had a minimum score of 2 (Only a little confident) (see table 7). For frequency tables on PNB Self-Efficacy posttest survey questions, please refer to appendix L. PNB Self-Efficacy Survey Table 7 Descriptive statistics Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Q14 Q15 Q16 4.58 4.58 4.42 4.58 4.42 4.17 4.42 4.33 4.5 4.42 4.42 4.42 3.58 4.08 4.17 4.58 0.52 0.52 0.67 0.52 0.79 0.72 0.67 0.65 0.67 0.52 0.52 0.79 0.9 0.67 0.72 0.52 Minimum 4 4 3 4 3 3 3 3 3 4 4 3 2 3 3 4 Maximum 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Mean Std. Deviation N = 12 Qualitative Results/Analysis Evaluation of the Perceived Benefits of Utilizing the Anatomage Table to Enhance Knowledge of Clinical Anatomy ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 32 Participants were asked three open ended qualitative question regarding perception of the AT as an adjunct to facilitate knowledge and competence in identifying anatomical structures that would translate to safety in performing peripheral nerve blocks (PNB) and laryngoscopy in the clinical setting. These questions included: 1. In what ways they felt the knowledge gained from the utilization of the AT would be helpful in their clinical and future practice as a CRNA 2. In what ways was the AT laboratory experience beneficial or not to their understanding of airway anatomy and innervation and lastly, 3. In what does the AT compared to prior methods utilized to learn airway anatomy. A total of 33 participants were involved in this DNP project. Three themes emerged from the analysis of the three open ended qualitative questions posed to the participants in a survey. These themes were: effective teaching tool, enhanced retention, and superiority of the AT teaching technique over other teaching modalities they had experienced. A full list of themes and codes are available in Table 7. Each of these themes will be discussed below with codes and exemplars. Table 7 Theme Code Effective teaching tool Enhanced Knowledge of anatomy Positive impact on clinical preparedness Enhanced retention Visual and kinesthetic learning Interactive 3D learning Superiority Realistic and applicable Engaging and communication Effective teaching tool ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 33 Of the 33 participants, all 33 (100%) indicated in the first question asked that the AT was an effective teaching tool which solidified their knowledge of anatomy, and positively impacted their confidence and preparedness for clinical competence. The two codes that were identified with this theme are: enhanced knowledge of anatomy and positive impact on preparedness. One of the participants replied stating that with the AT laboratory experience I will be able to better identify and be able to know where nerves come from and the tract they take as well as know the anatomy I am looking at while intubating. Utilizing the AT Table to learn airway anatomy and its innervations provided a sound working knowledge and mental representation of structures necessary to safely identify structures while executing an intubation was a benefit that occurred in 24 survey responses. Two other participants reported that I can better picture the innervation of the airway. Also, I can better identify the structures of the oral airway when intubating and I would like to continue studying with the Anatomage Table and I will use the knowledge of airway anatomy for class and clinical practice (knowledge of structures, functions, and associated injuries, etc. respectively. The AT having a positive impact on clinical preparedness also appeared 8 times in the survey responses where participants made statements such as This hands-on experience was very beneficial, and I think it will assist me in being more confident in clinical practice. Being able to visualize different structures and see the whole picture was incredibly helpful. Participants' responses were unanimous that their interaction with the AT solidified their knowledge and gave them a boost in confidence and decreased stress knowing they are equipped with knowledge to answer their preceptor questions in real-life airway scenarios. In similar comments, a participants indicated that This experience gives access to the most up-to-date simulation and allows for removal of structures for better visualization of procedures we will be ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 34 performing in the future, and the other stated that When I am verbalizing what I am visualizing to my preceptor during intubation, I feel that I will be confident in identifying structures. Enhanced retention A corresponding theme was notated to the 33 participants' responses to the second survey question. All 31 (89.77%) participants discussed enhanced retention as a benefit of the AT in enhancing knowledge of clinical anatomy. Two codes were identified from the responses, which include: visual and kinesthetic learning, and interactive 3D learning. The most frequent comments on this theme consisted of both codes equally. The participants strongly believed that the AT was instrumental in emphasizing concepts through its 3D future, color coding, labeling and its ability to peel off structures to allow for visualization of deeper structures unlike a cadaver. Some participants stated that with the AT Being able to see it helps commit to memory and some participants were specific about how the AT aids to commit anatomy to memory by allowing for visual and kinesthetic learning. A participant stated, I thought it was very helpful, I feel that I am a slow learner and would like to actually visually touch the table myself and then go back and forward when needed to fully retain what I am learning. Another participant responded by saying I love the colors provided in the anatomage. In the cadaver lab I can't easily differentiate structures when they're all the same color. The anatomage provides color and an easy 3D view. Along with visual and kinesthetic learning, participants stated that the AT creates an interactive 3D learning experience (15 responses). One participant compared the AT experience to the traditional use of mannikins for simulation stating that The visualization makes the structures more realistic compared to mannikins. A few other participants were impressed and valued how it simplified learning and understanding the intricacy of the muscles, nerves, and its ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 35 relationship to surrounding structures. A participant notated It helped me see how the RLN follows a groove on its way back up and how that is at a great risk of being damaged in a surgery. Some other participants responded stating that, Being able to peel away structures and see them from all angles is invaluable in understanding innervation. Another said that The Anatomage Table is much easier to see and learn the anatomical structures more so than the cadavers. Another responder appreciated the life-sized 3D interactive learning previewed by the AT, stating that, visually seeing the structures in detail was helpful for putting it all together and understanding the proportions of the muscle sizes.'' Superiority From 32 (89.44%) participants, the third theme was observed from responses to the third survey question that compared previous methods utilized to learn airway anatomy and its innervation to the AT. 2 codes were formed from survey responses: realistic and applicable, as well as engaging and communicative. Most of the responses addressed the realistic and the applicability of the AT in learning anatomy. Participants saw the implementation of the AT to be valuable in creating a more mirror image of real-life anatomy that would aid in the clinical application of knowledge. As one participant said, I think it would be a great adjunct to use when learning dense anatomy, such as those featured in our neuroanatomy lectures as well as identifying structures that we will be encountering when performing procedures. Another said, Very useful, very realistic view. Four participants compared learning airway anatomy and its innervation with Apex (CRNA board preparation tool), and cadavers versus the AT. A participant said, I prefer the table because of the visual representation resonates better than reading about the anatomy and still APEX pictures. Another participant reported that Apex modules give mnemonics to help remember structures functions, but the table allows for direct ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 36 visualization. Another participant said I think the Anatomage Table was so much better than any textbook picture or apex. I also think it is way better than the cadavers and I wish it was utilized more frequently. Most of the participants also found the AT to be engaging and communicative (13 responses). Traditional teaching methods are not always engaging and interactive as the Anatomage Table is a lot more visually appealing compared to the cadaver lab. The colors help to see a thorough picture of the anatomy. Also, being able to peel back unnecessary layers and structures using the Anatomage Table was super helpful. Another said, We have been able to look at cadavers, however the table provides a greater 3D view for us in order to see every angle that the nerves and muscles are located. Participants believed that the AT was an additive to the previous methods as the new technology allowed for a deeper level of understanding through the labeling and color coordinated features. Quantitative Discussion The medical field is ever evolving and the implementation of interactive technology to learning anatomy is no exception. The use of the AT as an adjunct to learning anatomy in college institutions is new, hence the limited data in the literature regarding its impact in students learning. This limitation inspired this DNP project. This DNP project utilization of the AT to improve knowledge of clinical anatomy and enhance performance of point-of-care assessments and interventional anesthesia procedures. The results for this DNP project showed that the SRNAs who watched the pre-briefing videos and attended the AT training achieved markedly higher scores in the airway anatomy knowledge posttest when compared to the pretest. While this was not statistically significant, it was close to the threshold and more data sampling might be needed to find a more definitive ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 37 result. The practical importance of the AT training effect cannot be overlooked as this indicates a noticeable clinical effect despite a small sample size. Higher posttest scores may suggest that the AT may be a more effective modality for short-term retention of information; however, further investigation with a larger sample is recommended. These findings are in congruence with literature in showing an increase in students knowledge and performance in anatomy course work, with the implementation of these modern human sized digital touch-screen table technology (Narnaware & Neumeier, 2021; Bhadoria, 2021; Boscolo-Berto et al., 2021; Whited et al., 2021). A consistent theme in literature are findings of improved academic performance with the use of an AT, and increased knowledge reflected through students examination scores and grade point average (GPA) (Narnaware & Neumeier, 2021; Bianchi et al., 2020). The overall time students worked with the AT (30 min), was very short with respect to their overall study hours during the preclinical anatomy course. However, despite the limited interaction time the project provided valuable insights in establishing potential integration of the AT into the Anesthesia curriculum. Nevertheless, future investigations with a larger sample size and longer working hours with the AT are required to verify the findings and to establish this technology as a valuable, supplemental learning modality. Moreover, most of the students had no prior knowledge or exposure to the AT. The AT technology learning curve coupled with the limited time presented an unfavorable impact on the interpretation of the results in this DNP project. Of the 33 SRNAs from the project group, only 27 data samples were analyzed. We had 33 responses to the pretest but only 27 responses to the post test. The pretests that did not have a corresponding posttest were eliminated from this project. ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 38 After further analyzing the data, it appeared that a few of the respondents randomly selected responses in order to complete the test as quickly as possible rather than answering the questions honestly. Of the 27 that were analyzed, two left at least one question blank and four answered the question correctly on the pretest but missed it on the post test. This does make a difference in the overall results for knowledge gain. It is possible that if all responses were answered honestly, the results may have been statistically significant. 17 of the 33 SRNAs voluntarily attended AT training for PNB before taking their end-ofyear check off exam while 16 SRNAs took their check off exams without attending AT training. The results of this DNP project most of the SRNAs were able to score 100% on the exam with the exception of two students in the project group and one student in the timed, and students did not fail the skill based on the ability to perform the task, but simply due to time constraint. Those that failed to score 100% could not perform the task within the time allotted. The goal of this project was to teach and assess identification of anatomy structures and to safely perform a PNB. Assessing how fast a PNB is performed was beyond the scope of this DNP project. Failure to attain 100% may have been erroneously synonymous with failure to perform a PNB. There is potential for future students to expand on this project. Future investigations are recommended, Thirty-three SRNAs who participated in the Laryngeal airway anatomy and nerve innervation AT training were given a post self-efficacy survey. The survey was given to assess the self-efficacy of students after participating in Laryngeal airway anatomy and nerve innervation AT training., the question relating to confidence in active participation in airway anatomical discussion with professors using the AT, had the greatest number of students (21%) who rated a maximum score of 5 (totally confident). Questions 12 and 13, related to confidence in locating anatomical structures in the human cadaver and confidence in identifying ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 39 abnormalities respectively, both of which were not directly addressed in this project. It is therefore reasonable that these questions yielded. 17 of 33 SRNAs who voluntarily attended the AT training for PNB before taking their end of year check off exam were also given a post self-efficacy survey. The survey was given to measure self-efficacy (self-confidence) in the ability to perform PNBs (interscalene block) after utilizing the AT training. There was a moderate response rate (70%) to the survey, however there were some significant findings. 43% of the questions had a maximum score of 5 (totally confident). 58% of the SRNAs rated a maximum score of 5 on questions relating to confidence in identifying, performing, and answering questions on interscalene blocks. One student (8.3%) had a minimum score of 2 (only a little confident) on the question relating to confidence with identifying abnormalities on a patient in clinical setting. This project did not address identifying abnormalities. Even though identification of abnormalities is one of the features of the AT Table, it was beyond the scope of this project, so it is understandable that this could be one of the lower scored questions in the survey. In analyzing the results and based upon the feedback we received after the project was completed, we believe that the AT technology learning curve was impactful and could have affected their confidence in the overall AT learning experience. Qualitative Discussion This DNP project was conducted among first year CRNA students at Marian University. The qualitative part of this project aimed to assess the students perceived benefits and overall satisfaction of the AT as an anatomy teaching tool to facilitate knowledge and competence in identifying anatomical structures that would translate to safety in performing anesthesia related procedures and interventions in the clinical setting. The students expressed a more positive attitude as a result of excellent anatomical knowledge gained from exposure to the AT. Twenty ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 40 participants went as far as comparing it to prior methods used to learn anatomy in the program (Apex, Cadavers, mannikins) and deemed their experience with the AT as far superior. Not all students perceived the AT as superior to prior teaching modalities but ranked it as equivalent and stated it would be a great adjunct to current anatomy teaching tools. Two of the responses to the second survey question had some drawbacks. One noted that the learning curve due to the lack of familiarity with this new technology interfered with their learning of anatomy. The second responder noted that while it did show nerve connections, it was harder to teach function. The first responders concern could be easily resolved with more exposure and interaction with the AT. The laboratory experience in this study was the first-time participants were exposed to the AT hands on. Even though we did provide a pre-briefing video going over some of its functionality and how to navigate the AT, the hands-on simulation was their first real experience with the technology. The second participants concern is not a function that the AT or any other anatomy teaching modality can do as of present. The AT cannot simulate what stimulation of the cranial nerve on the laryngeal muscles would look like, but rather it provides an avenue to easily comprehend the functionality. Review of participants responses showed that the majority of them found the AT to be an interactive, engaging, and effective teaching tool which helped them form a deeper understanding of core anatomical knowledge necessary to be safe, successful and confident in the clinical setting. The results from this DNP project teaching anatomy with the AT offered some unique advantages such as showing relationships between structures, allowing for removal of structures for better visualization and understanding, provision of colors to stay engaged and a better identification and differentiation between structures. Additional advantages also include accessibility without the presence of an instructor for students who need additional time ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 41 interacting with the AT. It allows a student to save work and revisit it numerous times to gain full comprehension. It provides a clean 3D view of structures that highlights the intricate details of the course of nerves, muscles, and ligaments. These attributes contributed to improved learning of anatomy. The AT enhanced active learning accordingly, this would help to develop skills for scientific reasoning, self-dependent study, and the value of teamwork and interpersonal skills. This finding supports the idea that the CRNA students prefer the combination of anatomage and traditional styles in teaching and learning anatomy. Results of previous research confirmed that combining multiple teaching methods is the best way to teach modern anatomy. Interactive 3D learning methods such as the AT are more effective anatomy learning methods than traditional methods. Although no single teaching tool has been found to meet all curriculum requirements, the multimodal approach has been advocated as the best way to teach modern anatomy (Estai & Bunt (2016). Conclusion The effectiveness of AT was assessed through several methodologies to fully ascertain its pros and cons and deduce its value, if any to SRNAs knowledge of anatomy. Qualitative data gathered compared the pretest taken before the AT intervention teaching to the posttest taken after the intervention. The posttest scores were higher than the pretest scores. Another qualitative assessment data gathered assessed students competence at identifying anatomical structures and their relationship to surrounding structures under the guidance of an ultrasound to safely perform and interscalene PNB. Results from this DNP project showed no significant difference between the means of the AT trained participants and those that did not have the AT training. However, the students in the AT group did not score low due to a lack of knowledge but as a result of time ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION constraints. Students perceptions were evaluated, and the AT was found to generate significantly more excitement along with an interactive learning process that increased clinical preparedness and overall knowledge and confidence. Findings from this DNP project the Anatomage Table is an effective anatomy teaching modality that fosters retention and recall of information thereby creating a working knowledge for the anesthesia professional. However, further investigation with a larger cohort is recommended. 42 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 43 References Abdulrahman, K. A. B., Jumaa, M. I., Hanafy, S. M., Elkordy, E. A., Arafa, M. A., Ahmad, T., & Rasheed, S. (2021). Students perceptions and attitudes after exposure to three different instructional strategies in applied anatomy. Advances in Medical Education and Practice, 12, 607-612. https://doi.org/10.2147/AMEP.S310147 Abernathy, J. & Reeves, S. (2010). Airway catastrophes. Current Opinion in Anaesthesiology, 23 (1), 41-46. https://doi.org/10.1097/ACO.0b013e328333b768 Afsharpour, S., Gonsalves, A., Hosek, R., & Partin, E. (2018). Analysis of immediate student outcomes following a change in gross anatomy laboratory teaching methodology. The Journal of Chiropractic Education, 32(2), 98-106. https://doi.org/10.7899/JCE-17-7 Ainscough, L., Foulis, E., Colthorpe, K., Zimbardi, K., Robertson-Dean, M., Chunduri, P., & Lluka, L. (2016). Changes in biology self-efficacy during a first-year university course. CBE Life Sciences Education, 15(2). https://doi.org/10.1187/cbe.15-04-0092 Alasmari, W. A. (2021). Medical students feedback of applying the Virtual Dissection Table (Anatomage) in learning anatomy: A Cross-sectional descriptive study. Advances in Medical Education and Practice, 12, 1303-1307. https://doi.org/10.2147/AMEP.S324520 Anand, M. K., & Singel, T. C. (2014). A comparative study of learning with Anatomage virtual dissection table versus traditional dissection method in neuroanatomy. Ind J Clin Anat Physiol, 4, 177-180. https://doi.org/10.18231/2394-2126.2017.0044 Baldwin, J. A., EbertMay, D., & Burns, D. J. (1999). The development of a college biology self efficacy instrument for nonmajors. Science Education, 83(4), 397-408. ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 44 https://psycnet.apa.org/doi/10.1002/(SICI)1098-237X(199907)83:4%3C397::AIDSCE1%3E3.0.CO;2-# Baratz, G., Wilson-Delfosse, A. L., Singelyn, B. M., Allan, K. C., Rieth, G. E., Ratnaparkhi, R., Jenks, B. P., Cartlton, C., Freeman, B. K., & Wish-Baratz, S. (2019). Evaluating the Anatomage table compared to cadaveric dissection as a learning modality for gross anatomy. Medical Science Educator, 29(2), 499-506. https://doi.org/10.1007/s40670-01900719-z Bhadoria, P. (2021). Virtual dissection- As a new medical teaching tool. European Journal of Biomedical and Pharmaceutical Sciences, 8(4), 276-280. https://www.researchgate.net/publication/351097217_VIRTUAL_DISSECTION__AS_A_NEW_MEDICAL_TEACHING_TOOL Bianchi, S., Bernardi, S., Perilli, E., Cipollone, C., Di Biasi, J., & Macchiarelli, G. (2020). Evaluation of effectiveness of digital technologies during anatomy learning in nursing school. Applied Sciences, 10(7), 1-7. https://doi.org/10.3390/app10072357 Boscolo-Berto, R., Tortorella, C., Porzionato, A., Stecco, C., Picardi, E. E. E., Macchi, V., & De Caro, R. (2021). The additional role of virtual to traditional dissection in teaching anatomy: A randomised controlled trial. Surgical and Radiologic Anatomy, 43(4), 469479.https://doi.org/10.1007/s00276-020-02551-2 Burgoon, J. M., Meece, J. L., & Granger, N. A. (2012). Self-efficacy's influence on student academic achievement in the medical anatomy curriculum. Anatomical Sciences Education, 5(5), 249255. https://doi.org/10.1002/ase.1283 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 45 Custer, T. M., & Michael, K. (2015). The utilization of the Anatomage virtual dissection table in the education of imaging science students. Journal of Tomography & Simulation, 1. https://doi.org/10.4172/jts.1000102 da Silveira, C. R., Miamoto Dias, P. E., Oenning, A. C., de Brito Junior, R. B., Turssi, C. P., & Oliveira, L. B. (2021). Digital anatomy table in teachinglearning process of the temporomandibular joint anatomy. European Journal of Dental Education: Official Journal of the Association for Dental Education in Europe. https://doi.org/10.1111/eje.12680 Estai, M., & Bunt, S. (2016). Best teaching practices in anatomy education: A critical review. Annals of anatomy = Anatomischer Anzeiger: Official organ of the Anatomische Gesellschaft, 208, 151157. https://doi.org/10.1016/j.aanat.2016.02.010 Fyfe, S., Fyfe, G., Dye, D., & Radley-Crabb, H. (2018). The Anatomage table: Differences in student ratings between initial implementation and established use. Focus on Health Professional Education, 19(2), 41-52. https://doi.org/10.11157/fohpe.v19i2.215 Ghosh S. K. (2017). Cadaveric dissection as an educational tool for anatomical sciences in the 21st century. Anatomical Sciences Education, 10(3), 286299. https://doi.org/10.1002/ase.1649 Helander, E. M., Kaye, A. J., Eng, M. R., Emelife, P. I., Motejunas, M. W., Bonneval, L. A., Terracciano, J. A., Cornett, E. M., & Kaye, A. D. (2019). Regional nerve blocks-best practice strategies for reduction in complications and comprehensive review. Current Pain and Headache Reports, 23(6), 43. https://doi.org/10.1007/s11916-019-0782-0 Hroux, J., Belley-Ct, E., Echav, P., Loignon, M.-J., Bessette, P.-O., Patenaude, N., ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 46 Baillargeon, J.-P., & DAragon, F. (2019). Functional recovery with peripheral nerve block versus general anesthesia for upper limb surgery: a systematic review protocol. Systematic Reviews, 8(1), 273. https://doi.org/10.1186/s13643-019-1204-4 Hewson, D. W., Bedforth, N. M., & Hardman, J. G. (2018). Peripheral nerve injury arising in anaesthesia practice. Anaesthesia, 73 Suppl 1, 5160. https://doi.org/10.1111/anae.14140 International Nursing Association for Clinical Simulation and Learning (2021). The Healthcare Simulation Standards of Best Practice. https://www.inacsl.org/healthcare-simulation standards Iwanaga, J., Loukas, M., Dumont, A. S., & Tubbs, R. S. (2021). A review of anatomy education during and after the COVID-19 pandemic: Revisiting traditional and modern methods to achieve future innovation. Clinical Anatomy (New York, N.Y.), 34(1), 108114. https://doi.org/10.1002/ca.23655 Kausar, T., Chandio, S., Quddus, I., Qureshi, G. S., Baloch, Z. H., & Pario, A. (2020). effectiveness of teaching with visualisation table in comparison to traditional lecture in anatomy department, Jinnah Sindh Medical University. Journal of the College of Physicians and SurgeonsPakistan:JCPSP, 30(10), 1074-1077. https://doi.org/10.29271/jcpsp.2020.10.1074 Kaoka, D., & Pilmane, M. (2017). Teaching and learning innovation in present and future of human anatomy course at RSU. Papers on Anthropology, 26(2), 4452. https://doi.org/10.12697/poa.2017.26.2.05 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 47 Kazoka, D., & Pilmane, M. (2019). 3D dissection tools in Anatomage supported interactive human anatomy teaching and learning. SHS Web of Conferences, 68(02015), 1-7. https://doi.org/10.1051/shsconf/20196802015 Kazoka, D., & Pilmane, M. (2019). Combination of new, innovative and demonstrative and 3D elements with learning methods in human anatomy course. Journal of International Scientific Publications, 17, 255-262 Keenan, I. D., & Ben Awadh, A. (2019). Integrating 3D visualisation technologies in undergraduate anatomy education. Advances in experimental medicine and biology, 1120, 3953. https://doi.org/10.1007/978-3-030-06070-1_4 Kolb, A. Y., & Kolb, D. A. (2009). Experiential learning theory: A dynamic, holistic approach to management learning, education, and development. In S.J. Armstrong, & C. V. Fukami The SAGE handbook of management learning, education, and development (pp. 42-68). SAGE Publications Ltd, https://www.doi.org/10.4135/9780857021038.n3 Langfield, T., Colthorpe, K., & Ainscough, L. (2018). Online instructional anatomy videos: Student usage, self-efficacy, and performance in upper limb regional anatomy assessment. Anatomical Sciences Education, 11(5), 461470. https://doi.org/10.1002/ase.1756 Narnaware, Y. R., & Neumeier, M. (2021). Use of a virtual human cadaver to improve knowledge of human anatomy in nursing students. Teaching and Learning in Nursing, 16(4), 309-314. https://doi.org/10.1016/j.teln.2021.06.003 Paech, D., Giesel, F. L., Unterhinninghofen, R., Schlemmer, H. P., Kuner, T., & Doll, S. (2017). ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 48 Cadaver-specific CT scans visualized at the dissection table combined with virtual dissection tables improve learning performance in general gross anatomy. European Radiology, 27(5), 2153-2160. https://doi.org/10.1007/s00330-016-4554-5 Patwa, A., & Shah, A. (2015). Anatomy and physiology of respiratory system relevant to anaesthesia. Indian Journal of Anaesthesia, 59(9), 533541. https://doi.org/10.4103/0019-5049.165849 Saverino, D. (2021). Teaching anatomy at the time of COVID-19. Clinical Anatomy (New York, N.Y.), 34(8), 1128. https://doi.org/10.1002/ca.23616 Singal, A., Bansal, A., & Chaudhary, P. (2020). Cadaverless anatomy: Darkness in the times of pandemic Covid-19. Morphologie: Bulletin de l'Association des Anatomistes, 104(346), 147150. https://doi.org/10.1016/j.morpho.2020.05.003 Tenaw, B. (2020). Teaching gross anatomy: Anatomage table as an innovative line of attack. International Journal of Anatomical Variations, 13(1), 76-79. https://www.pulsus.com/scholarly-articles/teaching-gross-anatomy-anatomage-table-asan-innovative-line-of-attack-5535.html Whited, T. M., DeClerk, L., Berber, A., & Phelan, K. D. (2021). An innovative technique to promote understanding of anatomy for nurse practitioner students. Journal of the American Association of Nurse Practitioners, 33(5), 348-352. https://doi.org/10.1097/JXX.0000000000000328 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 49 Appendix A Literature Review Matrix Reference Research Design Purpose / Aim Population / Sample Variables Instruments / Data collection Results didactic passive teaching, Anatomage table (AT), enhancement of knowledge, optimize the learning experience of nursing students Midterm exam scores, final exam scores, a satisfaction survey answered through a Likert scale of 1-5, i.e., outstanding, excellent, good, average, and unsatisfactory, Statistical analyses indicated that teaching human anatomy using the AT resulted in significant increases in the class average for all three mid-term examinations and of the final examination relative to students taught without the AT. The mean class average of comparison group 1 versus interventional group 2 for mid-term#1 was 67.4+-3.4 vs.71.4+-2.8, mid-term#2, 63.8+-2.6 vs. 68.3+-2.8, mid-term#3 62.9+-1.4 vs. 66.2+1.5 and final examination 64. +-2.4 vs. 68.9+-1.9. The over-all GPA for interventional group 2 was significantly (P<0.05) higher and was 3.0+-0.09 than comparison group 1 (2.74+0.12) The midterm and final laboratory examination scores, Laboratory exams mean scores and Lecture examination mean scores. The midterm and final laboratory examination scores were evaluated and showed successive increases in aggregate averages between cohort 1 (mean 14 n=x Narnaware, Y. R., & Neumeier, M. (2021). Use of a virtual human cadaver to improve knowledge of human anatomy in nursing students. Teaching and Learning in Nursing, 16(4), 309-314. A quasiexperimental subject design To examine whether the introduction of the Anatomage Table (AT) as a teaching strategy in the human anatomy course for nursing students enhances their knowledge in gross anatomy, and (2) whether the AT provides a suitable visual perception of the human body to optimize the learning experience of nursing students first year nursing students n= 635 Afsharpour, S., Gonsalves, A., Hosek, R., & Partin, E. (2018). Retrospective study To compare student performance following a change in laboratory teaching methodology 3 cohorts of students enrolled in a musculoskeletal Human Anatomy class comprising 60-80 students each were taught gross anatomy using didactic, passive teaching without the AT in Winter 2015, group 1 (n = 132). and Human Anatomy class comprising of 6080 students taught using the AT in Fall 2015, Winter and Fall 2016, and Winter 2017, thus serving as a comparison group 2 (n = 503). ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION Analysis of immediate student outcomes following a change in gross anatomy laboratory teaching methodology. Journal of Chiropractic Education, 32(2), 98-106. Paech, D., Giesel, F. L., Unterhinninghof en, R., Schlemmer, H. P., Kuner, T., & Doll, S. (2017). Cadaver-specific CT scans visualized at the dissection table combined with virtual dissection tables improve learning performance in general gross anatomy. European radiology, 27(5), 2153-2160. quasi experimental study from cadavers to models to virtual dissection table in a musculoskeletal gross anatomy course. gross anatomy course in a Doctor of Chiropractic program. The 1st cohort of students (n=352), The 2nd cohort of students (n=350), The 3rd cohort of students (n=393). Lecture examination scores. The purpose of this study was to quantify the benefit of the incorporation of radiologic anatomy (RA), in terms of student training in RA seminars, cadaver CT scans and life-size virtual dissection tables on the learning success in general anatomy Three groups of a total of 238 students were compared in a multiple choice general anatomy exam during first year gross anatomy: (1) a group (year 2015, n1 = 50) that received training in radiologic image interpretation (RA seminar) and additional access to cadaver CT scans (CT + seminar group); (2) a group (2011, n2 = 90) that was trained in the RA seminar only (RA seminar group); (3) a group (2011, n3 = 98) without Radiologic imaging (RA)interpretatio n training, CT scan seminar, conventional anatomy, student perception 50 76.1%), cohort 2 (mean 14 81.4%), and cohort 3 (mean 14 85.1%). Lecture examination scores remained consistent between the cohorts at 61.2%, 62.4%, and 61.1%, respectively. Significant improvements were seen in lab exam scores between cohorts (F [2, 2113] 14 58.6, p, .001), and no significant differences were seen in lecture exam scores. Test scores, survey The average test score of the CT + seminar group (21.8 5.0) was significantly higher when compared to both the RA seminar group (18.3 5.0) and the conventional anatomy group (17.1 4.7) (p < 0.001). ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 51 any radiologic image interpretation training (conventional anatomy group). Furthermore, the students perception of the new curriculum was assessed qualitatively through a survey Boscolo-Berto, R., Tortorella, C., Porzionato, A., Stecco, C., Picardi, E. E. E., Macchi, V., & De Caro, R. (2021). The additional role of virtual to traditional dissection in teaching anatomy: a randomized controlled trial. Surgical and Radiologic Anatomy, 43(4), 469-479. A randomized controlled didactical trial The purpose of the study was to examine if integrating the classical gross dissection with a supplemental virtual experience on digital human cadaver can improve the learning of anatomy with benefits on students performance. Second-year medical students enrolled in an elective anatomic dissection course (n=30). Experimental group (n=15), Control group (n=15). Anatomical knowledge, test performance, mean variation score of postexperimental examination The CONSORT guidelines and checklist for randomized trials. Pre-test and posttest. The rate of completed tests was 76.7%. Better overall test performance was detected for the group that applied to the virtual dissection (OR 3.75 with 95% CI 0.91 15.49; p = 0.06). A comparable performance between groups in basic anatomical knowledge (p 0.45 to 0.92) but not muscles and 2D-3D reporting of anatomical structures was found, for which the virtual dissection was of tendential benefit (p 0.08 to 0.13). Medical students who applied to the virtual dissection were over three times more likely to report a positive outcome at the post-dissection test than those who applied to textbooks of topographical anatomy. Kazoka, D., & Pilmane, M. (2019). 3D dissection tools in Anatomage supported Quasiexperimental study The main aim of the study was to present the usage and importance of 3D dissection tools in the teaching and learning of Anatomy 200 students of the Faculty of Medicine and Dentistry. The first group consisted of Advantages and disadvantages of virtual scalpels of the Anatomage Table. Effectiveness of Virtual dissection discussion answers to the questions about the usage of 3D dissection tool Results of the study showed that the advantages of adding virtual scalpels to a human anatomy course outweighed the disadvantages. Students of both groups ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION interactive human anatomy teaching and learning. In SHS Web of Conferences (Vol. 68, p. 02015). EDP Sciences. Fyfe, S., Fyfe, G., Dye, D., & Radley-Crabb, H. (2018). The Anatomage table: Differences in student ratings between initial implementation and established use. Focus on Health Professional Education, 19(2), 41-52. Quantitative study Kaoka, D., & Pilmane, M. (2017). Teaching and learning innovation in present and future of human anatomy course at RSU. Papers on Anthropology, 26(2), 44-52. Case study design and to describe and explain the experience with Anatomage Table in Human Anatomy studies at R ga Stradin s University. (n=100) students of the Faculty of Dentistry and second group consisted of (n=100) students of the Faculty of Medicine. virtual tools in the study of human anatomy The aim of this study was for students to rate perception of two medical student cohorts video/animations learning, models, plastinates, Anatomage table, the usefulness of the Anatomage table and other anatomy resources The aim of the study was to investigate the usefulness of the Anatomage Table (Virtual Dissection Table) and overall satisfaction among students in the teaching and learning of human anatomy at RSU. (2013, n = 333; 2014, n = 329) reported the use of a virtual dissection tool to be very beneficial in classes. Survey, Rating scale (1-100) students perception of usefulness The sample included Latvian and Foreign students and several tutors from the Human Anatomy course in the period of 20162017. knowledge 52 Discussion session video/animations rated most useful for learning (77.8/100), models (63.9/100), plastinates (58.4/100) and the Anatomage table (42.4/100), In 2014, respondents rated the Anatomage table more favorably (42.4/100) than in 2013 (36.9/100) (p = 0.022). The Anatomage table was rated most helpful for understanding relative sizes of organs but least helpful for using correct anatomical terminology. Qualitative data showed that in 2013, students were frustrated by screen-freezing problems and low-quality graphics, issues that were mostly addressed by 2014 The assessment of the discussions of students showed that most of them found that the Anatomage Table was an interesting and effective learning tool for developing their knowledge and skills, collaborative learning, using the anatomical language of images of dissections. The results from the current study suggested that teaching Human Anatomy with the Anatomage Table offered some advantage on the questions requiring relationships between structures. ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 53 Tenaw, B. (2020). Teaching gross anatomy: anatomage table as an innovative line of attack. Int J Anat Var Vol, 13(1), 76. Cross sectional study The aim of this study was to explore the practicality of the virtual body dissection table and inclusive gratification among medical students in the teaching and learning of gross human anatomy. Eighty-nine study participants (51 males and 38 females) second year medical students Anatomage table, students satisfaction/gratif ication 10-item Questionnaire 80.89% of medical students study participants were satisfied that the anatomage had a helpful starring role and it was a supplementary tool for their learning and learning human anatomy and gives wellknown numerous benefits of using the Anatomage table in the medical teaching and learning activities. Abdulrahman, K. A. B., Jumaa, M. I., Hanafy, S. M., Elkordy, E. A., Arafa, M. A., Ahmad, T., & Rasheed, S. (2021). Students Perceptions and Attitudes After Exposure to Three Different Instructional Strategies in Applied Anatomy. Advances in Medical Education and Practice, 12, 607. A crosssectional study The study aimed to assess medical students performance and overall satisfaction who used the Anatomage table and plastinated specimens for the teaching and learning anatomy courses and enrich academic knowledge with different anatomy teaching methods. 211 students of the first-year college of medicine at Imam Mohammad Ibn Saud Islamic University (IMSIU). Group A (n=70) learned with the Anatomage table and Group B (n=70) learned the same topics on plastinated specimens. Group C (n=70) was learned on both plastinated specimens and the Anatomage table Students views on educational methods. Exam scores Objective structured practical examination (OSPE) and a structured questionnaire using a 5-point Likerttype scale There was a statistically significant difference between the means of the total scale scores for the three teaching methods, where students expressed a higher attitude towards both strategies for teaching in comparison to the anatomage table and plastinated models for teaching, where the means were 184.4, 18.34.6, 20.45.6, respectively, F=12.6 and P=0.0001. There were higher and positive students attitudes regarding the five statements in favor of both models teaching compared to anatomage table and plastinated model teaching alone. Alasmari, W. A. (2021). Medical Students Feedback of Applying the Virtual Dissection Table (Anatomage) in Learning A cross sectional descriptive study The aim of this study was to address students opinions on applying the virtual dissection table (3D Anatomage) as an additional tool to cadaver dissection in learning anatomy. Medical students n= 78 Use of 3D anatomage, students opinion 6-question electronic questionnaire 81% (no=63/78) of the students preferred using 3D Anatomage as an additional tool to cadaveric dissected specimens in learning anatomy. 73% (no=57/78) of the students indicated that they benefited from applying the virtual 3D Anatomage in anatomy education (73%) (no=57/78) of the students found that applying 3D Anatomage during anatomy practical sessions with the ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION Anatomy: A Cross-sectional Descriptive Study. Advances in Medical Education and Practice, 12, 1303. Baratz, G., Wilson-Delfosse, A. L., Singelyn, B. M., Allan, K. C., Rieth, G. E., Ratnaparkhi, R., ... & WishBaratz, S. (2019). Evaluating the anatomage table compared to cadaveric dissection as a learning modality for gross anatomy. Medical Science Educator, 29(2), 499-506. 54 engagement of students in the discussion enhanced active learning 86% (no=67/78) of students strongly agreed that making sagittal, parasagittal, coronal and transverse sections of the digital body in 3D Anatomage boosts their understanding of the locations and relationships of the different internal body structures. A high proportion of 90% (no=70/78) of the students believed that the ability to rotate the digital body and dissect in 3D Anatomage helps in visualizing the body system. (72%) (no=56/78) of the students preferred the incorporation of imaging in 3D Anatomage, since it enables them to understand anatomy envisioned through medical imaging A crossover design study The purpose of this study was to compare the effectiveness and qualitative experience of learning gross anatomy of the pelvis and perineum (P/P) and musculoskeletal system (MSK) via cadaveric dissection to learning these same anatomical regions using the Anatomage table. 16 first year medical students volunteers Cadaver, anatomage, effectiveness and qualitative experience, exam scores, quizzes Likert scale survey, Pre and post quizzes, practical examination In the pre-lab survey, the groups did not demonstrate a statistically significant difference in perceived degree of comfort or degree of preparedness. However, the Anatomage group expressed a significantly higher degree of excitement than the control group for both blocks (p < 0.01). The results of the post-Lab survey for P/P and MSK comparing the combined intervention (Anatomage) and control (dissection) groups. While the groups did not demonstrate a statistically significant difference in perceived degree of difficulty in the post-Lab survey, there were significant differences in perceived degree of amount learned and excitement for next lab (p < 0.01). The results of the post-lab quizzes for both blocks comparing the intervention (Anatomage) and control (dissection) groups, no difference was found between the two modalities in P/P; however, in MSK, the Anatomage group had a significantly higher average quiz score than the control group (p = 0.03). exam scores for ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 55 the intervention (Anatomage) and control (dissection) groups in both the P/P and MSK anatomical regions, when comparing the results of the exam completed on the Anatomage table, the Anatomage group scored significantly higher than the dissection group (p = 0.01). However, when comparing the results of the cadaver practical exam, the dissection group scored significantly higher than the Anatomage group (p = 0.04). No significant difference was found when the mean exam scores of the Anatomage and cadaver practical exams were compared (p = 0.83). practical exam performance for both the Anatomage and control groups for MSK. No significant difference was found on the exam completed on the Anatomage table (p = 0.39). Similarly, no significant difference was found on the MSK cadaver practical exam between the two groups (p = 0.47). There was also no significant difference in the mean scores of the Anatomage and cadaver practical exams (p = 0.41). Bhadoria, P. (2021). VIRTUAL DISSECTION AS A NEW MEDICAL TEACHING TOOL. European Journal of Biomedical, 8(4), 276-280. Study type: Observational , Study design: Crosssectional, The aim of the study was to evaluate the impact of virtual dissection teaching techniques (VDTT) on first year MBBS students (Batch- 201920) in learning anatomy. First-year MBBS students (n=92) (Batch-2019-20) Marks obtained in monthly tests and an already validated questionnaire on Students Perceptions of VDTT Pre-test and Posttest, questionnaire on Students perceptions of virtual dissection teaching techniques (VDTT) Mean students' grades in monthly assessments before VDTT were 50.381.17(SE) and after VDTT were 56.941.18(SE). Mean marks significantly increased after the introduction of VDTT with P-value < 0.001. Students were classified into two groups: Good performers (scored marks 50) and Bad performers (scored marks <50). It was observed that out of 92 students, 45 were good performers and 47 were bad performers. Mean change in marks of good performers was 3.32.08 (SE) and in bad performers mean change in marks was 161.83(SE). Significant improvement in terms of marks obtained after the ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 56 introduction of VDTT, was seen in bad performers with P-value < 0.001. da Silveira, C. R., Miamoto Dias, P. E., Oenning, A. C., de Brito Junior, R. B., Turssi, C. P., & Oliveira, L. B. (2021). Digital anatomy table in teaching learning process of the temporomandibu lar joint anatomy. European Journal of Dental Education. A crosssectional study. The study aimed to evaluate the digital anatomy table in the teaching-learning process of the temporomandibular joint (TMJ) anatomy and the student's perception regarding this resource. The study was conducted on 41 undergraduate dental students. Knowledge, perception Knowledge assessment test scores in theoretical class, practical class and digital table. Perception survey When the teaching strategies were compared amongst each other, the medians of the scores with the digital anatomy table were significantly higher than after the theoretical and practical classes. At the end of the research, there were no differences amongst the three groups (theoretical class, practical class, and digital table). Regarding the perception, most of the students reported that the digital anatomy table helped them to understand the content of the theoretical class. Anand, M. K., & Singel, T. C. (2014). A comparative study of learning with anatomage virtual dissection table versus traditional dissection method in neuroanatomy. Ind J Clin Anat Physiol, 4, 177180. A randomized cross sectional prospective study to compare the learning with Anatomage virtual dissection table versus learning with traditional dissection in neuroanatomy. n = 122 1st year medical students were divided into two groups A and B. Group A studied internal capsule, basal ganglion and spinal cord by using Anatomage virtual dissection table. Group B learnt through the traditional dissection method. P anatomage virtual dissection table, students perception Pre and post-tests were conducted for all groups with a pre validated questionnaire. Feedback was obtained from students through a 5-point Likert scale. Students t test was applied for statistical analysis. There was no statistically significant difference in gain of knowledge in group A students in comparison to group B students. 51% students found that use of Anatomage virtual dissection table helped them understand topic better and majority (79%) felt that it enhanced their classroom experience. ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 57 Custer, T. M., & Michael, K. (2015). The utilization of the Anatomage virtual dissection table in the education of imaging science students. Journal of Tomography & Simulation, 1. qualitative, single-site case study The purpose of this research was to investigate the use of the Anatomage Virtual Dissection Table in the education of imaging science students and to assess the beliefs and perceptions of the students regarding using the Table for teaching imaging-based anatomy and pathology n= 17 medical imaging science post primary program students Anatomage table, students perception Focus group and interview questions based on previous experience and knowledge. All focus group sessions were audiotaped, transcribed and reviewed by the researchers for data analysis. Data gathered over time from the focus groups was positive. By mid-semester, 82% of the students felt the Anatomage Table was beneficial to their learning. This number rose to 88% by the end of the semester, and almost achieved 100% by the end of the study with one student remaining undecided Kausar, T., Chandio, S., Quddus, I., Qureshi, G. S., Baloch, Z. H., & Pario, A. (2020). Effectiveness of Teaching with Visualisation Table in Comparison to Traditional Lecture in Anatomy Department, Jinnah Sindh Medical University. Medical Education Crosssectional study To determine the effectiveness of Sectra visualization table (SVT) in a public sector setup and to compare the traditional (TRAD) lecture with SVT-aided teaching in terms of learning outcomes and students perception regarding SVT. Bachelor of Dental Surgery (BDS) students n= 50 students were randomly distributed in TRAD and SVT groups, both were exposed to 3 sessions of 1-hour duration. TRAD group attended lecture sessions, whereas SVT group were exposed to SVTaided teaching Visualization table, traditional lecture, test scores, VAK questionnaire, multiple choice question (MCQ) Test Scores of MCQs test between the groups showed non-significant difference (p = 0.24). Positive feedback was obtained in favor of SVT. Students of SVT group exposed to visual style of learning performed better. Whited, T. M., DeClerk, L., Berber, A., & Phelan, K. D. (2021). An innovative pretest/posttes t design The purpose of this evaluation was to determine if teaching with a computed tomography (CT)-based three-dimensional (3D) 17 students enrolled in a graduate level Health self-rate confidence in knowledge of pediatric anatomy for each body system, self- Presurvey and post surveys, A 5-point Pretest self-rated confidence in anatomy knowledge ranged from three to five in HEENT, and two to four in other systems. Most students rated themselves as four on HEENT, abdominal, and skin assessment. Posttests show self-ratings of four or five on Likert scale ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION technique to promote understanding of anatomy for nurse practitioner students. Journal of the American Association of Nurse Practitioners, 33(5), 348-352. Bianchi, S., Bernardi, S., Perilli, E., Cipollone, C., Di Biasi, J., & Macchiarelli, G. (2020). Evaluation of effectiveness of digital technologies during anatomy learning in nursing school. Applied Sciences, 10(7), 2357. crosssectional study anatomy table and cadaveric specimens improves Doctor of Nursing Practice (DNP) and NP students understanding of anatomy in health assessment. Assessment course. perceived, overall knowledge of human anatomy, perceived benefit of the anatomy table on overall anatomy knowledge and physical assessment skills. The aim of the study was to test the use of a virtual dissection table (DT) during the anatomy lectures of a nursing course, evaluating the anxiety level before the exam and evaluating the exam score. 133 first year nursing school students. Anxiety level, exam score, perception. 58 all systems, except for one student selecting a rating of three for the nervous system. Mean scores for self-rating knowledge per body system increased. Analysis using MannWhitney U test demonstrated a statistically significant difference in distribution of scores for heart and lung, abdomen, muscularskeletal, skin, and nervous systems between pre-assessment and post-assessment surveys. perception questionnaire, StateTrait Anxiety Inventory (STAI) test, anatomy exam 100% of students judged satisfying or very satisfying their degree of interest in the subject of the course (A), 95% percent of students perceived satisfying their level of interactivity during the lesson (B). The total of students judged satisfying or very satisfying the fulfillment of their initial expectation regarding the training contents (C). 100% of students appreciated the different teaching methods, giving satisfying or very satisfying scores (D). 98% of students scored satisfying or very satisfying. The adequacy in terms of function and comfort of the dedicated teaching room (E). 100% of students scored as satisfying or very satisfying the quality of the DT, paying particular attention to the completeness of contents and useful application in their nursing education (F). 37% of students scored as satisfying or very satisfying the interface of the anatomical table (G). The total of students scored as satisfying or very satisfying the final level of their own anatomical knowledge (H). The total of the students considered the strengths of these different teaching methods superior with respect to the limitations (I) and the total of them would suggest to a colleague to follow similar courses with this type of teaching ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 59 approach (J). The STAI mean values of the group of students who attended the DT laboratory session were significantly lower compared to the students who only attended the mandatory lectures. Kazoka, D., & Cross Pilmane, M. sectional? COMBINATION OF NEW, INNOVATIVE AND DEMONSTRATIV E 3D ELEMENTS WITH CLASSICAL LEARNING METHODS IN HUMAN ANATOMY COURSE. This work's aim was to study, compare and summarize our experience in combination of innovative and demonstrative 3D elements with classical learning methods in Human Anatomy course. 100 1st year medical school, and 100 students 2nd year medical school n= 200 an anonymous feedback questionnaire virtual dissection anatomage table, 3D printed anatomical models, classical human cadaveric dissections, students satisfaction In learning of structures 70% of the students were satisfied with the virtual dissection and/or their own prepared anatomical 3D models in group 1, but they liked to highlight the role and necessity of real dissection. 42.25% thought use of only virtual dissection Anatomage Table was enough to teach and study anatomy. 24.75% of students liked anatomy with prepared and printed 3D anatomical models. Some students were satisfied with the classical learning and teaching of Human Anatomy course when associated it with the use of different new, innovative and demonstrative 3D elements. Majority of students (90%) considered that virtual elements and models were useful in learning the study course outside the practical classes. In group 2 more than 95% of participants indicated that dissection anatomy should be regular and available to all students. Almost all students mentioned that dissections provided the real touch feeling of human body. In group 2 classical learning of anatomical structures obtained better results than only in the innovations supported group. When asked about necessity of advantages of dissection method, 96.23% of students indicated that it is necessary to become specialists in medicine, while 92.45% students marked that it is important for better understanding of clinical and surgical cases. Regarding possible combinations of methods in teaching and learning anatomy in both ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 60 groups, all students were asked about different variants of used methods as well as other methods (computer aided learning, plastinates, CT scans, imaging techniques). In both groups the large number of students gave preference to combination of real and virtual dissection, and printed 3D models (Fig. 1). In group 2 this combination was marked by 50.31% students, while in group 1 it was appreciated by 45.31% students. The need for increasing only real and virtual dissection methods was indicated by 32.14% students in group 2, while the need for dissection and printed 3D models combination was preferred by 24.75% students in group 1. Regarding possible combination with other methods in Human Anatomy course, only 4.78% and 7.23% students mentioned them in group 1 and group 2 respectively. When asked about other methods or improvements for methods in Human Anatomy course, students of both groups gave preference to the use of imaging techniques (radiological anatomy) and the use of CT scans (30.08% and 25.80%). Only 20.45% of students mentioned the use of computer aided learning. 20.45% of students indicated the use of plastinates. Comparison of students` perception scores of acquiring anatomical knowledge, using different learning methods in Human Anatomy course, demonstrated that classical method (dissection) was the best method for better level of knowledge, motivation of learning, identification of anatomical structures and their understanding. New innovations (virtual dissection and printed models) helped 44.62% of students identify and understand anatomical structures. 39.24% of ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 61 students reported that these methods were useful for better level of knowledge. It was found that the use of only one method of printed models received the least score (11.12%) in motivation of learning 62 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION Appendix B PRISMA 2009 Flow Diagram From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097. doi:10.1371/journal.pmed1000097 For more information, visit www.prisma-statement.org 63 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION Appendix C Kolbs Experiential learning theory Kolb & Kolb, (2009) 64 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION Appendix D 65 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION Appendix E Pre and post-test questions 1. What are the 3 paired cartilages of the Larynx? 2. What are the 3 non-paired cartilages of the Larynx? 3. Name 3 cranial nerves that innervate the airway. 4. Match the following laryngeal muscles with the nerve that innervates it. Laryngeal muscle Nerve innervated. - Cricothyroid Superior Laryngeal Nerve - Vocalis Recurrent Laryngeal nerve - Thyroarytenoids - Lateral cricoarytenoid - Posterior Cricoarytenoid 5. Match the following laryngeal muscles with the muscular action on the vocal cords. Cricothyroid tenses - Vocalis relaxes - Thyroarytenoids adducts - Lateral cricoarytenoids abducts - Posterior cricoarytenoids 66 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION Appendix F Open-Ended Questionnaire 1. In what ways they felt the knowledge gained from the utilization of the AT would be helpful in their clinical and future practice as a CRNA 2. In what ways was the AT laboratory experience beneficial or not to their understanding of airway anatomy and innervation and lastly, 3. In what does the AT compared to prior methods utilized to learn airway anatomy. A total of 33 participants were involved in this DNP project. 67 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION Appendix G Anatomical Self-Efficacy Instrument (Burgoon et al., 2012) 68 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION Appendix H PNB Self-Efficacy Survey Self-Efficacy ---Please Circle the number that applies. The answers to these questions can be the following: 1---If you are Not at All that you can do the task 2---If you are Only a Little confident that you can do the task 3---If you are Fairly confident that you can do the task 4---If you are Very confident that you can do the task 5---If you are Totally confident that you can do the task Not at All Only a Little 1) I am confident that I can identify Interscalene block anatomy on the anatomage table. 1 2 3 4 5 2) I am confident that I can answer questions on Interscalene block anatomy. 1 2 3 4 5 3) I am confident that I can use anatomage table to learn Interscalene block anatomy. 1 2 3 4 5 4) I am confident that I can identify internal structures related to Interscalene block. 1 2 3 4 5 5) I am confident that I can correctly pronounce Interscalene block anatomical terms. 1 2 3 4 5 6) I am confident at identifying Interscalene block anatomical relationships. 1 2 3 4 5 7) I am confident at identifying Interscalene block surgical indications and coverage. 1 2 3 4 5 8) I am confident that I can answer questions pertaining to the interscalene block successfully on the course written exams. 1 2 3 4 5 9) I am confident that I can perform successfully during test out over the Interscalene block during course lab practical exams. 1 2 3 4 5 10) I am confident that I will be able to retain and recall anatomical knowledge for use in a clinical setting. 1 2 3 4 5 Fairly Very Totally 69 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 11) I am confident that I can actively participate in Interscalene block anatomical discussions with the professors in the skills lab utilizing the anatomage table. 12) I am confident that I can locate anatomical structures on a patient in a clinical setting. 13) I am confident that I can identify anatomical abnormalities on a patient in a clinical setting 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 14) I am confident that I can describe Interscalene block anatomical structures to a non-medical person. 1 2 3 4 5 15) I am confident that I can successfully answer Interscalene block anatomical-based questions during clinical rotations. 1 2 3 4 5 16) I am confident that I can learn the Interscalene block anatomical content of this course. 1 2 3 4 5 70 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION Appendix I Laryngeal airway anatomy and nerve innervation Simulation Self-Efficacy survey Self-Efficacy ---Please Circle the number that applies. The answers to these questions can be the following: 1---If you are Not at All that you can do the task 2---If you are Only a Little confident that you can do the task 3---If you are Fairly confident that you can do the task 4---If you are Very confident that you can do the task 5---If you are Totally confident that you can do the task Not at All Only a Little 1) I am confident that I can identify laryngeal structures on the anatomage table. 1 2 3 4 5 2) I am confident that I can answer questions on laryngeal anatomy. 1 2 3 4 5 3) I am confident that I can use anatomage table to learn airway anatomy. 1 2 3 4 5 4) I am confident that I can identify airway innervation. 1 2 3 4 5 5) I am confident that I can correctly pronounce airway anatomical terms. 1 2 3 4 5 6) I am confident that I can learn airway anatomical relationships. 1 2 3 4 5 7) I am confident that I can learn airway anatomical terms and functions. 1 2 3 4 5 8) I am confident that I can perform successfully on the airway anatomy course written exams. 1 2 3 4 5 Fairly Very Totally 71 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 9) I am confident that I can perform successfully on the airway anatomy course lab 1 2 3 4 5 10) I am confident that I will be able to retain and recall anatomical knowledge for use in a clinical setting. 1 2 3 4 5 11) I am confident that I can actively participate in airway anatomical discussions with the professors in the skills lab utilizing the anatomage table. 1 2 3 4 5 12) I am confident that I can locate anatomical structures in the human cadaver 1 2 3 4 5 13) I am confident that I can identify airway anatomical abnormalities in the human cadaver. 1 2 3 4 5 14) I am confident that I can describe airway anatomical structures to a non-medical person. 1 2 3 4 5 15) I am confident that I can successfully answer airway anatomical-based questions during clinical rotations. 1 2 3 4 5 16) I am confident that I can learn the airway anatomical content of this course 1 2 3 4 5 72 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 73 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION Appendix J 74 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION Appendix K Laryngeal airway anatomy and nerve innervation Simulation Self-Efficacy posttest survey questions. Frequencies for Q1 Q1 Frequency 4 5 2 3 Missing Total 15 5 1 12 0 33 Percent 45.455 15.152 3.03 36.364 0 100 Valid Percent 45.455 15.152 3.03 36.364 Cumulative Percent 45.455 60.606 63.636 100 Frequencies for Q2 Q2 Frequency 4 5 2 3 Missing Total 19 2 2 10 0 33 Percent 57.576 6.061 6.061 30.303 0 100 Valid Percent 57.576 6.061 6.061 30.303 Cumulative Percent 57.576 63.636 69.697 100 Frequencies for Q3 Q3 Frequency 3 4 5 Missing Total Frequencies for Q4 7 18 8 0 33 Percent 21.212 54.545 24.242 0 100 Valid Percent 21.212 54.545 24.242 Cumulative Percent 21.212 75.758 100 75 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION Q4 Frequency 4 5 2 3 Missing Total 19 2 1 11 0 33 Percent 57.576 6.061 3.03 33.333 0 100 Valid Percent 57.576 6.061 3.03 33.333 Cumulative Percent 57.576 63.636 66.667 100 Frequencies for Q5 Q5 Frequency 3 4 5 Missing Total 7 18 8 0 33 Percent 21.212 54.545 24.242 0 100 Valid Percent 21.212 54.545 24.242 Cumulative Percent 21.212 75.758 100 Frequencies for Q6 Q6 Frequency 3 4 5 Missing Total 8 21 4 0 33 Percent 24.242 63.636 12.121 0 100 Valid Percent 24.242 63.636 12.121 Cumulative Percent 24.242 87.879 100 Frequencies for Q7 Q7 Frequency 3 4 5 Missing 8 19 6 0 Percent 24.242 57.576 18.182 0 Valid Percent 24.242 57.576 18.182 Cumulative Percent 24.242 81.818 100 76 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION Total 33 100 Frequencies for Q8 Q8 Frequency 3 4 5 2 Missing Total 8 17 6 2 0 33 Percent 24.242 51.515 18.182 6.061 0 100 Valid Percent 24.242 51.515 18.182 6.061 Cumulative Percent 24.242 75.758 93.939 100 Frequencies for Q9 Q9 Frequency 3 4 5 2 Missing Total 11 17 4 1 0 33 Percent 33.333 51.515 12.121 3.03 0 100 Valid Percent 33.333 51.515 12.121 3.03 Cumulative Percent 33.333 84.848 96.97 100 Frequencies for Q10 Q10 Frequency 4 5 2 3 Missing Total Frequencies for Q11 19 4 1 9 0 33 Percent 57.576 12.121 3.03 27.273 0 100 Valid Percent 57.576 12.121 3.03 27.273 Cumulative Percent 57.576 69.697 72.727 100 77 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION Q11 Frequency 4 5 2 3 Missing Total Percent 19 7 1 6 0 33 57.576 21.212 3.03 18.182 0 100 Valid Percent 57.576 21.212 3.03 18.182 Cumulative Percent 57.576 78.788 81.818 100 Frequencies for Q12 Q12 Frequency 3 4 5 1 Missing Total Percent 12 16 3 2 0 33 36.364 48.485 9.091 6.061 0 100 Valid Percent 36.364 48.485 9.091 6.061 Cumulative Percent 36.364 84.848 93.939 100 Frequencies for Q13 Q13 Frequency 2 3 4 5 1 Missing Total Percent 3 15 11 3 1 0 33 9.091 45.455 33.333 9.091 3.03 0 100 Valid Percent 9.091 45.455 33.333 9.091 3.03 Cumulative Percent 9.091 54.545 87.879 96.97 100 Frequencies for Q14 Q14 Frequency 3 Percent 9 27.273 Valid Percent 27.273 Cumulative Percent 27.273 78 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION 4 5 2 Missing Total 19 4 1 0 33 57.576 12.121 3.03 0 100 57.576 12.121 3.03 84.848 96.97 100 Frequencies for Q15 Q15 Frequency 3 4 5 2 Missing Total 11 18 3 1 0 33 Percent 33.333 54.545 9.091 3.03 0 100 Valid Percent 33.333 54.545 9.091 3.03 Cumulative Percent 33.333 87.879 96.97 100 Frequencies for Q16 Q16 Frequency 4 5 3 Missing Total 19 5 9 0 33 Percent 57.576 15.152 27.273 0 100 Valid Percent 57.576 15.152 27.273 Cumulative Percent 57.576 72.727 100 79 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION Appendix L Table 8 Frequency Tables PNB Self-efficacy survey questions Frequencies for Q1 Q1 Frequency Percent Valid Percent Cumulative Percent 4 5 41.667 41.667 41.667 5 7 58.333 58.333 100.000 Missin g 0 0.000 12 100.00 0 Total Frequencies for Q2 Q2 Frequency Percent Valid Percent Cumulative Percent 4 5 41.667 41.667 41.667 5 7 58.333 58.333 100.000 Missin g 0 0.000 12 100.00 0 Total Frequencies for Q3 Q3 Frequency Percent Valid Percent Cumulative Percent 3 1 8.333 8.333 8.333 4 5 41.667 41.667 50.000 5 6 50.000 50.000 100.000 80 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION Frequencies for Q3 Q3 Frequency Missin g Total Percent 0 0.000 12 100.00 0 Valid Percent Cumulative Percent Valid Percent Cumulative Percent Frequencies for Q4 Q4 Frequency Percent 4 5 41.667 41.667 41.667 5 7 58.333 58.333 100.000 Missin g 0 0.000 12 100.00 0 Total Frequencies for Q5 Q5 Frequency Percent Valid Percent Cumulative Percent 3 2 16.667 16.667 16.667 4 3 25.000 25.000 41.667 5 7 58.333 58.333 100.000 Missin g 0 0.000 12 100.00 0 Total Frequencies for Q6 Q6 3 Frequency 2 Percent 16.667 Valid Percent 16.667 Cumulative Percent 16.667 81 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION Frequencies for Q5 Q5 Frequency Percent Valid Percent Cumulative Percent 4 6 50.000 50.000 66.667 5 4 33.333 33.333 100.000 Missin g 0 0.000 12 100.00 0 Total Frequencies for Q7 Q7 Frequency Percent Valid Percent Cumulative Percent 3 1 8.333 8.333 8.333 4 5 41.667 41.667 50.000 5 6 50.000 50.000 100.000 Missin g 0 0.000 12 100.00 0 Total Frequencies for Q8 Q8 Frequency Percent Valid Percent Cumulative Percent 3 1 8.333 8.333 8.333 4 6 50.000 50.000 58.333 5 5 41.667 41.667 100.000 Missin g 0 0.000 12 100.00 0 Total 82 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION Frequencies for Q9 Q9 Frequency Percent Valid Percent Cumulative Percent 3 1 8.333 8.333 8.333 4 4 33.333 33.333 41.667 5 7 58.333 58.333 100.000 Missin g 0 0.000 12 100.00 0 Total Frequencies for Q10 Q10 Frequency Percent Valid Percent Cumulative Percent 4 7 58.333 58.333 58.333 5 5 41.667 41.667 100.000 Missin g 0 0.000 12 100.00 0 Total Frequencies for Q11 Q11 Frequency Percent Valid Percent Cumulative Percent 4 7 58.333 58.333 58.333 5 5 41.667 41.667 100.000 Missin g 0 0.000 12 100.00 0 Total Frequencies for Q12 83 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION Frequencies for Q11 Q11 Frequency Percent Valid Percent Cumulative Percent Q12 Frequency Percent Valid Percent Cumulative Percent 3 2 16.667 16.667 16.667 4 3 25.000 25.000 41.667 5 7 58.333 58.333 100.000 Missin g 0 0.000 12 100.00 0 Total Frequencies for Q13 Q13 Frequency Percent Valid Percent Cumulative Percent 2 1 8.333 8.333 8.333 3 5 41.667 41.667 50.000 4 4 33.333 33.333 83.333 5 2 16.667 16.667 100.000 Missin g 0 0.000 12 100.00 0 Total Frequencies for Q14 Q14 Frequency Percent Valid Percent Cumulative Percent 3 2 16.667 16.667 16.667 4 7 58.333 58.333 75.000 5 3 25.000 25.000 100.000 Missin g 0 0.000 84 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION Frequencies for Q13 Q13 Frequency Total 12 Percent Valid Percent Cumulative Percent Valid Percent Cumulative Percent 100.00 0 Frequencies for Q15 Q15 Frequency Percent 3 2 16.667 16.667 16.667 4 6 50.000 50.000 66.667 5 4 33.333 33.333 100.000 Missin g 0 0.000 12 100.00 0 Total Frequencies for Q16 Q16 Frequency Percent Valid Percent Cumulative Percent 4 5 41.667 41.667 41.667 5 7 58.333 58.333 100.000 Missin g 0 0.000 12 100.00 0 Total 85 ANATOMAGE TABLE AND EFFECTS ON CLINICAL ANATOMY APPLICATION  ...

... PREOPERATIVE PAIN MANAGEMENT Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2023 Preoperative Pain Management for Laparoscopic Cholecystectomy to Decrease Immediate Postoperative Pain and Opioid Consumption Valine C. Nnoruo and Bessem Enoweyere Chair: Dr. Bradley Stelflug (Signature) Project Team Members: Reed Stockman CRNA (Signature) Diana Madsen (Signature) Date of Submission: November 28, 2022 1 PREOPERATIVE PAIN MANAGEMENT Table of Contents Abstract .......................................................................................................................... 4 Introduction ................................................................................................................... 5 Background ............................................................................................................... 6 Problem Statement .................................................................................................... 6 Needs Assessment and Analysis ............................................................................... 8 Review of the Literature .................................................................................................. 9 Theoretical Framework....................... 20 Project Aim and Objectives 21 SWOT Analysis . 22 Project Design/Methods 23 Project Site and Population . 23 Data Collection Procedure ... 24 Ethical Considerations/Protection of Human Subjects .... 25 Project Evaluation Plan ... 25 Results. 25 Data Analysis ...... 26 Discussion 28 Project Limitation 30 2 PREOPERATIVE PAIN MANAGEMENT 3 Consideration and Future Recommendation . 31 Conclusion . 32 References . 33 Appendix A... 41 Appendix B...... 42 Appendix C 43 Appendix D 44 Appendix E . 45 Appendix F . 46 Appendix G . 47 Appendix H . 48 PREOPERATIVE PAIN MANAGEMENT 4 Abstract Inadequate pain management during a laparoscopic cholecystectomy can affect postoperative hemodynamics, impair recovery, and extend hospital stay. The use of opioid medications during and after surgeries can reduce postoperative pain, however, the complications of opioid use such as nausea, vomiting, respiratory depression with the associated cardiovascular implications, and pneumonia can also impair recovery from surgery, cause postoperative discomfort, prolong hospital stay and could potentially cause opioid abuse in some patient population with surgical exposure. Numerous studies have reported the crucial role of administering preoperative or intraoperative non-opioid medications to mitigate postoperative pain. The purpose of this project is to utilize preoperative non-opioid multimodal analgesics to manage postoperative pain and reduce intraoperative and postoperative opioid use. Eight patients were studied in this project to determine the efficacy of preoperative acetaminophen, in combination with gabapentin and ibuprofen to reduce post-operative pain perception and postoperative rescue opioid administration. The study determined that preoperative pain medications, intraoperative pain medications, duration of surgery, gender and age can all influence postoperative pain. Also, among the participants who perceived pain after surgery despite receiving preoperative treatment, pain was more significant among females compared to males, and pain rating was highest within the first 15 minutes and reduced as time progressed. Further studies need to include more variables such as comorbidities, and ethnic differences in how they affect postoperative pain. Also, more studies are needed to ascertain the best combination of preoperative non-opioid treatment regimen that can maximally reduce intraoperative and postoperative pain and opioid use. PREOPERATIVE PAIN MANAGEMENT 5 Preoperative Pain Management in Laparoscopic Cholecystectomy to Decrease Immediate Postoperative Pain and Opioid Consumption 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 Anesthesiology track. In more than 80% of surgical procedures done today, postoperative pain is inadequately treated with 71% of patients reporting moderate to severe pain (Apfelbaum et al., 2003). Although pain after surgery is a predictable part of the surgical experience, inadequate pain management may lead to profound implications with increasing clinical and surgical stress, morbidity, mortality, and a decrease in the quality of life (Apfelbaum et al., 2003). Also, ineffective postoperative pain management has shown to cause negative clinical outcomes like pulmonary embolism, deep vein thrombosis (DVT), coronary artery ischemia, myocardial infarction (MI), delayed wound healing, pneumonia, demoralization, and insomnia. Effective pain relief and prevention improves clinical outcomes, avoids clinical complications, saves healthcare resources, and improves quality of life for the patient. According to the Joint Commission on Accreditation of Healthcare Organizations, pain management must become part of all patient care activities (Apfelbaum et al., 2003). Due to the advancement in technology and the discovery of new medications, providers are required to stay current and incorporate in their practice new ways to manage and control the patients pain (Young et al., 2006). The purpose of this project is to evaluate the effectiveness of administering multimodal non-opioid medications (Tylenol, Gabapentin, and Ibuprofen) in the preoperative area to decrease pain and reduce the amount of opioid administered in the immediate post-anesthesia care unit (PACU) after a laparoscopic cholecystectomy (LC). Adequate pain management and limited opioid use not only improve recovery but are also associated with improved patients satisfaction and comfort. PREOPERATIVE PAIN MANAGEMENT 6 Background and Problem Statement Pain has become the primary concern after surgery for most patients as nociceptors are stimulated. Inflammation from injury to the nerve stimulates the buildup of prostanoids at the site of surgery. Numerous signal pathways augment nociceptive sensitivity distal to the site of the injury, which is referred to as peripheral sensitization. Peripheral sensitization causes hyperalgesia and allodynia (Lou & Min, 2017). When a painful stimulus is prolonged, the dorsal horn acts as the site of central sensitization because of repetitive nociceptive stimulation. The brainstem contributes to central sensitization by decreasing inhibitory modulation. A combination of central and peripheral sensitization causes hypersensitivity in the postoperative period due to the increased excitability of spinal nerves and decreased pain threshold in peripheral pain receptors (Lou & Min, 2017). According to Morgan and Mikhail (2008), pain may resolve quickly after the stimulus is removed or it can persist for a long time even after the stimulus is removed. The mainstay of surgical pain management is with opioid analgesics, but they have been shown to cause numerous side effects like nausea, vomiting, pruritus, urinary retention, and respiratory depression. This project is to evaluate the use of multimodal pain management techniques and to assure patients of the importance of decreased opioid consumption which is beneficial to their health. Apfelbaum et al. (2003) explained that there is an increasing number of ambulatory surgeries done today and decreasing the number of narcotics administered significantly improves the outcome and satisfaction of patients undergoing laparoscopic cholecystectomy. This minimizes opioid related side effects like decreased alertness, hypoventilation, and nausea. Laparoscopic procedures are the most common surgical procedures in the world, and LC is the prevailing surgical procedure for gallbladder disease. Due to its minimal nature, it has the PREOPERATIVE PAIN MANAGEMENT 7 advantage of minor pain, short length of hospital stays, minor trauma, and it is better tolerated compared to non-laparoscopic approaches. There are two kinds of laparoscopic surgeries: elective laparoscopic surgery performed as a same-day surgery, or emergency laparoscopic surgery which could be done for acute cholecystitis. The latter can result in prolonged hospital stay averaging about 4.5 days and results in more postoperative complications than the elective. Several factors contribute to the development of visceral pain following laparoscopic cholecystectomy. Some of these factors include phrenic nerve irritation resulting from pneumoperitoneum, port-size incisions, abdominal distension, trauma associated with gallbladder removal, and the sociocultural status of the patient (Karaca et al., 2019). Inadequate pain control can result in undesirable outcomes if left untreated. Most patients are admitted to PACU after their surgical procedure, and inadequate pain control in this setting can delay recovery (Luo & Min, 2017). About 41% of patients in the PACU report pain from the surgery and emergence from anesthesia, which end up affecting multiple organ systems (Lou & Min, 2017). As stated above, postoperative pain can cause serious side effects or problems due to either insufficient treatment or excessive use of opioid medications to reduce the pain. Complications could lead to cardiac, pulmonary, immune system, and thromboembolic dysfunction. More so, excessive sedation due to increased narcotic use can increase length of stay and impair quality of life. In cases like LC, adequate analgesia can be challenging after a painful stimulus due to hypersensitive receptors and central nervous system hyperexcitability (Karaca et al., 2017). Approaches which focus on the preoperative period, also known as preemptive analgesia, aim to decrease postoperative pain by decreasing the sensitivity of afferent pain receptor neurotransmitters caused by surgical stimulus, and by attenuating the effects of pain PREOPERATIVE PAIN MANAGEMENT 8 throughout surgery (Karaca et al., 2017). In preemptive analgesia, an analgesic is administered before tissue injury during surgery for better pain relief compared to when an analgesic is administered after the painful stimulus has occurred (Hariharan et al., 2009). Measures to antagonize the nociceptive signals before injury have been shown to prevent central hypersensitization, therefore reducing the intensity of pain after the injury. Medications like Tylenol, Gabapentin and Ibuprofen have been found useful in decreasing the need for postoperative analgesic when given in the preoperative area. Tylenol works on the central nervous system (CNS) by inhibiting prostaglandins via the cyclooxygenase pathway. Gabapentin inhibits gamma-aminobutyric acid (GABA) by preventing the release of neurotransmitters like glutamate, substance P, and noradrenaline that can promote pain transmission. Gabapentin is also effective at treating neuropathic pain. Ibuprofen is a nonsteroid analgesic which has antiinflammatory, antipyretic and analgesic effects. Though these medications are used routinely, combining them provides an additive or synergistic analgesia (Thybo et al., 2019). The use of multimodal pain management techniques has demonstrated an improvement in pain control when the patient is in the postoperative area (Hariharan et al., 2009). The fear of pain is significant prior to a surgical experience (Mumm, 2010). Tylenol, Gabapentin, and Ibuprofen may help reduce the intensity of pain, thereby improving the overall satisfaction level and the surgical experience. This project will evaluate outcomes of patients related to pain control after LC. Needs Assessment and Gap Analysis The purpose of this project is to facilitate change in the clinical setting as it relates to pain control after laparoscopic gallbladder surgery. To facilitate the effective use of the nonopioids stated above, an understanding of the timing of their administration and action on pain PREOPERATIVE PAIN MANAGEMENT 9 receptors will help in their preemptive analgesic role. Applying this same concept in reducing postoperative nausea and vomiting (PONV) has proven to be successful. It is believed that when a receptor site for PONV is blocked before a response to nauseous stimuli, it helps to reduce the incidence of nausea and vomiting. At a midwestern hospital in Indiana, a multimodal approach in treating pain preoperatively has not been introduced as an additional approach to pain management and opioid reduction strategy. Though there have been multiple approaches used in the past in treating postoperative pain, this project will focus on evaluating the effectiveness of routine use of Tylenol, Gabapentin and Ibuprofen when given preoperatively to decrease pain opioid consumption in the immediate postoperative period. Review of Literature Multimodal approaches to pain management are used to decrease the need for opioid consumption in the intraoperative state and postoperative setting. Acetaminophen, also known as Tylenol, Gabapentin, and Ibuprofen are not concurrently used preoperatively at this midwestern hospital in the state of Indiana. The purpose of this project is to decrease postoperative pain and opioid consumption by administrating Acetaminophen, Gabapentin, and Ibuprofen in the preoperative period before laparoscopic surgery. Methods Articles used for this literature review were focused on preemptive or preoperative use of acetaminophen, gabapentin, or ibuprofen for management of post-operative pain in patients undergoing laparoscopic cholecystectomy. The databases searched were Cochrane Library, Ovid MEDLINE, and Google Scholar. The keywords utilized were laparoscopic cholecystectomy, ibuprofen, gabapentin, acetaminophen, paracetamol, preemptive analgesia, preoperative, premedication, NSAID, and multimodal. BOOLEAN phrases constructed from the keywords that PREOPERATIVE PAIN MANAGEMENT 10 were used for these searches include laparoscopic cholecystectomy AND acetaminophen AND preemptive analgesia, laparoscopic cholecystectomy AND acetaminophen AND preoperative, laparoscopic cholecystectomy AND acetaminophen AND premedication, laparoscopic cholecystectomy AND acetaminophen AND multimodal, laparoscopic cholecystectomy AND paracetamol AND preemptive analgesia, laparoscopic cholecystectomy AND paracetamol AND preoperative, laparoscopic cholecystectomy AND paracetamol AND premedication, laparoscopic cholecystectomy AND paracetamol AND multimodal, laparoscopic cholecystectomy AND ibuprofen AND preemptive analgesia, laparoscopic cholecystectomy AND ibuprofen AND preoperative, laparoscopic cholecystectomy AND ibuprofen AND premedication, laparoscopic cholecystectomy AND ibuprofen AND multimodal, laparoscopic cholecystectomy AND gabapentin AND preemptive analgesia, laparoscopic cholecystectomy AND gabapentin AND preoperative, laparoscopic cholecystectomy AND gabapentin AND premedication, laparoscopic cholecystectomy AND gabapentin AND multimodal. These searches were conducted from November 2021 to December 2021. A total of eleven thousand and fifty-nine articles were found relating to one or more components of this topic. However, 11,039 of these articles were eliminated for not meeting the stipulated inclusion criteria. The inclusion criteria included primary sources and systematic reviewed articles from 2008 to 2021. The reason the literature search went back 13 years is due to the limited number of relevant literatures on this topic within the last decade. Other inclusion criteria are adult patients undergoing laparoscopic cholecystectomy, articles written in English language, and those specifically written about preemptive or preoperative acetaminophen, gabapentin, and ibuprofen (See Appendix A for the PRISMA Flow Diagram). PREOPERATIVE PAIN MANAGEMENT 11 The exclusion criteria are studies done beyond the last 13 years, non-laparoscopic cholecystectomies, and those evaluating medications or preoperative treatment modalities other than the ones being evaluated in this review. After applying the criteria for inclusion, 20 articles were selected for this literature review. Findings A considerable number of studies have been done to provide best evidence with the use of these medications in the preoperative phase to manage postoperative pain. 20 articles were reviewed, seven of these articles were focused on acetaminophen (Ekinci et al., 2019; Johnson et al., 2019; Kamali, et al., 2018; Medina et al., 2017; Salihoglu et al., 2009; Sami Mebazaa et al., 2008; Toleska & Dimitrovski, 2019), five of the studies investigated the efficacy of ibuprofen (Ahiskalioglu et al., 2017; Ekinci et al., 2019; Gurusamy et al., 2010; Kamali et al., 2016; Karaca et al., 2019), and nine studies were focused on gabapentin (Abbas & Bashir, 2009; Gilron et al., 2009; Hosseini et al., 2015; Karri et al., 2021; Kochlar et al., 2017; Kotsovolis et al., 2015; Mishra et al., 2016; Nakhli et al., 2018; Srivastava et al., 2010). Acetaminophen Multimodal approaches to perioperative pain management are becoming more popular due to the need to reduce opioid use with their associated adverse effects. Acetaminophen has been extensively studied as one of the most favored multimodal approaches to pain management. Acetaminophen, also known as Tylenol or Paracetamol is a derivative of p-aminophenol with analgesic and antipyretic properties. Although the exact mechanism of action is not completely understood, acetaminophen likely inhibits the nitric oxide (NO) pathway for pain generation and transmission through the central and peripheral nervous system. This pathway is mediated through Substance P and N-methyl-D-aspartate (NMDA) receptors leading to increased pain PREOPERATIVE PAIN MANAGEMENT 12 threshold. The antipyretic effect may result from inhibition of prostaglandin synthesis and release in the central nervous system (CNS) and prostaglandin-mediated effects on the heatregulating center in the anterior hypothalamus (National Center for Biotechnology Information, 2021). Acetaminophen is the most common analgesic. It is recommended by the World Health Organization (WHO) as first-line therapy in pain management (National Center for Biotechnology Information, 2021). In addition, its significance in perioperative pain management has been used to improve clinical practice. For the perioperative period, numerous studies have investigated its efficacy in the management of post-operative pain after a laparoscopic cholecystectomy and the role of acetaminophen in multimodal and opioid sparing analgesia when administered preoperatively. Some of the studies compared acetaminophen with nonsteroidal anti-inflammatory drugs (NSAIDs) such as ketorolac, celecoxib, and ibuprofen (Medina et al., 2017; Sami Mebazaa et al., 2008, Ekinci et al, 2019). Despite the variability in the pain scores between acetaminophen and the NSAIDs (ketorolac, celecoxib, and ibuprofen), preoperative administration of acetaminophen reduced postoperative analgesia following laparoscopic cholecystectomy. Additionally, when compared to an alpha- 2 agonist dexmedetomidine, postoperative pain scores were significantly less among the patients who received preemptive acetaminophen. Also, duration of analgesia among this group was longer with a lower postoperative opioid use compared to the group that received dexmedetomidine (Kamali, et al., 2018). Other supporting studies investigated the efficacy of preoperative acetaminophen in reducing intraoperative and postoperative opioid use (Toleska & Dimitrovski, 2019; Salihoglu et al., 2009). It was found that premedication with acetaminophen (paracetamol) can provide opioid PREOPERATIVE PAIN MANAGEMENT 13 free analgesia and reduce postoperative opioid use. Most research utilized preoperative intravenous (IV) acetaminophen for this surgical procedure, while some others administered oral acetaminophen to the participants. The common dosage is 1 gram (1000 mg), and both routes of administration reduced postoperative pain scores with no significant difference between the two routes (Johnson et al.,2019). Ibuprofen There are limited available studies involving the use of IV ibuprofen in decreasing postoperative opioid consumption, but the available few have shown that ibuprofen plays a beneficial role in the treatment of postoperative pain (Ahiskalioglu et al., 2017). Ibuprofen is a popular over the counter analgesic, antipyretic, and anti-inflammatory drug that has been used for over 40 years in the United States (US). Ibuprofen causes a reversible competitive inhibition of cyclooxygenase-1 (COX - 1), and COX-2 isoenzymes. It is the COX-2 inhibition effect that is responsible for the analgesic, antipyretic and anti-inflammatory responses that occur when it is administered (Ahiskalioglu et al., 2017). In a randomized double-blind study, 60 patients were selected and divided into two groups. The first group was administered 400mg of IV ibuprofen in 100 milliliters(mL) of saline preemptively, and the control group received 100 mL of saline 30 minutes before surgery (Ahiskalioghu et al., 2017). In another randomized double-blind study, Kamali et al. (2016), divided 55 patients into two groups. The experimental group, comprising of 28 patients received 800mg of ibuprofen within 10 minutes of anesthesia induction, and the control group made of 27 patients received 250 mL bag as a placebo. In another study, the efficacy of ibuprofen was compared with pregabalin. In this study, 58 patients were divided into two groups: Group P and Group PI, each group comprising of 29 patients. The former group received 150mg of PREOPERATIVE PAIN MANAGEMENT 14 pregabalin, while the latter received the same dose of pregabalin in addition to 400mg of Ibuprofen before surgery (Karaca et al., 2019). In the three studies above, the Visual Analog Scale (VAS) and 40-item Quality of Recovery questionnaire were used to assess pain scores after LC. The studies showed that the preemptive use of IV ibuprofen in LC reduced postoperative opioid consumptions in the first 24 hours. The study conducted by Ahiskalioglu et al. (2017) showed that there was a 45% decrease in opioid consumption while the other two showed that there was significant decline in pain and discomfort in the patients who received IV ibuprofen. In another study, Ekinci et al. (2019) evaluated and compared the influence of IV forms of Ibuprofen and acetaminophen on pain management and opioid consumption on patients undergoing LC surgery. The VAS score was used to evaluate opioid use and pain intensity in the postoperative period. Pain scores in both the ibuprofen and acetaminophen groups at all time periods were shown to be lower than those in group C who received neither medication. Those patients in group C had a significant increase in opioid consumption than those in the other groups. The result showed that IV ibuprofen reduced pain scores and opioid use more than acetaminophen in the postoperative period after LC surgery. Furthermore, Gurusamy et al. (2010) evaluated pharmacological intervention for prevention and treatment of postoperative pain in patients undergoing LC. Non-steroidal anti-inflammatory drugs like Ibuprofen was one of the pharmacological adjuncts used in the preoperative settings in decreasing the inflammatory response and peripheral nociception. Gabapentin was also used as a multimodal approach to analgesia. Gabapentin Gabapentin is a structural analogue of gamma aminobutyric acid (GABA) which was introduced in 1993 as an adjunct for treating partial seizures. For decades now it has been used in PREOPERATIVE PAIN MANAGEMENT 15 treating chronic neuropathic pain conditions (Srivastava et al., 2010). Recently, numerous studies have demonstrated a beneficial effect of gabapentin on postoperative opioid reduction and pain scores in a variety of procedures including LC (Srivastava et al., 2010). It works by having a high affinity for binding sites throughout the brain in the presence of voltage gated calcium channels which inhibits the release of excitatory neurotransmitters in the presynaptic area. Mishra et al. (2016) did a comparative study to evaluate postoperative analgesic benefit and efficacy in patients administered oral gabapentin or pregabalin as premedication for LC. In this study, 90 patients were placed into three groups A, B and C. Group A received vitamin B complex, group B received 900mg gabapentin each, and group C received 150mg pregabalin. All medications were given one hour prior to induction of anesthesia. The VAS was used to measure postoperative pain scores, total analgesic requirements, and side effects. Patients in groups B and C had lower VAS scores, prolonged timing of first rescue analgesic and less opioid consumption compared to group A. Kotsovolis et al., (2014) conducted a study to test whether the combination of gabapentin 600mg, ketamine 0.3mg/kg, lornoxicam 8mg and local ropivacaine 5ml 7.5% which is to be used at the insertion sites to provide superior analgesia in the first 24 hours after LC. This was a randomized controlled study done with a sample size of forty-eight patients assigned to 6 groups consisting of 28 patients each. Although the findings showed that gabapentin reduced postoperative pain, the combination of gabapentin, ketamine, lernoxicam and local ropivacaine was shown not to have a better analgesic action after LC, however, the incident of postoperative nausea and vomiting was reduced with this combination. In a randomized double blind control trial, Gilron et al, (2009) examined the preoperative effectiveness of gabapentin, and meloxicam in decreasing pain during the postoperative period. PREOPERATIVE PAIN MANAGEMENT 16 Postoperative pain intensity at rest and with movement was assessed using the numerical pain rating scale (NPRS). Based on the NPRS, the intensity of pain at rest was significantly lower with gabapentin alone versus meloxicam alone. There was a small difference in pain when a combination of meloxicam and gabapentin was used. Karri et al. (2021) in their randomized double-blind study found that patients who received 600mg of gabapentin before surgery had a lower numerical rating scale (NRS) scores at 15 minutes and 1 hour postoperatively when compared to memantine. Gabapentin was a preferable adjuvant analgesic for LC compared to memantine when given as a single preoperative dose. Srivastava et al. (2010) evaluated the efficacy of a single dose of 600mg gabapentin given preoperatively for reducing postoperative pain and opioid consumption after a mini-lap open cholecystectomy. 120 patients were randomly selected with the gabapentin group receiving 600mg and the controlled group receiving an identical looking capsule 2 hours before surgery. The Visual Analog Scale (VAS) measured that pain at rest and during movement was less in the gabapentin group than the placebo group. The number of opioids used in the first 24 hours after surgery was very low in the patients who received gabapentin compared to the placebo group. Abbas & Bashir (2019) evaluated how effective a preoperative use of gabapentin can be in reducing postoperative pain after LC. The VAS was used to measure pain after surgery with 0 being no pain and 10 being the worst imaginable pain. The result showed that 600mg of gabapentin was effective in reducing pain and analgesic use after LC. Abbas & Bashir (2019) found gabapentin to be a safe and well tolerated treatment modality allowing for fast postoperative recovery in patients following LC. PREOPERATIVE PAIN MANAGEMENT 17 Hosseini et al. (2015) evaluated if melatonin, clonidine, and gabapentin can reduce postoperative pain in patients undergoing LC. Pain intensity was measured using the VAS criteria for the first postoperative 24 hours. The highest score was noted in the placebo group while the intervention groups had less pain. Opioid consumption was also increased in the placebo group compared to the intervention group. The intensity of pain was significantly decreased, and pain reduction trend was different between the groups. In the different time periods, pain score was lowest with clonidine. One of the side effects after LC is postoperative pain which can be around the scapular. Although the mechanism is multifactorial, the prevailing theory is the presence of persistent carbon dioxide in the right diaphragm and hepatic dome (Nakhli et al., 2018). Gabapentin and pregabalin belong to the gabapentinoid family. In a study carried out by Nakhli et al. (2018), 90 patients undergoing LC were enrolled and divided into 3 groups of 30: a gabapentin group, a pregabalin group and the control group. The VAS was used to assess postoperative pain ranging from 0 to 10. The incidence of shoulder pain was significantly less in the gabapentinoids group compared to the control, and no significant difference was found in the intensity of postoperative shoulder pain between the two gabapentinoid drugs. Therefore, preemptive gabapentin or pregabalin can effectively reduce pain intensity and improve ambulatory practices after LC (Nakhli et al., 2018). Discussion In this review, the efficacies of preoperative acetaminophen, gabapentin and ibuprofen were investigated to determine their ability to reduce postoperative pain and opioid consumption following a laparoscopic cholecystectomy. When used preoperatively, the studies reviewed show that acetaminophen 1g (1000 mg) can decrease postoperative pain score and reduce PREOPERATIVE PAIN MANAGEMENT 18 postoperative opioid use. Ibuprofen as a potent NSAID also significantly reduced postoperative pain and opioid use following a laparoscopic cholecystectomy. Aside from producing favorable results in the outcomes mentioned, gabapentin as a single regime or in combination with other drugs also decreases postoperative nausea and vomiting (PONV), which is an added benefit to this medication (Nakhli et al., 2018; Abbas, & Bashir, 2019; Srivastava et al., 2010; Gilron et al., 2009; Kotsovolis et al., 2015). Same positive results were extrapolated for Ibuprofen. Premedication with PO or IV ibuprofen was associated with reduced stress response and inflammation, decreased postoperative pain and opioids used after LC (Karaca et al., 2019; Ahiskalioglu et al., 2017; Kamali et al., 2016; Ekinci et al., 2019). These findings provide a well understood, yet unique lens into a practice that can not only mitigate postoperative pain, but also reduce opioid use that has negatively impacted patients outcome both in the hospitals and communities. Furthermore, this practice can reduce healthcare costs and improve patient satisfaction after a surgical journey. Provided that each patient is unique, the efficacy of this practice is promising, and patients that meet the criteria for use should be assessed for how this practice can benefit them. Implication for Future Practice The findings from this literature review inform the different opioid free approaches to pain management following laparoscopic cholecystectomy. Although most of the studies looked at each drug regimen individually, the combination of the three drugs would likely have an additive effect (Hannam et al., 2018; Yoon & Yaksh,1999), and provide adequate postoperative pain management and reduction in the amount of opioid that is used in the postoperative area. PREOPERATIVE PAIN MANAGEMENT 19 Study Limitations This study provided some of the most common preoperative approaches that can be used to reduce postoperative pain and opioid use. However, it did not investigate the postoperative findings of the three medications that were looked at. Furthermore, most of the studies reviewed were based on monotherapy with each of the medications or in comparison with other adjuvant non-opioid analgesics. No available literature combined the three medications being used in this study for the preoperative management of postoperative pain. Another limitation is that 20 studies were reviewed that were carried out within the last 13 years, which may be an underrepresentation of all the available relevant information on this matter. Also, all the conclusions made in this review relied on the results that were presented by the original authors of the reviewed studies, and there was no way to validate the data. Future Research Further research can be done with a focus on the possible side effects of combining the three-medication regimen preoperatively. Also, although it might appear obvious that improving postoperative pain management and reducing opioid use with these medications will result in healthcare savings, more studies can be carried out to provide a more objective and numerical value of the healthcare cost when compared to opioid driven analgesia. Conclusion Although pain rates vary based on type of surgery, type of anesthetic and analgesics used, and the intraoperative and postoperative duration, studies have shown that postoperative pain is inadequately managed in over 80% of the US patient population (Gan, 2017). Inadequate postoperative pain management is directly correlated with increased morbidity, impaired quality of life and functionality, delayed recovery time, prolonged duration of opioid use, and increased PREOPERATIVE PAIN MANAGEMENT 20 cost of healthcare due to longer hospital stay and other pain related complications. Furthermore, the presence and intensity of acute postoperative pain is a prediction factor for the development of chronic pain (Gan, 2017). Progress has been made to recognize postoperative pain as a public health concern. Given the complexity of pain pathways, recent efforts have focused on multifaceted approaches to pain management. Multimodal pain management employs the use of different medications and approaches with varying mechanisms of action to prevent and mitigate pain. The idea of preoperative and preemptive analgesia with multimodal approach is to arrest tissue sensitization and pain transmission prior to initiating painful stimuli. As a monotherapy, numerous studies have investigated acetaminophen, ibuprofen, and gabapentin and found them to be efficacious in the management of postoperative pain and reduced amount of opioid administered in the recovery unit. The combined use of these medications is intended to provide postoperative pain management more effectively. This will further prevent the harmful effects of poorly controlled pain, reduce the incidence of chronic pain, and mitigate the adverse effects of opioid use. Theoretical Framework Nursing theories help to improve nursing care by providing the foundation for practice and evidence-based improvement. The theoretical framework that guides this project is Kolcabas nursing theory of comfort. It is a middle range theory which has been used to improve institutional outcomes and change (Kolcaba & Wilson, 2002). This theory describes comfort as an immediate desirable outcome of nursing care (Nursing Theory, 2019). It is pertinent to the peri-anesthesia setting because patient comfort and safety are established goals in this care environment. Comfort according to this theory is a state of being strengthened by having needs PREOPERATIVE PAIN MANAGEMENT 21 for relief, ease, and transcendence met in four contexts of experience (physical, psychospiritual, sociocultural and environmental) (Kolcab & Wilson, 2002). Relief describes having ones severe discomfort alleviated. Ease describes an absence of specific discomfort. Patients experience ease when the provider proactively minimizes the predisposing factors that can lead to discomfort. Finally, transcendence in the context of this theory is the capacity to surpass the discomfort in instances when they cannot be mitigated or avoided (Kolcaba & Wilson, 2002). Pain is a common cause of discomfort and preemptive pain management is intended to promote comfort preoperatively and post-operatively. Prior to surgical procedures, nurse anesthetists carry out this process by including patient comfort as an integral aspect of the preoperative planning. This plan should include preemptive analgesia which has been shown to effectively reduce postoperative pain. A good comfort measure in this stage will reduce complications in subsequent stages (Kolcaba & Wilson, 2002). Once comfort is achieved, it provides ease to the patient and improves their optimism towards recovery. Pain scales, physical assessment, and most importantly patient feedback are necessary indicators used daily to address pain and guide practice. Using Kolcabas theory supports the anesthetists ability to promote transcendence by educating the patients about surgical pain, and the need to control and manage pain to help patients adapt postoperatively. Project Aim and Objective The purpose of this project is to delineate a multimodal preoperative pain management to reduce pain and the amount of narcotic consumption in the postoperative period. This project aims to utilize preemptive analgesia preoperatively to mitigate immediate post-operative pain by antagonizing pain receptors before they are stimulated. This will also decrease post-operative opioid use in the recovery area. The objectives include oral administration of one gram of PREOPERATIVE PAIN MANAGEMENT 22 acetaminophen, 300 milligrams of gabapentin and 600 milligrams of ibuprofen a minimum of an hour before the scheduled procedure. Upon return to the recovery area, the patients postoperative pain level, and the need for further pain management will be assessed. SWOT Analysis The SWOT analysis is a visual display of the strengths, weaknesses, opportunities, and threats that are related to project planning (See Appendix B). For this project, some of the identified strengths include a previous experience with preemptive/preoperative pain management and a good grasp of the benefits of multimodal pain management to the patient and healthcare in general. Other identified strengths include the constant support provided by facility stakeholders towards this project, and the availability of computerized patient data which makes it possible to easily access patient information remotely. One of the noteworthy weaknesses surrounding this project includes a limited patient population that meets the inclusive criteria for this study. Other identified weaknesses are the financial burden that might be incurred, as well as limited staff training on the importance and process of preemptive analgesia. This project provides an opportunity to provide education to the staff, especially the preoperative and recovery nurses regarding preemptive analgesia, because these nurses will be involved in preoperative medication administration and postoperative pain assessment, respectively. With the projected shift away from opioid use because of nationwide opioid epidemic and their related adverse effects, this project provides an opportunity to implement an evidence-based multimodal opioid free pain management at this facility, which will improve pain management and reduce the number of opioids patients receive in the recovery area. Quality improvement projects can encounter certain levels of environmental threat. Some of the threats that are associated with this project include potential resistance by some of the staff PREOPERATIVE PAIN MANAGEMENT 23 members, the distance it takes to get to the project site, limited number of literatures on the project topic, and the length of time it takes to acquire Institutional Review Boards (IRB) (See Appendix E) approval which can delay the progression of this project. Project Design / Methods This is a practice intervention and process improvement DNP project. It will be a quantitative prospective nonrandomized study with historical control group. The reason for using historical controls is due to the limited number of patients available for this study. Project Site and Population This prospective trial will be conducted at a 58 bed, level 4, private hospital in the Midwest between March 2022 and October 2022. The project group will include 20 patients having elective laparoscopic cholecystectomy and the control group will be 20 patients with previous laparoscopic cholecystectomy. Inclusion criteria are age between 18 and 80 years, American Society of Anesthesiologists (ASA) physical status classification I or II, and a diagnosis of cholecystitis or any gallbladder diseases requiring an elective laparoscopic cholecystectomy. Criteria for exclusion include liver failure, renal dysfunction, chronic pain, opioid dependence, inability to accurately provide information due to neurological disease or intellectual disability, and patients with history of adverse reaction to ibuprofen, acetaminophen, or gabapentin. Prior to surgery, each patient will be informed of this study and its relevance. An Eligibility Survey (See Appendix F) will be used to determine patients who can participate in the project study. Before medication administration, patients signed informed consent to the study will be obtained and each patient will be educated on the numerical pain rating scale (NPRS) PREOPERATIVE PAIN MANAGEMENT 24 (See Appendix G for the NPRS). The NPRS will be used because it is an easy-to-use scale for adults with no cognitive impairment and data obtained can be easily measured. All 20 participants in the study group will receive PO one gram of acetaminophen, 600 mg of Ibuprofen, and 300mg of gabapentin at least one hour prior to the procedure but not administered more than two hours before the procedure. The dosages and duration of administration are based on current clinical practice. Data Collection Procedure Following extubation in the operating room, data such as surgery duration, intraoperative complications, and intra-operative analgesics will be recorded in the Intraoperative Patient Form (IP Form) (See Appendix H for the IP Form). Once in the post anesthesia recovery unit (PARU), patients will be evaluated at the bedside for postoperative pain using the NPRS at 15 minutes, 30 minutes, and 45 minutes. The NPRS uses a pain scale of 0 to 10. The number 0 indicates no pain and 10 corresponds to the worst possible pain. Fentanyl in increments of 25 micrograms will be used as the rescue analgesic for postoperative pain, unless if contraindicated. All postoperative pain data will be entered into the NPRS form. The amount of fentanyl used in the PACU, other analgesia requirements, and length of stay in the recovery unit will also be recorded. Ethical Considerations and Protection of Human Subjects Internal Review Board (IRB) approval was obtained prior to initiating this DNP project. All participants were provided a written informed consent and are protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) which protects the privacy of all patients medical records. Ethical approval was also obtained from the Marian Internal Review Board (MIRB). There is no risk to participation in this study other than receiving regular PREOPERATIVE PAIN MANAGEMENT 25 perioperative care and assessment. In addition, all relevant data were carefully collected, recorded with unique patient identifiers without identifiable patient information and stored in a password encrypted device that can only be accessed by authorized users for the period of the study. Project Evaluation Plan At the completion of the study, Statistical Package for the Social Sciences (SPSS) will be used to input and analyze the data which will be shown as mean and standard deviation (SD). The postoperative pain scores at 15 minutes, 30 minutes, 45 minutes will be calculated and analyzed with one-way ANOVA. Additionally, the total dose of fentanyl administered in the recovery unit for each group will be compared with the use of unpaired t tests. A P value <0.05 will be considered statistically significant. In an event that no control is obtained, the sample size is smaller than projected or does not fit a normal curve, then non-parametric equivalent to the above tests will be used to reduce statistical flaw. Results A total of eight patients participated in the project. There were no controls. The participants were aged between 18 and 72 years, and half were male. All the participants received Tylenol, Ibuprofen, and Gabapentin within one hour prior to surgery. No other preoperative medications were administered. Intraoperatively, five of the patients received Toradol 30 mg (two males and 3 female participants), one male patient received Toradol 15 mg in addition to fentanyl 100 mcg. One female participant received fentanyl 100 mcg and one male participant received fentanyl 75 mcg. One of the male patients who received Toradol 30 mg also received fentanyl 250 mcg, and one of the female participants who received Toradol 30 mg received an additional dose of PREOPERATIVE PAIN MANAGEMENT 26 dexmedetomidine 92 mcg. The mean duration of surgery is 124 minutes, with a standard deviation of 34.488. The chart below depicts the duration of surgery for each patient. Chart 1: Duration of the Laparoscopic Cholecystectomy for each patient. Duration of surgery in minutes Duration of surgery in minutes 187 157 135 116 115 108 89 86 86 Patient 1 Patient 2 patient 3 patient 4 patient 5 patient 6 patient 7 patient 8 Postoperatively, for the first 15 minutes, four of the male patients and one of the female patients experienced no pain, while the remaining three female patients rated their pain at 9,8, and 7 respectively. The second 15 minutes recorded decreased pain for the three female participants that reported pain, with zero pain for the other five participants. The last 15 minutes recorded a further decrease in pain for the three participants with existing pain. Also, at this time, four of the five patients with zero pain maintained a score of zero, while one (male participant) reported a pain score of 3. The mean postoperative pain perception is 6.7 for all the patients, which is categorized as moderate pain. Fentanyl, Vicodin, and meperidine were used as rescue analgesics for the three female patients with recorded pain scores. PREOPERATIVE PAIN MANAGEMENT 27 Data Analysis All the participants received intraoperative pain medications. The standard deviation (SD) for intraoperative medications is 1.959, with a mean of 2.88. One-way ANOVA was used to analyze the post-operative pain perceived within the first 45 minutes in 15 minutes intervals and the intraoperative medications administered. The table below depicts the results of the oneway ANOVA. Table 1: One-way ANOVA results ANOVA Sum of Squares postop_pain_zero_to_fiftheen Between Groups df Mean Square 73.333 5 14.667 48.667 2 24.333 122.000 7 post0p_pain_fiftheen_to_thirt Between Groups 43.500 5 8.700 y Within Groups 24.000 2 12.000 Total 67.500 7 37.333 5 7.467 .667 2 .333 38.000 7 Within Groups Total postop_pain_thirty_to_fortyfiv Between Groups e Within Groups Total F Sig. .603 .720 .725 .667 22.400 .043 The results were statistically insignificant, probably based on the small sample size in the study. The Independent T-test p-value of the total dose of fentanyl administered in the recovery unit for the study group was 0.444, which was statistically insignificant. The statistics show that the null hypothesis is maintained, and the alternative hypothesis is rejected. The insignificant pvalue confirms that the medications administered do not help reduce post-operative pain. This is PREOPERATIVE PAIN MANAGEMENT 28 likely due to the sample size and lack of control. In addition, due to the small sample size, lack of a control group and because data obtained do not meet the assumptions about the population sample, a non-parametric Mann-Whitney test was used to analyze postoperative pain scores between male and female participants at the different time intervals. At 15 minutes postoperative, the Mann-Whitney score is 2.000 with p-value of 0.047, indicating a significance in postoperative pain between males and females. At 30 minutes the Mann-Whitney test score is 2.000 with a p-value of 0.040, indicating a significance in the postoperative pain score between both genders. At 45 minutes postoperatively, there is no significant difference in the pain scores between both genders (p-value 0.122). Also, the participants were grouped into three different age groups. Group 1 (18-28 years), group 2 (51-61 years), and group 3 (62-72 years). Using the Krustal- Wallis test for analysis, there was no significant difference in the postoperative pain perceived between the three groups at 15 minutes (p-value 0.292), 30 minutes (p-value 0.195), and at 45 minutes (p-value 0. 084). Finally, participants were grouped based on the duration of surgery in minutes. Using the Krustal-Wallis non-parametric test, there was no significant difference in postoperative pain between surgeries that lasted 90 minutes or less, 91 to 120 minutes and surgeries that lasted over 120 minutes at 15 minutes (p-value 0.388), 30 minutes (pvalue 0.364), and at 45 minutes (p-value 0.354) postoperative intervals. Discussion The results of the data analyzed indicated that the preoperative medications did not significantly decrease post operative pain and opioids administered largely due to the small sample size and the lack of control participants. However, the study found that male patients experienced less postoperative pain within the first 30 minutes after surgery compared to the female patients. This is in line with previous studies indicating that pain perception is largely PREOPERATIVE PAIN MANAGEMENT 29 influenced by gender differences, as reported by (Logan & Rose, 2004). More pain medications were administered to the female participants in the PACU within the first 15 to 30 minutes, which might account for the lack of significant difference in pain scores between both genders at 45 minutes PACU time. None of the male participants received any medication in the PACU. Also, Fentanyl was the most common postoperative rescue analgesic administered, likely due to its quick onset and short duration of action. Chart 2: Post-operative medications administered by gender. The data analysis obtained showed no predictive relationship between age and the severity of postoperative pain. This can be attributed to the small sample size of eight. Also, the participants were further grouped into three different age groups which further diluted the sample size. On the contrary, Gustafsson et al. (2020) reported a significant correlation between extremes of age and postoperative pain compared to middle-aged adults. Studies have shown that a longer duration of surgery is a risk factor for postoperative pain and opioid use. According to Hah et al. (2018), laparoscopic surgeries with longer intraoperative operations were associated with more postoperative pain that impaired timely recovery. However, this study analysis showed that surgery duration did not significantly impact PREOPERATIVE PAIN MANAGEMENT 30 postoperative pain or opioids used. This can also be attributed to the small sample size. More so, the participants were split into three groups based on the duration of surgery, thereby further reducing the sample size. Toradol and Fentanyl were the most frequently administered intraoperative pain medications. Chart 3: Post-operative pain medications administered by surgery duration. Project Limitations The study lacked a control group which became a major setback, making it impossible to show the effectiveness of the preoperative pain medications in reducing postoperative pain and opioid use. Also, the small sample size was a major limitation. A study with an adequate sample size has a high level of evidence. Studies with a low sample size would have most variables statistically non-significant. This DNP project only had eight participants, making it a very low level of evidence. PREOPERATIVE PAIN MANAGEMENT 31 Considerations and Future Recommendations The study found that postoperative pain scores were highest during the first 15 to 30 minutes in the PACU. Therefore, more clinical trials are necessary to determine the correct mix of multimodal pain relief medications to be administered preoperatively to alleviate perioperative pain among surgical patients. Studies should focus on drugs with longer half-lives and fewer side effect profiles to ensure optimum pain control throughout the immediate postoperative period. According to Barazanchi et al. (2018), few clinical trials have adequately reported on multimodal pain management and effectively tested desirable drugs to efficiently control postoperative pain without regular dosing. To further complement the enhanced postoperative pain reduction, the role of extended-release single non-opioid agents should be investigated as they provide superior pain management properties. Adequate studies would inform policymaking to optimize postoperative pain control. The study had a limited number of patients to study the objectives in depth. Furthermore, a proper control group is needed to provide adequate evidence as to the desirable effects of the study. Although expensive, more high-quality studies with sufficient participants and control would provide a high level of evidence. As observed in the study, there is a significant variation in pain threshold influenced by factors like age and gender. Future clinical trials would consider such differences, including other variables like race, ethnicity, and comorbidities to provide a more detailed conclusion regarding their implication in postoperative pain management. PREOPERATIVE PAIN MANAGEMENT Conclusion The complexity of pain after a laparoscopic cholecystectomy possesses a snowballing challenge to recovery after surgery. The management of perioperative pain requires the administration of desired analgesics to optimize patient outcomes and mitigate extended postoperative stay. Opioids are commonly used to alleviate such postoperative pain, but they possess undesirable properties in the form of side effects. Additionally, their short half-lives make regular dosing a necessity. To reduce opioid use while still maintaining optimal pain control, multimodal pain management in the preoperative period using Ibuprofen, Gabapentin, and Tylenol can be implemented. More studies using these preoperative medications are recommended. Furthermore, the influence of gender, age, ethnicity, and comorbidities on preoperative management of postoperative pain using the above non-opioids need to be ascertained. Analyzing the role of these variables, as well as identifying the correct dosing of these preoperative medications can provide a better management of postoperative pain with minimal opioid administration. 32 PREOPERATIVE PAIN MANAGEMENT 33 References Abbas, Z., & Bashir, A. (2019). Effects of Gabapentin on Postoperative Pain and Total Analgesic Requirement After Laparoscopic Cholecystectomy. Biomedical and Pharmacology Journal, 12(2), 925-929. Ahiskalioglu, E. O., Ahiskalioglu, A., Aydin, P., Yayik, A. M., & Temiz, A. (2017). Effects of single-dose preemptive intravenous ibuprofen on postoperative opioid consumption and acute pain after laparoscopic cholecystectomy. Medicine, 96(8), e6200. https://doi.org/10.1097/MD.0000000000006200 Apfelbaum, J. L., Chen, C., Mehta, S. S., & Gan, and T. (2003). Postoperative pain experience: Results from a national survey suggest postoperative pain continues to be undermanaged. Anesthesia & Analgesia, 97(2), 534540. https://doi.org/10.1213/01.ane.0000068822.10113.9e Barazanchi, A. W. H., MacFater, W., Rahiri, J.-L., Tutone, S. D., Hill, A. G., & Joshi, G. (2018). Evidence-based management of pain after laparoscopic cholecystectomy: A Prospect Review. Journal of the American College of Surgeons, 227(4). https://doi.org/10.1016/j.jamcollsurg.2018.08.364 Ekinci, M., Ciftci, B., Celik, E. C., Kse, E. A., Karakaya, M. A., & Ozdenkaya, Y. (2019). A randomized, placebo-controlled, double-blind study that evaluates efficacy of intravenous ibuprofen and acetaminophen for postoperative pain treatment following laparoscopic cholecystectomy surgery. Journal of Gastrointestinal Surgery, 24(4), 780785. https://doi.org/10.1007/s11605-019-04220-1 PREOPERATIVE PAIN MANAGEMENT 34 Gan T. J. (2017). Poorly controlled postoperative pain: prevalence, consequences, and prevention. Journal of pain research, 10, 22872298. https://doi.org/10.2147/JPR.S144066 Gilron, I., Orr, E., Tu, D., Mercer, C. D., & Bond, D. (2009). A randomized, double-blind, controlled trial of perioperative administration of gabapentin, meloxicam and their combination for spontaneous and movement-evoked pain after ambulatory laparoscopic cholecystectomy. Anesthesia and analgesia, 108(2), 623630. https://doi.org/10.1213/ane.0b013e318193cd1b Gurusamy, K. S., Vaughan, J., Toon, C. D., & Davidson, B. R. (2014). Pharmacological interventions for prevention or treatment of postoperative pain in people undergoing laparoscopic cholecystectomy. The Cochrane database of systematic reviews, (3), CD008261. https://doi.org/10.1002/14651858.CD008261 Gustafsson, S., Strmqvist, M., Ekelund, J., & Engstrm, . (2020). Factors influencing early post-operative recovery after laparoscopic cholecystectomy. Journal of PeriAnesthesia Nursing, 35(1), 8084. https://doi.org/10.1016/j.jopan.2019.06.002 Hah, J., Mackey, S. C., Schmidt, P., McCue, R., Humphreys, K., Trafton, J., Efron, B., Clay, D., Sharifzadeh, Y., Ruchelli, G., Goodman, S., Huddleston, J., Maloney, W. J., Dirbas, F. M., Shrager, J., Costouros, J. G., Curtin, C., & Carroll, I. (2018). Effect of perioperative Gabapentin on post-operative pain resolution and opioid cessation in a mixed surgical cohort. JAMA Surgery, 153(4), 303. https://doi.org/10.1001/jamasurg.2017.4915 PREOPERATIVE PAIN MANAGEMENT 35 Hannam, J. A., Anderson, B. J., Potts, A. (2018). Acetaminophen, ibuprofen, and tramadol analgesic interactions after adenotonsillectomy. Paediatric Anaesthesia, 28, 841-851. https://dx.doi.org/10.1111/pan.13464 Hariharan, S., Moseley, H., Kumar, A., & Raju, S. (2009). The effect of preemptive analgesia in postoperative pain reliefa prospective double-blind randomized study. Pain Medicine, 10(1), 4953. https://doi.org/10.1111/j.1526-4637.2008.00547.x Hosseini, V. S., Yekta, R. A., Marashi, S., & Marashi, S. M. (2015). The efficacy of melatonin, Clonidine and Gabapentin in reducing preoperative anxiety and postoperative pain in patients undergoing laparoscopic Cholecystectomy: a randomized clinical trial. Archives of Anesthesiology and Critical Care, 1(4), 120-125. Johnson, R. J., Nguyen, D. K., Acosta, J. M., O'Brien, A. L., Doyle, P. D., & Medina-Rivera, G. (2019). Intravenous Versus Oral Acetaminophen in Ambulatory Surgical Center Laparoscopic Cholecystectomies: A Retrospective Analysis. P & T : a peer-reviewed journal for formulary management, 44(6), 359363. Kamali, A., Ashrafi, T. H., Rakei, S., Noori, G., & Norouzi, A. (2018). A comparative study on the prophylactic effects of paracetamol and dexmedetomidine for controlling hemodynamics during surgery and postoperative pain in patients with laparoscopic cholecystectomy. Medicine, 97(51), e13330. https://doi.org/10.1097/MD.0000000000013330 Kamali, A., Le, V., Kurnutala, L., SchianodiCola, J., Ahmed, K., Yarmush, J., Daniel Eloy, J., Shapiro, M., Haile, M., & Bekker, A. (2016). Premedication with Intravenous Ibuprofen Improves Recovery Characteristics and Stress Response in Adults Undergoing PREOPERATIVE PAIN MANAGEMENT 36 Laparoscopic Cholecystectomy: A Randomized Controlled Trial. Pain medicine (Malden, Mass.), 17(6), 11631173. https://doi.org/10.1093/pm/pnv113 Karaca, O., Pnar, H. U., Turk, E., Dogan, R., Ahiskalioglu, A., & Solak, S. K. (2019). Effects of Single-Dose Preemptive Pregabalin and Intravenous Ibuprofen on Postoperative Opioid Consumption and Acute Pain after Laparoscopic Cholecystectomy. Journal of investigative surgery: the official journal of the Academy of Surgical Research, 32(3), 189195. https://doi.org/10.1080/08941939.2017.1386738 Karri, S. R., Jayaram, K., Kumar, A., & Durga, P. (2021). Comparison of efficacy of gabapentin and memantine premedication in laparoscopic cholecystectomies for postoperative pain relief - A randomized placebo-controlled trial. Indian journal of anaesthesia, 65(7), 539 544. https://doi.org/10.4103/ija.IJA_140_21 Kochhar, A., Chouhan, K., Panjiar, P., & Vajifdar, H. (2017). Gabapentinoids as a Part of Multimodal Drug Regime for Pain Relief following Laproscopic Cholecystectomy: A Randomized Study. Anesthesia, essays and research, 11(3), 676680. https://doi.org/10.4103/0259-1162.204208 Kolcaba, K., & Wilson, L. (2002). Comfort care: A framework for perianesthesia nursing. Journal of PeriAnesthesia Nursing, 17(2), 102114. https://doi.org/10.1053/jpan.2002.31657 Kotsovolis, G., Karakoulas, K., Grosomanidis, V., & Tziris, N. (2015). Comparison between the combination of gabapentin, ketamine, lornoxicam, and local ropivacaine and each of these drugs alone for pain after laparoscopic cholecystectomy: a randomized trial. Pain PREOPERATIVE PAIN MANAGEMENT 37 practice: the official journal of World Institute of Pain, 15(4), 355363. https://doi.org/10.1111/papr.12183 Layman Young, J., Horton, F. M., & Davidhizar, R. (2006). Nursing attitudes and beliefs in pain assessment and management. Journal of Advanced Nursing, 53(4), 412421. https://doi.org/10.1111/j.1365-2648.2006.03735.x Logan, D. E., & Rose, J. B. (2004). Gender differences in post-operative pain and patientcontrolled analgesia use among adolescent surgical patients. Pain, 109(3), 481487. https://doi.org/10.1016/j.pain.2004.02.026 Luo, J., & Min, S. (2017). Postoperative pain management in the Postanesthesia Care Unit: An update. Journal of Pain Research, Volume 10, 26872698. https://doi.org/10.2147/jpr.s142889 Medina-Vera, A. J., & Novoa, L. M. (2017). Reduced anaesthetic requirements and postoperative analgesics in patients undergoing laparoscopic cholecystectomy: premedication with intravenous paracetamol versus ketorolac, a double blind and randomised clinical trial. Revista espanola de anestesiologia y reanimacion, 64(2), 64 70. https://doi.org/10.1016/j.redar.2016.05.007 Michaloliakou, C., Chung, F., & Sharma, S. (1996). Preoperative multimodal analgesia facilitates recovery after ambulatory laparoscopic cholecystectomy. Anesthesia & Analgesia, 82(1), 4451. https://doi.org/10.1213/00000539-199601000-00009 PREOPERATIVE PAIN MANAGEMENT 38 Mishra, R., Tripathi, M., & Chandola, H. C. (2016). Comparative clinical study of gabapentin and pregabalin for postoperative analgesia in laparoscopic cholecystectomy. Anesthesia, essays and research, 10(2), 201206. https://doi.org/10.4103/0259-1162.176409 Morgan, G. E., Mikhail, M. S., & Murray, M. J. (2006). Clinical anesthesiology. New York: Lange Medical Books/McGraw Hill Medical Pub. Division. Nakhli, M. S., Kahloul, M., Jebali, C., Frigui, W., & Naija, W. (2018). Effects of gabapentinoids premedication on shoulder pain and rehabilitation quality after laparoscopic cholecystectomy: pregabalin versus gabapentin. Pain Research and Management, 2018 National Center for Biotechnology Information (2021). PubChem Compound Summary for CID 1983, Acetaminophen. Retrieved December 17, 2021 from https://pubchem.ncbi.nlm.nih.gov/compound/Acetaminophen. Nursing Theory. (2019, August 21). Kolcaba's theory of comfort. Nursing Theory. Retrieved December 4, 2021, from https://nursing-theory.org/theories-and-models/kolcaba-theory-ofcomfort.php. Pnar, H. U., Karaca, ., Karako, F., & Doan, R. (2017). Effects of addition of preoperative intravenous ibuprofen to pregabalin on postoperative pain in posterior lumbar interbody fusion surgery. Pain Research and Management, 2017, 16. https://doi.org/10.1155/2017/1030491 Salihoglu, Z., Yildirim, M., Demiroluk, S., Kaya, G., Karatas, A., Ertem, M., & Aytac, E. (2009). Evaluation of intravenous paracetamol administration on postoperative pain and recovery characteristics in patients undergoing laparoscopic cholecystectomy. Surgical PREOPERATIVE PAIN MANAGEMENT 39 Laparoscopy, Endoscopy & Percutaneous Techniques, 19(4), 321323. https://doi.org/10.1097/sle.0b013e3181b13933 Sami Mebazaa, M., Frikha, N., Ben Hammouda, N., Mestiri, T., Mestiri, H., Khalfallah, T., & Ben Ammar, M. S. (2008). Analgesie postoperatoire pour cholecystectomie sous coelioscopie: comparaison de l'administration preoperatoire du celecoxib et du paracetamol [Postoperative analgesia after laparoscopic cholecystectomy: comparison of the preoperative administration of celecoxib with paracetamol?]. La Tunisie medicale, 86(10), 869873. Srivastava, U., Kumar, A., Saxena, S., Mishra, A. R., Saraswat, N., & Mishra, S. (2010). Effect of preoperative gabapentin on postoperative pain and tramadol consumption after minilap open cholecystectomy: a randomized double-blind, placebo-controlled trial. European journal of anaesthesiology, 27(4), 331335. https://doi.org/10.1097/EJA.0b013e328334de85 Thybo, K. H., Hgi-Pedersen, D., Dahl, J. B., Wetterslev, J., Nersesjan, M., Jakobsen, J. C., Pedersen, N. A., Overgaard, S., Schrder, H. M., Schmidt, H., Bjrck, J. G., Skovmand, K., Frederiksen, R., Buus-Nielsen, M., Srensen, C. V., Kruuse, L. S., Lindholm, P., & Mathiesen, O. (2019). Effect of combination of paracetamol (acetaminophen) and ibuprofen vs either alone on patient-controlled morphine consumption in the first 24 hours after total hip arthroplasty. JAMA, 321(6), 562. https://doi.org/10.1001/jama.2018.22039 Toleska, M., & Dimitrovski, A. (2019). Is Opioid-Free General Anesthesia More Superior for Postoperative Pain Versus Opioid General Anesthesia in Laparoscopic Cholecystectomy? Prilozi (Makedonska akademija na naukite i umetnostite. Oddelenie za medicinski nauki), 40(2), 8187. https://doi.org/10.2478/prilozi-2019-0018 PREOPERATIVE PAIN MANAGEMENT Yoon, M. H., & Yaksh, T. L. (1999). Evaluation of interaction between gabapentin and ibuprofen on the formalin test in rats. Anesthesiology, 91(4), 10061013. https://doi.org/10.1097/00000542-199910000-00021 Zhang, N., Wu, G., Zhou, Y., Liao, Z., Guo, J., Liu, Y., Huang, Q., & Li, X. (2020). Use of enhanced recovery after surgery (ERAS) in laparoscopic cholecystectomy (LC) combined with laparoscopic common bile duct exploration (LCBDE): A cohort study. Medical Science Monitor, 26. https://doi.org/10.12659/msm.924946 40 PREOPERATIVE PAIN MANAGEMENT Appendix A PRISMA Flow Diagram 41 PREOPERATIVE PAIN MANAGEMENT Appendix B SWOT Analysis 42 PREOPERATIVE PAIN MANAGEMENT Appendix C GANTT Chart 43 PREOPERATIVE PAIN MANAGEMENT 44 Appendix D Literature Review Matrix Reference Research Design & Level of Evidence Prospective, randomized, double-blinded study. Population / Sample n=x Patients aged 18 to 65, American Society of Anesthesiology (ASA) I-II and scheduled for laparoscopic cholecystectomy. n=60 Variables Instruments / Data collection Results Ibuprofen, postoperative pain, twenty-four-hour postoperative fentanyl consumption, any additional analgesia. Visual analogue pain scale (VAS) with active and passive movements. Ekinci, M., Ciftci, B., Celik, E. C., Kse, E. A., Karakaya, M. A., & Ozdenkaya, Y. (2019). A randomized, placebocontrolled, double-blind study that evaluates efficacy of intravenous ibuprofen and acetaminophen for postoperative pain treatment following laparoscopic cholecystectomy surgery. Journal of Gastrointestinal Surgery, 24(4), 780785. https://doi.org/10.1007/s11605-019-04220-1 Randomized doubke-blind control study n=30 for ibuprofen, n=30 for control group, n=30 for accetaminophen Acetaminophen, ibuprofen, reduced postoperative pain Visual analog scale Gilron, I., Orr, E., Tu, D., Mercer, C. D., & Bond, D. (2009). A randomized, double-blind, controlled trial of perioperative administration of gabapentin, meloxicam and their combination for spontaneous and movement-evoked pain after ambulatory laparoscopic cholecystectomy. Anesthesia and analgesia, 108(2), 623630. https://doi.org/10.1213/ane.0b013e318193cd1b Randomized, double-blind trial. 18 yr or older with a body mass index <36 kg/m2 that fit an ASA I or II classification before elective laparoscopic cholecystectom. N= meloxicam, gabapentin, a combination of the two, day of surgery spontaneous and movement-evoked pain. Pain on Days 1, 2, and 30, adverse effects, opioid consumption, Numerical rating scale, VAS scores in the IV ibuprofen group were statistically lower at postoperative 30 minutes and 1, 2, 4, 8, 12, and 24 hours. Twenty-four-hour opioid consumption was statistically significantly higher in the control group compared to the ibuprofen group. Additional analgesia use was statistically significantly higher in the control group than in the ibuprofen group, Pain scores in group 1 and group a were lower at all times than those in group C. group C had a significantly higher consumption than other groups. On the day of surgery, 60-min rest pain was significantly lower with gabapentin alone versus meloxicam alone. Observed pain differences between the combination and Ahiskalioglu, E. O., Ahiskalioglu, A., Aydin, P., Yayik, A. M., & Temiz, A. (2017). Effects of single-dose preemptive intravenous ibuprofen on postoperative opioid consumption and acute pain after laparoscopic cholecystectomy. Medicine, 96(8), e6200. https://doi.org/10.1097/MD.0000000000006200 PREOPERATIVE PAIN MANAGEMENT 45 spirometry, painrelated interference, hospital discharge time, return to work time, and patient satisfaction. gabapentin alone were fairly small in favor of gabapentin alone. Gurusamy, K. S., Vaughan, J., Toon, C. D., & Davidson, B. R. (2014). Pharmacological interventions for prevention or treatment of postoperative pain in people undergoing laparoscopic cholecystectomy. The Cochrane database of systematic reviews, (3), CD008261. https://doi.org/10.1002/14651858.CD008261.pub2 Systematic review of randomized clinical trials, and comparative non-randomized studies. Low anesthetic risk people undergoing elective laparoscopic cholecystectomy. n=2505 Nonsteroidal anti inflammatory drugs, opioids, and anticonvulsant analgesics, postoperative pain Review Manager 5 analysis. Visual analogue scale. Johnson, R. J., Nguyen, D. K., Acosta, J. M., O'Brien, A. L., Doyle, P. D., & Medina-Rivera, G. (2019). Intravenous Versus Oral Acetaminophen in Ambulatory Surgical Center Laparoscopic Cholecystectomies: A Retrospective Analysis. P & T: a peer-reviewed journal for formulary management, 44(6), 359363. Retrospective analysis 1,000 mg IV APAP intraoperatively (n = 319) or 1,000 mg PO APAP preoperatively (n = 260). IV tylenol, oral tylenol, postoperative opiod reduction Electroninc medical records Kamali, A., Ashrafi, T. H., Rakei, S., Noori, G., & Norouzi, A. (2018). A comparative study on the prophylactic effects of paracetamol and dexmedetomidine for controlling A comparative study Patients aged 18 to 70 years and from both genders, who Dexmedetomidine, Paracetamol, postoperative pain, Visual analog scale, The pain at 4 to 8 hours was generally reduced by about 1 to 2 cm on the visual analogue scale of 1 to 10 cm in the comparisons involving the different pharmacological agents and inactive controls. The pain at 9 to 24 hours was generally reduced by about 0.5 cm (a modest reduction) on the visual analogue scale of 1 to 10 cm in the comparisons involving the different pharmacological agents and inactive controls. Median pain scores were similar for both analgesic methods. PO APAPs noninferiority to IV APAP can be statistically concluded Pain score in the paracetamol group was significantly PREOPERATIVE PAIN MANAGEMENT 46 hemodynamics during surgery and postoperative pain in patients with laparoscopic cholecystectomy. Medicine, 97(51), e13330. https://doi.org/10.1097/MD.0000000000013330 Karaca, O., Pnar, H. U., Turk, E., Dogan, R., Ahiskalioglu, A., & Solak, S. K. (2019). Effects of Single-Dose Preemptive Pregabalin and Intravenous Ibuprofen on Postoperative Opioid Consumption and Acute Pain after Laparoscopic Cholecystectomy. Journal of investigative surgery: the official journal of the Academy of Surgical Research, 32(3), 189195. https://doi.org/10.1080/08941939.2017.1386738 Prospective, randomized, double-blinded study were candidates for emergency cholecystectomy or elective surgery. n=132 arterial blood pressure, heart rate Patients undergoing laparoscopic cholecystectomy. n=58 pregabalin, pregabalin plus ibuprofen, Postoperative fentanyl consumption, additional analgesia requirements and PACU stay. VAS lower than that in the dexmedetomidine group. No group differences in the mean scores of pain during these hours. The median opioid use in 24 hours after operation in the paracetamol group was lower when compared with that in the dexmedetomidine group, and the mean duration of analgesia in the paracetamol group was higher when comparing with dexmedetomidine group VAS scores in the group PI were statistically lower at PACU, 1and 2 hours at rest, at PACU, 1, 2, 4, 12 and 24 hours on movement compared to the group P. Opioid consumption was statistically significantly higher in the group P compared to the group PI. Rescue analgesia usage was statistically significantly higher in the group P than in the group PI. Four patients in the group PI did not need any opioid drug. Besides, PACU stay was PREOPERATIVE PAIN MANAGEMENT 47 Karri, S. R., Jayaram, K., Kumar, A., & Durga, P. (2021). Comparison of efficacy of gabapentin and memantine premedication in laparoscopic cholecystectomies for postoperative pain relief - A randomized placebo-controlled trial. Indian journal of anaesthesia, 65(7), 539544. https://doi.org/10.4103/ija.IJA_140_21 Randomized controlled study Patients posted for laparoscopic cholecystectomy. n=66 Gabapentin, memantine, Preoperative assessment, the baseline threshold, tolerance values of pain, pain scores reassessed, Ramsay sedation scores Numerical Rating Scale, Ramsey Sedation score, analgesiometer. Kochhar, A., Chouhan, K., Panjiar, P., & Vajifdar, H. (2017). Gabapentinoids as a Part of Multi-modal Drug Regime for Pain Relief following Laproscopic Cholecystectomy: A Randomized Study. Anesthesia, essays and research, 11(3), 676680. https://doi.org/10.4103/0259-1162.204208 Randomized, single-blind study Patients undergoing laparoscopic cholecystectomy under general anesthesia. n=50 Pregabalin, Gabapentin, Severity of postoperative pain, postoperative fentanyl requirement and incidence, and severity of side effects. Visual analog scale [VAS]), Ramsay sedation score shorter in the group PI than the group P. Gabapentin group had lower Numerical Rating Scale scores at 15 min and 1 h postoperatively when compared to the other two groups. Memantine group had a longer time for the first request for rescue analgesia (50.53 min) compared to gabapentin and placebo. Ramsay sedation scores were higher in the gabapentin group compared to the other two. The objective assessment of pain with algesiometer showed no statistical significance between the groups for both threshold and tolerance values A single preoperative dose of pregabalin (150 mg) or gabapentin (300 mg) are equally efficacious in providing pain relief following laparoscopic cholecystectomy as a part of multimodal regime without any side effects. PREOPERATIVE PAIN MANAGEMENT 48 Salihoglu, Z., Yildirim, M., Demiroluk, S., Kaya, G., Karatas, A., Ertem, M., & Aytac, E. (2009). Evaluation of intravenous paracetamol administration on postoperative pain and recovery characteristics in patients undergoing laparoscopic cholecystectomy. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 19(4), 321323. https://doi.org/10.1097/sle.0b013e3181b13933 Randomized study Patients were divided into equal groups with random number generator to receive either paracetamol (group 1; n = 20) or not (group 2; n = 20) Paracetamol, analgesia, postoperative pain Verbal and visual pain scores Verbal and visual pain scores of the paracetamol group were significantly lower than control group (P<0.05). First morphine requirement and total administered morphine dose and duration of staying in recovery room were significantly decreased in the paracetamol group (P<0.05) Sami Mebazaa, M., Frikha, N., Ben Hammouda, N., Mestiri, T., Mestiri, H., Khalfallah, T., & Ben Ammar, M. S. (2008). Analgesie postoperatoire pour cholecystectomie sous coelioscopie: comparaison de l'administration preoperatoire du celecoxib et du paracetamol [Postoperative analgesia after laparoscopic cholecystectomy: comparison of the preoperative administration of celecoxib with paracetamol?]. La Tunisie medicale, 86(10), 869873. Randomized prospective study Patients undergoing laparoscopic cholecystectomy. n=75 Paracetamol, celecoxib, VAS scores, hemodynamic parameters, adverse effects, The VAS at rest and effort (T(30mn) to T(h24), Hemodynamic parameters, Ramsay score and the adverse effects. Srivastava, U., Kumar, A., Saxena, S., Mishra, A. R., Saraswat, N., & Mishra, S. (2010). Effect of preoperative gabapentin on postoperative pain and tramadol consumption after minilap open cholecystectomy: a randomized doubleblind, placebo-controlled trial. European journal of anaesthesiology, 27(4), 331335. https://doi.org/10.1097/EJA.0b013e328334de85 A randomized double-blind, placebocontrolled trial Adult patients of either sex undergoing minilap open cholecystectomy. n=120 Gabapentin, Post op pain assessment at 0, 2, 4, 8, 12, 24 and 48 hrs, verbal analogue pain scores at rest and at movement. Consumption of tramadol on first and second postoperative days and any adverse effects. Verbal analogue pain scores at rest and at movement VAS scores show a significant difference between the groups P and T with the effort of cough at t24h and between the groups C and T at postoperative T 4h. Group C consumed to a significant degree less morphine 5.44 +/- 3.00 Mg against 7.83 +/- 4.00 Mg for the group P and 8.04 +/- 3.00 Mg for the group T Verbal analogue pain scores were significantly lower on first postoperative day at all times of observation both at rest and at movement in gabapentin group than in placebo group. Tramadol consumption was also reduced by 33% PREOPERATIVE PAIN MANAGEMENT 49 Toleska, M., & Dimitrovski, A. (2019). Is Opioid-Free General Anesthesia More Superior for Postoperative Pain Versus Opioid General Anesthesia in Laparoscopic Cholecystectomy? Prilozi (Makedonska akademija na naukite i umetnostite. Oddelenie za medicinski nauki), 40(2), 8187. https://doi.org/10.2478/prilozi-2019-0018 Randomized, single-blind clinical study Patients scheduled for elective laparoscopic cholecystectomy. n=60 Opioid-free anesthesia, fentanyl, postoperative pain scores at rest and on coughing, total opioid requirement VAS pain score Kamali, A., Le, V., Kurnutala, L., SchianodiCola, J., Ahmed, K., Yarmush, J., Daniel Eloy, J., Shapiro, M., Haile, M., & Bekker, A. (2016). Premedication with Intravenous Ibuprofen Improves Recovery Characteristics and Stress Response in Adults Undergoing Laparoscopic Cholecystectomy: A Randomized Controlled Trial. Pain medicine (Malden, Mass.), 17(6), 11631173. https://doi.org/10.1093/pm/pnv113 Randomized control double blind trial N=55 in two groups. Group A received a placebo and group B received 800mg of IV ibuprofen Anti-inflammatory, NSAIDs, cognitive function 40-item Quality of Recovery questionnaire, 9item modified Fatigue Severity Scale, 15-item Geriatric Depression Scale. in gabapentin group. But pain scores and tramadol consumption were similar in two groups on second postoperative day. Patients in the fentanyl group (FG) have higher pain scores at rest and on coughing in all analyzed timeframes compared to patients from the OFA group. In the OFA group 24 hours after surgery none of the patients reported pain at rest and when coughing number 7, 8, 9 and 10 according to the VAS pain score. The total opioid requirement in the postoperative period was significantly higher in the fentanyl group (FG) at rest and when coughing, compared to the OFA group. Ibuprofen attenuated the release of proinflammatory processes like interleukin-10 PREOPERATIVE PAIN MANAGEMENT 50 Kotsovolis, G., Karakoulas, K., Grosomanidis, V., & Tziris, N. (2015). Comparison between the combination of gabapentin, ketamine, lornoxicam, and local ropivacaine and each of these drugs alone for pain after laparoscopic cholecystectomy: a randomized trial. Pain practice : the official journal of World Institute of Pain, 15(4), 355363. https://doi.org/10.1111/papr.12183 Randomized placebocontrolled trial N=148 patients, between 18 and 70 years of age, were randomly assigned to 6 groups (28 in each group) with the use of computer software 24hour morphine consumption, opioid related side effects, gabapentin Computer software Only groups A (6.4 mg), B (9.46 mg), and D (9.36 mg) had lower morphine consumption than control group (20.29 mg) and. Group A was not different from B and D Mishra, R., Tripathi, M., & Chandola, H. C. (2016). Comparative clinical study of gabapentin and pregabalin for postoperative analgesia in laparoscopic cholecystectomy. Anesthesia, essays and research, 10(2), 201206. https://doi.org/10.4103/0259-1162.176409 Randomized study N=90 divided in Group A (placebo), B(gabapentin), and C(pregabalin). 30 patients in each group. Pain scores, sedation scores Data was recorded in a standard Performa. Test for analysis among three groups was done by analysis of variance (ANOVA), Visual analog scale (VAS) was used to record pain and sedation scores. Nakhli, M. S., Kahloul, M., Jebali, C., Frigui, W., & Naija, W. (2018). Effects of gabapentinoids premedication on shoulder pain and rehabilitation quality after laparoscopic cholecystectomy: pregabalin versus gabapentin. Pain Research and Management, 2018. Randomized double-blind clinical trial N=90 3 groups of 30 each. Patients of group 1 received 150 mg of pregabalin (2 capsules of 75 mg), those of group 2 received 600 mg of gabapentin (2 capsules of 300 mg), and those of group 3 received 2 capsules of placebo Gabapentin, lyrica, postoperative pain, postoperative nausea and vomiting Visual Analog Scale (VAS), Spiegel Scale In our study, we had used a single oral dose of 900 mg gabapentin and 150 mg pregabalin, which was administered 1 h prior to the procedure. Pregabalin and gabapentin group had lower visual analog scale (VAS) score prolonged timing of first rescue analgesic min, and less opioid Preemptive premedication with 600 mg of gabapentin or 150 mg of pregabalin improves several parameters of postoperative rehabilitation after laparoscopic cholecystectomy. It reduces significantly the intensity of postoperative shoulder pain, decreases the incidence of PONV, improves the quality of sleep during the first night, and PREOPERATIVE PAIN MANAGEMENT 51 shortens the time to first standing position Abbas, Z., & Bashir, A. (2019). Effects of Gabapentin on Postoperative Pain and Total Analgesic Requirement After Laparoscopic Cholecystectomy. Biomedical and Pharmacology Journal, 12(2), 925-929. Randomized placebocontrolled study Sixty adult patients listed for laparoscopic cholecystectomy were randomly allocated to two groups of 30 each to receive gabapentin 600 mg p.o. or a matching placebo 2 hours before surgery. Gabapentin, postoperative pain Visual Analog Scale (VAS: 0 = no pain; 10 = most severe pain). The software used was Statistical Package for Social Sciences (SPSS) and Microsoft Excel. Postoperative pain scores and total analgesic requirement was significantly less in gabapentin group compared to placebo group. A single 600 mg dose of gabapentin given preoperatively decreased postoperative pain and total analgesic requirement following laparoscopic cholecystectomy Hosseini, V. S., Yekta, R. A., Marashi, S., & Marashi, S. M. (2015). The efficacy of melatonin, Clonidine and Gabapentin in reducing preoperative anxiety and postoperative pain in patients undergoing laparoscopic Cholecystectomy: a randomized clinical trial. Archives of Anesthesiology and Critical Care, 1(4), 120-125 Randomized clinical trial total number of 88 patients were categorized into four groups to receive melatonin, clonidine, gabapentin and placebo (22 patients per group) Gabapentin, clonidine and melatonin State-Train Anxiety Inventory (STAI), VAS (Visual Analog Scale) The intensity of pain was significantly decreased by the time and depending on the assigned group, the pain reduction trend was different among treatment groups Medina-Vera, A. J., & Novoa, L. M. (2017). Reduced anaesthetic requirements and postoperative analgesics in patients undergoing laparoscopic cholecystectomy: premedication with intravenous paracetamol versus ketorolac, a double blind and randomised clinical trial. Revista espanola de anestesiologia y reanimacion, 64(2), 6470. https://doi.org/10.1016/j.redar.2016.05.007 Randomized double-blind clinical trial 100 patients randomized into 2 groups. Group 1: pre-medicated with paracetamol 1g, and Group 2: with ketorolac 30mg (both administered intravenously 30minutes prior to surgery). Paracetamol 1g, ketorolac 30mg Visual Analog Scale (VAS) Paracetamol 1g IV placed preoperatively decreased anesthetic requirements and the need for postoperative analgesics, like preoperative administration of ketorolac 30 mg IV. PREOPERATIVE PAIN MANAGEMENT 52 PREOPERATIVE PAIN MANAGEMENT Appendix E IRB Approval Letter 53 PREOPERATIVE PAIN MANAGEMENT Appendix F Eligibility Survey 54 PREOPERATIVE PAIN MANAGEMENT Appendix G Numerical Pain Rating Scale 55 PREOPERATIVE PAIN MANAGEMENT Appendix H Intraoperative Patient Form 56  ...

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MALIGNANT HYPERTHERMIA SIMULATION Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2023 Malignant Hyperthermia Simulation Brett Jamieson Leighton School of Nursing Marian University Project Chair: Date of Submission: Dr. Derrianne Monteiro May 5, 2023 1 MALIGNANT HYPERTHERMIA SIMULATION Table of Contents Abstract ....................................................................................................................................4 Introduction ..............................................................................................................................5 Background ..................................................................................................................5 Problem Statement .......................................................................................................7 Organizational Gap Analysis of Project Site ...........................................................7 Review of the Literature ..........................................................................................................9 Theoretical Framework...........12 Goals/Objectives/Expected Outcomes....13 Project Design/Methods...... ...14 Project Site and Population ........................................................................................14 Measurement Instrument(s) ........................................................................................14 Data Collection Procedure .........................................................................................15 Ethical Considerations/Protection of Human Subjects...15 Data Analysis and Results..16 Discussion...18 Conclusion ............................................................................................................................ 19 References ............................................................................................................................ 21 Appendix A ...........................................................................................................................24 Appendix B ...........................................................................................................................25 Appendix C....26 Appendix D....27 2 MALIGNANT HYPERTHERMIA SIMULATION Appendix E28 Appendix F29 3 MALIGNANT HYPERTHERMIA SIMULATION 4 Abstract Malignant hyperthermia is a rare but potentially catastrophic syndrome that can occur during general anesthesia. High mortality rates occur when this complication is left untreated or when care is delayed. Due to the rare nature of this process occurring there are few surgical staff members that have previous experience to fall back on should a MH crisis present itself. For this reason, developing a simulation for MH is a great way to prepare staff members and departments for a malignant hyperthermia event. Many facilities do not follow the recommended annual training on MH response. The purpose of this project was to establish MH simulation within the surgery department of a critical access hospital as a means of preparing the staff for a future MH event. The goal was to establish the simulation and demonstrate both an increase in knowledge gained by the staff as well as an improved confidence in ability to recognize symptoms and implement current treatment methodologies for MH. Assessment of these goals included evaluation of the staff by pre/posttests to assess learning and survey reflecting staff opinions on their confidence in handling a future live event. The results demonstrated improvements in both knowledge gained as well as learner confidence (p<0.01). Simulation is an effective method for educating operating room (OR) staff on the management of MH. Participants within the study had improved knowledge, confidence, and voiced satisfaction with the program. This serves as a potential method to implement at additional sites to encourage departmental preparation. Keywords: malignant hyperthermia simulation, malignant hyperthermia training, malignant hyperthermia anesthesia, MH simulation, MH training, and MH anesthesia MALIGNANT HYPERTHERMIA SIMULATION 5 Malignant Hyperthermia Simulation This project was submitted to the faculty of Marian University Leighton School of Nursing as partial fulfillment of degree requirements for the Doctor of Nursing Practice, Anesthesia track. Malignant Hyperthermia (MH) is a rare but serious medical condition that can arise during the intraoperative and postoperative phases of surgery. The incidence of MH is estimated to occur in 1 in 10,000- 250,000 anesthetic cases performed (Rosenburg et al., 2015). If MH is not rapidly recognized or left untreated the patient outcome is likely death (Mullins, 2017; Rosenburg et al., 2015). Previous simulations have demonstrated delays in recognizing early signs as well as improper mixing of treatment medications (Harrison et al., 2006). Implementation of a simulation-based MH scenario can strengthen the anesthesia providers ability and instincts to recognize and appropriately intervene to save a patient from MH (Schaad, 2017). Background An MH crisis is an event that requires an attentive and proactive anesthetist to quickly recognize the syndrome and promptly intervene. The cascade of symptoms of MH such as hypercarbia, hyperthermia, acidosis, muscle rigidity, and hyperkalemia can quickly spiral out of control putting the patient at risk of severe harm and even death (Yang et al., 2020). The highly metabolic state induced during MH had a mortality rate around 70% in the 1970s but with the advent of dantrolene used as an antidote medication, and with rapid administration, MH mortality is currently estimated to be around 5-10% (Kim et al., 2019; Yang et al., 2020). MH is now understood to be caused by hypersecretion of calcium from the sarcoplasmic reticulum (SR) which leads to uncontrolled skeletal muscle metabolism (Rosenberg et al, 2003; Yang et al, 2020). Genetic mutations in the ryanodine receptor (RYR1) have been implicated in most MALIGNANT HYPERTHERMIA SIMULATION 6 genetically studied MH cases (Kim, Kris, & Tautz, 2019; Yang et al, 2020). In addition to a likely genetic component, MH is known to be triggered by several pharmacologic agents that are commonly administered within the perioperative setting such as volatile anesthetics (isoflurane, sevoflurane, desflurane), and the depolarizing muscle relaxant, succinylcholine (Kim et al., 2019; Yang et al., 2020). Although the triggering medications are very common, the frequency with which MH occurs is relatively rare. A five-year retrospective study in New York found an incident rate of 1 in 100,000 anesthetic surgical cases performed with a significantly higher proportion of patients being male (Brady et al., 2009). After subsequent epidemiological studies were performed, an even higher incidence of MH was discovered in Wisconsin, California, and Florida (Lu, Rosenberg, & Li, 2017). Although the exact incidence rate is not fully understood, MH events have been recorded to effect individuals from all ages and can occur in any race (Yang et al., 2020). Adding another layer of difficulty to MH incidence is that it can occur within minutes after administration of a precipitating agent, or it can occur hours after initial exposure. Additionally, there is evidence of MH crisis recurring in up to 20% of patients successfully treated during the initial MH event (Burkman, Posners, & Domino, 2007). Due to the varied onset and occasional recurrence of MH it is critical the anesthetist be able to recognize symptoms even when a causative agent is not being currently administered. Furthermore, all surgical staff including nurses, surgical technologists, and anesthesia team members should be educated on signs and symptoms of MH since this can occur after the surgical event. As a consequence of the rarity with which MH occurs in the clinical setting, it is likely that student anesthetists will not encounter this pathological state while in school and many providers go their entire career without experiencing MH firsthand (Mullins, 2017). Owing to the infrequency with which MH is encountered it is easy to not be prepared to quickly recognize symptoms or be MALIGNANT HYPERTHERMIA SIMULATION 7 familiar with current treatment strategies (Mullins, 2017). Further studies into provider preparation for MH crisis found that cognitive aids throughout the simulated event such as the Malignant Hyperthermia Association of the United States (MHAUS) hotline or a poster from MHAUS improved provider success in recognition of symptoms, mixing the reversal medication, and progressing through simulation scenarios with appropriate interventions (Harrison et al., 2006). Problem Statement Due to the rare occurrence of this event, most perioperative and post anesthesia staff members are unlikely to have much, if any, experience in managing a MH crisis. The rare nature of this event is good news as it carries a relatively high mortality but leaves most departments susceptible to errors and suboptimal treatment should a patient develop MH. It is essential to have properly trained staff to handle this anesthesia emergency in a calm, timely, and appropriate manner. Implementation of a simulation-based training exercise to manage a malignant hyperthermia emergency should be an important aspect of any surgery department preparation and education. Comparison of current educational practices should be performed with a simulation-based training exercise to evaluate improved provider response to MH emergency. This led to the PICO question: for surgical staff, what is the effect of a malignant hyperthermia simulation training on event knowledge and management confidence? Needs Assessment & Gap Analysis Current educational practices covering MH readiness for this department are sparse and routine simulated competencies demonstrating appropriate treatment practices for a MH event did not exist. Several studies have indicated issues with providers preparing the antidote medication incorrectly, inability to properly diagnose the presence of a MH crisis or MALIGNANT HYPERTHERMIA SIMULATION 8 implementing inappropriate interventions to manage MH symptoms during simulated events (Harrison et al., 2006; Quick et al., 2017; Schaad, 2017). The simulation-based training exercises students and anesthesia providers have received for MH crises have been well-received and participants have responded favorably on surveys about the education received during simulated events (Harrison et al., 2006; Quick et al., 2017). Simulation-based training for MH with hospital operating room staff had favorable reviews and concluded with participants feeling empowered to treat MH should an event occur (Schaad, 2017). Additionally, the simulated environment with a debriefing afforded the participants an opportunity to ask questions and receive detailed explanations of critical aspects of the simulated emergency that would not normally occur in a live event (Schaad, 2017). The MH simulation empowered operating room (OR) staff to feel more prepared and comfortable handling a MH crisis should the need arise within the clinical setting. Project Aim and Objective The objective of this project was to improve the recognition, timeliness of treatment, comfort, and confidence of surgical caregivers when treating a patient that has developed Malignant Hyperthermia. By implementing a simulation-based approach, staff members are given the opportunity to experience a MH event without the added pressure of a real emergency. This method allows for learning promotion by encouraging discussion, feedback, questions, and addressing mistakes made during the mock event. Learning was assessed throughout the simulation as well as with pre-/posttest responses and surveys from participants. The expected outcome was to demonstrate an improved confidence and ability to recognize the signs and symptoms of MH as well as the appropriate treatment. SWOT Analysis MALIGNANT HYPERTHERMIA SIMULATION 9 As with any change to an educational program or intervention there are bound to be strengths and weaknesses. Performing a strengths, weaknesses, opportunities, and threats analysis (SWOT analysis) was important to reveal the shortcomings or major hurdles the program may encounter prior to or during implementation. The SWOT analysis of this project (Appendix D) demonstrated many strengths including a well-educated, collaborative workforce of potential participants. Additionally, there was buy-in from the surgery department nursing administration as well as the anesthesia department chair. Weaknesses for this simulation were identified as additional time constraints for staff members after their scheduled clinical working hours, recruiting staff members of the surgery department to actively participate in a simulation event, and lack of simulation equipment on site available to use that is relevant to this simulation. Opportunities from this simulation event included the framework for future MH simulations to be conducted at this site as well as additional sites. Further opportunities included staff carrying knowledge to other facilities or to use when educating future nurse anesthesia students performing their clinical rotations at this site. Threats to the simulation were identified as budget constraints to acquire needed equipment and no established simulation space dedicated to this simulation. The threat of COVID-19 or a pandemic closing clinical sites to non-essential employees was a very real possibility. Finally, if an emergency surgery case came in just before or during the simulation then multiple participants may have been pulled from the simulation to help a live case. Review of Literature Databases used for gathering research included PubMed, MEDLINE, and CINAHL. Search terms included: malignant hyperthermia simulation, malignant hyperthermia training, malignant hyperthermia anesthesia, MH simulation, MH training, and MH anesthesia. Critical MALIGNANT HYPERTHERMIA SIMULATION 10 to the search was reviewing current literature, so searches were limited to the years 2017-2022. Inclusion criteria composed of being published in the English language, peer-reviewed, and content consistent with the project. Additionally, the articles needed to include simulating a MH event with a facilitator and learner feedback or debriefing. Following identification and analysis, a final 10 articles with varying levels of evidence from 2 to 7 were included in this literature review (Appendix F). Simulation Simulation is the foundation for this project as well as the literature review. Simulation has become incredibly popular and prevalent in modern medical training (Kalaniti & Campbell, 2015). With the recent technological advancements and improvement in the quality of simulation mannequins and facilities, the level of fidelity associated with simulation has increased dramatically. Simulation provides a realistic patient scenario and environment without the threat of doing real patient harm. Participation in simulation also allows trainees the opportunity to develop clinical decision making, recognize knowledge deficiencies, and improve technical skills while receiving immediate feedback and debriefing post simulation. The knowledge, development of skills, and confidence gained during simulation can be critical when confronted with similar events in a real-life scenario. Utilizing simulation for MH events is beneficial for providers to become more familiar with triggering agents, risk identification, symptoms, and treatment of this rare adverse event. Providers undergoing simulation training acknowledge they feel more prepared to manage a MH emergency during an actual crisis (Bansal, Dobie, & Brock, 2019; Matsco, et al., 2020; Shear, et al., 2018) . Due to the rare nature of MH, simulation is beneficial for both students and experienced practitioners to better understand the roles everyone should have during the MALIGNANT HYPERTHERMIA SIMULATION 11 immediate response phase of a MH event (Kim, T. et al., 2019; Quick et al., 2017; Schaad, 2017; Thompson et al., 2017). While simulation can be an effective method of education and preparation for anesthesia providers there are other considerations that should be taken into account. Kim, T. et al investigated the cost associated with a simulation-based educational program as well as their cased-based design (2019). Their findings suggest that while students enjoyed the simulation and reported knowledge gain and increased confidence in treating MH, the expenses associated with running the number of simulations for their program were cost-prohibitive for continuing it as a simulation-based learning modality. Knowledge and Confidence With MH being such a rare event, it is common for providers to be delayed in recognizing the development of MH, properly treating the pathology, confidently knowing the reversal agent dosing, or implementing correct supportive care. Improved knowledge of the process as well as provider confidence in recognition and treatment were common themes identified in the articles (Kim, T. et al., 2019; Hardy et al., 2018; Matsco et al., 2020; Schaad, 2017; Thompson et al, 2017). Across various specialty providers and experience levels, an introduction or refresher simulation course provided practitioners with a simulated experience they normally do not receive in the clinical setting. Independent of specialty area or experience level, provider feedback voiced appreciation for the class as well as improved knowledge and confidence to correctly identify and treat a MH crisis in the future (Matsco et al., 2020; Quick et al., 2017; Schaad, 2017). Use of Cognitive Aids MALIGNANT HYPERTHERMIA SIMULATION 12 Cognitive aids assist healthcare providers with a list of appropriate treatment considerations as well as treatment algorithms for various health conditions. Cognitive aids were utilized for a variety of healthcare training and live scenarios. When a stressful emergency is coupled with a rare event there is often little to no real-life experience to fall back on. Having a cognitive aid can be critical during these stressful events when providers may be more likely to omit certain treatments. Cognitive aids have been developed for advanced cardiovascular life support, anesthesia machine checkouts, and cesarean section to help standardize care and promote improved patient outcomes (Harrison et al., 2006). While usage of an advanced cardiovascular life support cognitive aid may be beneficial for a cardiac emergency, a cognitive aid can also be used for MH management. The MH cognitive aid can be a beneficial tool during an emergency because it reminds the team of appropriate medication selection and dosing as well as listing common electrolyte and pathophysiological alterations that take place during such an event (Harrison et al., 2006). The usage of cognitive aids during simulated MH cases coincided with improved timing of both the recognition of critical event and time to administration of the antidote (Clebone, Watkins, & Tung, 2020; Gallegos & Hennen, 2022; Hardy et al., 2018; Shear et al., 2018). In some studies, the usage of a cognitive aid was delayed and resulted in missed critical components or delayed initiation of appropriate interventions (Clebone, Watkings, & Tung, 2020; Gallegos & Hennen, 2022). Cognitive aids have demonstrated to be effective in removing delays in elevating the patient to an appropriate level of care such as transfer from a surgery center to a facility capable of providing definitive treatment of a MH crisis (Bansal, Dobie, & Brock, 2019). Theoretical Framework MALIGNANT HYPERTHERMIA SIMULATION 13 The National League for Nursing (NLN) Jeffries Simulation Theory is a well-established framework for education utilizing simulation. The NLN Jeffries framework was created to assist educators in designing and implementing simulation experiences that facilitate learning (Jeffries, 2005). First developed in 2005, the Jeffries model has undergone several changes but currently settles on six main elements which include: context, background, design, educational practices, simulation experience, and outcomes (Cowperthwait, 2020). The NLN Jeffries model focuses on a dynamic experience between the facilitator of the simulation and the learner (Jeffries, Rodgers, & Adamson, 2015). This framework served to guide the design, implementation, and evaluation of the project. A visualization of the theoretical framework is included in appendix A. The quality of the simulation experience and knowledge gained is based off several variables during a simulated case. The attributes of the facilitator such as skill, educational techniques, and preparation are critical in creating a successful simulation (Jeffries, Rodgers, & Adamson, 2015). The attributes of the participant also affect the simulation experience. Attributes such as age, gender, anxiety, preparation, background knowledge, and self-confidence can significantly enhance the simulated event (Jeffries, Rodgers, & Adamson, 2015). The outcome from the NLN Jeffries theory focuses on the products of three key groups. These groups are the patient, participant, and the system. Due to the rarity of this event in a live situation the outcomes for patients down the road were not assessed. The outcomes for the system, and especially the participants, were much more accessible following the completion of the simulation. Goals, Objectives, and Expected Outcomes The focus of this project was to implement a simulated MH event. Specific additions to the educational model at this facility focused on adding a debriefing segment, hosting an interactive setting, working with an interdisciplinary team, and establishing collaboration. MALIGNANT HYPERTHERMIA SIMULATION 14 Utilizing a pre and posttest format, participants in the simulation demonstrated an expanded knowledge base of the symptoms and process as well as the treatment of a MH event. Additionally, staff were able to identify weaknesses and processes necessitating change to better address a real-life MH event. Project Design This DNP project led to a quality improvement design by implementing an educational intervention for a clinical facility. Quantitative data was collected with pre and post-test questionnaires as well as a survey. The data that was collected was used to identify changes in knowledge gained, confidence, and satisfaction. Project Site The project site took place in the surgical department at a rural midwestern critical access hospital. Staff members from the site included perioperative and postoperative care members. Staff members included surgical technologists, nurses, certified registered nurse anesthetists, and an anesthesiologist. The types of anesthetic cases performed at this site include endoscopy, orthopedics, podiatric, general surgery, bariatric, ear, nose, and throat (ENT) services, as well as pediatric dental cases. Methods The surgical staff were recruited to participate in an educational intervention and simulation. Participants completed a five question pre- and post-test as well as a NLN survey to assess satisfaction and confidence at the end of the session. Between the pre-test and post-test, a briefing of the simulated patient occurred and then the MH event took place, all of which lasted approximately 30 minutes. Participants were given the opportunity to listen to feedback and MALIGNANT HYPERTHERMIA SIMULATION 15 debrief following the simulated event. During the briefing portion of the presentation was a demonstration of proper handling and mixing of the reversal agent Dantrolene. Measurement Instruments Student Satisfaction and Self-Confidence in Learning The Student Satisfaction and Self-Confidence in Learning survey is a measurement tool produced by the NLN (Appendix B). The survey was a thirteen question Likert scale that first assessed how satisfied the learner was with the educational experience they just participated in and then assessed, with a greater number of questions, the learners perceived self-readiness to address this in the future on their own. Knowledge Survey Part of the educational process is retaining information for later use. Knowledge gain was assessed by establishing a baseline knowledge level with a pre-test prior to any educational or simulated learning. The pre/posttest was a basic five question tool (Appendix C). The test included two multiple choice questions, two select all that apply questions, and one true/false question. The questions were developed from content within the textbook Nurse Anesthesia (Nagelhout & Elisha, 2018). Data Collection Data was collected by the DNP student facilitator. Data collection occurred immediately prior to the simulated event in the form of a pre-test as well as immediately after the debriefing period with the post-test and survey. Paper surveys were used to improve participant assessment prior to and following the simulation. Tests were numbered so that pre and posttest analysis would match the same participant. All surveys were collected in a folder by the facilitator and MALIGNANT HYPERTHERMIA SIMULATION 16 shuffled upon removal to ensure anonymity. No participant information was placed on the survey or tests. Ethical Considerations Risks involved with the simulation were minimal and would include participants feeling uncomfortable or embarrassed by not knowing how to properly treat a patient during an emergency simulation. During the evaluation portion of the project, responses to surveys and tests were kept secure and confidential. The DNP designer did not collect any personal information from the participants. Marian University Institutional Review Board granted approval for the project prior to implementation and the project did not gather any personal health information, involve vulnerable populations, or include any gathering of participant specimens. Project Evaluation Plan The goal of the project was to improve the staffs knowledge and confidence in treating a MH event in a timely and coordinated effort. Evaluation was assessed via two different assessments. The first was a short knowledge-based pretest and posttest to assess whether participants gleaned information and knowledge during the event and debriefing period. The second assessment assessed the staffs confidence in dealing with a MH event via the NLN survey. Data analysis included a paired t-test utilizing the computer software IBM SPSS. Results There were 17 participants involved in the simulation and project. These individuals were a mix of preoperative nurses, perioperative nurses, postoperative nurses, surgical technologists, physician anesthesiologist, nurse anesthetists, and department nurse management. All participants completed a pretest to establish a baseline knowledge foundation. The mean scores MALIGNANT HYPERTHERMIA SIMULATION 17 from pretests are 3.76 out of a possible 5 points awarded. Assessment of knowledge gained from the simulation was evaluated by comparing the pre and posttest results. Mean correct scores reflected a 25% improvement as they increased by 0.94 following the simulation (Table 1). Table 1. Additional analysis of the two test results included a paired T-test demonstrated on Table 2. Included in the analysis is the p value of <0.001 which would indicate the results are statistically significant and promote the effectiveness of simulation on knowledge gain. Table 2. Posttest surveys assessed with the NLN Student Satisfaction and Self-Confidence survey identified the readiness of staff to feel prepared to intervene during MH crisis. Immediate feedback from the participants was overwhelmingly positive and many voiced appreciation for the educational experience they received. The NLN survey reflects an agree/disagree 5-point Likert scale. The NLN survey demonstrated the participants satisfaction with the educational approach and their perceived confidence and ability to perform the event in a real-life scenario (Table 3). Table 3. MALIGNANT HYPERTHERMIA SIMULATION 18 The mean scores for the NLN survey all fall within the range of 4.11-4.82 which would correlate with a response between 4 (agree) and 5 (strongly agree) when asked if they felt satisfied with the simulation and confident in carrying out the learned knowledge and skills. Discussion MH is a rare but serious complication from surgery and exposure to general anesthetics. Mortality is significantly increased by delayed or ineffective management of the crisis. The ability to simulate this event was critical for the surgery department to establish an effective treatment strategy, recognize weaknesses in treatment, and improve staff readiness for when a MH crisis does occur. Improvements in participant knowledge gained were apparent when comparing pre and posttest responses. For every test question, the sum of correct responses increased following the simulation. Interactions between the facilitator and the participants throughout the event as well as the debriefing following were incredibly important for participant knowledge gain. This was voiced as being a major bonus to the project as participants could correct improper medication errors, treatment plans, assessment findings, and have new considerations introduced that they initially did not have prior to interacting with the facilitator. The high Likert scores and verbalized responses during the debriefing period echoed similar responses to the published literature recorded by Matsco et al. and Quick et al. (2020; 2017). Participants were pleased to have experienced the simulation and expressed being receptive to learning other surgical events in a similar fashion. Strengths and Limitations MALIGNANT HYPERTHERMIA SIMULATION 19 A strength of the project is the demonstration of the effectiveness and overall reception the staff had for the implementation of the simulation. Debriefing included within the simulation is critical in facilitating knowledge gained and staff understanding what behaviors to change should a real event occur. Additional strengths of the simulation included the participation of interdisciplinary staff members with various roles within the department. Preoperative nurses brought a different perspective to the simulation compared to anesthesia and perioperative staff which contributed to improved interactions between facilitator and participants. Because the facilitator had a previously established working relationship with staff, the participants voiced a comfort and ease in asking questions throughout the experience. Limitations to the project include a rather small sample size and isolation to just one clinical site. Familiarity between the facilitator and participants may not occur at other sites. Expansion of the sample size and inclusion of multiple sites could add diversity in interactions, responses, and improve the strength of the findings. There were also varied interactions between participants and facilitator as some were more likely to ask questions and seek out additional information. Sampling bias is certainly a possibility with this study as convenience sampling was the method utilized for the project. Additional measurements that could be included in future projects would be additional testing months later to analyze retention of learned material. Conclusion Malignant hyperthermia is a serious and life-threatening complication that every facility performing anesthesia should be regularly prepared to manage. Training should include understanding susceptible patients, symptoms, and appropriate treatment of the condition. Delays in care contribute to increased mortality, which is why it is so imperative to have a staff that is confident in recognizing symptoms and knowledgeable of the steps to be taken next. Simulation MALIGNANT HYPERTHERMIA SIMULATION 20 is a viable method to promote the training and preparation of surgical staff for the possibility of a MH event. Participants within these simulations acknowledge they are better prepared, comfortable, and knowledgeable should they encounter MH. Debriefing following an event can help participants shore up knowledge deficiencies and promote confidence. Debriefing should be an aspect of any simulation event as an additional means of education. MALIGNANT HYPERTHERMIA SIMULATION 21 References Bansal, V.K., Dobie, K.H., & Brock, E.J. (2019). Emergency response in the ambulatory surgery center. Anesthesiology clinics, 37(2), 239-250. Brady, J. E., Sun, L. S., Rosenberg, H., Li, G. (2009). Prevalence of malignant hyperthermia due to anesthesia in New York state, 2001-2005. Anesthesia & Analgesia. 109(4), 1162-66. https:// doi.org/10.1213/ane.0b013e3181ac1548. Burkman J. M., Posner, K. L., Domino, K. B. (2007). Analysis of the clinical variables associated with recrudescence after malignant hyperthermia reactions. Anesthesiology 106: 901906. Clebone, A., Watkins, S.C., & Tung, A. (2020). The timing of cognitive aid access during simulated pediatric intraoperative critical events. Paediatric anaesthesia, 30(6), 676-682. Cowperthwait, A. (2020). NLN/Jeffries simulation framework for simulated participant methodology. Clinical Simulation in Nursing, 42, 1221. Gallegos, E., & Hennen, B. (2022). Malignant hyperthermia preparedness training: Using cognitive aids and emergency checklists in the perioperative setting. Journal of perianesthesia nursing: official journal of the American Society of PeriAnesthesia Nurses, 37(1), 24-28. Hardy, J.B., Gouin, A., Damm, C., Compere, V., Veber, B., & Dureuil, B. (2018). The use of a checklist improves anaesthesiologists technical and non-technical performance for simulated malignant hyperthermia management. Anaesthesia, critical care & pain medicine, 37(1), 17-23. Harrison, K. T., Manser, T., Howard, S., Gaba, D. M. (2006). Use of cognitive aids in a MALIGNANT HYPERTHERMIA SIMULATION simulated anesthetic crisis. Anesthesia & Analgesia. 103(3), 551-556. https://doi.org/10.1213/01.ane.0000229718.02478.c4 Jeffries, P. R., Rodgers, B., & Adamson, K. (2015). NLN Jeffries simulation theory: Brief narrative description. Nursing education perspectives, 36(5), 292293. https://doi.org/10.5480/1536-5026-36.5.292 Kalaniti, K., & Campbell, D. M. (2015). Simulation-based medical education: Time for a pedagogical shift. Indian Pediatrics. 52(1), 41-45. https://doi.org/10.1007/s13312-0150565- 6 Kim, K., Kriss, R. S., & Tautz, T. J. (2019). Malignant Hyperthermia: A clinical review. Advances in anesthesia, 37, 3551. https://doi.org/10.1016/j.aan.2019.08.003 Kim, T.W., Singh, S., Miller, C., Patel, S., Koka, R., Schiavi, A., &Schwengel, D. (2019). Efficacy and cost comparison of case-based learning to simulation-based learning for teaching malignant hyperthermia concepts to anesthesiology residents. The journal of education in perioperative medicine: JEPM, 21(4), E631. Lu, Z., Rosenberg, H., & Li, G. (2017). Prevalence of malignant hyperthermia diagnosis in hospital discharge records in California, Florida, New York, and Wisconsin. Journal of clinical anesthesia, 39, 1014. https://doi.org/10.1016/j.jclinane.2017.03.016 Matsco, M., Marich, M., & Parke, P. (2020). Setting the foundation for an in situ simulation program through the development of a malignant hyperthermia simulation in the operating room. Journal of continuing education in nursing, 51(11), 523-527. Mullins, M. F. (2017). Malignant hyperthermia: A review. Journal of perianesthesia nursing. https://doi.org/10.1016/j.jopan.2017.04.008. Nagelhout, JJ., Elisha, S. (2018). Nurse Anesthesia. 6th ed. St Louis, MO: Elsevier Quick, J., Murthy, R., Goyal, N., Margolis, S., Pond, G., & Jenkins, K. (2017). Malignant 22 MALIGNANT HYPERTHERMIA SIMULATION 23 hyperthermia: An anesthesiology simulation case for early anesthesia providers. MedEdPORTAL : The journal of teaching and learning resources, 13, 10550. https://doi.org/10.15766/mep_2374-8265.10550 Rosenberg, H., Sambuughin, N., Riazi, S., Dirksen, R. (2003). Malignant hyperthermia susceptibility. GeneReviews. University of Washington, Seattle. Rosenburg, H., Pollock, N., Schiemann, A., Bulger, T., Stowell, K. (2015). Malignant hyperthermia: a review. Orphanet Journal of Rare Diseases. https://doi.org/10.1186/s13023-015-0310-1 Schaad, S. (2017). Simulation-based training: Malignant hyperthermia. AORN Journal. 106(2), 158-161. https://doi.org/10.1016/j.aorn.2017.06.008. Shear, T.D., Deshur, M., Benson, J., Houg, S., Wang, C., Katz, J., Aitchison, P., Ochoa, P., Wang, E., & Szokol, J. (2018). The effect of an electronic dynamic cognitive aid versus a static cognitive aid on the management of a simulated crisis: A randomized controlled trial. Journal of medical systems, 43(1), 6. Thompson Bastin, M.L., Cook, A.M., & Flannery, A.H. (2017). Use of simulation training to prepare pharmacy residents for medical emergencies. American journal of health-system pharmacy: AJHP: official journal of the American society of health-system pharmacists, 74(6), 424-429. Yang, L., Tautz, T., Zhang, S., Fomina, A., & Liu, H. (2020). The current status of malignant hyperthermia. Journal of biomedical research, 34(2), 7585. https://doi.org/10.7555/JBR.33.20180089 MALIGNANT HYPERTHERMIA SIMULATION Appendix A Jeffries, P. R., Rodgers, B., & Adamson, K. (2015). NLN Jeffries simulation theory: Brief narrative description. Nursing education perspectives, 36(5), 292293. https://doi.org/10.5480/1536-5026-36.5.292 24 MALIGNANT HYPERTHERMIA SIMULATION Appendix B 25 MALIGNANT HYPERTHERMIA SIMULATION 26 Appendix C Pre/Post Test 1) What is the proper initial bolus dose of Dantrolene sodium? a. 1.5 mg/kg b. 2.5 mg/kg c. 5 mg/kg d. 10 mg/kg 2) Which of the following are possible Malignant Hyperthermia triggering agents? (Select all that apply) a. Succinylcholine b. Propofol c. Rocuronium d. Sevoflurane 3) Which method for surgery would be acceptable for a patient with a history of malignant hyperthermia? a. General anesthesia without triggering agents b. Regional anesthesia c. Local anesthesia d. All the above 4) True/False Patients who experienced a MH event should be monitored in the ICU for 24 hours? 5) Which of the following are symptoms of malignant hyperthermia? (Select all that apply) a. Fever b. Tachycardia c. Increased EtCO2 d. Masseter muscle spasm MALIGNANT HYPERTHERMIA SIMULATION Appendix D SWOT Analysis STRENGTHS WEAKNESSES Skilled workforce with knowledge and experience Culture of improvement at site Great teamwork and collaboration of staff Administrative support Anesthesia director support Time constraints of staff and participants Recruitment of staff to participate Lack of simulation equipment on site Buy-in from participants to make simulation as real as possible Future simulations can mirror this at additional sites Staff carry learned knowledge of simulation to other facilities Builds staff knowledge to educate future anesthesia students May lead to additional investment into simulation supplies OPPORTUNITIES May lead to purchase of necessary equipment for real-life event THREATS Appendix E GANTT Chart Budget constraints to acquire needed equipment/supplies COVID-19 can close down non-essential staff from the facility No dedicated simulation space at facility for this event Emergency surgery cases may remove available participants from the simulated event 27 MALIGNANT HYPERTHERMIA SIMULATION 28 Appendix F Literature Review MALIGNANT HYPERTHERMIA SIMULATION Reference in APA format Bansal, V.K., Dobie, K.H., & Brock, E.J. (2019). Emergency response in the ambulatory surgery center. Anesthesiology clinics, 37(2), 239-250. Level of Evidence Variables 29 Sample Level VII, Expert The impact of simulationThe participants were Opinion full time first year undergraduate students (n = 9) undertaking the RN BSc (Hons) Adult Nursing program, nurse educators (n = 3) who facilitated simulation sessions and registered nurse mentors (n = 4) who supported students in practice. Instruments Results A small-scale narrative case study. Semi-structured interviews by telephone and via e-mail. The interviews were tape recorded and transcribed verbatim. Video recordings of student simulation experiences. Data analysis through progressive focusing revealed that the nurse educators viewed simulation as a means of helping students to learn to be nurses, whilst the nurse mentors suggested that simulation helped them to determine nursing potential. The students' narratives showed that they approached simulation learning in different ways resulting in a range of outcomes: those who were successfully becoming nurses, those who were struggling or working hard to become nurses and those who were not becoming nurses. Clebone, A., Watkins, S.C., & Tung, A. (2020). The timing of Level IIUse of a cognitive aid or 89 anesthesia clinicians in 143 Cognitive aid from the Society for Pediatric cognitive aid access during simulated pediatric intraoperative retrospective not during an intraoperative events Anesthesia critical events. Paediatric anaesthesia, 30(6), 676-682. randomized control intraoperative event trial Use of a cognitive aid after implementing critical interventions improves emergency event management Gallegos, E., & Hennen, B. (2022). Malignant hyperthermia Level III- Quasi preparedness training: Using cognitive aids and emergency experimental checklists in the perioperative setting. Journal of perianesthesia nursing: official journal of the American Society of PeriAnesthesia Nurses, 37(1), 24-28. Use of a cognitive aid and individual perceptions of use of a device during an emergency Improvement perception of the use of a cognitive aid as well as increased likelihood of utilizing a cognitive aid during a malignant hyperthermia event Hardy, J.B., Gouin, A., Damm, C., Compere, V., Veber, B., & Dureuil, B. (2018). The use of a checklist improves anaesthesiologists technical and non-technical performance for simulated malignant hyperthermia management. Anaesthesia, critical care & pain medicine, 37(1), 17-23. Use of checklist during a n=24 anesthesiologists divided Use of the French Society of Anaesthesia and simulated MH event into 2 groups, one with a Intensive Care checklist for Malignant Hyperthermia checklist for MH treatment and crisis no checklist/control group Level II, Randomized control trial Convenience sampling. n=13, perioperative staff Stanford emergency manual cognitive aid Anesthesiologist treatment and initial bolus of dantrolene for a MH crisis was completed faster with the group using a MH checklist than the control group. Reduction of medical errors, improved communication, and improved treatment of symptoms occurred with the crisis checklist group as well. MALIGNANT HYPERTHERMIA SIMULATION Kim, T.W., Singh, S., Miller, C., Patel, S., Koka, R., Schiavi, A., Level II&Schwengel, D. (2019). Efficacy and cost comparison of case- Randomized based learning to simulation-based learning for teaching control trial malignant hyperthermia concepts to anesthesiology residents. The journal of education in perioperative medicine: JEPM, 21(4), E631. Matsco, M., Marich, M., & Parke, P. (2020). Setting the foundation for an in situ simulation program through the development of a malignant hyperthermia simulation in the operating room. Journal of continuing education in nursing, 51(11), 523-527. 30 Simulation based n=54 anesthesia residents learning group and case- varying in years 1-3 of based learning groups experience within residency Level V- Case study Simulation-based educational case study Case study, educational simulation Quick, J., Murthy, R., Goyal, N., Margolis, S., Pond, G., &Jenkins, Level VI-Qualitative Individual assessment of n=24 medical students with 2 K. (2017). Malignant hyperthermia: An anesthesiology study reception of educational weeks of anesthesia training simulation case for early anesthesia providers. MedEdPortal: style, opinions of the journal of teaching and learning resources, 13, 10550. simulation design, and Pre- and posttest developed by Johns Hopkins residency faculty and approved for use by the Malignant Hyperthermia Association of the United States (MHAUS) Both the case-based and simulation-based learning groups demonstrated similar learning and test results in the post test immediately following the experience as well as in 4-month follow-up posttest scores. Simulation-based learning was calculated to be a 17-fold increase in cost expense over case-based learning methods Debriefing tool following simulated MH event Participants and administration enjoyed the learning environment reflected in a simulated event. Since the simulated MH event, this led to additional simulated events within the health system to help educate staff on necessary treatment protocols and emergency management. Pre and post survey, open-ended questions designed The simulation was well-received by participants and a good to elucidate participant feedback methodology of how to educate/simulate rare emergency crisis that may occur within the operating room. knowledge gained. Schaad, S. (2017). Simulation-based training: malignant hyperthermia. AORN journal, 106(2), 158-161. Level III-Quasi experimental design Shear, T.D., Deshur, M., Benson, J., Houg, S., Wang, C., Katz, J., Level IIAitchison, P., Ochoa, P., Wang, E., & Szokol, J. (2018). The effect Randomized of an electronic dynamic cognitive aid versus a static cognitive control trial aid on the management of a simulated crisis: A randomized controlled trial. Journal of medical systems, 43(1), 6. Instructor/simulation n= >100 staff members variation depending on which of the four simulation groups the participant was placed in Using an electronic cognitive aid during the simulation or using a printed out cognitive aid An educational PowerPoint presentation prior to the simulation, checklist during the simulation of important points, a debriefing session immediately following the simulation to better assess strengths/weaknesses and address important educational takeaways n= 34 second and third year Electronic cognitive aids and static cognitive aids anesthesia residents, 19 in the utilized during MH simulation static cognitive aid group and 15 in the electronic cognitive aid group The use of malignant hyperthermia simulation improved teamwork and collaboration among the OR staff when encountering an emergency. Staff members better understood their roles and the importance of the other team members during a MH crisis. Improved clinical competency and recognition of MH symptoms occurred. Use of an electronic cognitive aid facilitated more checklist items to be correctly performed when compared to a static cognitive aid, this included proper dosing of the first line medication treatment of dantrolene. MALIGNANT HYPERTHERMIA SIMULATION Thompson Bastin, M.L., Cook, A.M., & Flannery, A.H. (2017). Use of simulation training to prepare pharmacy residents for medical emergencies. American journal of health-system pharmacy: AJHP: official journal of the American society of health-system pharmacists, 74(6), 424-429. Level III- Quasi experimental design Survey results after completing three separate emergency preparation simulation training scenarios. 31 n=13, 9 PGY1 pharmacy residents, 4 PGY2 pharmacy residents Evaluations on simulation training based on three specific areas of simulation training: bleeding and malignant hyperthermia, sepsis, and stroke and status epilepticus. Simulation training for medical emergencies including malignant hyperthermia improved pharmacy residents perceived preparedness both immediately after and at a 6 month post-simulation mark -  ...

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OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER Occupational Hazards: Considerations for the Pregnant Anesthesia Provider Teresa Rossetter Marian University Leighton School of Nursing Chair: Dr. Lee Ranalli Lee Ranalli, DNP, CRNA Lee Ranalli, DNP, CRNA (Apr 22, 2023 21:47 PDT) Project Team Members: Dr. Sara Franco Date of Submission: April 21. 2023 Table of Contents 1 OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER 2 Abstract ..............................................................................................................................................4 Introduction ........................................................................................................................................5 Background ............................................................................................................................5 Problem Statement ................................................................................................................6 Needs Assessment/Gap Analysis ............................................................................................6 Review of Literature ............................................................................................................................7 Theoretical Framework ......................................................................................................................13 Goals/Objectives/Expected Outcomes ...............................................................................................15 SWOT Analysis .....................................................................................................................................16 Project Design .....................................................................................................................................17 Project site and population ....................................................................................................18 Measurement Instruments/ Data Collection ..........................................................................18 Ethical Consideration/Protection of Human Subjects ............................................................19 Data Analysis and Results .....................................................................................................................19 Pre-Assessment .......................................................................................................................19 Post-Assessment .....................................................................................................................21 Analysis ...................................................................................................................................23 Discussion ............................................................................................................................................24 Conclusion ............................................................................................................................................25 References ............................................................................................................................................26 Appendix A ............................................................................................................................................30 Appendix B ............................................................................................................................................41 Appendix C ............................................................................................................................................41 Appendix D .........................................................................................................................................42 OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER 3 Appendix E ..........................................................................................................................................43 Appendix F ..........................................................................................................................................44 Abstract OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER 4 Background: Anesthesia providers are subjected to chemical, biological, physical, ergonomic, and psychosocial risk factors that threaten the individual's health. While pregnancy alone is not considered an independent risk factor for healthcare-associated occupational hazards, the fetus is rapidly developing and thus carries a much lower threshold to hazardous exposure than the adult. Purpose: To evaluate participants confidence levels related to their knowledge of environmental considerations for the pregnant anesthetist before and after implementing a self-paced online course presenting the findings from a review of the literature. Methods: Voluntary participants from a Midwest DNP nurse anesthesia program were invited to partake in a self-paced online course which included a pre- and post-assessment to evaluate confidence level related to the subject matter and its application into practice. Conclusion: Confidence levels in the participants' knowledge of the environmental risks for anesthesia personnel and pregnant anesthesia providers increased by 36.4% following implementation of literature review findings summarized into self-paced online course. Keywords: anesthesia, anesthesia care providers, anesthetic gases, anesthesiology, cognitive function impairment, environmental pollutants, exposure controls, fetal development, genomic instability, hospitals, hospital workers, indoor air pollution, inhaled anesthetics, neural cell damage, occupational exposure, occupational health, occupational radiation exposure, occupational risk, occupational safety, precautionary practices, pregnancy, pregnant surgeon, pregnant worker, reproductive health, research, risk management, sevoflurane, staff health, staff safety, surgeons, surgery, volatile anesthetics Occupational Hazards: Considerations for the Pregnant Anesthesia Provider OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER 5 Introduction This project was 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. The purpose of this DNP Project was to investigate confidence levels regarding participants knowledge of occupational hazards for the pregnant anesthesia provider before and after the dissemination of evidence-based safety recommendations from the literature. This study involved certified faculty and trainees of Marian University DNP Nurse Anesthesia Program. The project aimed to share literature review findings with anesthesia providers of all ages and genders as a reminder of standard safety precautions with consideration for the gravid anesthesia provider. Background Operating room personnel are at risk of exposure to numerous occupational hazards in their work environment. Anesthesia providers are subjected to chemical, biological, physical, ergonomic, and psychosocial risk factors that threaten the individual's health (Ayolu & Ayolu, 2021). Such occupational hazards include, but are not limited to, anesthetic gases, bloodborne pathogens, radiation, surgical plume, physical stress, and cytotoxic agents (Landford et al., 2021). Pregnant women working in healthcare should be aware of occupational hazards and precautions for protecting themselves and their unborn babies. While pregnancy alone is not considered an independent risk factor for healthcareassociated occupational hazards, the fetus is rapidly developing and thus carries a much lower threshold to hazardous exposure than the adult. Adverse outcomes associated with the female provider performing surgical activities include infertility, miscarriage, premature birth, intrauterine growth restriction of the fetus, hypertensive disorders of the mother, and placental abruption (Szczesna et al., 2019). Problem Statement OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER 6 This DNP project intended to investigate the confidence level of current practice guidelines and recommendations for the expectant practicing anesthesia by answering the following question: Among anesthesia learners and certified providers (P), will the delivery of summarized evidence-based practice recommendations for pregnant anesthesia providers in the operating room (I) improve confidence level toward ones knowledge of the information (O) compared to baseline understanding (C) upon completion of self-guided online course (T)? Needs Assessment & Gap Analysis The American Association of Nurse Anesthesiology (AANA) provides publicly accessible resources for nurse anesthesiology. A few examples of these resources include AANA definitions and policies, the code of ethics, the scope of practice, standards, guidelines, position statements, and practice considerations. Each webpage contains references and links to internal and external websites with additional information. A designated page of resources for health and wellness and peer assistance among nurse anesthetists covers topics such as burnout, stress, bullying, grief, suicide, physical wellbeing, substance abuse, and coping. Despite the depth of information provided in these sources, there are no statements made by the AANA regarding recommendations for the pregnant provider. In the didactic setting for the anesthesia learner, lessons on the topics related to safety for expecting anesthesia providers are not included in standard learning objectives. APEX Anesthesia Review, a resource for SRNA board review and CRNA continuing education, briefly outlines environmental concerns in the anesthesia setting, including the effect of anesthetic waste gases, allergic reactions in the provider, radiation exposure, excessive noise, and the second victim effect. None of the listed subsections specifically mention pregnancy or related considerations among providers. Anesthesia textbooks generally weave safety considerations for the anesthesia provider throughout the main text without a designated chapter heading for these evidence findings, if mentioned at all. OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER 7 Review of Literature Methodology The database Pubmed hosted by the National Library of Medicine (NIH), was used to search the Boolean phrase pregnant anesthesia provider safety limited to full-text English publications between 2016-2022. Translations included pregnant: "gravidity"[MeSH Terms] OR "gravidity"[All Fields] OR "pregnant"[All Fields] OR "pregnants"[All Fields] anesthesia: "anaesthesia"[All Fields] OR "anesthesia"[MeSH Terms] OR "anesthesia"[All Fields] OR "anaesthesias"[All Fields] OR "anesthesias"[All Fields], provider: "provide"[All Fields] OR "provided"[All Fields] OR "provider"[All Fields] OR "provider's"[All Fields] OR "providers"[All Fields] OR "provides"[All Fields] OR "providing"[All Fields], safety: "safety"[MeSH Terms] OR "safety"[All Fields] OR "safeties"[All Fields]. The yielded results were filtered to eliminate articles that were not directed at the specific target. The keywords identified for this search included anesthesia, anesthesia care providers, anesthetic gases, anesthesiology, cognitive function impairment, environmental pollutants, exposure controls, fetal development, genomic instability, hospitals, hospital workers, indoor air pollution, inhaled anesthetics, neural cell damage, occupational exposure, occupational health, occupational radiation exposure, occupational risk, occupational safety, precautionary practices, pregnancy, pregnant surgeon, pregnant worker, reproductive health, research, risk management, sevoflurane, staff health, staff safety, surgeons, surgery, volatile anesthetics. Anesthetic Gases The impact of anesthetics on fetal development was first studied in the 1960s and continues to prove worthy of further research. The first report of adverse effects related to chronic exposure to anesthetic waste gases (WAGs) came from a Russian scientist in 1967, which unveiled an increased prevalence of abortions among female anesthetists. Following this report, three extensive studies from the United Kingdom and the United States during the 1970s and 1980s confirmed the prevalence of OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER 8 spontaneous abortions among female anesthesiologists was significantly higher than among female physicians working in areas other than the operating room. Research from this period also determined an increased prevalence of congenital anomalies in children from female and male anesthesiologists compared to the control group of physician parents (Gropper et al., 2020). Additional survey-based studies from this era revealed associated health concerns, including renal and liver disease, cancer, miscarriage, and congenital defects (Varughese et al., 2021). Since then, copious studies have evaluated the consequences of exposure to inhalational anesthetics, but the conclusions are yet to provide definitive answers. In 2002, the American Society of Anesthesiologists (ASA) Committee on Occupational Health of Operating Room Personnel convened with The Task Force on Trace Anesthetic Gases to analyze the available research on the issue. The analysis could not systematically dissect the available data given the extraordinary number of variables and research approaches. The report from the ASA stated the incidence of children with congenital anomalies, spontaneous abortion, and rate of infertility among female anesthesiologists was equal to that of physicians in other specialties (Gropper et al., 2020). The ASA states, "there is no evidence that trace concentrations of waste anesthetic gases cause adverse health effects of personnel working in locations where scavenging of waste anesthetic gases is carried out" and "the general conclusion is that currently used anesthetics have no mutagenic potential." (Gropper et al., 2020). This statement lacks reassurance to the reproductive female considering previous findings. The document from the task force also provided summarized recommendations from the Occupational Safety and Health Administration's (OSHA) Workers' Rights to Information stating there are "potential adverse effects of exposure to waste anesthetic gases such as spontaneous abortions, and congenital abnormalities in children." (Gropper et al., 2020). The US National Institute for Occupational Safety and Health (NIOSH) recommends a maximal exposure level of 2ppm or less of halogenated anesthetic gases and 25ppm or less of nitrous oxide (N20) within one hour (Varughese et al., 2021). Additionally, NIOSH states that all T-tube devices, nonrebreathing systems, and OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER 9 anesthetic gas machines must have appropriate scavenging equipment to remove all WAGs (Varughese et al., 2021). Research shows these limits are often exceeded in daily practice (Gropper et al., 2020). If the volatile agent can be smelled, the concentration of exposure has significantly surpassed the recommended limit (Gropper et al., 2020). Considering the average daily exposure to WAGs by anesthesia personnel exceeds NIOSH recommended safe limits and the limitations of the study by the ASA in 2002, it can be implied that exposure to WAGs is an occupational hazard for the anesthesia provider (Gropper et al., 2020). Physical Stressors Szczesna et al. (2019) looked at the occupational hazards of the pregnant surgeon and the risk factors associated with her role in the operating room. Physical stress endured by the pregnant surgeon contributes to increased rates of high-risk pregnancies as compared to the general female population (Szczesna et al., 2019). Additionally, it has been shown that female physicians have longer time-topregnancy intervals and are more likely to receive infertility treatment than non-physicians (Szczesna et al., 2019). Occupational hazards, including the use of sharp instruments, surgical cases requiring attention overnight or at durations exceeding four hours, and the internal stress response elicited from emergencies are contributing factors to adverse outcomes in the pregnant surgeon (Szczesna et al., 2019). More specifically, in a study evaluating physician residents, females working more than six-night shifts per month and those with increased duration of operating hours were shown to have a higher risk of obstetric complications. Female residents were also at increased risk for hypertensive disorders, placental abruption, intrauterine growth restriction of the fetus, and miscarriage than general population females of similar age (Szczesna et al., 2019). Radiation Among operating room personnel, anesthesia providers are routinely exposed to both ionizing and non-ionizing electromagnetic radiation (Gropper et al., 2020). Ionizing electromagnetic radiation OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER 10 exposure includes radiation from intraoperative ultraviolet radiation rays, gamma rays, or less commonly, radioactive isotopes of gamma emissions, alpha, and beta rays (Landford et al., 2021). Within human tissue, ionizing radiation forces electrons out of a molecule's stabile orbit, generating ionized molecules and free radicals (Gropper et al., 2020). Severe exposure to this form of radiation can stimulate chromosomal abnormalities resulting in malignant tissue growth or destroying the tissue altogether (Gropper et al., 2020). Non-ionizing radiation results in an excitable movement of electrons within a molecule's orbit, creating heat that can ultimately cause damage to human tissue (Gropper et al., 2020). The proximity in which an individual is positioned to the radiation source exponentially increases the risk of exposure. Other variables contributing to radiation exposure include age, sex, and region of the body exposed. During neurointerventional angiographic procedures, the anesthesiologist is exposed to six times more radiation than other operating room personnel (Ayolu & Ayolu, 2020). Radiation exposure is measured by either Sievert (Sv) or rem, where one Sievert (Sv) equals 100 rem. This unit of measurement defines the biological damage from radiation adjusted to all tissues. OHSA has defined a set of guidelines for maximum radiation exposure by region of the body. For example, the hands can withstand greater exposure to radiation than the head, gonads, or eyes (Gropper et al., 2020). The annual radiation exposure limit is recommended to be less than 15mSv/year (Ayolu & Ayolu, 2020) with no more than 1.25 rem (12.5 mSv) per calendar quarter (Gropper et al., 2020). In 2007, the International Commission on Radiological Protection published stricter guidelines for the exposure limitations to radiation with maximum doses of 100 mRem/week and 5 Rem/year and relevant exposure limits defined by a specific region of the body (Gropper et al., 2020). Both OHSA and the International Commission on Radiological Protection concluded the limits for radiation exposure should be lower for women that are pregnant (Gropper et al., 2020). According to the National Council on Radiation Protection and Measurements, exposure exceeding 50mSv in pregnant females is associated with teratogenic effects. Thus, the recommended maximum dose of ionizing radiation should not exceed 50 OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER 11 mRem/month during gestation (Ayolu & Ayolu, 2020). Surgeries utilizing intraoperative imaging or fluoroscopy expose providers to an average range of radiation from 5 to 50 mRem/case, which equates to an average of 10 to 350 mRem/month, depending on the caseload. Other data findings suggest prenatal exposure limits of 50 mSv, with associations of childhood cancer, growth restriction, congenital anomalies, and spontaneous pregnancy termination when exposure exceeds 50 mSv (Landford et al., 2021). Despite the risk of radiation exposure, there are no regulations for monitoring occupational exposure in anesthesia providers, and many organizations fail to offer anesthesia providers the right to radiographic leave despite the elevated risk of occupational exposure (Ayolu & Ayolu, 2020). Reducing radiation exposure is dependent on three factors: distance, time, and shielding. Distance to radiation exposure follows the inverse square law, where the amount of x-ray exposure is inversely proportional to the square of the distance of the source. The impact of radiation exposure can be attributed to the accumulation of radiation over time. It is recommended that the radiation used during diagnostic procedures be limited to the least amount possible. Shielding devices such as lead aprons, thyroid protectors, glasses, caps, and radiation-reducing gloves can be used as an additional layer of protection when undergoing x-ray-guided procedures (Kim, 2018). Surgical Plume One form of biological occupational exposure in the operating room is the smoke from surgical cauterization from electrocautery, ultrasonic scalpel dissection, and lasers (Gropper et al., 2020). Data shows this byproduct, often referred to as surgical plume, contains aerosolized biological components including infectious bacteria and viruses, malignant cancer cells, and up to 150 chemical pollutants proving mutagenic and carcinogenic in nature (Landford et al., 2021). While many biological exposures are classified as bloodborne pathogens, some infectious materials, such as human papillomavirus, are transmitted via smoke plumes created by electrocautery and laser devices intraoperatively (Szczesna et al., 2019). The amount of surgical smoke emitted while using electrocautery on 1g of tissue equates to OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER 12 the carcinogens of six unfiltered cigarettes and three unfiltered cigarettes using carbon dioxide lasers. Mitigating exposure to the harmful elements of smoke plume should be a concern for operating room personnel. Standard surgical masks filter particles 5 m or greater, but 77% of particles are less than 1.1 m in diameter (Landford et al., 2021) with some as small as 0.31 m (Ayolu & Ayolu, 2020). These harmful fragments can enter the respiratory tract and permeate the endothelial lining of the alveolus (Landford et al., 2021). In the pregnant provider, exposure to surgical plume is associated with an increased risk of neural tube defects, restriction of growth development, preterm birth, stillbirth, and spontaneous abortion (Landford et al., 2021). The Occupational Safety and Health Administration (OSHA) recognizes the chemical components of surgical smoke and recommends the use of proper masks and evacuators to limit the risk of infectious material spread. When evaluating the effectiveness of smoke evacuation, the National Institute for Occupational Safety & Health (NIOSH) looks at capture velocity or the speed of inward airflow at the inlet of the collection tip. The NIOSH recommends the use of evacuation systems with a capture velocity of 30.5-47.5 m/min and the collection nozzle tip should be within 5.1cm of the site of cautery (Georgesen & Lipner, 2018). Bone Cement Methyl methacrylate (MMA) is a colorless, volatile liquid often used in orthopedic procedures, neurosurgery, and plastic surgery for cement on bone, metal, or other forms of synthetic implants. When the surgeon is ready to set the bone or prosthesis, the liquid methyl methacrylate is mixed with polymethylmethacrylate, a powder, to create a concrete mixture. This exothermic process creates a toxic emission of free radicals into the environment (Landford et al., 2021). Methyl methacrylate is converted into methacrylic acid within the body, which has proven to be toxic to numerous human tissues (Downes et al., 2014). For this reason, the US Environmental Protection Agency has declared the permissible exposure limit of MMA in the air to be 100 ppm over eight hours (Downes et al., 2014). In OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER 13 one study examining the exposure to MMA during several points throughout total hip arthroplasty procedures, the air concentration of MMA reached 280 ppm, well above the permissible ceiling vapor pressure (Downes et al., 2014). Exposure to MMA vapor can impact the human nervous system beginning with symptoms resembling that of intoxication (Kakazu et al., 2015). Individuals exposed to this fumigated toxin may experience headaches, dizziness, irritability, loss of appetite, nausea, and lethargy (Kakazu et al., 2015). If the vapor level of MMA reaches 125 ppm, exposed individuals may experience coughing, sore throat, teary eyes, and nasal irritation (Kakazu et al., 2015). Prolonged MMA exposure at 400 ppm resulted in tracheal damage in animal studies, but it is unknown whether this finding is consistent in humans (Kakazu et al., 2015). Direct contact of MMA with the skin can cause redness, burning, swelling, and itching that can lead to severe dermatitis or allergic reaction in some people (Kakazu et al., 2015). Concerns for exposure to MMA in pregnant women began in the 1960s with the discovery of teratogenic effects in rodents (Downes et al., 2014). Potential adverse effects of MMA toxicity in the parturient include increased fetal resorption, skeletal anomalies, and growth impedance (Downes et al., 2014). Theoretical Framework The framework for this project was based on the conceptual model designed by the Agency for Healthcare Research and Quality (AHRQ). Based on a patient safety initiative, the AHRQ created a knowledge transfer model that focuses on the transmission of research into practice. The AHRQ model describes the process of knowledge transfer into practice in three phases: 1. Knowledge creation and distillation, 2. Diffusion and dissemination, 3. Translation of research into practice (White et al., 2016). Framework Identification This DNP Project used the AHRQ model to assess the need for knowledge transfer related to occupational hazards for the pregnant anesthesia provider. Framework Explained OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER 14 Phase 1: Knowledge creation and distillation The first phase involved collecting research and devising information that may be meaningful and applicable to anesthesia providers. During the distillation process, it was crucial to consider the factors that may enhance or hinder the ability to transfer and generalize the research findings into current-day healthcare. A literature review concerning occupational hazards for the pregnant anesthesia provider was synthesized and categorically outlined according to current guidelines and considerations. Phase 2: Diffusion and dissemination The next phase of the AHRQ model for knowledge transfer emphasizes raising awareness of the research findings. This phase aimed to market the information, foster interest in enactment, and encourage mass diffusion efforts among organizations (White et al., 2016). Dissemination of the literature findings concerning pregnant anesthesia providers can be propagated through numerous forms of media. Phase 3: End-user adoption, implementation, and institutionalization The third and final phase concentrates on application. This last phase of the model acted on implementing the research, assessing the success within an organization, and investing in creative measures to encourage end-user adoption. This phase may take time and persistence while a group adapts to the change, but the goal is for the implemented knowledge to become a standard of care (White et al., 2016). While the time frame to institutionalize the recommendations from the literature exceeds the allotted time for this project, the authors focus is on end-user adoption. This information could trigger thoughtful consideration towards general safety practice standards in anesthesia and encourage reverence of pregnant providers by all who work in the specialty. A questionnaire survey was conducted to assess the interest in concept adoption and facility implementation. Framework Application OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER 15 The AHRQ model was implemented in three phases, as shown in Appendix B. The model allows for dynamic movement between objectives within each stage, depicted in corresponding boxes. The variability of the AHRQ model offers versatility in applying this framework. Goals, Objectives, and Expected Outcomes Project Aim This project aimed to investigate confidence levels before and after presenting the occupational hazards and safety considerations for the pregnant anesthesia provider. The comprehensive literature review aims to bridge the gap in practice guidelines related to the pregnant anesthesia provider. Participants will complete a survey to measure confidence levels related to the information distilled and the likelihood of translation into practice. Objectives 1. Identify a gap in the literature related to safety and practice considerations for the pregnant anesthesia provider through a preliminary literature search 2. Synthesize literature review from published research studies related to pregnant personnel in anesthesia or the operating room setting within the last ten years 3. Articulate the information to anesthesia providers and trainees 4. Evaluate understanding of the knowledge distillation and assess the motivation to apply the knowledge in practice using a voluntary survey questionnaire 5. Devise the data results and illustrate relevant responses related to the information surveys Expected Outcomes Determine baseline familiarity with material among a sample population of anesthesia practitioners and trainees OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER 16 Improve knowledge and confidence related to safety recommendations for the pregnant anesthesia provider SWOT A strengths, weaknesses, opportunities, and threats (SWOT) analysis was a beneficial component of the project development stage. This tool was helpful to direct the project toward a particular area of need or interest based on an assessment of a phenomenon. The SWOT analysis evaluated internal and external traits of the project, both positive and negative, that could affect the results. Intrinsic attributes involved aspects of the project that innately help, or hurt, the project's aim. Conversely, extrinsic factors included environmental elements or situations that may have impacted the targeted objectives. The SWOT analysis optimized the project design by detecting external sources for threats, minimizing internal weakness, and ascertaining areas of internal and external strength (Moran et al., 2019). The matrix visual for this tool is provided in Appendix C. Intrinsic Strengths & Weaknesses Though subjective, the SWOT analysis provided perspective of the project proposal for the creator and affiliated committee members. Internal strengths of the project design included its unique content and accessible approach, which may have enticed more voluntary participants. Dissemination of the information in the form of an online self-paced course was both modern and attractive to many different styles of learners. Additionally, there was a need for a comprehensive literature review on the topic, and there was a notable gap in the standard practice guidelines for pregnant anesthesia providers. The basis of the information was founded on universal safety standards in the anesthesia setting and thus indirectly benefited all anesthesia providers. The opportunity to use technology for engagement, surveying, and analysis is an internal factor that could have functioned as a strength or a weakness. Technology provides innovative and efficient results, but the project would have suffered in the event of a technological failure. Other internal weaknesses included the project's dependence on voluntary OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER 17 participation, and the subject matter may not have attracted the greater anesthesia provider population outside of female providers of childbearing age. The final internal threat was that the online course formatting and design were limited to the skillset of the author. External Threats The most significant external threat to this DNP Project was the limited number of voluntary participants. This project lacked outreach potential which significantly restricted the sample size for data analysis. Additionally, the project committee members were geographically located across three U.S. time zones which posed limitations in meeting times and the ability to connect face-to-face. Delayed initiation of the implementation phase while awaiting faculty feedback on drafted proposals and institution IRB approval was an external factor that altered the targeted project timeline. External Opportunities In the spirit of optimism, this SWOT analysis concluded with a list of hypothetical opportunities. This endeavor had the potential to motivate leaders in advanced practice roles to standardize safety guidelines and publish facility protocols according to the recommendations in the literature. Project Design This project design aims to evaluate participants confidence levels in their knowledge of occupational considerations for the pregnant anesthetist. A pre-assessment survey, presentation of course material, and post-assessment will be accessible through a self-paced online course through Marian University Canvas, an educational platform for online learning modules. Once published, the course will be distributed to the student registered nurse anesthetists and certified anesthesia faculty of Marian University Leighton School of Nursing DNP Nurse Anesthesia program. Participation is voluntary and there will be no monetary cost associated with the course. The virtual course allows the participants convenient access to the information without the scheduling constraints of attending a live lecture. The course can be accomplished in one sitting or in divided segments at the participants discretion to allow OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER 18 for flexible completion. Course content will include individual modules with subsections of the literature review findings with visual reinforcements such as photos and videos. Project Site and Population The target population for this project included enrolled students and certified anesthesia faculty of the Marian University Leighton School of Nursing DNP Nurse Anesthesia Program, which comprised 91 students and 5 faculty members. These individuals received an email explaining the project's aim and what is asked of the participants if willing to partake. The email included a link to enroll in the online course titled Occupational Hazards for the Pregnant Anesthesia Provider through the Marian University Canvas platform. The Marian University Canvas portal could only be accessed by individuals actively enrolled with Marian University. Once enrolled, the course would appear on the individuals Canvas Dashboard and participants could access the content at any time. Enrollment provided access to the course content but did not automatically involve individuals in the study. Surveys for data collection were embedded into the course modules with electronic informed consent. Measurement Instruments and Data Collection The Occupational Hazards course began with the Pre-Assessment, as shown in Appendix D, to survey participant demographics, confidence in participants knowledge of the subject matter, and confidence in translating the information to the workplace. Following the presentation of course material was the Post-Assessment survey asking the same questions as the Pre-Assessment with one additional free-text response related to the topic reception. The survey tools were developed by the course author using Qualtrics and implemented following approval from the project committee. Data collected from the evaluations on Qualtrics was processed using Microsoft Excel for statistical analysis. Ethical Considerations/ Protection of Human Subjects Subjects invited to partake in the study consented electronically before the initial assessment, informing participants of anonymity protection and lack of personal identifiers linked to the surveys. OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER 19 Individuals involved in the project had the right to abort the study at any time with no penalty or impact on their standing in the academic institution. Individuals enrolled in the Occupational Hazards course had access to the course content regardless of their participation in the surveys. The course modules and information will be accessible to enrollees for three years following the published date of February 26, 2023. Data Analysis and Results The target subjects were invited to take part in the course through an introduction email explaining the project aim and what is being asked of willing participants. This email was sent to enrolled students and certified faculty of Marian University Leighton School of Nursing DNP Nurse Anesthesia program, which included 91 students and 5 faculty members. Within the email was a link to the composed course on the Marian Canvas platform. Once enrolled in the course, participants could access and complete the surveys from February 26, 2023, to March 13, 2023. The yielded data from this study was collected from anonymous surveys conducted through Qualtrics. Pre-Assessment The Pre-Assessment survey was comprised of 8 multiple-choice questions. The first question served the purpose of electronic informed consent, which detailed the purpose of the survey as it relates to the study. This was the only question that required a response, in which the respondent needed to agree to the terms of the study to proceed with the survey. The following questions included three demographic questions about age, gender, and years of anesthesia experience. The final four questions asked participants to select the response that best correlates with how they relate to the question. A visual representation of the Pre-Assessment Survey, minus the informed consent page, can be found in Appendix D. The Pre-Assessment survey was completed by 35 participants. The demographics of this sample included 8 individuals 22-29 years of age comprising 22.8% of the responses. Most of the responses came from individuals aged 30-39, which included 24 of the 35 OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER 20 participants or 68.57%. There were 3 participants aged 40-49, totaling 8.57% of the partakers. Participants were asked to select the gender in which they most identify which unveiled 65.71% female participants and 34.29% males, or 23 and 12 of 35 respectively. Other selections provided when asked about gender included non-binary, non-conforming, and other genders not listed or prefer not to say. None of these gender selections were chosen. Next, participants were asked to disclose the amount of time in which they had been learning and/or practicing anesthesia. 8 of the 35 individuals, or 22.86%, reported less than one year. There were 17, which is 48.57%, who stated 2 years, and 10 of the 35, or 28.57%, had 3 years of anesthesia training. Other categories included 5 or more years and 10 or more years, but there were no participants who reported this amount of anesthesia experience. The next portion of the Pre-Assessment survey asked participants to rank their confidence level as it relates to occupational hazards in anesthesia and for the parturient working in anesthesia. The response choices were based on a Likert scale which included extremely confident (5), somewhat confident (4), neither confident nor unconfident (3), somewhat unconfident (2) and extremely unconfident (1). The first question in this series asked about the participants confidence in their knowledge of the environmental risks of delivering anesthesia. Of the 35 participants, none of them reported feeling extremely confident in their knowledge of the environmental risks of delivering anesthesia. There were 15 individuals, 42.86%, that reported feeling somewhat confident. 9 respondents reported indifference, and 9 others felt somewhat unconfident. This comprised 25.71% for each respective category. There were 2 people, accounting for 5.71%, who felt extremely unconfident in knowing the risks of delivering anesthesia. The next question asked about the participants confidence level in their knowledge of the occupational risks for a pregnant anesthesia provider. A nearly identical question, but the focus was shifted from the generalized anesthesia provider to a pregnant anesthesia provider. The mean confidence level in this scenario decreased by 12.6% from the previous question. There were no respondents to this question that felt extremely confident, and only 4 of 35, 11.34%, felt OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER 21 somewhat confident. There were 12, or 34.29% of the sample, who felt neither confident nor unconfident in this question. The most common response was somewhat unconfident, which 40% of the participants reported. There were 5 who stated feeling extremely unconfident, which accounted for 14.29% of the group. The following question in the Pre-Assessment survey presented an application scenario and asked participants to rate their confidence level in providing safety recommendations to a pregnant anesthesia provider. Interestingly, the confidence level decreased from the previous question by 4.6%. 9 individuals reported feeling extremely unconfident in providing safety recommendations to the parturient as opposed to the 5 individuals in the previous question who stated feeling extremely unconfident in their knowledge of occupational concerns for the expecting anesthesia provider. The final question in the Pre-Assessment survey asked respondents to rank the topic of occupational considerations for the pregnant anesthesia provider in terms of its usefulness in their role as a DNP-prepared Certified Registered Nurse Anesthetist. There were 11 of the 35 respondents, 31.43%, who reported feeling this information was extremely applicable. The majority felt this content was very applicable to their practice, which accounted for 48.57% of the responses. 6 individuals, 17.14%, selected moderately applicable and 1 person felt it was slightly applicable to their practice. There were no respondents who reported this material as not at all applicable to their practice. Post-Assessment The Post-Assessment survey posed identical questions in the same order as the Pre-Assessment, with one additional question at the end of the questionnaire. This final question was an optional freetext response asking participants to share what they found most beneficial from the corresponding online course titled Occupational Hazards for the Pregnant Anesthesia Provider. The Post-Assessment was completed by 29 participants: 7 reported 20-29 years of age, there were 20 between ages 30-39 and 2 participants between the ages of 40-49. There were no participants 50 years or older. Among the OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER 22 respondents, there were 11 males and 18 females, 37.4% and 62.1% respectively. No other genders were reported. 8 of the survey participants, 27.59%, have less than one year of anesthesia training, 14 of the 29, 48.28%, reported two years, and 7 reported three years which accounted for 24.24% of the sample. There were no participants with greater than 5 years of anesthesia training. When asked about the participants knowledge of the environmental risks of delivering anesthesia, the respondents reported an overall 23.6% increase in confidence level. There were 8 individuals, 27.59%, who stated feeling extremely confident in the Post-Assessment survey compared to 0 in the Pre-Assessment. Most Post-Assessment participants, 68.97%, stated feeling somewhat confident in their knowledge of environmental risk. There was 1 report of feeling neither confident nor unconfident on this question, but no participants reported feeling somewhat or extremely unconfident. Regarding the participants knowledge of environmental risks for the pregnant anesthesia provider, all the respondents reported feeling somewhat, 72.41%, or extremely, 27.59%, confident in the PostAssessment. This totaled 8 and 21 participants respectively. Similarly, 8 of the 29 Post-Assessment participants felt extremely confident providing safety recommendations to the pregnant anesthesia provider, 20, or 68.97%, reported feeling somewhat confident, and 1 respondent was neither confident nor unconfident toward this question. When asked how applicable the participants felt this information was in their practice as DNPprepared Certified Registered Nurse Anesthetists, over 72% reported extremely useful. There were 7 individuals comprising 24.14% of the Post-Assessment participants who selected very useful, and 1 participant selected slightly useful. The final question of the Post-Assessment survey was an optional free-text response asking participants what they felt was most beneficial from the course. The responses to the free-text question can be found in Appendix E. Analysis OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER 23 The investigative surveys consisted of three core questions about the participants confidence level in their knowledge of environmental risks for anesthesia personnel, including the parturient. Response choices were coded according to confidence level as follows: extremely confident (5), somewhat confident (4), neither confident nor unconfident (3), somewhat unconfident (2), and extremely unconfident (1). The first core question asked participants to select the confidence level that correlates with their knowledge of the environmental risks for anesthesia personnel. The Pre-Assessment confidence level averaged 3.06, whereas the Post-Assessment mean was 4.24. Next, participants were asked the same question but regarding pregnant anesthesia personnel. These scores for the PreAssessment and Post-Assessment were 2.43 and 4.28 respectively. The final core question asked participants to rank their level of confidence if asked to provide safety recommendations for a pregnant anesthesia colleague. These scores averaged 1.81 on the Pre-Assessment and 4.24 on the PostAssessment. The mean response scores on these core questions increased by 36.4% in the PostAssessment following the implementation of literature review findings summarized into a self-paced online course. A paired t-test was performed to compare the mean scores of the core survey questions from the Pre-Assessment and Post-Assessment. The null hypothesis states that the mean values of the PreAssessment are equal to the mean values of the Post-Assessment. The alternative hypothesis states that the mean scores for the surveys are not equal. For this analysis, we fail to reject the null hypothesis in which p= 0.0857 and the test statistic was -7.379 with 1 degree of freedom, where = 0.05. A visual representation of the mean response scores from the Pre-Assessment and Post-Assessment surveys can be found in Appendix F. The bar graph includes the final common question of the survey which asked respondents to select the answer choice that best correlates with how applicable they feel this information pertains to their career as a DNP-prepared Certified Registered Nurse Anesthetist. The response choices were coded as follows: extremely useful (5), very useful (4), moderately useful (3), OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER 24 slightly useful (2), and not at all useful (1). After participants were subjected to the course information, the respondents reported an 11.4% increase in the usefulness of the topic as it relates to their anesthesia practice. Discussion A significant limitation of this investigative study was the small sample size and narrow target population. The course invitation was sent to 91 enrolled student registered nurse anesthetists and 5 certified anesthesia faculty of Marian University Leighton School of Nursing DNP Nurse Anesthesia Program. Of the 96 invited, there were 38 individuals enrolled in the online course titled Occupational Hazards for the Pregnant Anesthesia Provider. Participants were invited to join the course regardless of whether they chose to partake in the surveys for data collection. This allowed individuals access to the content without feeling pressured to participate in the study. The questionnaires utilized for data collection were embedded into the course curriculum, thus it was necessary to accept the invitation to the course to take the survey. There were 35 respondents in the Pre-Assessment and 29 participants in the Post-Assessment. This accounted for 36.4% and 30.2% respectively. While these surveys were designed to be anonymous, there were zero participants reporting anesthesia experience exceeding 5 years, and there were no participants 50 years of age or older. Based on this information we can infer zero faculty members participated in the project. This implication limited the population to student registered nurse anesthetists from Marian University DNP Nurse Anesthesia Program. While the result analysis from this study revealed no statistical significance, there was limited data collection given the approximate 33% participation. The mean confidence level values present a clear positive trend from the Pre-Assessment to the Post-Assessment. Further research involving a larger and more diverse target population is recommended. There is a blatant gap in the literature as evidenced by the literature review for this project. A significant portion of the supportive data for this research comes from studies involving the resident, OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER 25 physician, or surgeon of specialties other than anesthesia. The anesthesia provider is often exposed to similar levels of occupational risk given their proximity to the procedure and obligation to tend to the patient with every heartbeat. Additional research related to environmental exposures of anesthesia personnel is recommended for the health and safety of future anesthesia providers. Conclusion In conclusion, this investigative study demonstrated a gap in the literature related to occupational hazards for the pregnant anesthesia provider and the need for further research on the topic. The findings of this study suggest increased confidence levels related to knowledge of the environmental risks of anesthesia and recommended occupational considerations for anesthesia personnel and pregnant anesthesia providers following the dissemination of the literature. Due to its limited sample size and narrow target population, the results of this study were not statistically significant to be conclusive with the proposed hypothesis. Additional research and translation of the findings into practice are vital to the future health and safety of anesthesia personnel. References OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER 26 Al-Rasheedi, K. A., Alqasoumi, A. A., & Emara, A. M. (2021). Effect of inhaled anesthetics gases on cytokines and oxidative stress alterations for the staff health status in hospitals. International archives of occupational and environmental health, 94(8), 19531962. https://doi.org/10.1007/s00420-021-01705-y American Psychological Association. (2020). Publication manual of the American Psychological Association (7th ed.). https://doi.org/10.1037/0000165-000 Ayolu, H., & Ayolu, F. N. (2021). Occupational risks for anaesthesiologists and precautions. Turkish Journal of Anaesthesiology and Reanimation, 49(2), 9399. https://doi.org/10.5152/TJAR.2020.219 Boiano, J. M., & Steege, A. L. (2016). Precautionary practices for administering anesthetic gases: A survey of physician anesthesiologists, nurse anesthetists and anesthesiologist assistants. Journal of Occupational and Environmental Hygiene, 13(10), 782793. https://doi.org/10.1080/15459624.2016.1177650 Bonnel, W. E. (2018). Proposal writing for clinical nursing and DNP projects. (K. V. Smith, Ed.) (Second). Springer Publishing Company. Ciompton, J., Clinger, J., Lawler, E., Otero, J., & O'Shaughnessy, P. (2020). Masks for the reduction of methyl methacrylate vapor inhalation. The Iowa Orthopaedic Journal, 40(1), 191193. Cui, F. H., Li, J., Li, K. Z., Xie, Y. G., & Zhao, X. L. (2021). Effects of sevoflurane exposure during different stages of pregnancy on the brain development of rat offspring. Journal of anesthesia, 35(5), 654662. https://doi.org/10.1007/s00540-021-02972-2 Downes, J., Rauk, P. N., & Vanheest, A. E. (2014). Occupational hazards for pregnant or lactating women in the orthopaedic operating room. The Journal of the American Academy of Orthopaedic Surgeons, 22(5), 326332. https://doi.org/10.5435/JAAOS-22-05-326 OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER 27 Gaya da Costa, M., Kalmar, A. F., & Struys, M. (2021). Inhaled Anesthetics: Environmental Role, Occupational Risk, and Clinical Use. Journal of clinical medicine, 10(6), 1306. https://doi.org/10.3390/jcm10061306 Georgesen, C., & Lipner, S. R. (2018). Surgical smoke: Risk assessment and mitigation strategies. Journal of the American Academy of Dermatology, 79(4), 746755. https://doi.org/10.1016/j.jaad.2018.06.003 Gropper, M.A., Cohen, N.H., Eriksson, L.I., Fleisher, L.A., Leslie, K., & Weiner-Kronish, J.P. (2020). Millers anesthesia: Volume II. Elsevier. Harnsberger, C. R., & Davids, J. S. (2019). The pregnant surgeon. Clinics in Colon and Rectal Surgery, 32(6), 450456. https://doi.org/10.1055/s-0039-1693012 Kakazu, C., Lippmann, M., & Karnwal, A. (2015). Hazards of bone cement: for patient and operating theatre personnel. British Journal of Anaesthesia, 114(1), 168169. https://doi.org/10.1093/bja/aeu433 Khamtuikrua, C., & Suksompong, S. (2020). Awareness about radiation hazards and knowledge about radiation protection among healthcare personnel: Quaternary care academic center-based study. SAGE Open Medicine, 8, 2050312120901733. https://doi.org/10.1177/2050312120901733 Kim J. H. (2018). Three principles for radiation safety: time, distance, and shielding. The Korean journal of pain, 31(3), 145146. https://doi.org/10.3344/kjp.2018.31.3.145 Landford, W. N., Stewart, T., Abousy, M., Ngaage, L. M., Kambouris, A., & Slezak, S. (2021). A Roadmap for Navigating Occupational Exposures for Surgeons: A Special Consideration for the Pregnant Surgeon. Plastic and reconstructive surgery, 147(2), 513523. https://doi.org/10.1097/PRS.0000000000007581 OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER 28 Landford, W. N., Ngaage, L. M., Lee, E., Rasko, Y., Yang, R., Slezak, S., & Redett, R. (2021). Occupational exposures in the operating room: Are surgeons well-equipped?. PloS One, 16(7), e0253785. https://doi.org/10.1371/journal.pone.0253785 Marx M. V. (2018). Baby on Board: Managing Occupational Radiation Exposure During Pregnancy. Techniques in vascular and interventional radiology, 21(1), 3236. https://doi.org/10.1053/j.tvir.2017.12.007 Moran, K. J., Burson, R., & Conrad, D. (2019). The doctor of nursing practice project: A framework for success. Jones & Bartlett Learning, LLC. Souza, K. M., Braz, L. G., Nogueira, F. R., Souza, M. B., Bincoleto, L. F., Aun, A. G., Corrente, J. E., Carvalho, L. R., Braz, J., & Braz, M. G. (2016). Occupational exposure to anesthetics leads to genomic instability, cytotoxicity and proliferative changes. Mutation Research, 791-792, 4248. https://doi.org/10.1016/j.mrfmmm.2016.09.002 Sun, M., Xie, Z., Zhang, J., & Leng, Y. (2021). Mechanistic insight into sevoflurane-associated developmental neurotoxicity. Cell biology and toxicology, 10.1007/s10565-021-09677-y. Advance online publication. https://doi.org/10.1007/s10565-021-09677-y Szczesna, A., Grzelak, K., Bieniasz, M., Kacperczyk-Bartnik, J., Dobrowolska-Redo, A., Bartnik, P., Zareba-Szczudlik, J., & Romejko-Wolniewicz, E. (2019). Pregnant surgeon - assessment of potential harm to the woman and her unborn child. Ginekologia Polska, 90(8), 470474. https://doi.org/10.5603/GP.2019.0081 Varughese, S., & Ahmed, R. (2021). Environmental and occupational considerations of anesthesia: A narrative review and update. Anesthesia and Analgesia, 133(4), 826835. https://doi.org/10.1213/ANE.0000000000005504 Wang, R. R., Kumar, A. H., Tanaka, P., & Macario, A. (2017). Occupational Radiation Exposure of Anesthesia Providers: A Summary of Key Learning Points and Resident-Led Radiation Safety OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER Projects. Seminars in cardiothoracic and vascular anesthesia, 21(2), 165171. https://doi.org/10.1177/1089253217692110 White, K. M., Dudley-Brown, S. P., & Terhaar, M. F. (2016). Translation of evidence into nursing and health care, second edition. Springer Publishing Company. 29 OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER 30 Appendix A Literature Review Matrix Reference Source/ Type Purpose / Aim Al-Rasheedi, K. A., Alqasoumi, A. A., & Emara, A. M. (2021). Effect of inhaled anesthetics gases on cytokines and oxidative stress alterations for the staff health status in hospitals. International archives of occupational and environmental health, 94(8), 19531962. https://doi.org/10.1007/s0 0420-021-01705-y Comparative crosssectional study; Level II to evaluate the effects of waste anesthetic gases on cytokines and oxidative stress of hospital health team members following exposure to waste anesthetic gases (WAGs) Ayolu, H., & Ayolu, F. N. (2021). Occupational risks for anaesthesiologists and precautions. Turkish Journal of Anaesthesiology Descriptive Study; Level VI to raise awareness about the occupational risks, hazards, and precautions in Population / Sample n=x n=180 Variables Instruments / Data collection Results Implications for future research Implications for future practice catalase (CAT), glutathione peroxidase (GSHpx) and superoxide dismutase (SOD) activities, plasma fluoride, serum interferon gamma (IFN-), serum interleukin 2 (IL2), serum interleukin 4 (IL4) and plasma thiobarbituric acid reactive substances (TBARS) Venous blood samples [plasma fluoride levels, enzymatic and non-enzymatic antioxidant assays, and cytokine assay]; statistical analysis via SPSS Further research that builds on the findings presented here is required to investigate in more detail the health effects of occupational exposure to WAGs Educate healthcare staff to reduce their risks of immunotoxicity by managing these gases. Furthermore, safety protocols for using anesthesia should be re-assessed frequently and improvements be implemented where possible. n/a Occupational hazards are classified as physical, chemical, Review derived from a composition of 27 medical literature pieces Anesthesiologists and their assistants exhibited the highest levels of plasma fluoride, serum IFN- and IL 2, exceeding the levels in detected in all the other occupational subgroups. Furthermore, the serum levels of IL4 were significantly raised in anesthesiologists and the difference between this group and other groups was statistically significant. elevated plasma TBARS and reduced CAT, GSHpx and SOD; these variances were also statistically significant. Anaesthesiologists are exposed to numerous potential risks that These risks are the major mortality and morbidity factors in There is a need for structured national occupational safety laws and procedures for job OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER Reference Source/ Type and Reanimation, 49(2), 9399. https://doi.org/10.5152/TJ AR.2020.219 Boiano, J. M., & Steege, A. L. (2016). Precautionary practices for administering anesthetic gases: A survey of physician anesthesiologists, nurse anesthetists and anesthesiologist assistants. Journal of Occupational and Environmental Hygiene, 13(10), 782793. https://doi.org/10.1080/15459 624.2016.1177650 Purpose / Aim Population / Sample n=x anesthesiology practice Descriptive study; Level VI to describe work practices including use of exposure controls and barriers to using scavenging systems by anesthesia care providers who administer general anesthesia to patients 31 Variables Instruments / Data collection biological, ergonomic and psychosocial factors n=2,987 anesthesia care providers (including 1,783 nurse anesthetists, 1,104 physician anesthesiologist s, and 100 anesthesiologist assistants) Training, employer procedures, administration practices, engineering controls, work practice controls, precautionary work practices, postadministration practices, filling anesthetic gas vaporizers, spills of liquid anesthetic agents, personal and environmental monitoring practices for anesthetic gases Web survey which included a screening module, core module, and seven hazard modules. Data were analyzed using SAS 9.3 Results Implications for future research Implications for future practice can harm their general health. anaesthesiologist s. Various preventive measures to be taken to ensure occupational safety in anaesthesia practices are extremely important for employee health Information on the effectiveness of waste gas scavenging systems, types of PPE used during spill cleanup and filling/draining vaporizers, and availability of and participation in a medical surveillance program, was not collected in this study and should be evaluated in future studies. safety in anaesthesiology Successful management of waste anesthetic gases should include scavenging systems, hazard awareness training, availability of standard procedures to minimize exposure, regular inspection of anesthesia delivery equipment for leaks, periodic air and exposure monitoring, prompt elimination of spills and leaks, and medical surveillance. Nearly one of every five respondents had not received training addressing safe handling of anesthetic agents, including more than a quarter of physician anesthesiologists. OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER Reference Cui, F. H., Li, J., Li, K. Z., Xie, Y. G., & Zhao, X. L. (2021). Effects of sevoflurane exposure during different stages of pregnancy on the brain development of rat offspring. Journal of anesthesia, 35(5), 654662. https://doi.org/10.1007/s0054 0-021-02972-2 Source/ Type Randomized control; Level II Purpose / Aim to explore the effects of sevoflurane exposure during different stages of pregnancy on the brain development of offspring Population / Sample n=x n=72 rat pups 32 Variables Instruments / Data collection Results Implications for future research Implications for future practice sevoflurane exposure in early (S1) pregnancy, sevoflurane exposure in middle (S2) pregnancy, and sevoflurane exposure in late (S3) pregnancy, interleukin (IL)1, IL-6, and tumor necrosis factor (TNF)-, Nissl body formation, BDNF and CPEB Morris water maze experiment to measure learning and memory capacity of subjects prior to experiment; Hippocampus tissue sample [levels of interleukin (IL)1, IL-6, and tumor necrosis factor (TNF)- in the hippocampus measured by ELISA. Nissl bodies in the hippocampus were analyzed using Nissl staining. Immunohistoche mistry was used to examine the expression of BDNF and CPEB], Statistical analysis via SPSS Memory and learning capacity significantly reduced in the S1 and S2 groups compared to the control group (p0.05). The level of IL-1 significantly increased (p<0.05) in the S1 group compared with the control group. Sevoflurane in early and middle pregnancy affect the formation of Nissl bodies. Expression of BDNF and CPEB2 in hippocampi of S1 offspring rats grealy decreased compared to control group (p<0.05). Expression of NR4A1 in hippocampi of rat offspring was signifcantly decreased in the S1 and S2 groups compared with the control group (p<0.05). The expression of proteins related to NF-B pathway increased in S1 group compared to control group (p<0.05). Additional experimental and mechanistic studies required to identify expression of memoryrelated genes during learning and memory formation, as well as involvement in memory impairment induced by maternal sevoflurane exposure during pregnancy The neurotoxic effect of maternal sevoflurane anesthesia on the brain development of offspring is higher when the exposure occurs in early pregnancy than in late pregnancy, and its mechanism might involve the NR4A1/NF-B pathway to increase the secretion of inflammatory cytokines. OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER Reference Downes, J., Rauk, P. N., & Vanheest, A. E. (2014). Occupational hazards for pregnant or lactating women in the orthopaedic operating room. The Journal of the American Academy of Orthopaedic Surgeons, 22(5), 326332. https://doi.org/10.5435/JAAOS -22-05-326 Gaya da Costa, M., Kalmar, A. F., & Struys, M. (2021). Inhaled Anesthetics: Environmental Role, Occupational Risk, and Clinical Use. Journal of clinical medicine, 10(6), 1306. https://doi.org/10.3390/jcm10 061306 Source/ Type Descriptive Review; Level IV Systematic Review; Level III 33 Purpose / Aim Population / Sample n=x Variables Instruments / Data collection Results Implications for future research Implications for future practice examine the potential occupational hazards present in the orthopaedic OR, including bloodbornerne pathogens, anesthetic gases, methylmethacrylate (MMA), physical stress, and radiation, and the risks that they pose to pregnant and lactating OR staff To recount the results of available scientific literature and interpretation of data related to inhaled anesthetics from three perspectives including environmental effects, occupational hazards* and the benefits or potential risks of clinical application n/a blood-borne pathogens, harmful chemicals, physical stress, and radiation Review of 48 studies; references 27, 28, and 38 are level II studies. References 23, 24, and 39 are level III studies Pregnant and lactating women who work in the orthopedic OR are exposed to several potential occupational hazards, including blood-borne pathogens, harmful chemicals, physical Effectiveness of preventative measures for occupational hazards in anesthesia Implementation of recommended prevention techniques to reduce the risk of workplace related perinatal complications An inclusive study reporting the (dis) advantages for the patient versus occupational risks and environmental effects is warranted to have a wellconsidered analysis of the possible clinical impacts of any changes in anesthesia practices Workplace conditions should be adequate and healthcare professionals should avoid exposure stress, and radiation n/a Cited 169 reference sources *Threshold of anesthetics in the workplace, prevention of exposure to WAGs, health risks related to inhaled anesthetics, n/a Although the most important health risks such as abortion were associated with inhaled anesthetics no longer in use, the concern related to long-term exposure is ongoing and warrants more regulatory involvement. The available data on occupational exposure to inhaled anesthetics are still controversial, but potential genotoxic and carcinogenic effects OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER Reference Source/ Type Purpose / Aim Population / Sample n=x 34 Variables Instruments / Data collection Harnsberger, C. R., & Davids, J. S. (2019). The pregnant surgeon. Clinics in Colon and Rectal Surgery, 32(6), 450456. https://doi.org/10.1055/s0039-1693012 Systematic Review; Level III to review the data while providing some practical advice for pregnant surgeons and those considering pregnancy n/a physical, logistical, and financial challenges facing the pregnant surgeon 31 referenced literature articles Kakazu, C., Lippmann, M., & Karnwal, A. (2015). Hazards of bone cement: for patient and operating theatre personnel. British Journal of Anaesthesia, 114(1), 168169. https://doi.org/10.1093/bj a/aeu433 Descriptive Review; Level VI to highlight several dangerous hazards of bone cement to the patient and operating room personnel n/a MMA, patient, operating room personnel 3 research studies Results cannot be excluded. WAG control measures should be implemented as a precaution. There are significant challenges faced by the pregnant and postpartum surgeon, as well as her colleagues and administrators, but with awareness, planning, and a supportive environment, there are sustainable solutions. By raising awareness of the specific physical, logistical, and financial challenges facing the pregnant surgeon, we hope to prepare pregnant surgeons, their colleagues, mentors, and administrators. MMA inhaled by a pregnant woman can reach the fetus and women who may be pregnant should avoid overexposure to MMA. Implications for future research Implications for future practice Sustainable solutions for the challenges faced by pregnant and postpartum surgeons The commitment to a healthy and sustainable pregnancy and maternity leave for surgeons is a worthy investment to sustain a full and productive career thereafter Effect of MMA on pregnancy in humans has not been studied, but birth defects were observed in high dose exposure among animals Operating theatres should be well ventilated with a laminar flow system to take care of the cement odor and fumes OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER Reference Source/ Type Purpose / Aim Population / Sample n=x Landford, W. N., Stewart, T., Abousy, M., Ngaage, L. M., Kambouris, A., & Slezak, S. (2021). A Roadmap for Navigating Occupational Exposures for Surgeons: A Special Consideration for the Pregnant Surgeon. Plastic and reconstructive surgery, 147(2), 513523. https://doi.org/10.1097/P RS.0000000000007581 Retrospective Study; Level III to provide current evidence and guidance to aid women in making an informed decision about their perinatal exposures, while maintaining their privacy during the early weeks of pregnancy. n/a Landford, W. N., Ngaage, L. M., Lee, E., Rasko, Y., Yang, R., Slezak, S., & Redett, R. (2021). Occupational exposures in the operating room: Are surgeons wellequipped?. PloS One, 16(7), e0253785. https://doi.org/10.1371/jo urnal.pone.0253785 Crosssectional survey; Level VI to elucidate the extent to which surgeons are trained in OR hazards and assess the self-reported exposure rate across surgical specialties and academic level n= 183 Evidence from 71 cited references 35 Variables Formaldehyde, methylmethacr ylate, anesthetic gases, antineoplastic drugs, poividoneiodone surgical hand scrub, laser/surgical plume, radiation, workplace demands, acoutstics/ vibration, bloodborne pathogens 13 occupational hazards: bloodborne pathogens, surgical smoke, ergonomics, radiation, sharp injuries, inhalation exposure to MMA, Instruments / Data collection Comprehensive summarization from 71 referenced sources A cross-sectional electronic questionnaire, Qualtrics, online survey and research tool Results Operating theatres should be well ventilated with a laminar flow system to take care of the cement odor and fumes Empirical evidence from animal and human studies shows a strong association between these hazards and reproductive outcomes. The results highlight gaps between training, perceived importance and actual practice of occupational risk management among surgeons. Implications for future research Implications for future practice Current data for exposure limits by expert agencies is outdated; further research needed to establish reliable exposure limits to occupational hazards Although pregnant surgeons cannot avoid all occupational exposures, knowledge regarding the risks and ways to mitigate these risks will improve the health of both women surgeons and their unborn children. Future studies investigating surgeon knowledge of hazards are warranted. The data supports the need for medical institutions and surgical specialties to educate the next generation of surgeons on occupational hazards and ensure their protection during training for the sake of surgeon safety. OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER Reference Marx M. V. (2018). Baby on Board: Managing Occupational Radiation Exposure During Pregnancy. Techniques in vascular and interventional radiology, 21(1), 3236. https://doi.org/10.1053/j.t vir.2017.12.007 Source/ Type Descriptive Study; Level VI Purpose / Aim This article reviews the issue of occupational radiation exposure as a deterrent to recruitment of women into the field of interventional radiology and provides the reader with three strategies to optimize radiation protection during fluoroscopically guided procedures Population / Sample n=x n/a 36 Variables cytotoxic drugs, formaldehyde, patient lifting, prolonged standing (greater than 3 hours), surgical hand scrub, surgical noise (anesthesia machines, monitors, vibratory devices, suctioning, music), and anesthetic gases Personal protective shielding, use of ancillary shielding, and techniques that limit fluoroscopy xray tube output Instruments / Data collection Results Implications for future research Implications for future practice 19 referenced literature citations With the implementation of optimal radiation safety practices in the interventional radiation suite, To date, no study has stated in its conclusion that all fetal ill effects of radiation have a distinct threshold dose. To provide education and work strategies to support safe practice for the healthcare providers in the interventional radiology suite OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER Reference Source/ Type Purpose / Aim Souza, K. M., Braz, L. G., Nogueira, F. R., Souza, M. B., Bincoleto, L. F., Aun, A. G., Corrente, J. E., Carvalho, L. R., Braz, J., & Braz, M. G. (2016). Occupational exposure to anesthetics leads to genomic instability, cytotoxicity and proliferative changes. Mutation Research, 791792, 4248. https://doi.org/10.1016/j. mrfmmm.2016.09.002 Randomized controlled trial; Level III this study investigates for the first time whether occupational exposure to WAGs is associated with oxidative stress, DNA damage, inflammation, and transcriptional modulation in university hospital anesthesia providers as a means of achieving a better understanding of these events Sun, M., Xie, Z., Zhang, J., & Leng, Y. (2021). Mechanistic insight into sevoflurane-associated developmental neurotoxicity. Cell biology and toxicology, 10.1007/s10565-02109677-y. Advance online publication. Systematic Review; Level IV .. to discuss mechanisms by which sevofurane exposure during development may induce long-lasting undesirable effects on the brain 37 Population / Sample n=x n= 60 [30 controlled, 30 exposed] Variables Instruments / Data collection Results Implications for future research Implications for future practice Workplace air/ scavenging, lipid peroxidation, nitric oxide metabolites, lipophilic antioxidants, antioxidant status, DNA damage, relative telomere length, inflammatory markers, gene expression, Venous blood samples were collected and assessed using Shapiro-Wilk test; t test analysis and categorical variable chisquare test, gene expression analysis via Mann-Whitney; correlation analysis using Pearson or Spearman Continued efforts to investigate the biological effects and health outcomes of exposure to WAGs are warranted to better understand the possible toxic mechanisms associated with WAG exposure, including those related to genetic susceptibility and epigenetic patterns. Reductions in WAGs exposure and increased biomonitoring should be considered for all occupationally exposed professionals. n/a Sevoflurane exposure, neural cell death, neural cell damage, assembly and plasticity of the neural circuit, tau Review of 142 referenced citations No significant differences (p > .0025) between the groups were observed for any parameter evaluated. Under the conditions of the study, the findings suggest that occupational exposure to WAGs is not associated with oxidative stress or inflammation when evaluated in serum/plasma, with DNA damage evaluated in lymphocytes and leucocytes or with molecular modulation assessed in peripheral blood cells in university anesthesia providers. The developing brain may be uniquely vulnerable to anesthesia, pending further investigation More research is needed to further reveal the underlying mechanisms by which sevoflurane and other anesthetics can More advanced technologies and methods should be applied to determine the underlying mechanism(s) and guide prevention and treatment of sevoflurane induced neurotoxicity. OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER Reference Source/ Type Purpose / Aim Population / Sample n=x https://doi.org/10.1007/s1 0565-021-09677-y Szczesna, A., Grzelak, K., Bieniasz, M., KacperczykBartnik, J., DobrowolskaRedo, A., Bartnik, P., Zareba-Szczudlik, J., & Romejko-Wolniewicz, E. (2019). Pregnant surgeon assessment of potential harm to the woman and her unborn child. Ginekologia Polska, 90(8), 470474. https://doi.org/10.5603/G P.2019.0081 Descriptive Study; VI to analyze the risks and consequences of working in the operating theatre during pregnancy n/a Varughese, S., & Ahmed, R. (2021). Environmental and occupational considerations of anesthesia: A narrative review and update. Anesthesia and Analgesia, 133(4), 826835. https://doi.org/10.1213/A NE.0000000000005504 Narrative Review; Level VI to summarize the current understand of the environmental and occupational exposure aspects of volatile anesthetic gases n/a Evidence from 13 referenced articles, with 80 referenced citations 38 Variables phosphorylatio n, and neuroendocrin e effects Laws and regulations, risk factors for gravid or lactating women, consequences of occupational exposure, prevention or lack thereof Environmental release and potential impact of volatile anesthetics, occupational exposure and potential impact of VAs, governmental exposure limits, impact Instruments / Data collection Results Implications for future research Implications for future practice induce developmental neurotoxicity. Review of 33 referenced citations PubMed literature search The unpredictability of this occupation, prolonged hours and stress associated with work can all affect the future mother and her child. The available research on potential risks for pregnant women performing surgical activities named such consequences as premature birth, miscarriage, fetal growth retardation, hypertensive disorders and infertility. Inhaled anesthetics contribute to GHG emissions, although their contributions are lower than those of other human produced substances. Volatile agents may pose a potential health risk Further research is needed for evidence-based guidelines for pregnant surgeons on how long and to which extent they should work to minimize risk of pregnancy complications The key is to maintain balance between limiting the likelihood of pregnancy complications and respecting womens voluntary wish to continue professional development Further research needed to understand longterm impacts and occupational exposure risk and outcomes associated with such exposure, and an increased focus on education and awareness Measures to reduce occupational exposure and environmental impact of inhaled anesthetics include efficient ventilation and scavenging system, monitoring airborne concentrations of waste gases to maintain below recommended OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER Reference Source/ Type Purpose / Aim Population / Sample n=x 39 Variables Instruments / Data collection of Waste Anesthesia Gas regulations, total intravenous anesthesia Wang, R. R., Kumar, A. H., Tanaka, P., & Macario, A. (2017). Occupational Radiation Exposure of Anesthesia Providers: A Summary of Key Learning Points and Resident-Led Radiation Safety Projects. Seminars in cardiothoracic and vascular anesthesia, 21(2), 165171. https://doi.org/10.1177/10 89253217692110 Descriptive Review; Level VI to summarize the key learning points for radiation safety related to basic physical principles, effects of ionizing radiation, radiation exposure measurement, occupational dose limits, radiation and pregnancy, sources of radiation exposure, factors affecting occupational exposure such as positioning and n= 57 key learning points: basic physical principles, effects of ionizing radiation, radiation exposure measurement, occupational dose limits, considerations during pregnancy, sources of exposure, factors affecting Review of 26 literature references; opt-in dosimeter study n=41 anesthesia residents Results Implications for future research Implications for future practice to operating-room personnel if not properly managed and scavenged among individuals, institutions, and governments to mitigate environmental and occupational health footprint associated with global use of volatile anesthetics. limits, ensuring anesthesia equipment is maintained without leaks, avoiding desflurane and N2O if possible and using appropriate FGF rates. TIVA may be an alternative to inhaled anesthetics due to decreased risks from occupational exposure, but agents such as propofol must be disposed of appropriately. Anesthesia providers are frequently exposed to radiation during routine patient care in the operating room and remote anesthetizing locations. Our quality improvement project involving resident exposure and published studies suggest that occupational radiation doses are generally well below the recommended threshold. Further dosimeter studies that meet the federal regulatory definition of research should be conducted Continued education and awareness of the risks, improvements in radiation shielding, and increasing distance from the source of ionizing radiation will reduce exposure and potential for associated sequelae OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER Reference Source/ Type Purpose / Aim shielding, and monitoring Population / Sample n=x 40 Variables occupational exposure such as positioning and shielding, and monitoring. Instruments / Data collection Results Implications for future research Implications for future practice OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER 41 Appendix B AHRQ Knowledge Transfer Framework (White et al., 2016) Appendix C Strengths, Weaknesses, Opportunities, & Threats Strengths Need for comprehensive literature review Unique project; potential to draw participants Project creator passionate about knowledge transfer on topic Use of technology for engagement, surveying, and analysis Public platform Aesthetically and professionally notable Capable of reaching large sample size Decreases resource expenditure from project creator for media production Weaknesses Topic and project title target small subset of the population Limited current research with direct focus on target group Participation dependent on voluntary interest Backup plan for information dissemination Less attractive Decreased likelihood of large sample size Aesthetically dependent on the limited media skills of the project creator SWOT Opportunities Threats Possibility of large sample size Potential to make positive impact on providers to consider the safety of pregnant anesthesia personnel Encourage facilities to publish practice guidelines and standardize care Refusal of participation Completion of course matter dependent on individual partcipants' timeline Project team geographically located across three U.S. time zones Initiation of implementation dependent on IRB approval OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER 42 Appendix D Pre-Assessment Survey Pre-Assessment Please select your age bracket: 20-29 30-39 40-49 > 50 Please select the gender in which you most identify: Male Female Non-binary / non-conforming Prefer not to say Other gender not listed How many years have you been learning and/or practicing anesthesia: 1 2 3 5 or more 10 or more How confident are you in your knowledge of the environmental risks of delivering anesthesia? Extremely confident Somewhat confident Neither confident nor unconfident Somewhat unconfident Extremely unconfident How confident are you in your knowledge of the occupational risks for a pregnant anesthesia provider? Extremely confident Somewhat confident Neither confident nor unconfident Somewhat unconfident Extremely unconfident An anesthesia colleague confides in you that she is newly pregnant. How confident would you feel providing her with some recommended safety considerations for her day-to-day in the workplace? Extremely confident Somewhat confident Neither confident nor unconfident Somewhat unconfident Extremely unconfident How applicable do you feel this information regarding occupational considerations for the pregnant anesthesia provider is for your role as a Doctor of Nursing Practice in Nurse Anesthesia? Extremely useful Very useful Moderately useful Slightly useful Not at all useful OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER Appendix E Post-Assessment Free-Text Responses Post-Assessment: What did you find most beneficial from this course? "I used to think only volatiles where hazardous to the fetus, I didn't realize how many elements exist in the OR that threaten fetal and parturient health" "Learning that even outside of anesthesia that there are many hazards in the OR environment and how to mitigate those hazards for myself and all the OR staff" "Interesting and succinct data for all providers, including parturients" "Turning down FGF instead of turning off vaporizer before intubating" "There were a couple of different exposure risks I hadn't considered prior to the course such as the MMA amount within the OR air. This was a good review and reminder of many of the exposures and risks we face as anesthesia providers." "Learning how to properly fill vaporizers" "The actual ppm of MMA that can be released into the OR during a hip case was alarming. measures we can take to protect ourselves or others from various hazards in the OR" "All the data in this module was extremely beneficial" "I appreciated the review of environment exposures. Cement and gas is often discussed, but I had no idea about the cautery!" 43 OCCUPATIONAL HAZARDS: THE PREGNANT ANESTHESIA PROVIDER 44 Appendix F Graph Depicting Mean Confidence Levels of Pre-Assessment vs. Post-Assessment PREASSESSMENT VS. POSTASSESSMENT BY CONFIDENCE LEVEL 4.66 4.09 4.24 4.24 1.81 2.43 3.06 MEAN CONFIDENCE LEVEL PostAssessment 4.28 PreAssessment ENVIRONMENTAL RISKS ENVIRONMENTAL RISKS FOR ANESTHESIA FOR PREGNANT PERSONNEL ANESTHESIA PERSONNEL PROVIDING USEFULNESS OF TOPIC RECOMMENDATIONS INFORMATION FOR PREGNANT ANESTHESIA PERSONNEL RossetterFinalManuscript Final Audit Report Created: 2023-04-22 By: Tess Rossetter (tkromar195@marian.edu) Status: Signed Transaction ID: CBJCHBCAABAA_rtsRaPgJgjrHFW49gk2oG84F-BueA3U 2023-04-23 "RossetterFinalManuscript" History Document created by Tess Rossetter (tkromar195@marian.edu) 2023-04-22 - 2:26:33 PM GMT Document emailed to lranalli@marian.edu for signature 2023-04-22 - 2:27:44 PM GMT Email viewed by lranalli@marian.edu 2023-04-23 - 4:46:45 AM GMT Signer lranalli@marian.edu entered name at signing as Lee Ranalli, DNP, CRNA 2023-04-23 - 4:47:05 AM GMT Document e-signed by Lee Ranalli, DNP, CRNA (lranalli@marian.edu) Signature Date: 2023-04-23 - 4:47:07 AM GMT - Time Source: server Agreement completed. 2023-04-23 - 4:47:07 AM GMT Names and email addresses are entered into the Acrobat Sign service by Acrobat Sign users and are unverified unless otherwise noted.  ...

... SUBSTANCE USE DISORDER EDUCATION 1 Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2023 Educating SRNAs on Substance Use Disorder Prevalence, Risk, and Prevention Kursten R. Smith Marian University Leighton School of Nursing Chair: Lee Ranalli, DNP, CRNA _________________________ (Signature) Committee Member(s): Gregory Yant, MSN, CRNA _________________________ (Signature) Date of Submission: October 30th, 2022 SUBSTANCE USE DISORDER EDUCATION 2 Table of Contents Dedication4 Acknowledgments............................................................................................................................5 Abstract............................................................................................................................................6 Introduction .....................................................................................................................................7 Background .........................................................................................................................7 Problem Statement...............................................................................................................8 Gap Analysis........................................................................................................................9 Review of the Literature .................................................................................................................9 Literature Review Conclusion ..........................................................................................14 Conceptual Framework..................................................................................................................15 Goals, Objectives, and SWOT Analysis....................................................................................17 Project Design............18 Project Site and Sample ....................................................................................................18 Methods.............................................................................................................................18 Measurement Instrument ..................................................................................................19 Data Collection .................................................................................................................19 Data Evaluation......20 Ethical Considerations ......................................................................................................20 Analysis..............................................................................................................................20 Results............................................................................................................................................20 Summary ...........................................................................................................................23 Discussion .....................................................................................................................................23 Conclusion ....................................................................................................................................24 References......................................................................................................................................25 SUBSTANCE USE DISORDER EDUCATION Appendices.....................................................................................................................................29 Appendix A- PRISMA Table.....29 Appendix B- Literature Review Matrix ............................................................................30 Appendix C- SWOT Analysis...............................................................................37 Appendix D- Gant Timeline..............................................................38 Appendix E- Implied Consent.......................................................................39 Appendix F- Demographic Questionnaire/Knowledge Assessment Pretest & Post-test...40 Appendix G- Outline for Online Learning Module Education..........................................42 Appendix H- Kotters 8-Step Model of Change ...............................................................43 Appendix I- IRB Exemption Form....................................................................................44 Appendix J- Tables............................................................................................................45 3 SUBSTANCE USE DISORDER EDUCATION 4 Dedication This project is dedicated to all providers directly and indirectly impacted by substance use disorder (SUD) within the anesthesia profession. Traditionally this has been a controversial and taboo topic with underpinnings of mental health components that many providers prefer not to acknowledge. It is my hope that this research and accompanying information bring awareness and thoughtful change to anesthesia students perception of SUD. SUBSTANCE USE DISORDER EDUCATION 5 Acknowledgment I would like to acknowledge my project chair Dr. Ranalli for mentoring and encouraging me to pursue this topic for my project. His passion for this topic has shown through during our many discussions regarding SUD, education, and clinical practice. I would also like to thank my project mentor and committee member Mr. Yant for allowing me to include my project in his course curriculum. I am thankful that his passion for SUD recognition and prevention in anesthesia providers matches my own passion for this topic. SUBSTANCE USE DISORDER EDUCATION 6 Abstract Background and Review of Literature: Substance use disorder (SUD) is increasing nationwide, including within the anesthesia provider community. Anesthesia providers are shown to be at an increased risk of developing SUD compared to other healthcare professionals. Detrimental effects on those under the care of an anesthesia provider with SUD can, and do, occur. Current Council of Accreditation (COA) guidelines necessitate the inclusion of limited SUD teaching to student registered nurse anesthetists (SRNAs), but professional organizations, such as the American Association of Nurse Anesthesiologists (AANA), recommend the provision of additional information. Purpose: This DNP projects purpose was to provide education regarding SUD in anesthesia personnel via a virtual module to second-year SRNAs to increase prior knowledge and awareness on the topic. Methods: This project utilized a quasi-experimental design and was evaluated by an expertcertified pretest/post-test questionnaire. A convenience sample was obtained using currently enrolled second-year SRNAs at Marian University in Indianapolis, Indiana. Results: Thirty-two SRNAs participated in the project and 22 participants completed all questions in the pretest and post-test for a 69% completion rate. Pretest responses were matched with post-test responses. Using a paired t-test, the results show the provided education module significantly increased prior knowledge of SUD in the anesthesia profession (p= <0.001). Participants gained an average of 1.87 points (95% CI) on post-test scores after completing the module. Implications/Conclusion: The introduction of an in-depth SUD education module increased SRNAs knowledge of SUD in the anesthesia profession. Enhancing SUD knowledge related to incidence, risk factors, warning signs, and prevention in anesthesia providers in training is recommended by experts to prevent providers illicit use of substances, which can harm both providers and patients (Bell et al., 1999 & Booth et al., 2002). Further, increased awareness about SUD among anesthesia providers and the provision of available resources is beneficial to assist those affected by SUD. Keywords: CRNA, drug diversion, medication diversion, anesthe*, substance abuse, drug dependence, diversion SUBSTANCE USE DISORDER EDUCATION Educating SRNAs on Substance Use Disorder Prevalence, Risk, and Prevention This project is submitted to Marian University Leighton School of Nursing faculty as partial fulfillment of degree requirements for the Doctor of Nursing Practice, Certified Registered Nurse Anesthetist track. Substance use disorder is increasing in prevalence nationwide. One of every 12 Indiana residents is at risk of developing SUD (Indiana University Health, 2021). Evidence shows an increased incidence of SUD and diversion in the anesthesia profession relative to other medical professions and the general population. Substance use disorder is a long-standing problem affecting anesthesia professionals that has direct negative impacts on providers and patients, along with many other undesirable sequelae. Studies have shown the first years after provider immersion in the workforce are the most vulnerable to SUD (Alexander et al., 2000, Warner et al., 2013, & Wilson et al., 2008). Experts recommend better prevention support, including the use of high-quality, mandatory education. The purpose of this project was to provide education via a virtual module to second-year SRNAs. Background There are few studies involved in discovering the incidence of SUD and controlled substance misuse among anesthesia providers, including physicians, nurses, and students. Due to the limited literature, incidence ranges are broad. Bell et al. (1999) conducted the landmark comparative study of SUD in anesthesia providers and found a prevalence rate of 9.8% for controlled substance misuse in certified registered nurse anesthetists (CRNAs). Booth et al. (2002) found the prevalence to be 1.6% among medical residents and 1.0% among medical doctor (MD) anesthesia faculty throughout the study period of 12 years. A cross-sectional retrospective study by Bozimowski et al. (2014) found the 5-year prevalence of substance abuse 7 SUBSTANCE USE DISORDER EDUCATION among SRNAs to be 0.65%. Warner et al. (2013) and Bell et al. (1999) found a higher prevalence of diversion and substance abuse among males in MD and CRNA groups, with 2.16 incidents per 1000 resident hours and 1 of every 10 male providers misusing controlled substances, respectively. Alexander et al. (2000), Warner et al. (2013), and Wilson et al. (2008) found that newly licensed anesthesia providers were more likely to develop a SUD within the first 4 to 5 years following graduation. A review of this evidence supports the notion this is a vulnerable period for providers. One recommendation to decrease the incidence of SUD is to provide high-quality formal education on SUD that may better prepare clinicians entering the anesthesia profession. Studies by Bell et al. (1999) and Booth et al. (2002) show that mandatory formal education for SRNAs in this area is lacking and should be considered an important concept in preparation for entering the profession. Booth et al. (2002) found that only 47% of programs utilized a formal educational session related to SUD, and 31% of these programs did not mandate learners to complete the training. To provide education in this area, students should be offered education highlighting incidence, risk factors, recognition, and prevention. Problem Statement Second-year SRNAs at Marian University receive education in the form of discussions and article reviews related to substances of abuse in anesthesia professionals, along with issues surrounding reentry into practice after treatment. Although these exercises help bring general awareness to SUD, the adequate portrayal of the increased risks and grave consequences of SUD in the anesthesia profession may be lacking. Upon consent to participate, second-year SRNAs were required to complete a pretest followed by an online course module highlighting areas of SUD prevalence, risk factors, recognition, prevention techniques, and resources. Participants 8 SUBSTANCE USE DISORDER EDUCATION were then administered a post-test after completion of the modules to determine the efficacy of instruction. Gap Analysis Although the current instruction was mandatory at the project site, it did not include a comprehensive overview, in-depth analysis of SUD, or align with recommended content, according to the American Association of Nurse Anesthesiology (AANA) (American Association of Nurse Anesthesiology, 2021). Clark (1994), in partnership with the AANA, completed an extensive study of best practices regarding the implementation of SUD into the content curriculum of anesthesia schools. The AANA accepted and promoted these recommendations centering on an array of detailed information about SUD risk, diagnosis, incidence, prevention, and treatment specific to anesthesia providers. Standards set by the Council of Accreditation (COA) for CRNAs including wellness strategies, detection of SUD, and reentry into the workplace after SUD treatment are present in the current curriculum (Council on Accreditation, 2015). The projects online educational module addressed the AANA recommendation deficits and provided information in accordance with the most recent literature. Review of Literature A review of the literature was completed to investigate incidence rates of SUD in anesthesia providers. Addiction is a widely prevalent problem in the United States today with about 21 million Americans suffering from at least one addictive substance (Yerby, 2019). Those working in the medical community are not spared from the risk of developing SUD. It is estimated that 15.4% of healthcare providers have SUD (Bryson, 2020). Anesthesia providers, including physician anesthesiologists, CRNAs, and trainees, are a subset of medical providers 9 SUBSTANCE USE DISORDER EDUCATION 10 that, due to a variety of factors, have a propensity for an increased rate of controlled substance diversion and subsequent abuse. Factors, although not all-inclusive, that may account for the increase in diversion rates and SUD in anesthesia providers are readily available potential drugs of abuse and the ease of access to highly potent medications, specialized knowledge of widely abused drugs that most other specialties in the medical community do not come in direct contact with, and repeatedly visualizing the effects on patients (Mayall, 2016). Drug diversion, specifically in the anesthesia community, is a trending concern that impacts many critical areas such as patient safety, provider safety and wellness, community health related to viral outbreaks, medication and healthcare costs, trust in the profession, and other aspects. It is essential to have knowledge related to the prevalence of these issues to appreciate the full scope of the adverse effects related to SUD and drug diversion in the anesthesia community. Studies that outline factors leading to the tendency to divert and use controlled substances, the resulting problems associated with drug diversion and professional performance while under the influence, and the return to the anesthesia profession have been performed. There is a gap in the literature as to the prevalence of drug diversion and subsequent abuse in the anesthesia population. This led to the following PICO question to be developed: In CRNA students, does the implementation of an education module increase the knowledge of substance use disorder in the anesthesia community? Literature Review Methods This review had a primary focus to include articles with incidence rates of drug diversion in anesthesia professionals including physician anesthesiologists, CRNAs, and students in respective professions published between 1992 and 2020. Inclusion criteria consisted of primary SUBSTANCE USE DISORDER EDUCATION 11 research, written in the English language, peer-reviewed, and human subjects. The search was conducted in PubMed with Search Mode: BOOLEAN/Phrase. Primary search terms used include CRNA OR anesthe*, drug diversion OR opioid diversion. Using the BOOLEAN phrase CRNA OR anesthe* AND drug diversion OR opioid diversion, 112 results were identified. In addition to these results, 5 articles were identified from other sources. Studies that were excluded were populations outside the anesthesia provider role, studies focused on risk factors associated with drug diversion, and studies focused on the prevention of drug diversion within the anesthesia provider role or other populations. After exclusion criteria were applied, 10 articles met the criteria for inclusion in this review. The literature review PRISMA diagram and matrix can be seen in Appendix A and B, respectively. This search was completed in October 2020. Literature Review Results Research Samples Seven of the reviewed studies focused solely on CRNA or physician anesthesiologist populations, while 3 combined population groups. Booth et al. (2002) found the prevalence to be 1.0% among MD faculty and 1.6% among residents throughout the study period. Warner et al. (2013) and Bell et al. (1999) found a higher prevalence of diversion and substance abuse among males in MD and CRNA groups, with 2.16 incidents per 1000 resident hours and 1 of every 10 providers misusing controlled substances, respectively. Alexander et al. (2000) conducted research focused on accidental poisonings and suicide rates of anesthesiologists compared to internists. It was found that male anesthesiologists were 1.4 times more likely to die of drugrelated causes than their internist peers (Alexander et al., 2000). Timing of Diversion and Abuse SUBSTANCE USE DISORDER EDUCATION 12 Alexander et al. (2000), Warner et al. (2013), and Wilson et al. (2008) collected data that concluded the highest prevalence of controlled substance diversion and abuse occurred within the first 4-5 years of training in an anesthesia program in both MD and CRNA groups. Bell et al. (1999) concluded the greatest prevalence in the CRNA group took place 6-10 years after the completion of training. Based on these data collections, it is recommended to focus on these time frames for additional vigilance, education, provision of resources, and risk mitigation strategies. Drug of Choice An alarming trend was noted in several studies regarding the preferred drug of choice throughout the years. The first documented propofol diversion and, more profound, dependence data, was reported by Follette & Farley (1992). Bell et al. (1999) found an increase in the use of benzodiazepines, inhalational, and propofol in the CRNA group starting during the mid-1990s, and Wischmeyer et al. (2007) discovered a propofol use incidence of 0.1% over 10 years between 1995 to 2005 in both MD and CRNA groups. In 2008, Wilson et al. published the first inhalational diversion and abuse study, using trainees of anesthesia programs, consultants, anesthesia technicians, and other operating room personnel. Results concluded consultants, trainees, and CRNAs were most at risk for abusing inhalational agents. It is noted by Bell et al. (1999), Wilson et al. (2008), and Wischmeyer et al. (2007) that, due to the highly detrimental method of action of propofol, benzodiazepines, and inhalational anesthetics, providers were often only found to have SUD once they were deceased. Discussion and Implications for Practice, Education, and Research Current research recognizes a lack of data related to the prevalence of controlled substance and anesthetic agent diversion with subsequent abuse rates in the United States and SUBSTANCE USE DISORDER EDUCATION 13 worldwide by anesthesia providers. It is clear from the evidence provided these issues are a growing concern in the anesthesia community. Booth et al. (2002), Kintz et al. (2005), and Warner et al. (2013) cite a lack of data on anesthesiologists and CRNAs, along with their respective counterparts, as a limitation regarding comparable data on diversion and substance use. Due to the lack of longitudinal data, the rate and drug of choice trends are difficult to appreciate in both MD and CRNA groups. Another limitation is the inclusion of other substances of abuse, including alcohol, which may be a factor influencing data conclusions. Alcohol is not an agent prone to diversion in the anesthesia community, but it is included in some data as one of abuse. Alexander et al. (2000) state the measures to prevent controlled and anesthetic substance diversion and abuse are inadequate. A change in current practice in anesthesia training programs and clinical areas should be instituted to slow and reverse the upward trend of diversion and SUD in the anesthesia community. Education plays a vital role in alerting trainees, providers, and peers of the prevalence of drug diversion and abuse in the profession. Booth et al. (2002) found that only 47% of programs utilized a formal educational session related to SUD, and 31% of these programs did not mandate learners to complete the training. Bell et al. (1999) and Booth et al. (2002) concluded education is lacking in these topics and speculate increasing educational requirements could benefit both trainees and clinicians. More research needs to be conducted to determine the relationship between the amount of education provided and completed related to positive diversion and abuse. It is theorized a variety of risk factors may put anesthesia providers at increased risk for diversion and developing SUD. One prevention method that should be implemented into practice is prescreening using rigorous risk assessment strategies upon entry into training programs and SUBSTANCE USE DISORDER EDUCATION 14 clinical areas. Bozimowski et al. (2014) and Collins et al. (2005) note that pre-enrollment screenings are inadequate in the current state. Collins et al. (2005) suggest the use of a preenrollment risk assessment tool as part of a standardized evaluation before entering anesthesia training. Policies should promote periodic drug screens throughout training and while in practice. Depending on the drug of choice, urine, blood, and hair toxicology can be examined to determine levels in the body (Follette & Farley, 1992; Kintz et al., 2005; Wischmeyer et al., 2007). It is recommended that future research focus on prevalence studies within the anesthesia profession, including training programs and clinical positions (Kintz et al., 2005; Warner et al., 2013). Longitudinal data in areas of diversion and SUD, along with cofactors and outcomes, would be of help to determine the overall prevalence, long-term effects of SUD, and further areas that may be improved upon (Bell et al., 1999; Booth et al., 2002). Although Collins et al. (2005) recommend the use of a pre-enrollment risk assessment tool in practice, there is limited research concerning risk factors, and no available tool has been developed thus far. Literature Review Conclusion The available research acknowledges an upward trend in substance diversion and abuse with a worrisome trend toward propofol and inhalational drugs. Due to the devastating outcomes associated with improper use of the medications, it is recommended to increase the preenrollment risk factor and toxicology screening before admittance into an anesthesia training program, continue screening through the completion of training programs, and into professional provider clinical areas following employment. It is further recommended to ensure education regarding SUD is available, encouraged, and mandatory for anesthesia residents of all types during training. SUBSTANCE USE DISORDER EDUCATION 15 Conceptual Framework This project's conceptual framework was derived from Kotters Model of Change. In 1996 John Kotter, author of Leading Change, introduced the 8-step Model of Change after researching and interviewing staff at 100 organizations in the process of undergoing a change. Since the original work was published, Kotter further expounded on the topic and subsequently created an online learning platform. According to Kotters 2021 revised online work, the 8 steps include creating urgency, building a strong guiding team, developing a vision, communicating for buy-in, empowering action, creating short-term wins, consolidating gains, and sustaining change. Each step has a particular focus and should be followed to encourage the effective use of the model. The first step in Kotters Model of Change, creating urgency, ensures the target population senses the need for change. Without realizing the need, people will not own the challenge of creating a change. Step 2 is to create a strong, influential team to guide the change process. A transformational leadership style to empower the change group and promote a positive environment in which to encourage the change process is beneficial (Marshal & Broome, 2017). Creating a strategic plan to guide a clear vision is step 3. A clear, concise vision is key as the project group is more likely to feel ownership and buy into the project (Appelbaum et al., 2012). A strategic plan involves determining goals and objectives, developing a timeline of events, and creating an evaluation plan (Kotter, 2021). Step 4 of Kotters Model of Change is appealing for buy-in to the group by communicating the importance and impacts of the project. Communication is critical throughout the project, especially during the appeal for change agents, and can positively or negatively affect outcomes. If effectively performed, this step reduces uncertainty and ambiguity while steering the project toward positive outcomes (Appelbaum et SUBSTANCE USE DISORDER EDUCATION 16 al., 2012). Empowering individuals to jump into action is step 5. This step acts to reduce obstacles that may hinder change agents during the process. Communication continues to be critical in this step as open discussions about obstacles, solutions, and follow-through are generally all that is required to promote forward momentum. Step number 6 involves creating short-term wins to validate that the efforts of participants are paying off. Visualizing these wins helps ensure sustainability in participants, along with a renewed effort to continue endeavors of change (Appelbaum et al., 2012). Consolidating gains in step 7 refers to the process of taking each short-term win into account to prove the efficacy of the desired change and then using this force to promote the forward energy of the project. This step helps sustain continuous improvement during the project by encouraging supporters and converting cynics into advocates (Kotter, 2021 & Appelbaum et al., 2012). The final step, step 8, endeavors to anchor the change in the culture of the organization. This step relates project successes to positively correlated results, maintains visibility in the environment, and ensures continued support by organizational leaders. Following Kotters 8-step Model of Change provides a solid foundation and direction for the change outcome sought by this project. An urgency to present information and encourage perception shift was acknowledged by instructors and recognized by participants once the module is accessed. This projects team provided a strong leadership group that facilitated the target sites structure change as well as individual participants approach to SUD. The project's vision was evident in the problem statement and specific objectives. Project leadership ensured open communication was offered to support participant buy-in. Action was empowered in multiple ways: providing transformational leadership style, open communication, and empowering participants to create change within as an individual and throughout the anesthesia SUBSTANCE USE DISORDER EDUCATION 17 community. The educational module had built-in reflection points to promote short-term wins for participants. Upon completion of the module, short-term wins were recognized so individuals felt confident in the knowledge and benefits of change. Finally, change sustainment occurs at an individual level due to increased SUD risk assessment knowledge and confidence in abilities to identify SUD in peers. Change at the program site is intended to be sustained as the use of this project and educational module will continue to be available to course instructors after project completion. Goals, Objectives, and SWOT Analysis This DNP project aimed to determine if providing second-year SRNAs with education regarding SUD in anesthesia personnel increased prior knowledge on the topic. The project's specific objectives were to: 1. enhance second-year SRNAs' knowledge of SUD incidence in the anesthesia profession by 25% 2. enhance knowledge of risk factors by 25% 3. provide signs to watch for in peers suspected of misusing 4. discuss prevention measures 5. provide resources for individuals affected by SUD A SWOT analysis was performed for this DNP project. Strengths included in-depth information dedicated to SUD in an easily accessible and flexible Canvas module and a strong project team targeting participants at Marian University. Weaknesses included a potentially increased time commitment for the project module versus merely completing work in the previously designed class structure. An opportunity for this project is the retention of information that the target audience is likely to achieve due to being in a learning mindset during the SUBSTANCE USE DISORDER EDUCATION 18 completion of graduate coursework. Other opportunities include the expounding on the potential limited exposure to SUD by second-year SRNAs and the creation of a Wellness Committee, unrelated to the project, at the target site, which may reinforce the importance of the project. Threats to this project include participant stress and information overload related to other coursework, the requirement of online learning adaptability, and technology issues with the internet or Canvas infrastructure. Project Design Project Site and Sample The site for this project was Marian University. The projects educational intervention was inserted into an existing course, Nursing 615 Anesthesia Seminar 1, which was taught by this projects faculty mentor Greg Yant MSN, CRNA. Historically, this course introduced provider well-being and chemical dependency in anesthesia providers. This project gathered a convenience sample of 32 second-year CRNA students enrolled in courses on track for completing a 3-year Doctor of Nursing Practice degree. Students were in the fourth of 9 total semesters, enrolled in Nursing 615 Anesthesia Seminar 1, and had completed all prerequisites. Students not meeting these criteria were excluded from data collection. Methods Before developing this quasi-experimental project, an exemption was obtained from Marian University's Institutional Review Board (IRB), after which the educational curriculum module was developed. This qualitative project utilized a pretest/post-test design for an educational intervention in which the entire cohort was invited to participate over a 4-week SUBSTANCE USE DISORDER EDUCATION 19 period. The curriculum was offered at the beginning of the semester to reduce bias brought on by other coursework related to SUD. The course curriculum was developed utilizing the most up-todate evidence-based research on all 5 module topics: prevalence, risk factors, signs of SUD, prevention, and resources for SUD victims. The pretest was required to be completed before advancement through the modules. Pretest scores were matched with post-test scores upon completion of data collection. Measurement Instrument A knowledge assessment pretest/post-test measurement instrument was administered to participants in this project. A set of demographic questions was administered during the pretest survey to discover more information on the population. The demographic questions included age range, sex, and years of experience working as a registered nurse. Semester or year within the nurse anesthesia program was not included as all invited participants were from the same cohort. The pretest and post-test consisted of the same content knowledge questions and included 4 single answer questions and 3 multiple answer questions for a total of 7 questions. This project's chair and expert in the anesthesia field, Dr. Ranalli, established the validity of the content in the pretest/post-test and material in the educational module. See Appendix F for the pretest/post-test and Appendix G for an outline of the course material. Data Collection The education module included an external link to Qualtrics surveys for the pretest, including demographic information, as well as for the post-test once the module was completed. This DNP student collected all data upon completion of the 4-week period in which the module was available for project participation. All responses remained confidential and anonymous. SUBSTANCE USE DISORDER EDUCATION 20 Data Evaluation The results gathered through Qualtrics from the pretests were compared to the results of post-tests using a paired t-Test statistical analysis conducted through SPSS software. The projects results were disseminated to participants and available to the public upon project completion. Ethical Considerations Approval for exempt status from the IRB was obtained before initiating this DNP project. Participation in this project was voluntary, as noted in the consent section of the demographic and pretest survey, and did not affect the final grade for this course. Confidentiality and anonymity were maintained during and after the project. The anonymous results were only available to this DNP student via a password-protected computer. Data was deleted upon completion of project dissemination. There were no foreseen risks to participation in this project. Analysis Data were analyzed using descriptive statistics. Variability, frequency, and central tendency measures were included in the analysis. Frequency tables were utilized for all categorical and numerical data points. IBM SPSS Statistics (Version 27) was used to perform all statistical analyses. Results A total of 32 second-year students were eligible and enrolled in this project. All participants enrolled completed at least partial work in the project. Upon completion, 22 functional data points were obtained (n= 22). Of the total respondents, 7 participants neglected to SUBSTANCE USE DISORDER EDUCATION 21 complete all information for the pretest, and 5 neglected to complete all information in the posttest for a 69% completion rate. Most respondents (59.1%) were female, were between 22-29 years of age (45.5%), and have practiced as registered nurses for less than 5 years (50%). Please see Table 1 below to view survey respondent demographics. Table 1 Demographics and Characteristics of All Survey Respondents Characteristics Gender Male Female Age 22-29 30-39 40-49 Experience as a Registered Nurse (years) <5 6-10 11-15 16-20 *Note, n= 22 n % 9 13 40.9 59.1 10 9 3 45.5 40.9 13.6 11 8 2 1 50 36.4 9.1 4.5 Knowledge Assessment Pretest and Post-Test Results Upon completion of demographic characteristic questions in the pretest, students were asked 7 questions about SUD content to ascertain baseline SUD knowledge. Please see Table 2 below for questions, correct answers, and correctly answered percentages for the pretest and post-test. The mean pretest knowledge total score was 3.18, while the mean post-test total score was 5.05. Post-test final scores reveal a significant increase averaging 1.87 points (95% CI, t= 5.23 p <0.001) in SUD knowledge after completing the course content. Table 3, seen below and in Appendix I, illustrates statistical analysis performed using SPSS software. The effect size is SUBSTANCE USE DISORDER EDUCATION 22 1.58, which means the post-test scores are more than one standard deviation better than the pretest total scores. This correlates to a high effect size. Table 2 Results of the Survey Question What is the prevalence of SUD in healthcare professionals? What is the prevalence of SUD in anesthesia professionals? What are the most commonly abused anesthetic agents among anesthesia professionals? (pick 2) What are risk factors associated with increased incidence of SUD in anesthesia personnel? (pick 3) What are signs of SUD in anesthesia providers? (pick 3) Pretest No. (%) Correct Post-test No. (%) Correct 15% 59.1 86.4 Up to 20% 18.2 77.3 Opioids, Propofol 36.4 90.9 13.6 36.4 59.1 86.4 Correct Answer Frequent visualized efficacy of anesthetics, History of trauma, Family history of substance abuse Behavior changes, Personal appearance decline, Difficulty with concentration and memory Which of the following is NOT an evidence-based intervention to prevent SUD in anesthesia personnel? For-cause drug testing 27.3 45.5 What resources are available to assist victims of SUD? All of the above 100 95.5 SUBSTANCE USE DISORDER EDUCATION Table 3 Statistical Analysis: Paired Samples Test Paired Samples Test Paired Differences 95% Confidence Interval of the Std. Difference Std. Error Mean Deviation Mean Lower Upper t Pair 1 Pretest 1.670 .356 -2.604 -1.123 Score 1.864 5.233 Post-test Score 23 Significance OneTwoSided Sided df p p 21 <.001 <.001 Summary A total of 32 SRNAs participated in the pretest, course, and post-test, giving a completion rate of 100%. After eliminating participant data with incomplete information, a total of 22 participants (69%) provided usable data for this project. Overall, respondents had a statistically significant increase in the percentage answered correctly on most questions in the post-test with an increase of 1.87 points (95% CI, p< 0.001) on total scores. Discussion All anesthesia providers are directly or indirectly impacted by SUD in the provider community. The need for mandatory, quality information regarding SUD is recommended in anesthesia training, yet the majority of programs do not mandate this education (Booth et al., 2002). Data supports most anesthesia providers with SUD are newly licensed providers within SUBSTANCE USE DISORDER EDUCATION 24 the first 10 years of training completion, and the majority are discovered within the first 5 years (Alexander et al., 2000, Bell et al., 1999, Warner et al., 2013, and Wilson et al., 2008). Trainee awareness and education related to SUD in anesthesia providers have been recommended as one way to decrease detrimental impacts on providers and patients. This project aimed to increase SRNA knowledge of various aspects of anesthesia provider SUD by comparing baseline pretest knowledge to total scores after a virtual education course was completed. The goal to increase overall SUD knowledge and risk factors related to SUD by 25% upon the completion of the module was met and exceeded. Additional objectives of information provision associated with symptom recognition, prevention measures, and available resources were also met. Post-test scores following completion of the SUD educational module show an increase in knowledge of baseline levels in second-year Marian University SRNAs. Conclusion The findings of this project will help bridge the SRNA knowledge gap of anesthesia provider SUD by utilizing an educational module comprising SUD incidence, risk factors, warning signs, prevention, and resources. One recommended path anesthesia educators can take to prevent further increases in first-time use and relapse rates of anesthesia provider SUD is by raising awareness related to the higher risk and incidence of SUD in those completing training. This project demonstrates positive results of using a virtual format to accomplish this recommendation. Further recommendations discovered during this project include completing additional research into risk assessment strategies in perspective anesthesia trainees and the development of wellness strategies aimed toward SUD risk mitigation. SUBSTANCE USE DISORDER EDUCATION 25 References: Alexander, B. H., Checkoway, H., Nagahama, S. I., & Domino, K. B. (2000). Cause-specific mortality risks of anesthesiologists. Anesthesiology, 93(4), 922930. https://doi.org/10.1097/00000542-200010000-00008 American Association of Nurse Anesthesiology (2021). Addressing substance use disorder for anesthesia professionals: Position statement and policy considerations. Retrieved December 14, 2021, from https://www.aana.com/docs/default-source/practice-aana-comweb-documents-(all)/professional-practice-manual/addressing-substance-use-disorder-foranesthesia-professionals.pdf?sfvrsn=ff0049b1_10 Appelbaum, S. H., Habashy, S., Malo, J. L., & Shafiq, H. (2012). Back to the future: Revisiting Kotter's 1996 change model. Journal of Management Development, 31(8), 764782. https://doi.org/10.1108/02621711211253231 Bell, D.M., McDonough, J.P., Ellison, J.S., & Fitzhugh, E.C. (1999). Controlled drug misuse by Certified Registered Nurse Anesthetists. AANA Journal, 67(2), 133-40. Retrieved from https://pubmed.ncbi.nlm.nih.gov/10488287/ Booth, J., Grossman, D., Moore, J., Lineberger, C., Reynolds, J., Reves, J. G., & Sheffield, D. (2002). Substance abuse among physicians: A survey of academic anesthesiology programs. Anesthesia & Analgesia, 95, 1024-1030. https://doi.org/10.1213/00000539200210000-00043 SUBSTANCE USE DISORDER EDUCATION 26 Bozimowski, G., Groh, C., Rouen, P., & Dosch, M. (2014). The Prevalence and Patterns of Substance Abuse Among Nurse Anesthesia Students. AANA Journal, 82(4), 277283. Retrieved from https://web.s.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=0&sid=97ba5641-29a646ef-b220-99d1eabb6627%40redis Bryson, E. (2020). The impact of chemical dependency on health care professionals involved with the delivery of anesthesia. International Anesthesiology Clinics, 58(1), 45-49. http://doi.org/10.1097/AIA.0000000000000257 Clark, G. (1994). A model didactic and clinical substance abuse curriculum developed for schools of nurse anesthesia. Retrieved from https://www.aana.com/docs/defaultsource/wellness-aana.com-web-documents(all)/clark_model_substance_abuse_curriculum94fbd526731dff6ddbb37cff0000940c19.p df?sfvrsn=862c4bb1_2 Collins, G., McAllister, M., Jensen, M., & Gooden, T. (2005). Chemical dependency treatment outcomes of residents in anesthesiology: Results of a survey. Anesthesia & Analgesia, 101, 1457-1462. https://doi.org/10.1213/01.ANE.0000180837.78169.04 Council on Accreditation. (2015, January 23). Accreditation standards, policies and procedures, and guidelines. Standards For Accreditation of Nurse Anesthesia Programs: Practice Doctorate. Retrieved August 21, 2022, from https://www.coacrna.org/accreditation/accreditation-standards-policies-and-proceduresand-guidelines/ SUBSTANCE USE DISORDER EDUCATION 27 Follette, J., & Farley, W. (1992). Anesthesiologist Addicted to Propofol. Anesthesiology, 77(4), 817-818. https://doi.org/10.1097/00000542-199210000-00028 Indiana University Health. (2021). The crisis in Indiana. Addictions. Retrieved December 14, 2021, from https://addictions.iu.edu/understanding-crisis/crisis-in-indiana.html Kintz, P., Villain, M., Dumestre, V., & Cirimele, V. (2005). Evidence of addiction by anesthesiologists as documented by hair analysis. Forensic science international, 153(1), 8184. https://doi.org/10.1016/j.forsciint.2005.04.033 Kotter, J. (2021). The 8-step process for leading change. Kotter. Retrieved January 29, 2022, from https://www.kotterinc.com/8-step-process-for-leading-change/ Marshal, E.S. & Broome, M.E. (2017). Transformational leadership in nursing: From expert clinician to influential leader (2nd ed.). New York: Springer Publishing Company. Mayall, R.M. (2016) Substance abuse in anaesthetists. BJA Education, 16(7), 236 241. https://doi.org/10.1093/bjaed/mkv054 Warner, D. O., Berge, K., Sun, H., Harman, A., Hanson, A., & Schroeder, D. R. (2013). Substance use disorder among anesthesiology residents, 1975-2009. JAMA, 310(21), 22892296. https://doi.org/10.1001/jama.2013.281954 Wilson, J.E., Kiselanova, N., Stevens, Q., Lutz, R., Mandler, T., Tran, Z.V., & Wischmeyer, P.E. (2008). A survey of inhalational anaesthetic abuse in anaesthesia training programmes. Anaesthesia, 63(6), 616-20. https://doi.org/10.1111/j.1365-2044.2008.05444.x SUBSTANCE USE DISORDER EDUCATION Yerby, N. (2019, June). Addiction statistics. Addiction Statistics. Retrieved August 21, 2022, from https://www.addictioncenter.com/addiction/addiction-statistics/ 28 SUBSTANCE USE DISORDER EDUCATION 29 Appendix A From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097. doi:10.1371/journal.pmed1000097 SUBSTANCE USE DISORDER EDUCATION 30 Appendix B Reference Alexander, B. H., Checkoway, H., Nagahama, S. I., & Domino, K. B. (2000). Causespecific mortality risks of anesthesiologis ts. Anesthesiol ogy, 93(4), 922930. https://doi.org/ 10.1097/00000 54220001000000008 Researc h Design & Level of Evidenc e Case Control Purpose / Aim Population / Sample n=x Variable s Instruments / Data collection Results Implications for future research Implications for future practice The healthrelated effects of the operating room environme nt are unclear. N= 40,285 anesthesiol ogists n= 40,269 internists. All born before January 1, 1979 and graduated medical school by December 31, 1995 Specialty , age (decade of birth), gender, cause of death, citizenshi p status, race The data was compiled from the Physician Master File (PMF) maintained by the American Medical Association. Results yielded almost 3 times as many internists, therefore a stratified random sample was selected as a comparison group. Male anesthesiologists experienced a 34% excess risk of death from an accidental poisoning compared with the general population. Mortality rates resulting from suicide were 50% greater for anesthesiologists and the rate ratio for drug related suicide was more than double. All drug-related deaths rates for anesthesiologists were 2.79 times higher than in the internist group. HIVrelated deaths, and cerebrovascular disease were higher for anesthesiologists compared with internists. Rates of death were greatest in the first 5 years after graduation for both groups and gradually declined with increasing years of practice. Continued attention to drug misuse among anesthesia providers is warranted, although no specific direction is identified. Death rates by anesthesiologis ts continue to be elevated despite introduction of increased awareness and formal education regarding occupational hazards of drug abuse indicating current preventive measures are inadequate. SUBSTANCE USE DISORDER EDUCATION Bell, D.M., McDonough, J.P., Ellison, J.S., & Fitzhugh, E.C. (1999). Controlled drug misuse by Certified Registered Nurse Anesthetists. AANA Journal, 67(2), 133-40. Correlati onal study Booth, J., Grossman, D., Moore, J., Lineberger, C., Reynolds, J., Reves, J. G., & Sheffield, D. (2002). Substance abuse among physicians: A Compar ative Descript ive design The primary purpose of this study was to determine the prevalence of controlled drug misuase among actively practicing Certified Registered Nurse Anesthetist s (CRNAs). A second purpose was to determined variance in controlled drug misuse by the variables of age, sex, population and geographic area of residence, type of anesthesia position currently held, and number of years in anesthesia practice. In this study, we sought to examine whether there have been changes in the incidence of CS 31 N= 167 CRNAs with history or current use of controlled substances Age, years of practice, sex, type of controlle d substanc e Survey 167 CRNAs admitted history or current use of controlled substances and 62.9% were represented by males with 6-10 years of clinical practice. A chisquare test revealed a significant relationship between likelihood of misuse and variables of sex and number of years in anesthesia practice. 9.8% admitted to misuse (diversion from patient). Controlled drugs of choice have trended from opioids to inhalation agents, benzodiazepines, and propofol. Dissociative drugs, narcotic agonistantagonists, and barbiturates declined significantly. A longitudinal study to clearly delineate the issue of CRNA drug misuse with variables of illicit and uncontrolled drug use and misuseassociated behavior would be ideal. Strengthening education and preventionuse of this study as a needs assessment for CRNAs, educating SRNAs for potential occupational hazards for addictive behavior, creation of SRNA student support systems N = 133 residents with substance use disorder n= 34 faculty with substance Drug used, type/amo unt of formal drug abuse educatio n, method of Survey 133 of 8111 residents and 34 of 3555 faculty members in 123 anesthesiology programs nationwide were identified to have a substance abuse disorder. 18% died or Studies verifying regional and national data on controlled substance abuse in anesthesiologis ts are needed to verify this study results A valuable tool to help identify anesthesiologis t who are using controlled substances may be the addition of random drug SUBSTANCE USE DISORDER EDUCATION survey of academic anesthesiology programs. Anesthesia & Analgesia, 95, 1024-1030. https://doi.org/ 10.1213/00000 53920021000000043 Bozimowski, G., Groh, C., Rouen, P., & Dosch, M. (2014). The prevalence and patterns of substance abuse among nurse anesthesia students. AANA Journal, 82(4), 277-83. Crosssectional retrospe ctive study 32 abuse since 1990 and whether education and regulation policies designed to reduce CS abuse have been adopted on a widespread scale. use disorder dispensin g/disposi ng/accou nting for controlle d substanc es The purpose of this study was to assess the prevalence, demograph ic factors, outcomes, and preventativ e measures for substance abuse among nurse anesthesia students over a 5year period from 2008 to 2012. N= 16 SRNAs identified as having substance abuse Type of drug misused, preenrollme nt risk factors, outcomes Survey required resuscitation before abuse was suspected. The population found to be abusers remained stable from prior studies. Formal drug abuse education was present in 47% of the programs but only 69% required completion. Education had been shown to increase during the study period. 63% of programs had made changes to dispensing, disposing and waste procedure in the study timeframe. 8% of programs utilized random drug urine testing in the population. Of 2,439 SRNAs, 16 incidents were identified, with opioids as the most frequent drug of choice (n=9). Outcomes included 10 entered into voluntary treatment, 7 were dismissed from the program, 2 lost nursing licenses and 1 death occurred. Most reported screening included preenrollment background checks and drug and would be valuable as a trending measure screens. A national registry to measure outcomes of addiction reduction programs should be implemented. Further research regarding proactive risk assessment postgraduation and evaluation of wellness promotion effort effectiveness for risk reduction The authors suggest faculty should be more active in promoting wellness programs if further research identifies effectiveness. It was also noted currently used screening processes may not be adequate to identify students with risks unless a background check identifies prior SUBSTANCE USE DISORDER EDUCATION 33 Collins, G., McAllister, M., Jensen, M., & Gooden, T. (2005). Chemical dependency treatment outcomes of residents in anesthesiology : Results of a survey. Anesthesia & Analgesia, 101, 14571462. https://doi.org/ 10.1213/01.A NE.000018083 7.78169.04 Longitu dinal observat ional study We performed this study to determine if improveme nt has been made in the treatment outcomes of residents in anesthesiol ogy compared with earlier studies. N= 199 anesthesiol ogy residents treated for substance abuse Type of drug misused, outcomes Survey with follow up of treated residents years later Follette, J., & Farley, W. (1992). Anesthesiologi st Addicted to Propofol. Anes thesiology, 77( 4), 817-818. https://doi.org/ 10.1097/00000 54219921000000028 Case Study This is a case report on an anesthesiol ogist who abused and became dependent on propofol. N= 1 anesthesiol ogist with propofol abuse None Case report of one anesthesiologist screens. Prevalence rates were found to be lower in SRNAs vs. CRNAs. 80% of responding anesthesia resident programs had experience with at least 1 impaired trainee, which constitutes the largest percentage to date. Of the residents treated for chemical dependency, 92% resumed anesthesia training, with only 59% successful in completing training. Residents were followed long term and 56% were found to be successful in the practice of medicine, but it could not be determined what percentage stayed in anesthesia. 16% were found to leave medicine entirely after treatment. An anesthesiologist was determined to be diverting and abusing propofol after being found unconscious in a bathroom at work. The case study contains drug abuse risk factors, substance abuse. Research regarding the impact of preemployment toxicology on the incidence of abuse is lacking Few programs were found to prescreen for substance abuse or perform preemployment toxicology. A more proactive approach may be of benefit, considering the prevalence of substance abuse in medicine and especially in the practice of anesthesiology . The use of risk assessment tools should be considered when interviewing potential residents for anesthesiology programs. Redirection of treated residents into a lower risk specialty should be considered. None identified. Hospitals should know about the resources available for drug abusing/diverti ng providers. The importance of monitoring programs for treatment SUBSTANCE USE DISORDER EDUCATION 34 incidence of starting propofol abuse and developing dependence. This is the first studied event of propofol dependence. Kintz, P., Villain, M., Dumestre, V., & Cirimele, V. (2005). Evidence of addiction by anesthesiologis ts as documented by hair analysis. Foren sic science international, 153(1), 8184. https://doi.org/ 10.1016/j.forsc iint.2005.04.03 3 Case Study This report presents four authentic cases of anesthesiol ogists addicted to fentanyl derivatives where evidence was given by hair testing. N= 4; 3 living anesthesiol ogists and 1 deceased nurse anesthetist determined to use controlled substances Sampling of hair via drug analysis, urine drug screens performe d/number of negatives , narrative backgrou nd on work performa nce Collection of hair samples from 3 living participants in medico-legal cases and 1 sample collected post mortem All 4 samples contained traces of substances of abuse, including amounts that correlate to term of use whereas urine toxicology failed to register the presence of any substance of abuse. The problem of drug use in the anesthesia profession is not widely recognized and more prevalence studies would be of benefit. Warner, D. O., Berge, K., Sun, H., Harman, A., Hanson, A., & Schroeder, D. R. (2013). Substance use disorder among anesthesiology residents, 19752009. JAMA, 3 10(21), 2289 2296. https://doi.org/ 10.1001/jama. 2013.281954 Retrospe ctive cohort study To describe the incidence and outcomes of SUD among anesthesiol ogy residents. N= 384 residents reported to have a substance use disorder while in training Cases of substanc e use disorder including initial event and relapse, vital status, cause of death, and professio nal conseque nces Review of American Board of Anesthesiology (ABA) records for substance use disorder (SUD) flag Of 44,612 who had been enrolled in anesthesia training, the SUD flag was set for 1042 cases and confirmatory evidence was available for 842 cases. As this study focuses on residents, 384 cases were identified, including 26 deaths within 4 years of starting training. This represents 0.86% of those who began primary training in anesthesia. 8% were women, In general, more data is needed in this subject matter to better guide policy and practice. Comparable data for other physician specialties is lacking, which would help determine if SUD is more prevalent in the anesthesia profession. programs is discussed, as well as the information that propofol and its metabolites are identifiable in urine toxicology screens. The practice of hair analysis over blood or urine toxicology tests point to a more accurate testing method, is easy, costeffective, and can be directly witnessed to deter tampering. None noted SUBSTANCE USE DISORDER EDUCATION Wilson, J.E., Kiselanova, N., Stevens, Q., Lutz, R., Mandler, T., Tran, Z.V., & Wischmeyer, P.E. (2008). A survey of inhalational anaesthetic abuse in anaesthesia training programmes. Anaesthesia, 63(6), 616-20. https://doi.org/ 10.1111/j.1365 2044.2008.054 44.x Crosssectional retrospe ctive study This study aims to assess the prevalence and outcomes of inhalational anaesthetic abuse among anaesthesia training programme s. N= 31 trainees identified to be abusing inhalational anesthetics 35 Type of inhalatio nal anestheti c abused, personne l type (consulta nt, trainee, CRNA, technicia n, other), populatio n abusing inhalatio n anestheti cs, deaths, those sent to rehab, successfu l completi on of rehab, return to specialty with relapse, change in specialty, those that left medicine Survey median age was 31, overall incidence was 2.16 per 1000 resident years with 177,848 resident-years analyzed. SUD history before residency was found in 56 individuals. The most common substance was IV opioids. 91 individuals relapsed at least once, and 6% did so in training. This is the first published study of abuse of inhalational anesthetics. Surveys were sent to 126 anesthesia program directors with a response of 106 (84%). 22% of responding programs had at least 1 incidence of abuse. 15/31 identified trainees were sent for rehab and only 7 of those were able to successfully return to practice anesthesia. 97/104 departments did not have a pharmacy accounting program for the inhalational anesthetics. Overall mortality was 26%. Trainees and CRNAs were Further studies may be needed to determine predisposing addictive risk factors. Prevention needs to be a more prevalent practice and focus should be in the first 5 years after graduation. Risk factor assessment should be implemented. SUBSTANCE USE DISORDER EDUCATION Wischmeyer, P., Johnson, B., Wilson, J., Dingmann, C., Bachman, H., Roller, E., Tran, Z. V., & Henthorn, T. (2007). A survey of propofol abuse in academic anesthesia programs. Anesthesia & Analgesia, 105, 10661071. https://doi.org/ 10.1213/01.ane .0000270215.8 6253.30 Crosssectional retrospe ctive study With this supporting information for the abuse potential of propofol, we attempted to determine the prevalence and outcome of propofol abuse in academic anesthesiol ogy department with residency training programs in the United States. N= 25 abuse events, including attending physicians, residents, CRNAs, and OR/anesthe sia technicians 36 Propofol identified as drug of choice, type of anesthesi a provider, pharmac y accounti ng of propofol, year of abusers birth, year abuse was identified , how abuse was discovere d, outcome of abuser (alive/de ceased), 36nterve ntion outcome, years in anesthesi a, comorbid psychiatr ic condition s, past substanc e abuse/fa mily history, relapse status Survey to identify propofol abusers in a 10year period reported the most frequently. Of 126 programs surveyed, 25 propofol abuse events occurred in 23 programs among attending physicians, residents, CRNAs, and OR/Anesthesia technician. 7 deaths were reported, propofol abuse was not evident until the time of death. The incidence among all anesthesia personnel (attendings, residents, CRNAs= 23,385) was 0.1% for 10 years. 18 departments intervened with propofol abusers: 13 volunteered for rehab. 6 returned to anesthesia (3 then relapsed), 5 changed specialty, 10 left medical practice. Pharmacy regulation of propofol was studied: 90 of 126 institutions did not regulate propofol. Positive diversion/abuse was significantly associated with no control measures with propofol. Further research should be completed to outline the attraction of propofol used as a drug of choice. The potential for aerosolization of propofol should be examined. Pharmacy accounting of propofol in institutions should be instituted. Urine toxicology including propofol should be utilized in atrisk or suspected individuals. Early identification of individuals abusing propofol is key to limiting morbidity and mortality. SUBSTANCE USE DISORDER EDUCATION 37 Appendix C Strengths: In-depth information dedicated to SUD Flexible course Strong project team Project site at Marian Canvas site ease of use Accessible 24/7 Weaknesses: Increased time commitment versus previous structure Opportunities: Target audience is already in learning mode Second-year SRNAs have little exposure to SUD Creation of the developing Wellness Committee could reinforce project importance Threats: Stress Information overload related to other coursework Online learning required Technology issues- internet or Canvas SUBSTANCE USE DISORDER EDUCATION 38 Appendix D SUBSTANCE USE DISORDER EDUCATION 39 Appendix E You are invited to participate in an investigative project titled Educating SRNAs on Substance Use Disorder Prevalence, Risk, and Prevention. This project is being conducted by Kursten Smith (primary investigator) from Marian University in fulfillment of her DNP graduate project. You were selected to participate in this project because you are a second-year student, enrolled in the nurse anesthesia program at Marian University, and registered to take Nursing 615 Anesthesia Seminar 1. The purpose of this project is to provide SRNAs with a comprehensive overview of substance use disorder (SUD) in anesthesia professionals. If you agree to take part in this project, you will be asked to complete the survey on the next page. This survey will ask about your current knowledge of SUD. It will take you approximately 3 minutes to complete. Your answers in this project will remain confidential and results will be reported in the aggregate. Confidentiality will be maintained, and risks of breaches will be minimized by data storage in a password-protected computer securely kept with the primary investigator and the data will be deleted upon completion of the project. Your participation in this project is voluntary. You may withdraw from the project at any time. You are free to skip any question you choose. Withdrawal from the project does not affect your course grade. If you have questions about this project or if you have any issues with the project, you may contact the primary investigator, Kursten Smith at (765) 702-1155. If you have any questions concerning your rights as a project subject, you may contact the Marian University Institutional Review Board Chair, Dr. Amanda C. Egan at aegan@marian.edu or irb@marian.edu. By completing the pre-survey, you are indicating that you are at least 18 years old, have read and understood this consent form, and agree to participate in this project. I understand and agree to continue SUBSTANCE USE DISORDER EDUCATION 40 Appendix F Please select your age bracket: 22-29 30-39 40-49 50 Please select your gender Male Female Nonbinary Prefer not to say How many years of professional experience do you have? 5 years 6-10 years 11-15 years 16-20 years 20 years What is the prevalence of SUD in healthcare professionals? 1% 15% 25% 50% What is the prevalence of SUD in the healthcare subset of anesthesia professionals? 10% 15% 25% 50% What are the most commonly abused substances in anesthesia professionals (pick 2)? Benzodiazepines Opioids Alcohol Ketamine Propofol -What are risk factors associated with increased incidence of SUD in anesthesia personnel? (Pick 3) Increased pharmacy oversight Frequent visualized efficacy of anesthetics Age <30 SUBSTANCE USE DISORDER EDUCATION History of trauma Family history of substance abuse 15+ years in the anesthesia profession -What are signs of SUD in anesthesia providers? (Pick 3) Behavior changes Personal appearance decline Highly reliable in job performance Quickly accomplishes tasks Simple excuses for errors Difficulty with concentration and memory -What is NOT a way to prevent SUD in anesthesia personnel? For-cause drug testing Chart analysis/auditing Adequate provider self-care Return bins with availability to quantitatively test deposited drugs -What resources are available to assist victims of SUD? AANA Peer Assistance Helpline 800-654-5167 Anesthetists in Recovery (AIR) Employee Assistance Program (EAP) through the workplace All of the above 41 SUBSTANCE USE DISORDER EDUCATION 42 Appendix G 1.) Objectives By the end of this workshop, learners will: -Understand the incidence of SUD in the anesthesia profession -Understand the risk factors, signs of SUD, and prevention strategies -Obtain information on available resources for victims of SUD in the anesthesia community 2.) Survey Analyze the learners knowledge before and after the workshop -Collect demographic information: -Age -Gender -Years of experience as a professional -Knowledge of SUD before the module: -What is the prevalence of SUD in anesthesia professionals? -What are risk factors associated with increased incidence of SUD in anesthesia personnel? (Pick 3) -What are signs of SUD in anesthesia providers? (Pick 3) -What is NOT a way to prevent SUD in anesthesia personnel? -What resource is available to assist victims of SUD? -Knowledge of SUD after module completion: -Same questions as above 3.) Key Concepts -SUD incidence, risk factors, signs of abuse, prevention strategies, and resources 4.) Topics and Subtopics of modules -Incidence - Both general population and anesthesia providers, most abused substances, trends -Risk factors - Profession: Availability, lacking checks/balances, desired effects visualized daily - Individual: Timing after initial licensure, gender, personality traits -Signs of abuse - picking up extra shifts/call hours, behavior change, unreliability -Prevention strategies - Awareness and education, drug screens, risk factor screening, policy/procedure improvements -Resources SUBSTANCE USE DISORDER EDUCATION 43 Appendix H Kotters 8-Step Model of Change Juneja, P. (n.d.). Kotters 8 step Model of Change. Management Study Guide. Retrieved from https://www.managementstudyguide.com/contingency-model-of-change-management.htm SUBSTANCE USE DISORDER EDUCATION 44 Appendix I Institutional Review Board DATE: 4-26-2022 TO: Kursten Smith & Dr. Lee Ranalli FROM: Institutional Review Board RE: S22.131 TITLE: Education of SRNAs on Substance Use Disorder Prevalence, Risk, and Prevention SUBMISSION TYPE: New Project ACTION: Determination of EXEMPT Status DECISION DATE: 4-26-2022 The Institutional Review Board at Marian University has reviewed your protocol and has determined the procedures proposed are appropriate for exemption under the federal regulations. As such, there will be no further review of your protocol and you are cleared to proceed with your project. The protocol will remain on file with the Marian University IRB as a matter of record. Please be mindful of the importance of reporting only de-identified, HIPPA-compliant information about the patient in any exhibit or publication. Although researchers for exempt studies are not required to complete online CITI training for research involving human subjects, the IRB recommends that they do so, particularly as a learning exercise in the case of student researchers. Information on CITI training can be found on the IRBs website: http://www.marian.edu/academics/institutional-review-board. It is the responsibility of the PI (and, if applicable, the faculty supervisor) to inform the IRB if the procedures presented in this protocol are to be modified of if problems related to human research participants arise in connection with this project. Any procedural modifications must be evaluated by the IRB before being implemented, as some modifications may change the review status of this project. Please contact me if you are unsure whether your proposed modification requires review. Proposed modifications should be addressed in writing to the IRB. Please reference the above IRB protocol number in any communication to the IRB regarding this project. __________________________________________ Amanda C. Egan, Ph.D. SUBSTANCE USE DISORDER EDUCATION 45 Appendix J Table 1 Demographics and Characteristics of All Survey Respondents Characteristics Gender Male Female Age 22-29 30-39 40-49 Experience as a Registered Nurse (years) <5 6-10 11-15 16-20 *Note, n= 22 n % 9 13 40.9 59.1 10 9 3 45.5 40.9 13.6 11 8 2 1 50 36.4 9.1 4.5 SUBSTANCE USE DISORDER EDUCATION 46 Table 2 Results of the Survey Question What is the prevalence of SUD in healthcare professionals? What is the prevalence of SUD in anesthesia professionals? What are the most commonly abused anesthetic agents among anesthesia professionals? (pick 2) What are risk factors associated with increased incidence of SUD in anesthesia personnel? (pick 3) What are signs of SUD in anesthesia providers? (pick 3) Pre-Test No. (%) Correct Post-test No. (%) Correct 15% 59.1 86.4 Up to 20% 18.2 77.3 Opioids, Propofol 36.4 90.9 13.6 36.4 59.1 86.4 Correct Answer Frequent visualized efficacy of anesthetics, History of trauma, Family history of substance abuse Behavior changes, Personal appearance decline, Difficulty with concentration and memory Which of the following is NOT an evidence-based intervention to prevent SUD in anesthesia personnel? For-cause drug testing 27.3 45.5 What resources are available to assist victims of SUD? All of the above 100 95.5 SUBSTANCE USE DISORDER EDUCATION 47 Table 3 Statistical Analysis: Paired Samples Test Paired Samples Test Pair 1 Pretest Score Post-test Score Paired Differences 95% Confidence Interval of the Std. Difference Std. Error Mean Deviation Mean Lower Upper t 1.670 .356 -2.604 -1.123 1.864 5.233 Significance OneTwoSided Sided df p p 21 <.001 <.001  ...

... ASSESSING PACU HANDOFF REPORT CONFIDENCE Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2023 Assessing PACU Handoff Report Confidence Majid Nasir Siddiqi Marian University Leighton School of Nursing Chair: Dr. Brad Stelflug DrAP, CRNA _________________________ (Signature) 04/25/23 _______________ SRNA, DNP Marian University Class of 2023. 1 ASSESSING PACU HANDOFF REPORT CONFIDENCE 2 Table of Contents Abstract3 Introduction & Background ..4 Problem Statement.......9 Purpose Statement....9 Theoretical Framework........9 Strengths, Weaknesses, Opportunities, Threats (SWOT) Analysis...11 Search Strategy..13 Literature Review...13 Project Design14 Data Collection......15 Ethical Consideration and Protection of Human Subjects.16 Results17 Discussion......18 Conclusion.20 Timeline.23 Appendix A15 Appendix B16 Appendix C....23 CITI....50 IRB Approval.....52 References..53 ASSESSING PACU HANDOFF REPORT CONFIDENCE 3 Abstract Effective communication during the handoff process between anesthesia providers and post-anesthesia care unit (PACU) nurses is crucial for ensuring patient safety. This Doctor of Nursing Practice (DNP) project aimed to investigate and develop an evidence-based educational intervention to enhance Student Registered Nurse Anesthetists' (SRNAs) confidence and competency in delivering standardized handoff reports, with the goal of promoting patient safety and reducing medical errors. Participants were required to complete a pre-test assessing baseline characteristics consisting of prior experience, confidence, knowledge, and comfort when giving PACU handoff reports. The pre-test was followed by the educational intervention which was provided in the form of an evidence-based presentation. Upon reviewing the presentation, participants were required to complete a post-test assessing confidence, knowledge, skills, and comfort when giving PACU handoff reports. The results indicated that the educational intervention improved SRNAs' confidence, knowledge, and skills related to post-operative care unit reports. The findings of this project have significant implications for practice, highlighting the importance of ongoing efforts to enhance SRNAs abilities to conduct standardized handoff reports in post-operative care units. Further research is needed to confirm the findings and investigate the long-term effects of educational interventions on patient outcomes. ASSESSING PACU HANDOFF REPORT CONFIDENCE 4 Background Anesthesia care begins with the preoperative evaluation of the patient and is not complete until the patient has recovered to their biological preoperative condition. Surgical postoperative care, also known as postoperative treatment, starts immediately after surgery is completed. Complications connected with anesthetics have been documented since the introduction of inhalation anesthesia in the mid-19th century (Ramsay, 2006). In recent years, there has been growing recognition of the importance of effective communication in healthcare, including during patient handoffs. Handoff reports are a critical component of anesthesia care and have been found to have a significant impact on patient safety (Jurewicz et al., 2018). During the period of immediate postoperative recovery, when complications may still occur, the nurse anesthetist is integrating care with other members of the healthcare team in the post anesthesia care unit (PACU). Anesthesia providers take part in patient handoffs on a number of occasions for each patient under their supervision. Each handoff has the potential to create a communication breakdown, jeopardizing the patient's safety. Practitioners are required to provide a verbal handoff report to the PACU nurse to ensure patient safety and continuity of care. The handoff report must include all components of the presurgical, anesthetic, and surgical courses that have an effect on the surgical and anesthetic outcomes, as well as the PACU care plan (Yap et al., 2019). It is crucial to transfer patients from the operating room to the post anesthesia care unit in a standardized and complete way. The transfer is an opportunity for the PACU nurse and anesthesia provider to discuss and clarify details regarding the patients care. The American Association of Nurse Anesthetists (AANA) Standards of Practice emphasize the necessity of the anesthesia report: Standard VII: Evaluate the patients status and ASSESSING PACU HANDOFF REPORT CONFIDENCE 5 determine when it is safe to transfer the responsibility of care. Accurately report the patients condition, including all essential information, and transfer the responsibility of care to another qualified health care provider in a manner that assures continuity of care and patient safety (AANA, 2016). Despite these standards, errors and variations in the content and quality of information shared during handoffs can occur due to factors such as inadequate preparation, weak communication skills, loss of a standard protocol, insufficient time for transfer, information loss, diversions, delays, and a lack of opportunities to ask questions or express concerns (Roth et al., 2018). These communication breakdowns can result in medication errors, inaccuracies in treatment planning, delays in patient transfer to critical care, hospital discharge delays, and repeated testing (Roth et al., 2018). Despite these standards, the content and quality of information shared may still vary. Errors might be made during the handover procedure. It has been difficult to complete proper handoffs due to inadequate preparation, weak communication skills, loss of a standard protocol, insufficient time for transfer, information loss, diversions, delays, and a lack of chances to ask questions or express concerns. Unfortunately, these effects include medication mistakes, inaccuracies in treatment planning, delays in patient transfer to critical care, hospital discharge delays, and recurrent testing (Segall et al., 2012). Post-anesthesia recovery refers to the processes undertaken to manage a patient following the completion of a surgical or nonsurgical procedure during which anesthesia, analgesia, or sedative has been administered. When transferring patients from the operating room to the postanesthesia recovery area, it is crucial to identify and communicate the likely phase the patient will be in before moving them. The PACU period of care is divided into three phases: early ASSESSING PACU HANDOFF REPORT CONFIDENCE 6 recovery (Phase I), intermediate recovery (Phase II), and late recovery (Phase III) (Kinsella et al., 2018). Immediately after surgery, a patient enters Phase I of the recovery process. This stage takes place in the PACU, where the patient stays until their breathing, level of awareness, blood pressure, and activity levels return to normal. After adequate recovery, the surgical patient is transferred to Phase II. In this step-down unit, patients receive food and drink and are prepared to return home following a brief stay. It is essential to recognize that patient handoffs occur during each recovery phase, and the information exchanged during these handoffs can significantly impact patient outcomes (Byrne et al., 2020). Late recovery, also known as Phase III, takes place either in the hospital or at the patient's place of residence for ambulatory surgical patients, and will be completed when the patient has fully recovered from their surgical operation (Byrne et al., 2020). It is important to recognize that even when treatment is not being provided in a hospital environment, proper standards must be followed to prevent harm to the patient. Additionally, it is not uncommon for the entire recovery process to take up to six weeks (Chughtai et al., 2017). Complications of postoperative anesthesia may vary from moderate to severe. According to the findings of a retrospective research postoperative nausea and vomiting are the most often reported symptom in the post-anesthesia care unit (PACU). In a study of 3,132 patients, 36% experienced postoperative nausea and vomiting (Akerman et al., 2017). Numerous additional complications were documented, including laryngospasm, hypotension, hypertension, dysrhythmia, and serious cardiac events (Villafranca et al., 2015). The majority of these issues could have easily been avoided if the anesthetic care professionals took proper precautions. Improper handoffs resulting from lack of proper protocols have been identified as a contributing ASSESSING PACU HANDOFF REPORT CONFIDENCE 7 factor to these complications. In a study of 160 patient handoffs, only 7% of the handoffs met all six key communication elements, including active communication of patient information, prioritization of tasks, and opportunities for the receiver to ask questions (Bergs et al., 2017). Furthermore, handoff errors have been associated with increased length of stay and readmission rates, as well as higher healthcare costs (Sexton et al., 2014). Effective communication during handoffs is essential to avoid complications and ensure patient safety. There has been a correlation established between handoff reports and patient harm. Handoff reports are vital to the success of the patients outcome (Jurewicz et al., 2018). The major goal of post-anesthesia recovery is to examine and stabilize patients after these treatment procedures with a focus on preventing and detecting problems. During previous clinical site visits, handoff reports have varied substantially. There have been comprehensive handoff reports that provided detailed treatment plans whereas others only provided a few sentences of highlevel information. There was little emphasis placed on providing a standardized report to the PACU nurse. There did not seem to be a clear indicator of what precisely should be reported during the hand-off. Unfortunately, this may easily result in damage to the patient's well-being and cause them to be injured by a variety of factors. A recognized method to evaluate safe release from the post-anesthesia care unit did not exist before to 1970, when Dr. J.A. Aldrete established the post-anesthesia recovery score, which is still in use today (PACU). Dr. Aldrete argued that a monitoring tool that could be used to standardize the treatment of surgical patients throughout the globe was urgently needed (Aldrete, 1995). A patients awareness, activity, respiration, and blood pressure are all measured using the Aldrete scoring system, which has become well-known in the medical community for its ability to assess recovery following anesthesia (Aldrete, 1995). Dr. Aldrete improved this score in 1995 ASSESSING PACU HANDOFF REPORT CONFIDENCE 8 to add oxygen saturation scores, since the previous method employed a skin color index to determine oxygen saturation (Aldrete, 1995). Each of the five categories is assigned a number ranging from 0 to 2, with a maximum score of 10. Depending on the score received, the patient is then considered for readiness to be discharged from the PACU unit. Patients admitted to the PACU are presumed to be in unstable condition unless proved otherwise due to the rapidity with which a patient's status might change in the PACU, accurate and careful nurse evaluation is essential. The most important reason for providing an accurate report during the handoff time is to prevent complications from getting worse (Kothari et al., 2021). There are numerous important elements about the patient's physiologic condition that the PACU nurse should be aware of at the time of admission. It is important to ensure that patients undergo periodic reexaminations in order to detect physiological trends, establish the patient's baseline level and the effect of previous medical conditions. The patients current physiology, ongoing status of the surgical site, effect of preexisting conditions and the patients recovery from anesthesia is assessed to prevent residual effects and treat complications that arise as the nurse monitors the patients progress (Kothari et al., 2021). The Joint Commission has recommended improvements to the handoff process as a national goal to improve patient safety (The Joint Commission, 2017). The best practice for any anesthesia provider is to provide complete care from the beginning to the end of the patient encounter. Previous clinical site visits have shown that facilities do not have protocols in place for standardized reports. With the goal of enhancing communication and providing standardized hand off report, this DNP project aims to change the practice of patient handoff report. A Quality Improvement technique using non-experimental pre- and post-surveys will be held for SRNA students for providing handoff reports. The proposed standardized handoff report will implement ASSESSING PACU HANDOFF REPORT CONFIDENCE 9 the SBAR tool and consist of the following parameters: patients airway patency, respiratory rate, peripheral oxygen saturation, heart rate, blood pressure, the electrocardiogram, mental status, neuromuscular function, temperature, pain, and nausea or vomiting. Project statement & Purpose Statement The purpose of this Doctor of Nursing Practice (DNP) project is to evaluate and enhance the confidence and competency of Student Registered Nurse Anesthetists (SRNAs) in delivering standardized handoff reports to improve post-operative patient safety. This project will employ a pre-test, post-test design with an evidence-based educational intervention to assess the impact of the training on SRNAs' knowledge, confidence, and practices related to standardized handoff reports in the post-anesthesia care unit (PACU). Effective communication during handoffs between anesthesia providers and postanesthesia care unit nurses is critical for patient safety and continuity of care. Inconsistencies in handoff practices, lack of standardized protocols, and inadequate training can lead to miscommunication, resulting in adverse patient outcomes, increased length of stay, and higher healthcare costs. The current practice environment has identified gaps in the confidence and competency of SRNAs in delivering standardized handoff reports, which may compromise patient safety. This is the reason why this DNP project aims to address these gaps and enhance the quality of handoff communication, ultimately contributing to improved patient safety in the post-operative setting. Theoretical Framework The theoretical framework for this DNP project is based on the Communication Theory of Nursing (CTN) and incorporates the Situation-Background-Assessment-Recommendation (SBAR) communication tool to support the development of confidence in standardized handoff ASSESSING PACU HANDOFF REPORT CONFIDENCE 10 reports. The CTN highlights the crucial role of effective communication in nursing practice, asserting that the exchange of clear and precise information is essential for maintaining patient safety and delivering high-quality care (Arnold & Boggs, 2019). This project's goal is to enhance handoff report confidence by improving the communication processes between anesthesia providers and PACU nurses. The SBAR communication tool acts as a practical guide for organizing the handoff report. This widely accepted approach enables clear, concise, and focused communication during patient handoffs (Agency for Healthcare Research and Quality, 2019). By implementing the SBAR tool into the handoff process, anesthesia providers can systematically share crucial patient information, thus improving confidence in the handoff report and reducing the risk of communication errors. The tool is structured into four components: 1. Situation: A concise statement of the patient's current status and the reason for the handoff. 2. Background: Pertinent medical history, including diagnoses, allergies, and recent interventions or treatments. 3. Assessment: The patient's current clinical condition, including vital signs, pain level, and any concerns or complications. 4. Recommendation: Expected needs or actions, such as ongoing monitoring, interventions, or consultations with other healthcare professionals. By integrating the CTN and the SBAR tool as the theoretical framework for this project, the aim is to enhance the confidence in standardized handoff reports and ensure effective communication, ultimately improving patient safety and overall quality of care during the perioperative period. ASSESSING PACU HANDOFF REPORT CONFIDENCE 11 This DNP project will focus on educating and training Student Registered Nurse Anesthetists (SRNAs) on the importance of effective communication and the use of the SBAR tool during handoffs. Through a combination of didactic teaching, role-playing, and feedback, SRNAs will develop the skills necessary to deliver comprehensive and standardized handoff reports. The project will also evaluate the impact of the educational intervention on the knowledge, confidence, and practices of SRNAs in relation to standardized handoff reports in the PACU. By addressing the existing gaps in SRNAs' confidence and competency, this project seeks to create a culture of consistent and effective communication during the handoff process. The goal is to reduce miscommunication-related errors, enhance patient safety, and contribute to better patient outcomes in the post-operative setting. The adoption of the CTN and the SBAR tool as the theoretical framework will provide a solid foundation for the project's success and promote lasting improvements in handoff communication practices. Strengths, Weaknesses, Opportunities, Threats (SWOT) Analysis The DNP project has several strengths, including its evidence-based approach, focus on patient safety, and potential for improvement in SRNA confidence and competency. Utilizing an evidence-based educational intervention ensures that the training provided to the SRNAs is based on current best practices and research. By addressing patient safety concerns through targeting the crucial handoff communication process, the project aims to enhance patient outcomes. Additionally, the project has the potential to significantly increase the confidence and competency of SRNAs in delivering standardized handoff reports. However, there are some weaknesses, such as the limited sample size, convenience sampling, and reliance on self-reported data. The small sample size may limit the generalizability of the results, while the use of convenience sampling could introduce selection bias, potentially ASSESSING PACU HANDOFF REPORT CONFIDENCE 12 affecting the external validity of the findings. Furthermore, the project's reliance on self-reported data from SRNAs may be subject to social desirability and recall bias. Despite these weaknesses, there are opportunities for the project's findings to contribute to the ongoing development of best practices in handoff communication and patient safety, benefiting the wider healthcare community. The project could serve as a basis for future educational interventions, targeting other healthcare professionals involved in the handoff process or expanding the scope to other aspects of patient care. Moreover, the project's findings may inform the development of standardized handoff protocols and guidelines, leading to improved patient safety across healthcare settings. Nevertheless, threats to the project's success should be considered, including resistance to change, time constraints, and external factors. Healthcare professionals, including SRNAs, may be resistant to change, making the implementation of new handoff practices challenging. Busy schedules and high workloads could limit the time available for SRNAs to participate in the educational intervention, affecting the project's success. Lastly, factors outside the control of the project, such as changes in healthcare policy or the emergence of new technologies, may impact the relevance or effectiveness of the proposed intervention. Search Strategy and Literature Review Various databases were used to gather evidence-based practice on patient safety among anesthesia providers. The databases included Cumulative Index to Nursing and Allied Health Literature (CINAHL), Public MEDLINE (PubMed), Medical Literature Analysis and Retrieval System (MEDLINE), Ovid Databases, Cochrane Library, and MeSH. Search terms for patient handoffs included: handoff, handover, transfer of care, patient handoff, patient handover, communication, and report. Search terms for anesthesia care included: anesthesia, anesthetist, ASSESSING PACU HANDOFF REPORT CONFIDENCE 13 nurse anesthetist, SRNA, PACU, post-anesthesia care unit, perioperative care, and postoperative care. Search terms for educational interventions included: education, training, intervention, program, curriculum, and competency. The terms were combined from each category in the search strategy, such as "patient handoff" AND "anesthesia care" AND "educational intervention." This search was performed in each of the selected databases. The search was limited to last five years (2017-2022) and excluded articles that did not provided enough data to support evidence-based practice on providing standardized communication handoff tool. Appendix A is available for search strategies, keywords, and results. After the initial search, the results were screened for relevance by reviewing titles and abstracts. Relevant articles were retrieved and assessed for eligibility based on predefined inclusion and exclusion criteria. Inclusion criteria consisted of articles that focused on handoff communication in anesthesia care, educational interventions for healthcare professionals, and patient safety outcomes related to handoffs. Exclusion criteria of articles consisted of articles that were not in English, published more than 5 years ago, or did not pertain to the topic of interest. In the literature review, findings of the selected articles were summarized, focusing on the importance of standardized handoff reports, best practices in handoff communication, the impact of educational interventions on healthcare professionals' confidence and competency, and the relationship between handoff communication and patient safety outcomes. Through this review, gaps were identified in the existing literature, providing a rationale for the DNP project and its potential contribution to the field. Project Design The project design is a pre-test, post-test survey aimed to assess and improve the confidence and competency of Student Registered Nurse Anesthetists (SRNAs) in standardized ASSESSING PACU HANDOFF REPORT CONFIDENCE 14 handoff report communication. The design begins with the recruitment of a convenience sample of SRNAs from an anesthesia program, ensuring that informed consent is obtained from all participants. A pre-test survey using Qualtrics (qualtrics.com) was then administered to gather baseline data on the SRNAs' current knowledge, confidence, and practices related to standardized handoff reports, including demographics, previous experience, and self-assessment of handoff communication skills. Following the pre-test survey, an educational intervention was developed and delivered in the form of an evidence-based PowerPoint presentation. This intervention educates SRNAs on the importance of standardized handoff reports, best practices, and effective communication techniques, focusing on providing practical guidance, case studies, and interactive activities to enhance their confidence and skills in conducting handoff reports. After the intervention, a post-test survey using Qualtrics (qualtrics.com) was administered to SRNAs to evaluate the impact of the training on their knowledge, confidence, and practices related to standardized handoff reports. The post-test survey includes the same questions as the pre-test survey to enable comparison and assessment of the intervention's effectiveness. Data from the pre-test and post-test surveys were analyzed using descriptive and inferential statistics to evaluate the effectiveness of the educational intervention in enhancing SRNAs' confidence and competency in delivering handoff reports. The analysis identifies any significant differences in knowledge, confidence, and practices between the pre-test and post-test results. The outcomes were evaluated, and any remaining gaps or areas for further improvement were identified. The project findings will be shared with the anesthesia program, stakeholders, ASSESSING PACU HANDOFF REPORT CONFIDENCE 15 and the wider healthcare community to contribute to the ongoing development of best practices in handoff communication and patient safety. Data Collection Data collection consisted of two primary sources: the pre-test survey and the post-test survey. Both surveys were administered using the online survey platform Qualtrics (qualtrics.com) to gather data regarding the Student Registered Nurse Anesthetists' (SRNAs) knowledge, confidence, and practices related to standardized PACU handoff reports. Participants were required to complete the pre-test survey before the educational intervention to assess baseline data. The survey included questions about demographics, previous experiences, self-assessment of handoff communication skills, and current practices regarding handoff reports. This data provided insight into the initial state of the SRNAs and served as a reference point for assessing the impact of the educational intervention. After reviewing the provided the educational materials, the participants were required to complete a post-test survey. This survey contained similar questions to the pre-test survey allowing for a comparison of the participants' knowledge, confidence, and practices before and after the intervention. Utilizing the data collected in the post-test survey, the intervention's effectiveness in improving the SRNAs' confidence and competency in delivering handoff reports was evaluated. Throughout the data collection process, it was crucial to ensure that participants' confidentiality was maintained and that the data was securely stored. Following the completion of data collection, the data was prepared for analysis by cleaning and organizing it into a format suitable for statistical analysis. This process involved the removal of any personally identifiable information and the conversion of categorical variables into numerical values, if necessary. ASSESSING PACU HANDOFF REPORT CONFIDENCE 16 Ethical Consideration & Protection of Human Subjects To ensure that the project was conducted ethically and that the rights, privacy, and wellbeing of participants were protected, several measures were taken. Approval from the Institutional Review Board (IRB) was sought before the initiation of the project, ensuring that the project adhered to ethical guidelines and standards, minimizing risks to participants and protecting their rights. Informed consent was obtained from all participants, providing them with a written informed consent form outlining the purpose, procedures, risks, and benefits of the study. Participants were informed that their participation was voluntary, and they could withdraw from the project at any time without any consequences. The consent form also outlined how participants' confidentiality would be maintained throughout the study. To protect the privacy of participants, all data collected were de-identified and stored securely, with access restricted to authorized research personnel. Results were reported in aggregate, and any identifying information was removed to ensure participants could not be linked to the data. The project was designed to minimize any potential risks or harms to participants, and the intervention was evidence-based and aligned with best practices in nursing education. Any potential discomfort or inconvenience related to survey completion was minimized by keeping the surveys concise and straightforward. Lastly, the findings of the project will be shared with participants, the anesthesia program, stakeholders, and the broader healthcare community to contribute to the development of best practices in handoff communication and patient safety. This dissemination of information ensures that the research can have a positive impact on patient care and nursing practice. By adhering to these ethical considerations and guidelines for the protection of human subjects, the DNP project was conducted responsibly and ethically, ensuring that the rights and well-being of participants were upheld. ASSESSING PACU HANDOFF REPORT CONFIDENCE 17 Throughout the project, ongoing monitoring and evaluation took place to identify any unforeseen risks or issues that might have arisen. If any concerns were identified, they were promptly addressed, and any necessary modifications to the research protocol were made to prioritize the safety and well-being of participants. Participants were also encouraged to ask questions and express concerns throughout the research process, fostering an open and transparent environment that respected their autonomy and acknowledged their contributions to the study. Research personnel were committed to maintaining a high level of ethical conduct and professionalism, which further supported the protection of human subjects. In conclusion, the DNP project prioritized the ethical considerations and protection of human subjects, taking all necessary steps to ensure the rights, privacy, and well-being of participants were maintained. By seeking IRB approval, obtaining informed consent, protecting confidentiality, and minimizing risks, the research team was able to conduct the study responsibly and ethically. This commitment to ethical research practices not only upheld the integrity of the project but also contributed to the advancement of nursing knowledge and improvements in patient care. Results Surveys were sent to the students from the DNP class of 2023 and 2024. There were a total of 16 responses. Results of the pre- and post-survey were matched using the participants IP address. Of the 16 respondents, 7 responses were excluded from further analysis as the participant did not complete the post-survey. An additional response was excluded as the participant completed the post-survey but did not complete the pre-survey. Of the remaining 8 ASSESSING PACU HANDOFF REPORT CONFIDENCE 18 participants, there were 4 males and 4 females. Demographics from the remaining 8 participants are characterized below. Demographic characteristics of study participants Parameter Sex Age Range (years) Cohort Total Reports Male Female 4 4 20-30 3 30-40 40-50 4 1 DNP Class of 2023 DNP Class of 2024 5 3 Survey Analysis The pre-survey consisted of foundational questions to identify the participants prior experience and training giving PACU reports. Of the 8 participants, 6 reported to have never received any training or coaching on giving post-operative care unit reports whereas 2 participants reported receiving prior training on giving PACU reports. All participants reported experiencing challenges when giving PACU reports. Among the students, there was an average of 131 PACU reports given over the past 6 months. Seven participants reported that they received feedback regarding their handoffs. Of the 7 participants that received feedback, 4 participants received positive feedback and 3 participants reported that there was room for improvement. ASSESSING PACU HANDOFF REPORT CONFIDENCE 19 Participants confidence, skills, availability of resources, and comfort in seeking help when giving PACU handoff reports were assessed before and after the educational intervention using a Likert-type scale where 0 = not at all and 10 = extremely likely. These findings are characterized in the chart below. Comparision of Parameters Affecting PACU Handoff Reports1 9 Assessment Questions Comfort level in asking questions or seeking help 6.5 9 Adequate support and resources available 6.5 9 Necessary knowledge and skills 5.5 9 Confidence when giving PACU reports 7.5 0 Post-survey 1Values 1 2 3 4 5 6 7 8 9 10 Pre-survey from the surveys represent the median scores. There was in increase in the participants confidence, knowledge, and comfort after the educational intervention. The confidence improved by 1.5 points (7.5 to 9), the self-assessment of necessary knowledge and skills improved by 3.5 points (5.5 to 9), the assessment of support and resources availability improved by 2.5 points (6.5 to 9), and the comfort level in asking questions or seeking help improved by 2.5 points (6.5 to 9). Discussion The results of this DNP project indicate that educational interventions can positively impact SRNAs' confidence, knowledge, and skills related to post-operative care unit reports. The improvements observed in the post-test survey suggest that the provided educational materials addressed the gaps in understanding and abilities. These findings underscore the importance of ASSESSING PACU HANDOFF REPORT CONFIDENCE 20 targeted training initiatives in promoting patient safety and improving the overall quality of care in the post-anesthesia care process. The success of the educational intervention in this project has important implications for practice. It suggests that incorporating similar educational modules into the SRNAs' curriculum could lead to better prepared and more competent practitioners, capable of delivering accurate and thorough handoff reports. Furthermore, by standardizing the handoff process and improving communication, the likelihood of errors and complications can be reduced, ultimately contributing to improved patient outcomes. There are several limitations to this DNP project. First, the sample size was small, with only 8 participants completing both the pre-test and post-test surveys. This limits the generalizability of the results and highlights the need for a larger sample to confirm the findings. Second, the study relied on self-reported assessments of confidence, knowledge, skills, and comfort which may be subject to bias. Incorporating objective measures of performance, such as direct observation or simulation-based evaluations, could provide a more comprehensive understanding of the intervention's effectiveness. Future research should aim to expand upon the findings of this DNP project by exploring the long-term effects of educational interventions on SRNAs' abilities to conduct standardized handoff reports in post-operative care units. Larger sample sizes should be employed to ensure broader applicability, and objective measures of performance should be incorporated to validate self-reported assessments. Additionally, future studies could investigate the use of such interventions in a cross-functional setting at a health system as well as assess the impact of such interventions on patient outcomes, providing further evidence of the importance of effective communication and standardized handoff reports in post-anesthesia care. ASSESSING PACU HANDOFF REPORT CONFIDENCE 21 Conclusion In conclusion, this Doctor of Nursing Practice project underscores the importance of educational interventions in improving Student Registered Nurse Anesthetists' (SRNAs) confidence, knowledge, and skills related to post-operative care unit reports. The results demonstrated that providing targeted education materials, such as the evidence-based PowerPoint presentation used in this project, enhanced the participants' abilities in these critical aspects of patient care. This finding has significant implications for practice, suggesting that incorporating standardized handoff training within the curriculum as well as health systems could lead to better patient outcomes and increased safety in post-anesthesia care units. The project's positive outcomes not only emphasize the value of educational interventions but also highlight the need for continuous improvement and reinforcement of best practices in handoff communication. By addressing gaps in knowledge and skills, SRNAs can become more confident and competent in their roles, ultimately contributing to enhanced patient safety and a reduction in adverse events related to handoff errors. Despite the limitations of this study, including the small sample size and reliance on selfreported assessments, the positive results warrant further research to expand upon these findings. Future studies should investigate the long-term effects of educational interventions, utilize objective measures of performance, and explore the impact on patient outcomes. Additionally, researchers may consider examining the influence of different teaching methods, such as simulation-based training or peer mentoring, on SRNAs' handoff skills and confidence. Furthermore, this project's results may serve as a catalyst for collaboration between anesthesia programs, healthcare institutions, and professional organizations in the development and dissemination of standardized handoff protocols and best practices. By fostering a culture of ASSESSING PACU HANDOFF REPORT CONFIDENCE 22 continuous learning and improvement, the healthcare community can work together to ensure that SRNAs and other healthcare providers are well-equipped to deliver high-quality care and effectively communicate during critical handoff processes. Ultimately, this project emphasizes the importance of effective communication and standardized handoff processes in post-anesthesia care, advocating for the continued development and implementation of targeted educational initiatives. By focusing on the training and development of SRNAs and other healthcare professionals, patient safety can be consistently prioritized and handoff-related errors will be minimized. ASSESSING PACU HANDOFF REPORT CONFIDENCE Appendix A Keywords, CINAHL, Ovid Databases, PubMed, Cochrane, MEDLINE, MeSH, and Search Strategy. Keywords Anesthesia, anesthesiologist, anesthetists, handoff, handover, hand-off, shift report, PACU, PACU- nurses, post Anesthesia, recovery, recovery room, Recovery Unit, Post-surgery, after surgery, surgery, communication, communications errors cost-effective, morbidity, mortality, checklist, safety, incomplete handoffs, errors, sign-out, and operating rooms. Keywords CINAHL Ovid PubMed Cochrane Limits, Results, Results kept Handoff, handover, PACU handoff, Communication PACU, and Communication error. Handoff, handover, PACU handoff, Communication PACU, and Communication error. Last 5 years (2017-2022), English, 83 results, and 13 results kept. Operating room, OR PACU, Communication errors, handoff, and handover. Last 5 years (2017-2022), English, 263 results, and 6 results kept. PACU OR, post anesthesia care unit, handoff and handover Last 5 years (2017-2022), English, 183 results, and 8 results kept Last 5 years (2017-2022), English, 353 results, and 8 results kept. 23 ASSESSING PACU HANDOFF REPORT CONFIDENCE 24 Appendix B Citation Research Design & Level of Evidence Population / Major Sample Variables size n=x Instruments / Data collection Results Benton, S. E., Hueckel, R. M., Taicher, B., & Muckler, V. C. (2020). Usability Assessment of an Electronic Handoff Tool to Facilitate and Improve Postoperative Communication Between Anesthesia and Intensive Care Unit Staff. Computers, informatics, nursing : CIN, 38(10), 500 507. https://doi.org/10.1097/CIN.00 00000000000563 Quality Improvem ent N= 38 Using a semi structured interview guide adapted from a previous study, participants were approached in person and questioned about the current handoff procedure, including the quantity and quality of information transferred, the current workflow, areas for improvement, and the impact of postoperative handoff on teamwork and patient safety. The findings of this study indicate that participants rated the postoperative IPASS handoff form as simple to use (87.5 percent), good (75.0 percent), and user-friendly (75.0 percent), all of which might contribute to its broad adoption. Level of evidence =1 Certified RN anesthetists [CRNAs], Anesthesiol ogists and Anesthesia residents, and PACU ASSESSING PACU HANDOFF REPORT CONFIDENCE Boat, A. C., & Spaeth, J. P. (2013). Handoff checklists improve the reliability of patient handoffs in the operating room and postanesthesia care unit. Paediatric anaesthesia, 23(7), 647654. https://doi.org/10.1111/pan.12 199 Quality Improvem ent Level of evidence =1 N = 58 25 PACU nurse Anesthesiol ogist Nurse anesthetists Based on input from anesthesia and nursing staff, key driving diagrams and'smart objectives' were built for each process, and handoff checklists were developed and refined utilizing numerous plandostudy-act cycles. Prior to the start of the projects, and during the 6-month With the implementation of the intraoperative handoff checklist, the dependability of intraoperative anesthetic handoffs increased from 20% to 100%. Similarly, when a standardized PACU checklist was implemented, the dependability of PACU duration of the programs, data on the dependability of the handoff procedures were collected. handoffs increased from 59% to better than 90%. ASSESSING PACU HANDOFF REPORT CONFIDENCE Boet, S., Djokhdem, H., Leir, S. A., Thberge, I., Mansour, F., & Etherington, N. (2020). Association of intraoperative anaesthesia handovers with patient morbidity and mortality: a systematic review and meta-analysis. British journal of anaesthesia, 125(4), 605613. https://doi.org/10.1016/j.bja.20 20.05.062 Prospectiv npatients=605 e and 678 Retrospect ive nproviders=307 clinical studies Level of evidence: 3 26 Nurse anesthetists , anesthesiol ogists and PACU nurses The research created a narrative synthesis of the findings by using particular qualitative and quantitative data. Additionally, a posthoc exploratory metaanalysis was done to assess the influence of handover on patient outcome in a group of similar trials. The metaanalysis was done using Review Manager 5.0 and a random-effects model (Cochrane Collaboration, London, UK). Risk ratios (RR) with 95% confidence intervals were used to quantify the effects of dichotomous outcomes (CI). The I2 statistic was used to determine statistical heterogeneity.15 Where data were unavailable, the study's original authors were contacted. For studies that reported continuous handovers, occurrences were categorized as Seven studies found a link between anesthetic handovers and worse patient outcomes, whereas one showed that handovers may aid in mistake detection or correction. When an anaesthetic handover happens during the operation, a meta-analysis of four trials showed a 40% increase in the likelihood of patients having an adverse event. ASSESSING PACU HANDOFF REPORT CONFIDENCE 27 'handover' or 'no' (zero) handovers. Jaulin, Francois, Lopes, Thomas & Martin, Frederic. (2021). Standardised handover process with checklist improves quality and safety of care in the postanaesthesia care unit: the Postanaesthesia Team Handover trial. BJA: British Journal of Anaesthesia, 127, 962-970. https://doi.org/10.1016/j.bja.20 21.07.002 This was a N=294 singlecentre, prospectiv e, pre/postimplement ation study conducted , Level of evidence: 2 Adult patients (aged 1880 yr) Anesthesia PACU The research was conducted in three parts. Stage 1 consisted of a baseline assessment conducted prior to the PATH checklist's deployment. Stage 2 featured a four-week period devoted to PATH checklist training sessions for the whole anesthesia PACU staff. Stage 3 was identical to Stage 1, except that it included an independent examination of the criteria. Hypoxemia episodes occurred at a rate of 4.1 percent before to the implementation of the PATH checklist and at a rate of 0.8 percent thereafter. Patients in the PATH group had a 5.6fold lower risk of hypoxemia than those in the control group. Lambert, L., & Adams, J. (2018). Improved anesthesia handoff after implementation of the written handoff anesthesia tool (WHAT). AANA Journal, 86(5), 361370. https://search.proquest.c om/docview/212151718 0?accountid=10639 Quality Improvem ent CRNA PACU nurses The TST for handoff communication was created to quantify and assess the existing handoff process, to identify the causes of insufficient handoffs, to develop solutions for improving the handoff process, and to review the handoff process after the While using the WHAT tool, a significant improvement was made to an incomplete report. Additionally, there was an increase in report satisfaction between CRNAs and PACU RNs. Level of evidence =1 N= 37 ASSESSING PACU HANDOFF REPORT CONFIDENCE 28 implementation of corrective measures. Park, L. S., Yang, G., Tan, K. S., Wong, C. H., Oskar, S., Borchardt, R. A., & Tollinche, A crosssectional L. E. (2017). Does Checklist Implementation Improve Quantity of Data Transfer: An Observation in Postanesthesia Care Unit (PACU). Open Journal of Anesthesiology, 7(4), 6982. https://doi.org/10.4236/ojanes. 2017.74007 observatio nal study. Level of evidence= IV N= 60 Nurses, PACU midlevel Providers, Anesthesia staff, and Surgical staff. Physical checklist was A physical checklist created including key facilitated data elements of the transfer of transmission and reduced care measures recommended by The American Society of Anesthesiologists. the omission of vital patient information. ASSESSING PACU HANDOFF REPORT CONFIDENCE Leonardsen, Moen, Kalsoen, & Hovland. (2019). A quantitative study on personnels experiences with patient handovers between the operating room and the postoperative anesthesia care unit before and after the implementation of a structured communication tool. Nursing Reports, 9(1). Doi: 10.4081/nursrep.2019.8 041 Quantitativ e Study Randmaa, M., Engstrm, M., Swenne, C. L., & Mrtensson, G. (2017). The postoperative handover: a focus group interview study with nurse anaesthetists, anaesthesiologists and PACU Focus group interview study with a descriptive design using 29 N= 290000 PACU nurses Age Gender Years of experience Positive and negative experiences were classified as agree and partially agree, while disagree and partly disagree were classified as disagree and partly disagree. Summative statistics were employed to illustrate the sample's characteristics. T-tests were utilized to demonstrate differences between pre- and postimplementation periods, as well as between employees. The tool enhanced the quality and safety of handovers and had a favorable effect on employee satisfaction. N=23 Nurse anesthetists , anesthesiol ogists and PACU nurses Six focus group interviews were conducted (2 groups for each profession). A semi structured interview guide was used covering opening questions, introductory questions, Five patterns were identified: (1) having different temporal foci during handover, (2) insecurity when information is transferred from one team to another, Level of evidence= IV ASSESSING PACU HANDOFF REPORT CONFIDENCE nurses. BMJ open, 7(8), e015038. https://doi.org/10.1136/bmjope n-2016-015038 30 qualitative content analysis of transcripts. transition questions and key questions. A moderator interviewed the participants while the assistant moderator took notes on the overall interaction/attitudes. Meaningful sentences/phrases across the groups were coded into categories and subcategories. These categories were compared for similarities and differences across the 6 focus groups. Level of evidence: 5 Jones, P. M., Cherry, R. A., Allen, B. N., Jenkyn, K., Shariff, S. Z., Flier, S., Vogt, K. N., & Wijeysundera, D. N. (2018). Association Between Handover of Anesthesia Care and Adverse Postoperative Outcomes Among Patients Undergoing Major Surgery. JAMA, 319(2), 143 153. A N = 313066 retrospecti ve population -based cohort study Level of evidence: 3 Adult patients (18 years) Data were obtained from the Canadian Institute for Health Informations Discharge Abstract Longer than Database (CIHI-DAD; inhospital outcomes), the 2 hours National Ambulatory Care surge ries. Reporting System (CIHINACRS; emergency department [ED] visits), the Same Day Surgery Database (CIHI-SDS), the (3) striving to ensure quality of the handover, (4) weighing the advantages and disadvantages of the bedside handover and (5) having different perspectives on the transfer of responsibility. While the professionals perceptions of post-op handover differed in regards to temporal foci, all groups agreed upon the need to ensure quality of care. There are gaps between different professionals practices of post-op care which can be minimized. 56% of the cohort's 313 066 patients were female; the mean (SD) age was 60 (16) years; 49% of procedures were conducted in academic facilities; 72% of surgeries were elective; and the median time of surgery was 182 minutes (interquartile [IQR] range, 124-255). 5941 (1.9 ASSESSING PACU HANDOFF REPORT CONFIDENCE https://doi.org/10.1001/jama.2 017.20040 31 Ontario Health Insurance Plan (physician billings), the Corporate Provider Database (physician demographic data from Ontarios Ministry of Health and Long-Term Care), and the Registered Persons Database (patient demographics and vital status). percent) patients had surgery with full anesthesia care handover. Each year of the research, the number of patients having surgery with a transfer of anesthesiology treatment grew, reaching 2.9 percent in 2015. The main outcome happened in 44% of the full handover group and 29% of the no handover group in the unweighted sample. ASSESSING PACU HANDOFF REPORT CONFIDENCE Krishnan, S., Kumar, N., Diaz, E., Thornton, I., Ghoddoussi, F., & Ellis, T. A., 2nd (2020). Anesthesiology Handoff Simulation Case: A Handoff From Intensive Care Unit to Operating Room for Anesthesiology Learners. MedEdPORTAL : the journal of teaching and learning resources, 16, 10887. https://doi.org/10.15766/mep_ 2374-8265.10887 Quality Improvem ent Level of evidence: 1 N= 27 32 Medical Student and Student Nurse Anesthetist This simulation was created for anesthesiology students to practice executing complete and content-appropriate handoffs in the perioperative context. The quantitative component of the scoring key assessed their ability to convey required patient information and to assimilate and comprehend medical concerns with anesthetic implications. The qualitative section of the scoring key provided feedback to learners on the effectiveness and This handoff scenario had twenty-seven learners. The participants indicated that the simulation increased their comprehension of the anesthetic implications of medical problems and the important components of a handoff. Additionally, learners felt that the simulation's debriefing phase was beneficial in filling in some of their medical knowledge gaps and improving their handoff abilities. ASSESSING PACU HANDOFF REPORT CONFIDENCE 33 appropriateness of the handoff based on the Accreditation Council for Graduate Medical Education's (ACGME) core competencies, which include patient care and procedural skills, practicebased learning and improvement, professionalism, and interpersonal and communication skills. ASSESSING PACU HANDOFF REPORT CONFIDENCE Reine, E., Aase, K., Raeder, J., Thorud, A., Aarsnes, R. M., & Rusten, T. (2021). Exploring postoperative handover quality in relation to patient condition: A mixed methods study. Journal of clinical nursing, 30(7-8), 10461059. https://doi.org/10.1111/jocn.15 650 Observati onal mixed methods convergen t design. Level of evidence: 5 Quantitative (n = 109) & Qualitative data (n = 48) 34 Type of surgery Patient ASA classificati on Type of Anesthesia Gender Transferrin g team The postoperative handover assessment instrument (PoHAT) and a grading system for patient condition were used to obtain quantitative data. Qualitative data were gathered via the use of unstructured field notes and an observational guide. The study follows the GRAMMS standard for reporting mixed methods research. The observed information omissions in handovers varied from 1 to 13. (median 7). Handovers of critically stable and pleasant patients were related with a higher rate of report omissions. 50 handovers (46%) were interrupted, and checklist compliance was poor (13%, n = 14). Three topics emerged from the qualitative data analysis: "adaptation of handover," "information transfer tactics," and "contextual and individual variables." The factors that promoted excellent practices were adapting the handover to the patient's state and situational conditions, organized verbal reporting, giving patient evaluations, and team communication. ASSESSING PACU HANDOFF REPORT CONFIDENCE Shah, A. C., Herstein, A. R., Flynn-O'Brien, K. T., Oh, D. C., Xue, A. H., & Flanagan, M. R. (2019). Six Sigma Methodology and Postoperative Information Reporting: A Multidisciplinary Quality Improvement Study With Interrupted Time-Series Regression. Journal of surgical education, 76(4), 10481067. https://doi.org/10.1016/j.jsurg. 2018.12.010 Quality improvem ent Level of evidence: 1 N= 417 35 Physician trainees in anesthesia, Surgical subspecialti es, Certified registered nurse anesthetists , Recovery room registered nurses. The major end measure was the frequency of correct data transmission during verbal handover (cumulative handover score, CHS), which was calculated by comparing data items to the patient's electronic health record (EHR). A secondary result assessed the incidence of incorrect information reporting, the overall time of the TOC, and the participation of surgical subspecialty representatives. In January 2015 (pre-implementation) and May 2018 (postimplementation), a 5question survey was issued to PACU RNs (3 years postimplementation). After controlling for preintervention time trends, cumulative handover scores improved by 18.3 points in the postimplementation period (n = 70) compared to preimplementation handovers (n = 69), a result that remained statistically significant after adjusting for pre-intervention time trends. There were no statistically significant differences in the length of handover across groups. ASSESSING PACU HANDOFF REPORT TEMPLATE Appendix C DNP Project Timeline Date Task October 2021 DNP Proposal Approval November 2021 Proposal Draft 1 December 2021 Proposal Draft 2 February 2022 Proposal Draft 3 February 2022 IRB Approval March 2022 Pre Surveys sent May 2022 Post Surveys Sent June 2022 Data Collection and Analysis July 2022 Submit Initial Draft August 2022 Reassess the Initial Draft August 2022 Submission of the Initial Draft March 2023 Project Poster presentation 36 ASSESSING PACU HANDOFF REPORT TEMPLATE 37 ASSESSING PACU HANDOFF REPORT TEMPLATE 38 ASSESSING PACU HANDOFF REPORT TEMPLATE 39 ASSESSING PACU HANDOFF REPORT TEMPLATE 40 ASSESSING PACU HANDOFF REPORT TEMPLATE 41 ASSESSING PACU HANDOFF REPORT TEMPLATE 42 ASSESSING PACU HANDOFF REPORT TEMPLATE 43 ASSESSING PACU HANDOFF REPORT TEMPLATE 44 ASSESSING PACU HANDOFF REPORT TEMPLATE 45 ASSESSING PACU HANDOFF REPORT TEMPLATE 46 ASSESSING PACU HANDOFF REPORT TEMPLATE 47 ASSESSING PACU HANDOFF REPORT TEMPLATE 48 ASSESSING PACU HANDOFF REPORT TEMPLATE 49 ASSESSING PACU HANDOFF REPORT TEMPLATE 50 ASSESSING PACU HANDOFF REPORT TEMPLATE 51 ASSESSING PACU HANDOFF REPORT TEMPLATE 52 ASSESSING PACU HANDOFF REPORT TEMPLATE 53 References Aldrete, J. A. (1995). The post-anesthesia recovery score revisited. Journal of Clinical Anesthesia, 7, 89-91. DOI: 10.1016/0952-8180(94)00001-K American Association of Nurse Anesthesiology. (2020). AANA Professional Practice Manual. Retrieved April 4, 2022, from https://www.aana.com/practice/practice-manual Arnold, E. C., & Boggs, K. U. (2019). Interpersonal Relationships: Professional Communication Skills for Nurses (8th ed.). St. Louis, MO: Elsevier. Agency for Healthcare Research and Quality. (2019). SBAR Technique for Communication: A Situational Briefing Model. Retrieved from https://www.ahrq.gov/teamstepps/instructor/reference/sbar.html Bergs, J., Lambrechts, F., Simons, P., Vlayen, A., Marneffe, W., Hellings, J., & Cleemput, I. (2017). Barriers and facilitators related to the implementation of surgical safety checklists: a systematic review of the qualitative evidence. BMJ Quality & Safety, 26(12), 9971005. https://doi.org/10.1136/bmjqs-2015-005019 Daly, J., Willis, K., Small, R., Green, J., Welch, N., Kealy, M., & Hughes, E. (2007). A hierarchy of evidence for assessing qualitative health research. Journal of clinical epidemiology, 60(1), 4349. https://doi.org/10.1016/j.jclinepi.2006.03.014 Hines, R., Barash, P. G., Watrous, G., & O'Connor, T. (1992). Complications occurring in the Post anesthesia Care Unit. Anesthesia & Analgesia, 74(4). https://doi.org/10.1213/00000539-199204000-00006 Joint Commission international accreditation standards for hospitals. (2013). In Joint Commission accreditation participation requirements: Anesthesia and surgical care. DOI: 10.37573/9781585284474.002 ASSESSING PACU HANDOFF REPORT TEMPLATE 54 Jurewicz, K., Alfred, M., Neyens, D. M., Catchpole, K., Joseph, A., & Reeves, S. T. (2018). Investigating intraoperative and interprofessional handoffs in anesthesia. Proceedings of the Human Factors and Ergonomics Society Annual Meeting, 62(1), 469473. DOI: 10.1177/1541931218621107 Jurewicz, K., Manojlovich, M., & Miller, A. (2018). Quality of anesthesia handoffs and association with adverse events. Journal of Perianesthesia Nursing, 33(6), 914-923. https://doi.org/10.1016/j.jopan.2017.12.003 Kellner, D. B., Urman, R. D., Greenberg, P., & Brovman, E. Y. (2018). Analysis of adverse outcomes in the post-anesthesia care unit based on Anesthesia Liability Data. Journal of Clinical Anesthesia, 50, 4856. https://doi.org/10.1016/j.jclinane.2018.06.038 Kinsella, S. M., Girgirah, K., Scrutton, M. J. L., & Vaughan, D. J. A. (2018). Factors affecting recovery room times Kluger, M. T., & Bullock, M. F. (2002). Recovery room incidents: A review of 419 reports from the Anesthetic Incident Monitoring Study (AIMS). Anesthesia, 57(11), 10601066. https://doi.org/10.1046/j.1365-2044.2002.02865.x Kothari, A., Bhatnagar, S., & Sharma, C. (2021). Handover Communication in PostAnesthesia Care Unit: An Observational Study. Anesthesia, Essays and Researches, 15(1), 6974. doi: 10.4103/aer.aer_22_21 Leslie, J., & Scott, J. (2021). Personal SWOT analysis: Making the most of your talents and opportunities. Career Planning from MindTools.com. Retrieved April 4, 2022, from https://www.mindtools.com/pages/article/newTMC_05_1.htm McGrath, B., & Chung, F. (2003). Postoperative recovery and Discharge. Anesthesiology Clinics of North America, 21(2), 367386. ASSESSING PACU HANDOFF REPORT TEMPLATE 55 Ramsay, M. A. (2006). John Snow, MD: Anesthetist to the Queen of England and pioneer epidemiologist. Baylor University. Medical Center, 19(1), 24-28. DOI: 10.1080%2F08998280.2006.11928120 Rosswurm, M., & Larrabee, J. H. (1999, December). A model for Change to EvidencedBased Practice. Image: Journal of Nursing Scholarship, 31 (4), 317-322. DOI: 10.1111/j.15475069.1999.tb00510.x Sexton, J. B., Helmreich, R. L., Neilands, T. B., Rowan, K., Vella, K., Boyden, J., ... & Thomas, E. J. (2006). The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Services Research, 6(1), 1-10. https://doi.org/10.1186/1472-6963-6-44 Villafranca, A., McKinnon, J., & Houle, T. T. (2015). The effect of intraoperative temperature management on surgical site infection. Anesthesia & Analgesia, 120(5), 978-990. https://doi.org/10.1213/ANE.0000000000000659 Yap, Y. L., Hsu, Y. C., Kuo, M. C., Lee, M. H., & Lin, K. H. (2019). A handover protocol improves the quality of handover in anesthetic practice. BMC Anesthesiology, 19(1), 196. https://doi.org/10.1186/s12871-019-0872-2  ...

... PROGRAM STRUCTURES ON SRNA STRESS 1 Nurse Anesthesia Program Structures Impact on SRNA Stress Levels Brigette Pennington Marian University Leighton School of Nursing Chair: Lee Ranalli _________________________ Project Team Members: Madeline Wagner _________________________ Bradley Stelflug _________________________ 4/19/2023 Date of Submission: April, 10th, 2023 PROGRAM STRUCTURES ON SRNA STRESS 2 Table of Contents Abstract4 Introduction..5 Background .5 Problem Statement ..7 Organization Gap Analysis of Project Site .8 Review of Literature ...9 Theoretical Framework .11 Goals/Objectives/Expected Outcomes ..14 SWOT Analysis 15 Project Design/Methods 17 Project site and population 17 Measurement Instruments..18 Data Collection Procedure 18 Ethical Consideration/Protection of Human Subjects18 Data Analysis and Results.19 Discussion..23 Conclusion.26 References.28 Appendix A....32 Appendix B38 Appendix C....39 Appendix D....41 PROGRAM STRUCTURES ON SRNA STRESS 3 Appendix E42 Appendix F.50 Appendix G53 PROGRAM STRUCTURES ON SRNA STRESS 4 Abstract Understanding the effect of stress on Student Registered Nurse Anesthetists (SRNAs) during their CRNA school could improve the development or expansion of program structure and wellness interventions to help manage stress during school. Support by CRNA programs and faculty could improve coping strategies and address areas of concern that extreme levels of anxiety, depression, and stress can have on SRNAs. After the approval from the Institutional Review Board, a survey was created on Qualtrics and was sent out through email as a solicitation to four CRNA programs: three programs being frontloaded curriculum structures and one school an integrated program. Responses to the survey included a total of 114 SRNAs at various levels of their education in CRNA schools. Results of the survey showed that SRNAs experience higher than normal, in some cases, extreme levels of stress, anxiety, and depression during CRNA school. Education on stress and positive coping should begin as early as the interview process for future SRNA candidates and continue throughout their career in anesthesia school. Furthermore, most students participating in the survey did not feel that their school or faculty supported their mental health and well-being. The conclusion is that the development of wellness programs and mental health education is necessary for SRNAs during CRNA school. These programs should begin early to help the SRNA develop positive coping mechanisms to utilize during CRNA school. More research is needed to determine if the structure of the CRNA curriculum frontloaded verse integrated influences the stress load that an SRNA experiences during CRNA school. Keywords: CRNA, SRNA, stress, depression, anxiety, wellness program, mental health, front-loaded, integrated, CRNA school PROGRAM STRUCTURES ON SRNA STRESS 5 Nurse Anesthesia Program Structures Impact on SRNA Stress Levels Student Registered Nurse Anesthetists (SRNAs) face enormous amounts of stress during nurse anesthesia programs, which are comprised of over 2,000 hours of intense didactic work and extensive clinical training (Council on Accreditation for Nurse Anesthesia Educational Programs, 2019). To an extent, stress can be a positive motivator for students, but at a certain level, the stress can lead to the inability to perform adequately. Sources of stress can include but are not limited to: moving away from home for education and training, decreased income due to the inability to work, and adapting to the rigors demand of a graduate education program (Chipas et al., 2012). Chipas et al. (2012) states that 47.3% of SRNAs reported depression, and 21.2% reported suicidal ideation. Unmanaged stress can lead to an inferior academic performance, decreased retention of knowledge, and poor health of the SRNA (Chipas et al., 2012). Currently, there is no standard approach to wellness training across the national nurse anesthesia programs, but more have opted to incorporate wellness and stress reduction education into their curriculums (Kent, 2021). Further evaluation is needed to determine additional sources of stress the SRNAs experiences while completing this advanced degree. This research will allow programs to implement stress management education at an optimal time for knowledge retention. Background The Council on Accreditation of Nurse Anesthesia Education Programs (COA) accredits nurse anesthesia programs within the United States and Puerto Rico that award post-masters certificates, masters, or doctoral degrees. The standards created by COA are designed to prepared graduates with competencies for entry into anesthesia practice. Entry-into-practice competencies for the nurse anesthesia professional prepared at the doctoral level are those PROGRAM STRUCTURES ON SRNA STRESS 6 required at the time of graduation to provide safe, competent, and ethical anesthesia and anesthesia-related care to patients for diagnostic, therapeutic, and surgical procedures. The SRNA didactic curriculum includes 24-51 months of intense doctoral coursework including advanced anesthesiology, pathophysiology, anatomy and physiology, pharmacology, leadership, healthcare policy, and healthcare information and technology (Council on Accreditation of Nurse Anesthesia Educational Programs, 2019). Although the COA has these standards in place, SRNAs can obtain their education from either a front-loaded or integrated program. Front-loaded programs have a curriculum structure where you take all, or a majority, of the didactic coursework up-front. Didactic education provides students with a foundation in the basic sciences as well as all aspects of anesthesia equipment and anesthesia principles (Imus et al., 2015). After the didactic coursework is complete, students begin clinicals. The implementation of clinical experiences may be done gradually or immediately, full-time. Students that are in didactically formatted programs have anxiety and apprehension when transitioning to the clinical portion of their education (Imus et al., 2015). The research that showed this called for a modification to program structure which then created the integrated program structure. Integrated nurse anesthesia programs have classes and clinical experiences running simultaneously. The clinical training component of SRNA education which overlaps the didactic curriculum in integrated programs includes two years of learning in a high-stakes atmosphere, executing knowledge, and responsibility and rigor in practice on vulnerable patients (Conner, 2015). Stressors among SRNAs can be either academic or personal. Common personal stressors include changes body image, decreased self-esteem, quitting their job to start school, financial PROGRAM STRUCTURES ON SRNA STRESS 7 challenges, lack of personal/family time, and transitioning into the student role (Fernandez & Klopfenstein, 2020). Academic stress can be defined as the anxiety and discomfort experienced during the learning process, especially during challenging graduate education programs (Chipas et al., 2012). Common academic causes of stress are ineffective time management, clinical assignments, different teaching styles, and fear of dismissal due to poor grades (Chipas et al., 2012). Chipas (2012) found that stress levels continuously rise over the first 18 months of the program. Problem Statement Based on the literature and research on wellness for SRNAs I focused my PICOT question to address the goal of analyzing how nurse anesthesia students perceive feelings of support from their CRNA program regarding their well-being and stress management during academic careers. This research will be conducted through several academic programs to increase the understanding of different curriculum structures and wellness programs and education at different universities. My PICOT question is as follows: Do student registered nurse anesthetist (P) feel that their CRNA program (C) provides support, education, and resources for their mental health and well-being (I) resulting in decreased feelings of stress, anxiety, and positive coping mechanisms (O) during their academic career in CRNA school (T)? Academic programs are required by COA to provide education on wellness and substance abuse for anesthesia students and it is imperative that this educational requirement is being implemented in the curriculum in a way that is creating a positive impact on the mental health and wellness of SRNAs. PROGRAM STRUCTURES ON SRNA STRESS 8 Organizational Gap Analysis of Project Site Seventeen percent of SRNAs reported taking prescription medications to help decrease or manage their stress, and 78% of SRNAs report that their programs did not offer stress management resources (Chipas et al., 2012). Increased rates of depression and suicidal ideation and lack of perceived stress management resources show that adequate wellness and stress management among SRNAs is clearly needed. Even more specifically, there is a lack of research related to the causes of stress in nurse anesthesia students. I am currently enrolled in a front-loaded nurse anesthesia program. My biggest academic stressors include lack of income, clinical assignments, and increased travel. Since starting my program, I have also started taking prescription medications to help decrease and manage my stress level. I have a close friend who is enrolled in an integrated program. Based on certain conversations we have had, she does report an increased level of stress, but doesnt report anxiety related to clinical because she is required to complete shadow days. She also hasnt started taking prescription medications to help manage or decrease her stress levels. We may have different responses to stress due to personal factors, but I have an interest in analyzing if our varying levels of stress are related to the academic factor of different program structures. The information obtained from this study could help nurse anesthesia program directors format their programs in a way that positively impacts their students levels of stress. Program directors may also gain insight as to when stress management resources need to be offered in relation to the students coursework. PROGRAM STRUCTURES ON SRNA STRESS 9 Review of the Literature An initial search was conducted in March 2022 using two different electronic databases MEDLINE-EBSCO, and the AANA journal. The keywords were developed from the PICOT question and those keywords included "stress and well-being, anxiety, mental health, SRNA, student-registered nurse anesthetist, CRNA, curriculum, program, school, anesthesiology. From the keywords, four different BOOLEAN phrases were used to search MEDLINE-EBSCO. The first phrase was "student nurse anesthetist and stress" which obtained 13 results on EBSCO. The second search phrase used was "anxiety and SRNA" and this resulted in 5 articles on EBSCO with 3 articles being duplicates. The third phase used was "Wellness or well-being AND student nurse anesthetist" which resulted in 10 articles on EBSCO and 6 duplicates. The fourth search phrase used was "CRNA school and curriculum" and this resulted in 266 articles on EBSCO with 83 articles being duplicates and only two articles being used for the literature review. Finally, the last search phrase was SRNA stress and this was searched in the AANA journal database resulting in 26 articles with 14 being duplicates from previous searches listed above. An additional article was added to the list of used articles--a prominent study on the stress and wellbeing of SRNAs which was published in 1999, out of our inclusion criteria timeline. The inclusion criteria for the articles searched were published within the last 12 years, published in English, with full articles provided, involving participants who were nurse anesthesia students and CRNAs, and were relevant to the PICOT question. The exclusion criteria included any articles published more than 12 years ago, those with an incorrect setting, review articles, metaanalysis articles, and topics not relevant to the PICOT question. A total of 320 articles from the electronic databases MEDLINE-EBSCO and AANA journals database were recorded. A total of 104 duplicate articles were excluded. 216 articles were screened based on title, abstract, and PROGRAM STRUCTURES ON SRNA STRESS 10 study design, which resulted in 202 articles being further excluded. That left 13 articles for the literature matrix with the additional article of the landmark article bringing the literature matrix article total to 14 articles. The 14 articles that were reviewed and assessed for this project have varying levels of evidence and different studies that include SRNAs in the majority and a few of the articles include SRNAs and CRNAs. One of the landmark studies that was completed outside of the inclusion criteria was conducted in 1999 and included 1,504 SRNA participants that completed a survey assessing varying categories to determine the level of stress and support of stress management from their CRNA program (Perez & Carroll-Perez, 1999). This study reported that 76% of nurse anesthesia students did not attend a school that had a stress or wellness program specific to their CRNA program. Of the 14% of students who reported having a stress management program at their school, only 7.9% of the students utilized this resource. The results of this study identified the most stressful factors nurse anesthesia students faced which were fear of failure in classes and exams, fear of being perceived as incompetent, exhaustion, lack of social life, and fear of making a medical error. Overall, this study showcased the need for CRNA programs to create and implement programs and education on stress management (Perez & Carroll-Perez, 1999). A research study by Foley and Lanzillotta-Rangeley (2021), conducted an educational 10-day program on mindfulness and meditation that had students participate in 10 minutes of meditation for 10 days. The students took a demographic survey prior to starting and a standardized stress scale DASS-21 that was taken pre-intervention and post-intervention. After completing the meditation practice for 10 days SRNAs felt decreased anxiety, depression, and stress, and 44% of the participants wanted to continue practicing mindfulness and incorporating PROGRAM STRUCTURES ON SRNA STRESS 11 it into their daily routine (Foley & Lanzillotta-Rangeley, 2021). Mesisca and Mainwaring (2021), used surveys to assess 76 SRNAs anxiety, mental wellbeing, stress, and support from academic resources, and preceptor support. The data for this study was collected with online surveys using three validated tools: the Perceived Stress Scale-10 (PSS-10), Medical Student Well-Being Index (MSWBI), and the Penn State Worry Questionnaire (PSWQ). From this study it was found that in doctoral nurse anesthesia education programs there is low well-being and consistently high levels of stress and distress for the SRNAs while going through school. The conclusion of this article was that there needs to be increased awareness of the impact of low well-being among SRNAs in school, and intervention and wellness programs are needed, and more research needs to be conducted on this subject matter. Students want more support from their CRNA programs and education to learn to manage their mental health more effectively (Mesisca & Mainwaring, 2021). Overall, looking at the last twenty years, articles and research studies have continued to demonstrate the known high levels of stress SRNAs endure during their academic career while in school and the lack of support, education, and resources on mental health for SRNAs from their academic program. Theoretical Framework Theories of stress have always noted the importance of both person and environment in understanding the nature and consequences of stress. The interactive perspective in psychology shows that behavior, attitudes, and well-being are brought together by the person and environment (Pervin, 1989). This perspective has been formalized into the person-environment (P-E) theory of stress (Appendix D) and is the theory that was used to guide this project. The premise of this theory is that stress arises not from the person or environment separately but rather by their fit with one another. There are three basic divisions that are central PROGRAM STRUCTURES ON SRNA STRESS 12 to the P-E fit theory. The first is between the person and the environment which is needed for conceptualization of the theory and provides the foundation for examining reciprocal causation (Edwards et al., 1998). The second division is between objective and subjective representations of the person and environment. Objective person refers to characteristics that exist, and the subjective person is the perception one has about their own characteristic and attributes. The objective environment includes physical and social situations as they exist independent of the person's perceptions. The subjective environment is related to situations and events that the person perceives (Edwards et al., 1998). These two divisions produce four types of correlations between person and environment: (1) Objective P-E fit, which is the fit between the objective person and the objective environment (2) Subjective P-E fit, which is the fit between the subjective person and the subjective environment (3) Contact with reality, which is the degree that the subjective environment relates to the objective environment (4) Accuracy of self-assessment, which is the match between the subjective and objective person The third and final division differentiates two types of P-E fits. The first involves the fit between the demands of the environment and the abilities of the person. Demands include work requirements, role expectations, and upholding group and organizational standards. Abilities include skills, training, time, and energy the person may need to meet the demands (Edwards et al., 1998). The second involves the balance between the needs of the person and the supplies in the environment that relate to that persons needs. The theory characterizes needs as innate PROGRAM STRUCTURES ON SRNA STRESS 13 biological and psychical requirements, ascertained values, and rationale to achieve desired ends (Harrison, 1985). Supplies refer to extrinsic and intrinsic resources and rewards that may fulfill the persons needs, such as nourishment, housing, financial stability, and social involvement (Harrison, 1978). In the early stages of this theory, the premonition of good mental health was characterized by decreased differences between objective P-E fit, subjective P-E fit, contact with reality, and accuracy of self-assessment (French et al., 1974; Harrison, 1978). Modifications of the theory revealed that objective P-E fit has minimal impact on mental health unless it is perceived by the person and thereby translated into subjective P-E fit (Caplan, 1983). Current treatments of the P-E fit theory highlights the subjective P-E fit as the critical pathway to mental health and well-being (Edwards et al., 1998). Subjective misfits are caused by the discrepancies between the environment's supply and demands or the person's abilities and needs. These discrepancies produce two sets of possible outcomes. The first set includes psychological, physical, and behavioral strains. Strains are defined as changes from normal functioning or normal baseline (Caplan et al., 1980). Psychological strains include unhappiness, anxiety, insomnia, or restlessness. Physiological strains include elevated blood pressure, increased total cholesterol, and a weakened immune system function. Behavioral strains include tobaccos use, excessive eating, and frequent utilization of health care services. When these responses occur risk factors for other diseases increase. The frequency and accumulation of the experience of strains over time can lead to mental and physical illnesses such as chronic depression, elevated blood pressure, cardiovascular disease, peptic ulcers, and cancer (Edwards & Cooper, 2013). The second outcome includes efforts to resolve P-E misfit, which involves the use of coping and defense. Coping tries to PROGRAM STRUCTURES ON SRNA STRESS 14 improve objective P-E fit by changing the objective person or the objective environment (French et al., 1974). Defense involves efforts to enhance subjective P-E fit through cognitive distortion of the subjective person or environment without changing their objective counterparts (French et al., 1974). Defense may also include denial of experience strain, where the person acknowledges subjective P-E misfit but discounts its resulting negative impacts on their health (Harrison, 1978). Overall, SRNA stress could occur if the supplies provided in the environment are insufficient to fulfill needs. Insufficient supplies also occur because of unmet environmental demands. Front-loaded and integrated SRNA program structures present the students with different environmental supplies and demands. This theory will be used to analyze if the SRNA environment, either a front-loaded or integrated program, leads to a subjective P-E misfit. Goals, Objectives and Expected Outcomes The principle aim of this project was to gather data to determine the need for a restructuring of CRNA programs to create a better learning environment that prioritized the mental health and wellness of SRNAs. Objectives: x Explore current literature within the last 10 years related to the wellness of SRNAs in nurse anesthesia graduate programs x Send SRNAs a validated survey to collect data on stress, anxiety, and perceived mental health support from current program x Analyze the data collected to measure the level of perceived anxiety and stress in SRNA students at their current position in a CRNA program PROGRAM STRUCTURES ON SRNA STRESS 15 Expected outcomes: x Determine if different program structures create a significant difference in SRNAs perceived stress levels x Formulate recommendations to improve wellness initiatives in nurse anesthesia graduate programs based upon survey results SWOT Analysis A SWOT analysis was used to evaluate internal and external factors specific to the strengths, weaknesses, opportunities, and threats that could affect the implementation and progression of the doctoral nursing project (Appendix B). An internal strength was having two students working together on this project. This project encompassed data from multiple nurse anesthesia programs, so the two students helped divide the large workload for the project. Both students are passionate about mental health and wellness. Both students have previous backgrounds in working on wellness committees. Another internal strength was faculty involvement with a project chair that is passionate about gathering more information on stress and anxiety in SRNAs. The faculty chair believes in the benefit of the research project. Finally, having the program director as a co-chair for this project allowed for additional input, insight, and guidance to help facilitate the development and progression of this research project. External strengths include the access to other programs through faculty that teach at multiple CRNA programs. These faculty teachers assisted with the distribution of research projects which increased the sample size of the student nurse anesthetist population. Being able to work with four other nurse anesthesia programs expanded the knowledge that we gathered from this PROGRAM STRUCTURES ON SRNA STRESS 16 research project. Another external strength was the use of technology to gather the data with an online survey. An internal weakness for this project was the physical distance between the two students heading this research project and the project chair. Meetings for this project were held virtually through online meetings and conference calls, which can lead to miscommunication. Scheduling conflicts are also another weakness since both students were in clinical on opposite days during the week, limiting the availability for meetings. An external weakness was determining a valid survey to use for the research project that would gather the most pertinent data. There are several valid surveys that focus on anxiety, depression, wellness, mental health, and overall wellbeing, so deciding which survey will be most applicable to the information that needed to be collected was an issue. The distribution of the surveys by faculty members who teach at the different facilities was also a weakness in this project because the distribution of the surveys was dependent on another party involved in the project. The lack of direct access to the other schools participating created barriers to sending out the surveys within the projected timeline. A large sample size of students from different CRNA programs is one of the major opportunities for this project that could lead to data that can be presented to the American Association of Nurse Anesthesiology. This data could impact schools curriculum structure and highlight the need for more mental health services and education. A change in the environment for meeting with the chair of the project in person could be an opportunity to impact the trajectory of the project and allow for concise direction for the next steps needed to be completed. One of the external threats to this project was that this project relied heavily on technology and virtual communication. Using several CRNA programs without direct communication could limit the number of surveys that are completed by the students affecting PROGRAM STRUCTURES ON SRNA STRESS 17 the possible population size for data collection. Other students in the same program and cohort as the student chairs in charge of this project are completing other doctoral projects that have similar themes such as depression assessment and wellness initiatives. These other projects that include surveys could impact the results of the surveys that are sent out for this research project and alter the data results. The chair of this project was aware of the threat of another doctoral project and created a timeline to distribute the surveys to avoid interference. Project Design/Methods After Institutional Review Board (IRB) approval, a survey research design was conducted to evaluate the stress perception of SRNAs in CRNA programs that are structured differently. Utilization of this research design allowed the unbiased representation of the population at interest and a standardized measurement. The survey design was a cross-sectional study, which means data will be collected at one point in time from a sample selected to represent a larger population. Project Site and Population The project took place at 4 accredited CRNA programs throughout the United States. Three of the programs have a frontloaded structure, where the students participate in at least one year of didactic coursework up-front without clinical involvement. After the majority of didactic coursework is completed, the student begins integrating into the clinical setting. One of the programs had an integrated structure where the classes and clinical experiences run simultaneously within one year of the program start. All SRNA students (cohort of 2023, 2024, and 2025) currently enrolled in these programs will be sent the survey. PROGRAM STRUCTURES ON SRNA STRESS 18 Measurement Instruments The first section of the survey consisted of questions related to demographic data and the use/availability of stress management programs. The second section of the survey was the DASS-21. The DASS-21 is a clinical assessment that measures the three related states of depression, anxiety, and stress. It has 21 questions and takes about 3 minutes to complete. Students are asked to read each statement and circle a number, from 0 (did not apply to me at all) to 3 (applied to me very much or most of the time) dictating how much the statement applied to them over the past week. The third section contained a list of stressors related to anesthesia school. Students were asked to rate the sources of stress on a scale from 1 (no stress) to 5 (extremely stressful). The final section of the questionnaire addressed the use of coping strategies by the students. Seven coping strategies were measured by a scale rating the frequency of use from 1 (always) to 4 (never). The survey (Appendix E) was utilized after validation by two students from the same cohort, two nurse anesthesia faculty member, and one faculty member outside the nurse anesthesia department. Data Collection Procedures An online Qualtrics survey was utilized for the dissemination of this project. Qualtrics meets the highest IRB and security standards in the industry. Survey reminders were sent out every two weeks after the initial request for participation. Data collection was completed in a 12week period. Stats iQ uncovers the meaning in data, identifies hidden trends, and produces predictive models. Stats iQ automatically runs the right statistical test and visualizations, and then trends the results into simple language that can be put into action. Ethical Considerations/Protection of Human Subjects PROGRAM STRUCTURES ON SRNA STRESS 19 Students were asked to provide electronic informed voluntary consent allowing those refusing to participate to do so. Participants had the right to withdraw from the study at any time with no penalty and it had no effect on their academic performance. Only the scholarly project team had access to the date which was stored on a password protect computer. Data will be deleted three years following project completion. Data Analysis and Results The survey was sent out through email solicitation with a link that was created through Qualtrics. The survey was sent to SRNAs at Marian University, Clarkson College, National University, and The University of South Florida. Marian University, Clarkson College, and National University fall under the category of a front-loaded program. The University of South Florida is an integrated program. Distribution of the survey started on November 21, 2022, and continued through February 19, 2023, for a total of 90 days. There were 114 surveys started and a total of 112 completed surveys. Data collected from the surveys resulted in the following: Marian University, 70 SRNA participants; Clarkson College, 16 SRNA participants; National University, 6 SRNA participants; and University of South Florida with 22 SRNA participants. Each participant was asked to select her year in CRNA school, and there were 47 first year SRNAs, 44 second year SRNAs, and 23 third year SRNAs (Qualtrics, 2022-2023). Demographics of the students were collected. The average age of SRNAs was between 25-35 years old with the 25-30 age group resulting in 42.9% of the total population surveyed and the age category 30-35 making up 32.46% for a total of 75.36%. The gender division of SRNA students resulted in 70 female student and 44 male student respondents. Relationship status showed that majority of SRNA participants were some types of a relationship with 53.51% married and 25.44% in a committed relationship. The other relationship categories resulted in PROGRAM STRUCTURES ON SRNA STRESS 20 19.3% of respondents marking single and less than 1% in divorced or other category (Qualtrics, 2022-2023). Students were asked if their CRNA school provided resources and education for mental health. 71.38% of students responded yes, 23.68% selected no, and 4.39% selected unsure. Utilizing the mental health resources provided by the school was only used by 11.40% of students; however, reaching out for mental health or other counseling services were utilized by 26.32% of students. 16.67% of students did not use any mental health services, but recognized that they needed such a service., and 57% of the SRNAs did not utilize any mental health services at all. These results show that a little more than one quarter of the students were actively engaged in counseling services during their current enrollment in CRNA school (Qualtrics, 2022-2023). The DASS-21 questionnaire was chosen because of the standardization of the stress scale measuring three categories of anxiety, depression, and stress. The DASS-21 items questionnaire is self-reporting and was included in the survey sent out to students. The DASS-21 can be referenced in Appendix E, section 2. The DASS-21 questionnaire has categorized results of depression, anxiety, and stress, in sections of normal, moderate, severe, and extremely severe. Based on the scoring key, the mean score for each question in the DASS-21 survey was calculated to report the total score and define the category resulting from that total score. This calculation was decided on because of the validity of responses attributed to a standard deviation of <1.0 for each question. For depression, the score was 24.28, which is categorized as severe depression. Anxiety category was a total of 26.08 which is categorized as extremely severe, and the stress category score was 31.76 which is severe. These results show that the SRNAs who participated in this section of the survey are past the moderate levels of anxiety, stress, and PROGRAM STRUCTURES ON SRNA STRESS 21 depression and are experiencing much higher-than-normal levels while in CRNA school (Qualtrics, 2022-2023). The next data collected reflected on questions about items and events that have occurred for the students during their time in CRNA school. The highlights of this question show that 27.6% of participants experienced the death of close person or family member. Divorce and marital separation effected 7.41%, and 11.11% had a birth of a child while in CRNA school. Changes in personal habits were experienced by 83.78%, and 83.94% has a change in their financial state. This question and the entire results are in Appendix F Table 1. Further evaluation of specific sources of stress were asked in question 13 of the survey, and the full results of the question are in Appendix F Table 2. Stress factors that scored highly were fear of a clinical error with a SD= 1.08 and categorized as highly stressed by 35.14% and as moderate stress by 25.23% of SRNAs. Mental and physical exhaustion resulted in a SD= 1.08 with 25.23% reporting as highly stressed and 28.83% in the moderate stress category (Qualtrics, 2022-2023). Assessment of the use of 6 coping strategies was asked in question 14 (Appendix F Table 3) with the answer selection of always, frequently, seldom, and never. The results showed that only 0.91% always communicated with faculty regarding feelings or frustrations, 7% frequently, 55.45% seldomly. 36.36% of respondents expressed frustrations with classmates, 26.36% always, 53.64% frequently, 18.18% seldom, and 1.82% never. The use of relaxation or meditation techniques to deal with stressful situations was only used by 8.18% always, 33.64% frequently, 40.91% seldom, and 17.27% never. Seek guidance from a professional counselor always was 4.59%, frequently 10.09%, 22.94% seldom, and 62.39% never. The exercise category showed 18.18% always, 33.64% frequently, 43.64% seldom, and 4.55% never. The final coping strategy of relying on personal support systems showed 47.27% selected always, PROGRAM STRUCTURES ON SRNA STRESS 22 while 39.09% chose frequently, 12.73% seldom, and 0.91% never. The coping strategies show that support systems were the most significantly utilized in the always category, and professional counseling was the highest reported for the never category (Qualtrics, 2022 2023). The University of South Florida (USF) CRNA school is an integrated program and had 22 first year SRNA students participate in the survey. SRNAs gender characteristics were 14 female and 6 male students. Four students were in the 2025-year range, twelve students in the 2530-year range, two students in the 30-35 year range, and four students in the 35-40 year range. The students reported 31.82% single and 68.18% in a relationship or marriage. The SRNAs at USF answered 72.73% yes to having resources provided to them for mental health from their school, but 90% have not used the resources. Only 13.64% of the students have reached out for professional counseling services, and another 13.64% answered that they have not but they do need to seek out counseling. The majority, 68.18%, selected that yes, they feel supported by faculty regarding their mental health (Qualtrics, 20222023). Results of the DASS-21 questionnaire has categorized each section of depression, anxiety, and stress, as normal, moderate, severe, and extremely severe. Based on the scoring key the mean score for each question in the DASS-21 survey was calculated to report the total score and define the category to which the total score contributed. This calculation was decided on because of the validity of responses attributed to a standard deviation of <1.07 for each question. For depression, the score was 10.41, which is in the normal category. Anxiety category was a total of 12.87, which is categorized as moderate, and the stress category score was 10.46, which is the normal category. The front-loaded programs had a depression score of 24.28, which is categorized as severe depression. The anxiety category was a total of 26.08 which is categorized PROGRAM STRUCTURES ON SRNA STRESS 23 as extremely severe, and the stress category was 31.76 which is severe. The coping strategy results for USF SRNAs were like those at other schools in all six categories (Qualtrics, 2022 2023). Further evaluation of specific sources of stress were asked in question 13 of the survey, and the full results of the question for USF SRNAs is in Appendix G. The biggest difference between the front-loaded curriculum and integrated curriculum structure is when SRNAs start clinical. For front-loaded, the implementation of clinical experiences may be done gradually or immediately, full time. Integrated nurse anesthesia programs have classes and clinical experiences running simultaneously. For USF SRNAs, the fear of clinical error was 31.82% for extremely stressed, and for Marian SRNAs it was a 38.81% for highly stressed. USF students scored mental and physical exhaustion at 45.45% for moderately stressed, and for Marian SRNAs it was 31.34% for highly stressed. Discussion The survey was sent out through email solicitation with a link that was created through Qualtrics. The survey was sent to SRNAs at Marian University, Clarkson College, National University, and the University of South Florida. Marian University, Clarkson College, and National University fall under the category of a front-loaded program. The University of South Florida is an integrated program. Distribution of the survey started on November 21, 2022, and continued through February 19, 2023, for a total of 90 days. 114 surveys were started and a total of 112 completed surveys were received. Data collected from the surveys was gleaned from Marian University's 70 SRNA participants, Clarkson College's 16 SRNA participants, National University's 6 SRNA participants, and the University of South Floridas 22 SRNA participants. PROGRAM STRUCTURES ON SRNA STRESS 24 Each participant was asked to select her year in CRNA school, and there were 47 first year SRNAs, 44 second year SRNAs, and 23 third year SRNAs (Qualtrics, 20222023). Demographics of the students were collected, and the average age of SRNAs was between 2535 years old with the 25-30 age group resulting in 42.9% and the age category of 30-35 making up 32.46% for a total of 75.36%. The gender division of SRNA students resulted in 70 female students and 44 male student respondents. Relationship status showed that the majority of SRNA participants were in some type of relationship with 53.51% married, and 25.44% in a committed relationship. The other relationship categories resulted in 19.3% of students labeling themselves as single and less than 1% were in a divorced or other category (Qualtrics, 20222023). Students were asked if their CRNA school provided resources and education for mental health, and 71.38% of students responded yes, 23.68% selected no, and 4.39% selected unsure. Utilizing the mental health resources provided by the school was only done by 11.40% of students; however, reaching out for mental health or other counseling services was utilized by 26.32% of students. 16.67% of students did not use offered services, but recognized they needed to do so, and 57% of the SRNAs did not utilize any services at all. These results show that a little over a quarter of students were actively engaged in counseling services during their current enrollment in CRNA school (Qualtrics, 20222023). The DASS-21 questionnaire was chosen because of the standardization of the stress scale measuring three categories of anxiety, depression, and stress. The DASS-21 items questionnaire is self-reporting and was included in the survey sent out to students. The DASS-21 can be referenced in Appendix E section 2. The DASS-21 questionnaire has categorized results of depression, anxiety, and stress, into sections of normal, moderate, severe, and extremely severe. PROGRAM STRUCTURES ON SRNA STRESS 25 Based on the scoring key, the mean score for each question in the DASS-21 survey was calculated to report the total score and define the category to which the total score contributed. This calculation was decided on because of the validity of responses attributed to a standard deviation of <1.0 for each question. For depression, the score was 24.28, which is categorized as severe depression. The anxiety category was a total of 26.08 which is categorized as extremely severe, and the stress category score was 31.76 which is severe. These results show that the SRNAs who participated in this section of the survey are past the moderate levels of anxiety, stress, and depression and are experiencing many higher-than-normal levels while in CRNA school (Qualtrics, 20222023). The next data collected reflected on questions about situations and events that occurred for the students during their time in CRNA school. The highlights of this question show that 27.6% of participants experienced the death of a close person or family member. Divorce and marital separation affected 7.41%, and 11.11% had the birth of a child while in CRNA school. Changes in personal habits were reported by 83.78%, and 83.94% had a change in their financial state. This question and the entire results are in Appendix F Table 1. Further evaluation of specific sources of stress was asked in question 13 of the survey, and the full results of the question are in Appendix F Table 2. Stress factors that scored high were fear of a clinical error with an SD= 1.08 and categorized as highly stressed by 35.14% and moderately stressed by 25.23% of SRNAs. Mental and physical exhaustion scored an SD= 1.08 with 25.23% highly stressed and 28.83% in the moderate stress category (Qualtrics, 20222023). Assessment of the use of 6 coping strategies was asked in question 14 (Appendix F Table 3) with the answer selection of always, frequently, seldom, and never. The results showed that only 0.91% always communicated with faculty regarding feelings or frustrations, 7% frequently, PROGRAM STRUCTURES ON SRNA STRESS 26 and 55.45% seldomly. 36.36% expressed frustrations with classmates: 26.36% always, 53.64% frequently, 18.18% seldomly, and 1.82% never. The use of relaxation or meditation techniques to deal with stressful situations was only used by 8.18% always, 33.64% frequently, 40.91% seldom, and 17.27% never. Seeking guidance from a professional counselor always was 4.59%, frequently 10.09%, 22.94% seldom, and 62.39% never. The exercise category showed 18.18% always, 33.64% frequently, 43.64% seldom, and 4.55% never. The final coping strategy of relying on personal support systems showed 47.27% selected always, 39.09% frequently, 12.73% seldom, and 0.91% never. The coping strategies show that support systems were the most significantly utilized in the always category, and professional counseling was the highest reported for the never category (Qualtrics, 20222023). University of South Florida (USF) CRNA school is an integrated program and had 22 first year SRNA students participate in the survey. SRNAs were 14 female and 6 male students with four students in the 2025-year range, twelve students in the 2530-year range, two students in the 3035-year range, and four students in the 3540-year range. The students reported 31.82% were single, and 68.18% were in a relationship or marriage. The SRNAs at USF answered 72.73% yes to having resources provided to them for mental health from their school, but 90% have not used the resources. Only 13.64% of the students have reached out for professional counseling services, and another 13.64% answered that they have not, but they need to seek out counseling. The majority, 68.18%, selected yes that they feel supported by faculty regarding their mental health (Qualtrics, 20222023). Results of the DASS-21 questionnaire have categorized each section of depression, anxiety, and stress as normal, moderate, severe, and extremely severe. Based on the scoring key, the mean score for each question in the DASS-21 survey was calculated to report the total score PROGRAM STRUCTURES ON SRNA STRESS 27 and define the category to which the total score contributed. This calculation was decided on because of the validity of responses attributed to a standard deviation of <1.07 for each question. For depression, the score was 10.41 which is in the normal category. The anxiety category was a total of 12.87 which is categorized as moderate, and the stress category score was 10.46 which is the normal category. The front-loaded programs had a depression score of 24.28, which is categorized as severe depression. The anxiety category was a total of 26.08 which is categorized as extremely severe, and the stress category was 31.76 which is severe. The coping strategy results for USF SRNAs were similar to those at other schools in all six categories (Qualtrics, 20222023). Conclusion Analyzing the findings from the survey and the relevant literature, a recommendation for wellness programs in nurse anesthesia graduate training programs became apparent. It is crucial for programs to provide a clear pathway in policy and procedure for students to have access to mental health resources. However, programs need to do more than just provide instructions for mental health and wellness assistance. It is essential to have an ongoing assessment of students well-being during their journey in CRNA school The stress that SRNAs experience during their time in school changes with each year of the program and varies based on program structure such as front-loaded versus integrated programs. Multiple studies over the last thirty years have proven that CRNA school is challenging not only academically but on the mental and emotional health of the SRNAs. Currently, there is no data supporting one particular approach to improving SRNA wellness over another, but nurse anesthesia educational programs must improve their wellness efforts and prioritize the mental health of their students. Further research may develop PROGRAM STRUCTURES ON SRNA STRESS 28 curricular innovation for nurse anesthesia education and, possibly, for graduate programs in other professional clinical disciplines. PROGRAM STRUCTURES ON SRNA STRESS 29 References Bozimowski, G., CRNA, DNP, Groh, C., RN, PhD, Rouen, P., RN, PhD, & Dosch, M., CRNA, PhD. (2014). The prevalence and patterns of substance abuse among nurse anesthesia students. AANA, 82(4), 277283. Caplan, R. D. (1983). Person-environment fit: Past, present, and future. In C. L. Cooper (Ed.), Stress research (pp. 35-78). Caplan, R. D., Cobb, S., French, J. R. P., Jr., Harrison, R. V., & Pinneau, S. R. (1980). Job demands and worker health: Main effects and occupational differences. Chipas, A., CRNA, PhD, & McKenna, D., CRNA, MSNA. (2011). Stress and burnout in nurse anesthesia. AANA, 79(2), 122128. Chipas, A., Cordrey, D., Floyd, D., Grubbs, L., Miller, S., & Tyre, B. (2012, August). Stress: Perceptions, manifestations, and coping mechanisms of student registered nurse anesthetists. American Association of Nurse Anesthetists Journal, 80(4), 49- 55. Retrieved from https://pdfs.semanticscholar.org/28ab/95c2955219073a5cc9ae6913156b83334c0f. pdf Conner, M. (2015, April). Self-efficacy, stress, and social support in retention of student registered nurse anesthetists. American Association of Nurse Anesthetists Journal, 83(2), 133-138. Retrieved from https://www.aana.com/docs/default-source/aana- journal-webdocuments-1/self-efficacy-stress-0415-pp133- 138.pdf?sfvrsn=2bcd48b1_6 PROGRAM STRUCTURES ON SRNA STRESS 30 Council on Accreditation of Nurse Anesthesia Educational Programs. (2019). Standards for accreditation of nurse anesthesia programs - practice doctorate. https://www.coacrna.org/ Edwards, J. R., & Cooper, C. L. (2013). The impacts of positive psychological states on Physical Health: A Review and theoretical framework. Stress to Wellbeing , 1, 6690. https://doi.org/10.1057/9781137310651_4 Edwards, J. R., Caplan, R. D., & Van Harrison, R. (1998). Person-environment fit theory. Theories of organizational stress, 28(1), 67-94. Elisha, S., & Rutledge, D. N. (2011). Clinical education experiences: perceptions of student registered nurse anesthetists. AANA Journal, 79(4 Suppl), S35S42. Farina, C., Hranchook, A. M., Bittinger, A. C., & Aebersold, M. (2021). The Flipped Classroom with Case-Based Learning in Graduate Nurse Anesthesia Education. AANA Journal, 89(3), 254260. Fernandez, V., & Klopfenstein, M. (2020). Reducing Stress Among SRNAs: Implementation of a Pre-Matriculation Wellness Module (thesis). Flynn, F. M., Bing-Jonsson, P. C., Falk, R. S., Tnnessen, S., & Valeberg, B. T. (2022). Educating for Excellence: A Cohort Study on Assessing Student Nurse Anesthetist Non-Technical Skills in Clinical Practice. AANA Journal, 91(1), 715. Foley, T., DNP, CRNA, & Lanzillotta-Rangeley, J., PhD, CRNA. (2021). Stress reduction through mindfulness meditation in student registered nurse anesthetists. AANA, 89(4), 284289. PROGRAM STRUCTURES ON SRNA STRESS 31 French, J. R. P., Jr., Rodgers, W. L., & Cobb, S. (1974). Adjustment as person-environment fit. In G. Coelho, D. Hamburg, & J. Adams (Eds.), Coping and adaptation (pp. 316-333). Griffin, A., PhD, CRNA, APN, Yancey, V., PhD, CHPN, HNC-A, RN, & Dudley, M., PhD. (2017). Wellness and thriving in a student registered nurse anesthetist population. AANA, 85(5), 325330. Harrison, R. V. (1978). Person-environment fit and job stress. In C. L. Cooper and R. Payne (Eds.), Stress at work (pp. 175-205). Harrison, R. V. (1985). The person-environment fit model and the study of job stress. In T. A. Beehr & R. S. Bhagat (Eds.), Human stress and cognition in organizations (pp. 23-55). Imus, F. S., & Burns, S. (2015). What to Consider Before Beginning Graduate Education: A Pilot Study. AANA Journal, 83(5), 345350. Imus, F. S., Burns, S. M., Fisher, R., & Ranalli, L. (2015). Students perceptions on pre-clinical experience in a front-loaded nurse anesthesia program. Journal of Nursing Education and Practice, 5(10). https://doi.org/10.5430/jnep.v5n10p22 Kent, S. (2021). Wellness programs for healthcare graduate students: a literature review with recommendations for nurse anesthesia programs (thesis). Khetarpa, R., Chatrath, V., Kau, J., & Verma, A. (2015). Occupational stress in anesthesiologists and coping strategies. International Journal of Scientific Study, 3(6), 188192. https://doi.org/10.17354/ijss/2015/420 Mesisca, J., DNP, CRNA, & Mainwaring, J., DNP, MS CRNA. (2021). Stress, anxiety, and wellbeing in nurse anesthesia doctoral students. AANA, 89(5), 396402. PROGRAM STRUCTURES ON SRNA STRESS 32 Pervin, L. A. (1989). Persons, situations, interactions: The history of a controversy and a discussion of theoretical models. Academy of Management Review, 14, 350-360. Perez, E. C., CRNA, MS, & Carroll-Perez, I., CRNA, MS. (1999). A national study: stress perception by nurse anesthesia students. AANA, 67(1), 7986. Qualtrics. (2022-2023). SRNA stress in CRNA school [Unpublished raw data]. Qualtrics results. https://marian.co1.qualtrics.com/reportingdashboard/web/63fcedd6e2b16600086acf0b/pages/Page_ccf90298-0102-4be3-81457aa5872ac54a/view?surveyId=SV_6QzR7l5iu0PuWTY Stillwell, S. B., Vermeesch, A. L., & Scott, J. G. (2017). Interventions to Reduce Perceived Stress Among Graduate Students: A Systematic Review with Implications for EvidenceBased Practice. Worldviews on evidence-based nursing, 14(6), 507513. https://doi.org/10.1111/wvn.12250 Warner, D. O., Berge, K., Sun, H., Harman, A., & Wang, T. (2020). Substance use disorder in physicians after completion of training in anesthesiology in the United States from 1977 to 2013. Anesthesiology, 133(2), 342349. https://doi.org/10.1097/aln.0000000000003310 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), S49S55. Retrospective study Bozimowski, G., Groh, C., Rouen, P., & Dosch, M. (2014). The prevalence and patterns of substance abuse among nurse anesthesia students. AANA Journal, 82(4), 277283. Descriptive Study Level VI Level III Research Design & Level of Evidence Citation Study has limited the analysis to descriptive data, the addition of correlative data could have provided more insight and no psychometric assessments were performed to ensure validity or reliability Gender, race/ethnicity, program type, semester in school, depression, suicidal ideation, symptoms, exercise, coping mechanisms N = 1,282 Major Variables An online SurveyMonkey questionnaire composed of 54 study-specific questions was developed to assess stress in the SRNA population. Statistical procedures used to analyze data included independent t-tests for response levels in various domains and Pearson correlation coefficient. Internal consistency was determined by calculating the average of split-half correlations using statistical analysis software. Surveys were sent via email to the program directors of 111 CRNA schools to send to their students to collect over a 5-year period. The result of the surveys included 2,439 students that participated. The surveys were analyzed by statistical software. Instruments / Data collection Appendix A N= 2,439 Population / Sample size n=x PROGRAM STRUCTURES ON SRNA STRESS SRNAs have a substantially higher level of stress than practitioners. This high level may not be fully appreciated by educators, clinical staff, or the AANA. It is essential that this community understand the issues contributing to the high levels of stress within this population so we can work toward implementing solutions that reduce the stress. The academic community and the AANA have a role in helping students cope with stress. The result in 0.65% prevalence of substance abuse among SRNAs while in school from the study. This study was used to assess the frequency, prevalence, outcomes, and preventative measures for substance abuse among SRNAs over a 5year period from 2008 to 2012. Wellness promotion and mental health education were the most frequent prevention strategies needed to decrease substance abuse among SRNAs. Results 33 Elisha, S., & Rutledge, D. N. (2011). Clinical education experiences: perceptions of student registered nurse anesthetists. AANA Journal, 79(4 Suppl), S35 S42. Chipas, A., CRNA, PhD, & McKenna, D., CRNA, MSNA. (2011). Stress and burnout in nurse anesthesia. AANA, 79(2), 122128. Level VI A descriptive study using a crosssectional survey method Level VI A descriptive study using a crosssectional survey method N=696 N=5,737 Survey sent via email and no validation of reported experiences, invalid email addresses Survey sent to CRNAs and SRNAs and did not differentiate between level of experience or year in program. PROGRAM STRUCTURES ON SRNA STRESS SRNAs received informational email message to inform them that they would receive an invitation to participate in a study and a brief explanation of the study. A 54-item questionnaire was sent 52 questions that required closed-ended responses and 2 were open-ended. Data were analyzed using the SPSS statistical software program. A survey was sent to emails in the ANNA database to all CRNAs and SRNAs 5,737 surveys were completed to be used for data for this study. The respondents were 85% practicing CRNAs and 15% were SRNAs. The results were analyzed and distributed into different categories. The study's focus was to examine SRNA experiences during clinical education rotations. SRNA participants report high numbers of verbal abuse (69%), sexual harassment (13%), physical abuse (14%), or racial discrimination (12%) was experienced by less than 15% of the SRNAs. Learning can be enhanced by a reduction in perceived mistreatment of all types. The results of this study show that this information could be used to create educational modules and standards of conduct for preceptors in the clinical setting. SRNAs reported to be more stressed than CRNAs with 90% of the stress coming from school. Of the CRNAs that were stressed majority of them were educators that reported a higher level of stress. Results concluded that the anesthesia profession is a stressful job, and that stress management should start during anesthesia school. 34 Foley, T., DNP, CRNA, & LanzillottaRangeley, J., PhD, CRNA. (2021). Stress reduction Flynn, F. M., BingJonsson, P. C., Falk, R. S., Tnnessen, S., & Valeberg, B. T. (2022). Educating for Excellence: A Cohort Study on Assessing Student Nurse Anesthetist Non-Technical Skills in Clinical Practice. AANA Journal, 91(1), 7 15. Farina, C., Hranchook, A. M., Bittinger, A. C., & Aebersold, M. (2021). The Flipped Classroom with Case-Based Learning in Graduate Nurse Anesthesia Education. AANA Journal, 89(3), 254260. RCT -Cohort study Level II Level IV Cohort Study Level II RCT - Pilot study N=33 N=22 N=36 A cohort of SRNAs was prospectively followed over a 12- months during anesthesia education, SRNAs were assessed at 3 different time points, 9 weeks into clinical rotations, 20 weeks after clinical rotation, and 37 weeks in clinical practice. Data was collected using the assessment instrument NANTS-no to assess the SRNAs non-technical skills in clinical practice between January 2018 to January 2019. Non-technical skills should be rated according to what is expected of a qualified CRNA The preintervention and postintervention survey answers were paired together with unique user identifier code and compared. A singletailed t test was used to analyze decreases in the categories of Limited sample size n=33, small sample size of students that completed preintervention and postintervention survey (n=33) compared to the Academic performance and course satisfaction were compared using a precourse, and post-course satisfaction survey from a neuro anesthesia graduate course comparing two different first-year cohorts one with a traditional teaching method (n=19) and one that incorporated a flipped classroom model (n =17) that had case studies. The data was analyzed using a mixed methods model that also measured demographic data to compare the two cohorts for similarities regarding age, and prior nursing experience. size of the sample, recruitment method was for convenience sample, a possible threat to the studys objectivity was the first author is a clinical supervisor, but no invalidation was found Certain groups of students were not exposed to a flipped classroom model and limited to a small cohort of nurse anesthesia students to try the model of a flipped classroom. Other limitations related to curriculum limitations regarding deadlines and length of the course PROGRAM STRUCTURES ON SRNA STRESS The results of this study showed a decrease in depression after completing the course on wellness and mediation and completing ten days of practicing meditation. Students reported wanting to continue the use Of the SRNAs that participated in this study only seventeen SRNAs nontechnical skills were rated at all 3-time points, while 3 SNAs non-technical skills were rated at 2 of the time points. Descriptive statistics were presented for the SRNAs showing an improvement of the SRNAs non-technical skills and the SRNAs scored themselves significantly lower in all 4 categories compared to the expert groups of clinical educators and mentors. This study shows the lack of confidence the SRNA has in their own skill level and performance of nontechnical skills. The satisfaction scores between the two cohorts were not significantly different. However, there was an increase in satisfaction scores in both cohorts between the pre-course survey and post course survey. The study results that there is potential for flipped base classroom model to be used in graduate anesthesia school and that there is a need for further research and studies on this topic. 35 Imus, F. S., Burns, S. M., Fisher, R., & Ranalli, L. (2015). Imus, F. S., & Burns, S. (2015). What to Consider Before Beginning Graduate Education: A Pilot Study. AANA Journal, 83(5), 345350. Level VI Descriptive Study Level III Descriptive Pilot study Level II RCT pilot study N = 29 N=66 N=75 The self-efficacy results are prominent predictors of a student nurse anesthetist clinical performance and that SRNAs have decreased self-efficacy compared to the students only enrolled in didactic courses All students found that the pre-clinical experience helped reinforce their didactic curriculum. Many of the students General Self-Efficacy Scale (GSE), a survey sent to the students and data were collected with electronic data tool, analyzed with descriptive and correlational statistics (Pearson R) An online surgery was used to collect data related to the perception of the pre-clinical Age, gender, academic year, previous years of experience as a nurse, number of clinical cases, call hours, and years since attending an academic program Open ended questions, benefits of clinical training, 16 months of following 3 cohorts demonstrated that there is a strong correlation between self-efficacy and higher perceived wellness scores. There is a need for further evidence to study the relationship between these two factors and student nurse anesthetists during CRNA school. Increased levels of stress and decreased wellness were shown in programs with a doctoral curriculum versus a master's program. Salutogenic Wellness Promotion Scale (SWPS), Perceived Self-Efficacy Scale (PSE), and Academic Achievement. To measure a student's academic success - GPA. Data analysis using multiple regression analysis, and SWPS was selected as the predictor variable. Different cohorts, different class levels, demographics such as gender, age, marital status, and previous nursing experience Griffin, A., PhD, CRNA, APN, Yancey, V., PhD, CHPN, HNC-A, RN, & Dudley, M., PhD. (2017). Wellness and thriving in a student registered nurse anesthetist population. AANA, 85(5), 325330. of a meditation method and incorporate time for mindfulness into their daily routine. 36 depression, anxiety, and stress Results of the DASS-21 questionnaire was analyzed by a Wilcoxon signed rank test that resulted in a significant decrease in depression and anxiety of the participants that participated in the mindfulness meditation management. number of students that enrolled in the course (n=71). through mindfulness meditation in student registered nurse anesthetists. AANA, 89(4), 284 289. PROGRAM STRUCTURES ON SRNA STRESS RCT -Cohort study Surveys were mailed to the addresses of student nurse anesthetists and could have been filled out with other individuals' opinions involved (spouse, children, and friends or classmates). Level II Perez EC, & Carroll-Perez I. (1999). A national study: stress perception by nurse anesthesia students. AANA Journal, 67(1), 7986. N= 1,504 Class levels, open-ended questions, previous nursing experience, demographics Crosssectional mixedmethods study Level I Mesisca, J., DNP, CRNA, & Mainwaring, J., DNP, MS CRNA. (2021). Stress, anxiety, and wellbeing in nurse anesthesia doctoral students. AANA, 89(5), 396402. N=76 study habits, lab time, anxiety, and confidence. Students' perceptions on preclinical experience in a front-loaded nurse anesthesia program. Journal of Nursing Education and Practice, 5(10), 2227. https://doi.org/10.5 430/jnep.v5n10p22 PROGRAM STRUCTURES ON SRNA STRESS Survey questionnaires were mailed to the national list of student nurse anesthetists and of the 2,200 questionnaires sent out only 1,504 were filled out and returned and 1,400 of those surveys were analyzed for the data collected through the questionnaire. Data was collected and dispersed with an online survey. Three validated measurement tools used Perceived Stress Scale-10 (PSS-10), Penn State Worry Questionnaire (PSWQ), and Medical Student Well-Being Index (MSWBI) experience. It was a 21-item Likert scale style survey. Results of this study showed that 76% of the students reported that their program did not have a stress management program. Of the remaining students that reported a stress management program only 7.9% participated in it. For the life crisis portion of the survey, 26% of students fell into the moderate life crisis category and 73% were in the major life crisis category. In conclusion, this study showed the need for CRNA programs to CRNA programs result in SRNAs having low well-being, high stress, and high anxiety levels. Students want more support from programs and education and managing their mental health. There is a need for more research on this subject matter. additionally stated that this experience encouraged and motivated them to want to learn and study. There is a benefit to early integration into the clinical arena. Continued research is recommended regarding the benefits of preclinical education affecting students' confidence and anxiety levels. 37 Stillwell, S. B., Vermeesch, A. L., & Scott, J. G. (2017). Interventions to Reduce Perceived Stress Among Graduate Students: A Systematic Review with Implications for Evidence-Based Practice. Worldviews on evidence-based nursing, 14(6), 507513. https://doi.org/10.1 111/wvn.12250 Systematic review Level 1 N= 373 Stress, stress management course, yoga, meditation, deep breathing, mindfulness training, anxiety PROGRAM STRUCTURES ON SRNA STRESS Data was collected from the following databases: CINAHL plus, MEDLINE, PsycINFO. The search terms used included study, intervention, experiment, research, selfcare, stress, coping, anxiety, and mindfulness. Two authors completed an asynchronous review of the articles and one expert evidence-based practice mentor and one wellness expert conducted rigorous appraisal of the eight identified studies. Evidence was evaluated and synthesized, and recommendations for practice were determined. Self-care interventions reduced the perceived stress levels in graduate health science students. Implementing a selfcare mind-body stress reduction (MBSR) program may be encouraging for students. MBSR includes yoga, breath work, meditation and mindfulness. More research needs to be done to develop a standardized MBSR protocol. create or better implement a stress management program for SRNAs. 38 PROGRAM STRUCTURES ON SRNA STRESS 39 Appendix B STRENGTHS WEAKNESSES Two students working on a larger research project Project chair has a background on this topic Director of program is co-chair for the project . Ability to reach different programs to increase data collection Use of technology to distribute and analyze data Inabiltiy to meet in person with project chair Heavy reliability on technology for communication Indirect comminication with other CRNA programs through faculty teachers Relying on faculty to distribute the survey at other programs OPPORTUNITIES THREATS Large sample size from several CRNA programs Increased data collection Impact CRNA course curriculum to benefit students Gain insight into the need for better mental health resources Present data to the AANA Miscommunication through virtual communication Lack of access to the other programs participating in the survey Relying on others to distribute survey lead to delayed timeline Not receiving IRB approval Technology issues with survey being accessed or completed Similar themes in other DNP projects PROGRAM STRUCTURES ON SRNA STRESS Appendix C 40 PROGRAM STRUCTURES ON SRNA STRESS 41 PROGRAM STRUCTURES ON SRNA STRESS Appendix D 42 PROGRAM STRUCTURES ON SRNA STRESS Appendix E Section 1 Demographics 1. Please select age category a. 20-25 b. 25-30 c. 30-35 d. 35-40 e. 40+ 2. Please select your gender a. Male b. Female c. Other d. Decline to answer 3. Relationship status a. Single b. Married c. Relationship d. Divorced e. Other 4. Please select the CRNA school that you attend a. Marian University b. Clarkson College c. National University d. Webster University e. Southern Illinois State University f. Midwestern University g. University of South Florida h. Kaiser Permanente School of Anesthesia 5. Please select your year in anesthesia school a. First b. Second c. Third 6. Does your CRNA school provide education or resources for mental health? a. Yes b. No c. Not sure 7. Have you used the resources for mental health from your CRNA program? a. Yes 43 PROGRAM STRUCTURES ON SRNA STRESS b. No c. No resources available 8. Have you reached out for mental health/counseling services while in CRNA school? a. Yes b. No c. Have not needed services 9. Do you feel supported by your CRNA school faculty regarding your mental health and wellbeing? a. Yes b. No c. Sometimes d. Never 44 PROGRAM STRUCTURES ON SRNA STRESS Section 2 DASS 21 45 PROGRAM STRUCTURES ON SRNA STRESS 46 PROGRAM STRUCTURES ON SRNA STRESS Section 3 Sources of Stress Please select the items that have occurred since your admission to nurse anesthesia school 1. Death of spouse 2. Divorce 3. Marital separation 4. Death of close family member 5. Personal injury/illness 6. Marriage 7. Marital reconciliation 8. Change in health 9. Pregnancy 10. Change in financial state 11. Death of a close friend 12. Change in number of arguments with spouse 13. Change in living conditions 14. Change in personal habits 15. Change in residence 16. Change in church activities 17. Change in social activities 18. Change in sleeping habits 19. Change in eating habits 20. Change in number of family gatherings Use the rating scale below to answer the following questions 1- No stress 2- Mild stress 3- Moderate stress 4- Highly stressed 5- Extremely stressed 1. Fear of dismissal a. 1 b. 2 c. 3 d. 4 e. 5 2. Fear of academic failure a. 1 b. 2 c. 3 d. 4 e. 5 47 PROGRAM STRUCTURES ON SRNA STRESS 3. Fear of instructors perception of being incompetent a. 1 b. 2 c. 3 d. 4 e. 5 4. Fear of clinical error a. 1 b. 2 c. 3 d. 4 e. 5 5. Written clinical evaluations of performance a. 1 b. 2 c. 3 d. 4 e. 5 6. Ongoing personal conflict with a specific instructor a. 1 b. 2 c. 3 d. 4 e. 5 7. Ongoing personal conflict with peers a. 1 b. 2 c. 3 d. 4 e. 5 8. Mental and physical exhaustion a. 1 b. 2 c. 3 d. 4 e. 5 9. Ineffective time management a. 1 b. 2 c. 3 48 PROGRAM STRUCTURES ON SRNA STRESS d. 4 e. 5 10. Adjusting to different styles of instruction a. 1 b. 2 c. 3 d. 4 e. 5 11. Lack of time for leisure or social activates a. 1 b. 2 c. 3 d. 4 e. 5 12. Lack of autonomy and control over schedule and assignments a. 1 b. 2 c. 3 d. 4 e. 5 13. Successful completion of the national certification examination a. 1 b. 2 c. 3 d. 4 e. 5 14. Preparedness for graduation as a competent practitioner a. 1 b. 2 c. 3 d. 4 e. 5 15. Expected vigilance despite increased fatigue and workload a. 1 b. 2 c. 3 d. 4 e. 5 49 PROGRAM STRUCTURES ON SRNA STRESS Section 4 Utilizing Coping Strategies Please indicate the frequency with which you use the following strategies based on the scale below 1- Always 2- Frequently 3- Seldom 4- Never 1. Communicate your feelings and/or frustrations to the faculty a. 1 b. 2 c. 3 d. 4 2. Ventilate your frustrations to your fellow classmates a. 1 b. 2 c. 3 d. 4 3. Use relaxation techniques to deal with stressful situations a. 1 b. 2 c. 3 d. 4 4. Seek guidance from a professional counselor a. 1 b. 2 c. 3 d. 4 5. Exercise a. 1 b. 2 c. 3 d. 4 6. Reliance on personal support systems a. 1 b. 2 c. 3 d. 4 50 PROGRAM STRUCTURES ON SRNA STRESS 51 Appendix F Table 1 - Question 12 (all schools included) #12 Please select the items that have occurred since your admission to nurse anesthesia school 1 Death of a spouse 2 Death of close family member 3 Death of close friend 4 Marriage 5 Marital separation 6 Divorce 7 Personal injury/illness 23.85% 26 76.15% 83 109 8 Change in health 35.78% 39 64.22% 70 109 9 Pregnancy 6 94.44% 102 108 10 Birth of new child 11.11% 12 88.89% 96 108 11 Change in financial state 83.93% 94 16.07% 18 112 12 Change in living conditions 54.13% 59 45.87% 50 109 13 Change in personal habits 83.78% 93 16.22% 18 111 14 Change in residence 64.22% 70 35.78% 39 109 15 Change in church activities 33.94% 37 66.06% 72 109 16 Change in social activities 82.73% 91 17.27% 19 110 17 Change in sleeping habits 79.28% 88 20.72% 23 111 18 Change in exercise habits 90.09% 100 9.91% 11 111 19 Change in eating habits 79.28% 88 20.72% 23 111 20 Change in the number of family gatherings 83.78% 93 16.22% 18 111 Yes 1.85% 19.27% 6.48% 13.89% No Total 2 98.15% 106 21 80.73% 108 88 109 7 93.52% 101 108 93 108 4.63% 5 95.37% 103 108 2.78% 3 97.22% 105 108 5.56% 15 86.11% PROGRAM STRUCTURES ON SRNA STRESS 52 Table 2 - Question 13 (all schools included) 2mild stress 3moderate stress 4highly stressed 5extremely stressed #13 Question 1 - No stress 1 Fear of dismissal 14.41% 16 27.03% 30 24.32% 27 15.32% 17 18.92% 21 111 6.31% 7 18.92% 21 24.32% 27 29.73% 33 20.72% 23 111 5.45% 6 24.55% 27 21.82% 24 27.27% 30 20.91% 23 110 3.60% 4 11.71% 13 25.23% 28 35.14% 39 24.32% 27 111 18.92% 21 19.82% 22 34.23% 38 18.02% 20 9.01% 10 111 63.96% 71 14.41% 16 9.01% 10 6.31% 7 6.31% 7 111 68.47% 76 19.82% 22 7.21% 8 1.80% 2 2.70% 3 111 4.50% 5 12.61% 14 28.83% 32 28.83% 32 25.23% 28 111 7.27% 8 38.18% 42 29.09% 32 16.36% 18 9.09% 10 110 9.09% 10 30.00% 33 31.82% 35 15.45% 17 13.64% 15 110 5.41% 6 17.12% 19 33.33% 37 26.13% 29 18.02% 20 111 8.11% 9 26.13% 29 32.43% 36 17.12% 19 16.22% 18 111 8.18% 9 19.09% 21 30.91% 34 20.91% 23 20.91% 23 110 7.21% 8 20.72% 23 33.33% 37 15.32% 17 23.42% 26 111 7.21% 8 18.92% 21 34.23% 38 22.52% 25 17.12% 19 111 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Fear of academic failure Fear of instructors perception of being incompetent Fear of clinical error Written evaluation of performance Ongoing personal conflict with a specific instructor Ongoing personal conflict with peers Mental and physical exhaustion Ineffective time management Adjusting to different styles of instruction Lack for time for leisure or social activities Lack of autonomy and control over schedule and assignments Successful completion of the national certification exam Preparedness for graduation as a competent practitioner Expected vigilance despite increased fatigue and workload Total PROGRAM STRUCTURES ON SRNA STRESS 53 Table 3 - Question 14 (all schools included) #14 1 2 3 4 Question Communicate your feelings and/or frustrations to the faculty Express your frustrations to your fellow classmates Use relaxation/meditation techniques to deal with stressful situations Seek guidance from a professional counselor 1Always 2Frequently 3Seldom 4Never Total 0.91% 1 7.27% 8 55.45% 61 36.36% 40 110 26.36% 29 53.64% 59 18.18% 20 1.82% 2 110 8.18% 9 33.64% 37 40.91% 45 17.27% 19 110 4.59% 5 10.09% 11 22.94% 25 62.39% 68 109 5 Exercise 18.18% 20 33.64% 37 43.64% 48 4.55% 5 110 6 Reliance on personal support systems 47.27% 52 39.09% 43 12.73% 14 0.91% 1 110 PROGRAM STRUCTURES ON SRNA STRESS 54 Appendix G Table 1 Question 13 (USF student responses only) 2mild stress 3moderate stress 4highly stressed 5extremely stressed #13 Question Sources of Stress 1 - No stress 1 Fear of dismissal 13.64% 3 36.36% 8 18.18% 4 13.64% 3 18.18% 4 22 0.00% 0 22.73% 5 18.18% 4 36.36% 8 22.73% 5 22 0.00% 0 42.86% 9 14.29% 3 28.57% 6 14.29% 3 21 0.00% 0 9.09% 2 27.27% 6 31.82% 7 31.82% 7 22 13.64% 3 9.09% 2 54.55% 12 18.18% 4 4.55% 1 22 90.91% 20 4.55% 1 0.00% 0 0.00% 0 4.55% 1 22 81.82% 18 13.64% 3 0.00% 0 0.00% 0 4.55% 1 22 4.55% 1 9.09% 2 45.45% 10 22.73% 5 18.18% 4 22 13.64% 3 31.82% 7 40.91% 9 13.64% 3 0.00% 0 22 9.09% 2 31.82% 7 36.36% 8 9.09% 2 13.64% 3 22 4.55% 1 13.64% 3 36.36% 8 22.73% 5 22.73% 5 22 13.64% 3 40.91% 9 18.18% 4 9.09% 2 18.18% 4 22 4.55% 1 18.18% 4 36.36% 8 27.27% 6 13.64% 3 22 0.00% 0 22.73% 5 45.45% 10 18.18% 4 13.64% 3 22 9.09% 2 9.09% 2 59.09% 13 9.09% 2 13.64% 3 22 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Fear of academic failure Fear of instructors perception of being incompetent Fear of clinical error Written evaluation of performance Ongoing personal conflict with a specific instructor On going personal conflict with peers Mental and physical exhaustion Ineffective time management Adjusting to different styles of instruction Lack for time for leisure or social activities Lack of autonomy and control over schedule and assignments Successful completion of the national certification exam Preparedness for graduation as a competent practitioner Expected vigilance despite increased fatigue and workload Total  ...

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PROGRAM STRUCTURES ON SRNA STRESS 1 Nurse Anesthesia Program Structures Impact on SRNA Stress Levels Madeline Wagner Marian University Leighton School of Nursing Chair: Lee Ranalli Project Team Members: Brigette Pennington Bradley Stelflug 4/19/2023 Date of Submission: April 24th, 2023 PROGRAM STRUCTURES ON SRNA STRESS 2 Table of Contents Abstract ........................................................................................................................................... 4 Introduction ................................................................................................................................. 5 Background ......................................................................................................................... 5 Problem Statement .............................................................................................................. 7 Organization Gap Analysis of Project Site ...................................................................... 7 Review of Literature........................................................................................................................ 8 Theoretical Framework ................................................................................................................. 11 Goals/Objectives/Expected Outcomes .......................................................................................... 14 SWOT Analysis ............................................................................................................................ 15 Project Design/Methods .................................................................................................................17 Project site and population ................................................................................................ 17 Measurement Instruments ................................................................................................. 17 Data Collection Procedure ................................................................................................ 18 Ethical Consideration/Protection of Human Subjects ........................................................ 18 Data Analysis and Results ............................................................................................................. 19 Discussion ................................................................................................................................. 23 Conclusion................................................................................................................................. 26 References .................................................................................................................................... 28 Appendix A ................................................................................................................................... 32 Appendix B ................................................................................................................................... 38 Appendix C ................................................................................................................................... 39 Appendix D ................................................................................................................................... 41 PROGRAM STRUCTURES ON SRNA STRESS 3 Appendix E ................................................................................................................................... 42 Appendix F..................................................................................................................................... 50 Appendix G ................................................................................................................................... 53 PROGRAM STRUCTURES ON SRNA STRESS 4 Abstract Understanding the effect of stress on Student Registered Nurse Anesthetists (SRNAs) during their CRNA school could improve the development or expansion of program structure and wellness interventions to help manage stress during school. Support by CRNA programs and faculty could improve coping strategies and address areas of concern that extreme levels of anxiety, depression, and stress can have on SRNAs. After the approval from the Institutional Review Board, a survey was created on Qualtrics and was sent out through email as a solicitation to four CRNA programs: three programs being frontloaded curriculum structures and one school an integrated program. Responses to the survey included a total of 114 SRNAs at various levels of their education in CRNA schools. Results of the survey showed that SRNAs experience higher than normal, in some cases, extreme levels of stress, anxiety, and depression during CRNA school. Education on stress and positive coping should begin as early as the interview process for future SRNA candidates and continue throughout their career in anesthesia school. Furthermore, most students participating in the survey did not feel that their school or faculty supported their mental health and well-being. The conclusion is that the development of wellness programs and mental health education is necessary for SRNAs during CRNA school. These programs should begin early to help the SRNA develop positive coping mechanisms to utilize during CRNA school. More research is needed to determine if the structure of the CRNA curriculum frontloaded verse integrated influences the stress load that an SRNA experiences during CRNA school. Keywords: CRNA, SRNA, stress, depression, anxiety, wellness program, mental health, front-loaded, integrated, CRNA school PROGRAM STRUCTURES ON SRNA STRESS 5 Nurse Anesthesia Program Structures Impact on SRNA Stress Levels Student Registered Nurse Anesthetists (SRNAs) face enormous amounts of stress during nurse anesthesia programs, which are comprised of over 2,000 hours of intense didactic work and extensive clinical training (Council on Accreditation for Nurse Anesthesia Educational Programs, 2019). To an extent, stress can be a positive motivator for students, but at a certain level, the stress can lead to the inability to perform adequately. Sources of stress can include but are not limited to: moving away from home for education and training, decreased income due to the inability to work, and adapting to the rigors demand of a graduate education program (Chipas et al., 2012). Chipas et al. (2012) states that 47.3% of SRNAs reported depression, and 21.2% reported suicidal ideation. Unmanaged stress can lead to an inferior academic performance, decreased retention of knowledge, and poor health of the SRNA (Chipas et al., 2012). Currently, there is no standard approach to wellness training across the national nurse anesthesia programs, but more have opted to incorporate wellness and stress reduction education into their curriculums (Kent, 2021). Further evaluation is needed to determine additional sources of stress the SRNAs experiences while completing this advanced degree. This research will allow programs to implement stress management education at an optimal time for knowledge retention. Background The Council on Accreditation of Nurse Anesthesia Education Programs (COA) accredits nurse anesthesia programs within the United States and Puerto Rico that award post-masters certificates, masters, or doctoral degrees. The standards created by COA are designed to prepared graduates with competencies for entry into anesthesia practice. Entry-into-practice competencies for the nurse anesthesia professional prepared at the doctoral level are those PROGRAM STRUCTURES ON SRNA STRESS 6 required at the time of graduation to provide safe, competent, and ethical anesthesia and anesthesia-related care to patients for diagnostic, therapeutic, and surgical procedures. The SRNA didactic curriculum includes 24-51 months of intense doctoral coursework including advanced anesthesiology, pathophysiology, anatomy and physiology, pharmacology, leadership, healthcare policy, and healthcare information and technology (Council on Accreditation of Nurse Anesthesia Educational Programs, 2019). Although the COA has these standards in place, SRNAs can obtain their education from either a front-loaded or integrated program. Front-loaded programs have a curriculum structure where you take all, or a majority, of the didactic coursework up-front. Didactic education provides students with a foundation in the basic sciences as well as all aspects of anesthesia equipment and anesthesia principles (Imus et al., 2015). After the didactic coursework is complete, students begin clinicals. The implementation of clinical experiences may be done gradually or immediately, full-time. Students that are in didactically formatted programs have anxiety and apprehension when transitioning to the clinical portion of their education (Imus et al., 2015). The research that showed this called for a modification to program structure which then created the integrated program structure. Integrated nurse anesthesia programs have classes and clinical experiences running simultaneously. The clinical training component of SRNA education which overlaps the didactic curriculum in integrated programs includes two years of learning in a high-stakes atmosphere, executing knowledge, and responsibility and rigor in practice on vulnerable patients (Conner, 2015). Stressors among SRNAs can be either academic or personal. Common personal stressors include changes body image, decreased self-esteem, quitting their job to start school, financial PROGRAM STRUCTURES ON SRNA STRESS 7 challenges, lack of personal/family time, and transitioning into the student role (Fernandez & Klopfenstein, 2020). Academic stress can be defined as the anxiety and discomfort experienced during the learning process, especially during challenging graduate education programs (Chipas et al., 2012). Common academic causes of stress are ineffective time management, clinical assignments, different teaching styles, and fear of dismissal due to poor grades (Chipas et al., 2012). Chipas (2012) found that stress levels continuously rise over the first 18 months of the program. Problem Statement Based on the literature and research related to academic causes of stress for SRNAs, I focused my PICOT question on how different CRNA programs structure of coursework effects the SRNAs stress levels. This research was conducted throughout several academic programs to increase the understanding of front-loaded compared to integrated program structures. My PICOT question is as follows: Do student registered nurse anesthetists (P) at integrated CRNA programs (I) experience varying levels of stress (O) when compared to front-loaded CRNA programs (C) during their academic career in nurse anesthesia school (T)? Organizational Gap Analysis of Project Site Seventeen percent of SRNAs reported taking prescription medications to help decrease or manage their stress, and 78% of SRNAs report that their programs did not offer stress management resources (Chipas et al., 2012). Increased rates of depression and suicidal ideation and lack of perceived stress management resources show that adequate wellness and stress PROGRAM STRUCTURES ON SRNA STRESS 8 management among SRNAs is clearly needed. Even more specifically, there is a lack of research related to the causes of stress in nurse anesthesia students. I am currently enrolled in a front-loaded nurse anesthesia program. My biggest academic stressors include lack of income, clinical assignments, and increased travel. Since starting my program, I have also started taking prescription medications to help decrease and manage my stress level. I have a close friend who is enrolled in an integrated program. Based on certain conversations we have had, she does report an increased level of stress, but doesnt report anxiety related to clinical because she is required to complete shadow days. She also hasnt started taking prescription medications to help manage or decrease her stress levels. We may have different responses to stress due to personal factors, but I have an interest in analyzing if our varying levels of stress are related to the academic factor of different program structures. The information obtained from this study could help nurse anesthesia program directors format their programs in a way that positively impacts their students levels of stress. Program directors may also gain insight as to when stress management resources need to be offered in relation to the students coursework. Review of the Literature An initial search was conducted in March 2022 using two different electronic databases MEDLINE-EBSCO, and the AANA journal. The keywords were developed from the PICOT question and those keywords included "stress and well-being, anxiety, mental health, SRNA, student-registered nurse anesthetist, CRNA, curriculum, program, school, anesthesiology. From the keywords, four different BOOLEAN phrases were used to search MEDLINE-EBSCO. The first phrase was "student nurse anesthetist and stress" which obtained 13 results on EBSCO. The PROGRAM STRUCTURES ON SRNA STRESS 9 second search phrase used was "anxiety and SRNA" and this resulted in 5 articles on EBSCO with 3 articles being duplicates. The third phase used was "Wellness or well-being AND student nurse anesthetist" which resulted in 10 articles on EBSCO and 6 duplicates. The fourth search phrase used was "CRNA school and curriculum" and this resulted in 266 articles on EBSCO with 83 articles being duplicates and only two articles being used for the literature review. Finally, the last search phrase was SRNA stress and this was searched in the AANA journal database resulting in 26 articles with 14 being duplicates from previous searches listed above. An additional article was added to the list of used articles--a prominent study on the stress and wellbeing of SRNAs which was published in 1999, out of our inclusion criteria timeline. The inclusion criteria for the articles searched were published within the last 12 years, published in English, with full articles provided, involving participants who were nurse anesthesia students and CRNAs, and were relevant to the PICOT question. The exclusion criteria included any articles published more than 12 years ago, those with an incorrect setting, review articles, metaanalysis articles, and topics not relevant to the PICOT question. A total of 320 articles from the electronic databases MEDLINE-EBSCO and AANA journals database were recorded. A total of 104 duplicate articles were excluded. 216 articles were screened based on title, abstract, and study design, which resulted in 202 articles being further excluded. That left 13 articles for the literature matrix with the additional article of the landmark article bringing the literature matrix article total to 14 articles. The 14 articles that were reviewed and assessed for this project have varying levels of evidence and different studies that include SRNAs in the majority and a few of the articles include SRNAs and CRNAs. One of the landmark studies that was completed outside of the inclusion criteria was conducted in 1999 and included 1,504 SRNA participants that completed a PROGRAM STRUCTURES ON SRNA STRESS 10 survey assessing varying categories to determine the level of stress and support of stress management from their CRNA program (Perez & Carroll-Perez, 1999). This study reported that 76% of nurse anesthesia students did not attend a school that had a stress or wellness program specific to their CRNA program. Of the 14% of students who reported having a stress management program at their school, only 7.9% of the students utilized this resource. The results of this study identified the most stressful factors nurse anesthesia students faced which were fear of failure in classes and exams, fear of being perceived as incompetent, exhaustion, lack of social life, and fear of making a medical error. Overall, this study showcased the need for CRNA programs to create and implement programs and education on stress management (Perez & Carroll-Perez, 1999). A research study by Foley and Lanzillotta-Rangeley (2021), conducted an educational 10-day program on mindfulness and meditation that had students participate in 10 minutes of meditation for 10 days. The students took a demographic survey prior to starting and a standardized stress scale DASS-21 that was taken pre-intervention and post-intervention. After completing the meditation practice for 10 days SRNAs felt decreased anxiety, depression, and stress, and 44% of the participants wanted to continue practicing mindfulness and incorporating it into their daily routine (Foley & Lanzillotta-Rangeley, 2021). Mesisca and Mainwaring (2021), used surveys to assess 76 SRNAs anxiety, mental wellbeing, stress, and support from academic resources, and preceptor support. The data for this study was collected with online surveys using three validated tools: the Perceived Stress Scale-10 (PSS-10), Medical Student Well-Being Index (MSWBI), and the Penn State Worry Questionnaire (PSWQ). From this study it was found that in doctoral nurse anesthesia education programs there is low well-being and consistently high levels of stress and distress for the SRNAs while going through school. The PROGRAM STRUCTURES ON SRNA STRESS 11 conclusion of this article was that there needs to be increased awareness of the impact of low well-being among SRNAs in school, and intervention and wellness programs are needed, and more research needs to be conducted on this subject matter. Students want more support from their CRNA programs and education to learn to manage their mental health more effectively (Mesisca & Mainwaring, 2021). Overall, looking at the last twenty years, articles and research studies have continued to demonstrate the known high levels of stress SRNAs endure during their academic career while in school and the lack of support, education, and resources on mental health for SRNAs from their academic program. Theoretical Framework Theories of stress have always noted the importance of both person and environment in understanding the nature and consequences of stress. The interactive perspective in psychology shows that behavior, attitudes, and well-being are brought together by the person and environment (Pervin, 1989). This perspective has been formalized into the person-environment (P-E) theory of stress (Appendix D) and is the theory that was used to guide this project. The premise of this theory is that stress arises not from the person or environment separately but rather by their fit with one another. There are three basic divisions that are central to the P-E fit theory. The first is between the person and the environment which is needed for conceptualization of the theory and provides the foundation for examining reciprocal causation (Edwards et al., 1998). The second division is between objective and subjective representations of the person and environment. Objective person refers to characteristics that exist, and the subjective person is the perception one has about their own characteristic and attributes. The objective environment includes physical and social situations as they exist independent of the person's perceptions. The subjective environment is related to situations and events that the PROGRAM STRUCTURES ON SRNA STRESS 12 person perceives (Edwards et al., 1998). These two divisions produce four types of correlations between person and environment: (1) Objective P-E fit, which is the fit between the objective person and the objective environment (2) Subjective P-E fit, which is the fit between the subjective person and the subjective environment (3) Contact with reality, which is the degree that the subjective environment relates to the objective environment (4) Accuracy of self-assessment, which is the match between the subjective and objective person The third and final division differentiates two types of P-E fits. The first involves the fit between the demands of the environment and the abilities of the person. Demands include work requirements, role expectations, and upholding group and organizational standards. Abilities include skills, training, time, and energy the person may need to meet the demands (Edwards et al., 1998). The second involves the balance between the needs of the person and the supplies in the environment that relate to that persons needs. The theory characterizes needs as innate biological and psychical requirements, ascertained values, and rationale to achieve desired ends (Harrison, 1985). Supplies refer to extrinsic and intrinsic resources and rewards that may fulfill the persons needs, such as nourishment, housing, financial stability, and social involvement (Harrison, 1978). In the early stages of this theory, the premonition of good mental health was characterized by decreased differences between objective P-E fit, subjective P-E fit, contact with reality, and accuracy of self-assessment (French et al., 1974; Harrison, 1978). Modifications of PROGRAM STRUCTURES ON SRNA STRESS 13 the theory revealed that objective P-E fit has minimal impact on mental health unless it is perceived by the person and thereby translated into subjective P-E fit (Caplan, 1983). Current treatments of the P-E fit theory highlights the subjective P-E fit as the critical pathway to mental health and well-being (Edwards et al., 1998). Subjective misfits are caused by the discrepancies between the environment's supply and demands or the person's abilities and needs. These discrepancies produce two sets of possible outcomes. The first set includes psychological, physical, and behavioral strains. Strains are defined as changes from normal functioning or normal baseline (Caplan et al., 1980). Psychological strains include unhappiness, anxiety, insomnia, or restlessness. Physiological strains include elevated blood pressure, increased total cholesterol, and a weakened immune system function. Behavioral strains include tobaccos use, excessive eating, and frequent utilization of health care services. When these responses occur risk factors for other diseases increase. The frequency and accumulation of the experience of strains over time can lead to mental and physical illnesses such as chronic depression, elevated blood pressure, cardiovascular disease, peptic ulcers, and cancer (Edwards & Cooper, 2013). The second outcome includes efforts to resolve P-E misfit, which involves the use of coping and defense. Coping tries to improve objective P-E fit by changing the objective person or the objective environment (French et al., 1974). Defense involves efforts to enhance subjective P-E fit through cognitive distortion of the subjective person or environment without changing their objective counterparts (French et al., 1974). Defense may also include denial of experience strain, where the person acknowledges subjective P-E misfit but discounts its resulting negative impacts on their health (Harrison, 1978). PROGRAM STRUCTURES ON SRNA STRESS 14 Overall, SRNA stress could occur if the supplies provided in the environment are insufficient to fulfill needs. Insufficient supplies also occur because of unmet environmental demands. Front-loaded and integrated SRNA program structures present the students with different environmental supplies and demands. This theory will be used to analyze if the SRNA environment, either a front-loaded or integrated program, leads to a subjective P-E misfit. Goals, Objectives and Expected Outcomes The principle aim of this project was to gather data to determine the need for a restructuring of CRNA programs to create a better learning environment that prioritized the mental health and wellness of SRNAs. Objectives: Explore current literature within the last 10 years related to the wellness of SRNAs in nurse anesthesia graduate programs Send SRNAs a validated survey to collect data on stress, anxiety, and perceived mental health support from current program Analyze the data collected to measure the level of perceived anxiety and stress in SRNA students at their current position in a CRNA program Expected outcomes: Determine if different program structures create a significant difference in SRNAs perceived stress levels Formulate recommendations to improve wellness initiatives in nurse anesthesia graduate programs based upon survey results PROGRAM STRUCTURES ON SRNA STRESS 15 SWOT Analysis A SWOT analysis was used to evaluate internal and external factors specific to the strengths, weaknesses, opportunities, and threats that could affect the implementation and progression of the doctoral nursing project (Appendix B). An internal strength was having two students working together on this project. This project encompassed data from multiple nurse anesthesia programs, so the two students helped divide the large workload for the project. Both students are passionate about mental health and wellness. Both students have previous backgrounds in working on wellness committees. Another internal strength was faculty involvement with a project chair that is passionate about gathering more information on stress and anxiety in SRNAs. The faculty chair believes in the benefit of the research project. Finally, having the program director as a co-chair for this project allowed for additional input, insight, and guidance to help facilitate the development and progression of this research project. External strengths include the access to other programs through faculty that teach at multiple CRNA programs. These faculty teachers assisted with the distribution of research projects which increased the sample size of the student nurse anesthetist population. Being able to work with four other nurse anesthesia programs expanded the knowledge that we gathered from this research project. Another external strength was the use of technology to gather the data with an online survey. An internal weakness for this project was the physical distance between the two students heading this research project and the project chair. Meetings for this project were held virtually through online meetings and conference calls, which can lead to miscommunication. Scheduling conflicts are also another weakness since both students were in clinical on opposite days during the week, limiting the availability for meetings. An external weakness was determining a valid PROGRAM STRUCTURES ON SRNA STRESS 16 survey to use for the research project that would gather the most pertinent data. There are several valid surveys that focus on anxiety, depression, wellness, mental health, and overall wellbeing, so deciding which survey will be most applicable to the information that needed to be collected was an issue. The distribution of the surveys by faculty members who teach at the different facilities was also a weakness in this project because the distribution of the surveys was dependent on another party involved in the project. The lack of direct access to the other schools participating created barriers to sending out the surveys within the projected timeline. A large sample size of students from different CRNA programs is one of the major opportunities for this project that could lead to data that can be presented to the American Association of Nurse Anesthesiology. This data could impact schools curriculum structure and highlight the need for more mental health services and education. A change in the environment for meeting with the chair of the project in person could be an opportunity to impact the trajectory of the project and allow for concise direction for the next steps needed to be completed. One of the external threats to this project was that this project relied heavily on technology and virtual communication. Using several CRNA programs without direct communication could limit the number of surveys that are completed by the students affecting the possible population size for data collection. Other students in the same program and cohort as the student chairs in charge of this project are completing other doctoral projects that have similar themes such as depression assessment and wellness initiatives. These other projects that include surveys could impact the results of the surveys that are sent out for this research project and alter the data results. The chair of this project was aware of the threat of another doctoral project and created a timeline to distribute the surveys to avoid interference. PROGRAM STRUCTURES ON SRNA STRESS 17 Project Design/Methods After Institutional Review Board (IRB) approval, a survey research design was conducted to evaluate the stress perception of SRNAs in CRNA programs that are structured differently. Utilization of this research design allowed the unbiased representation of the population at interest and a standardized measurement. The survey design was a cross-sectional study, which means data will be collected at one point in time from a sample selected to represent a larger population. Project Site and Population The project took place at 4 accredited CRNA programs throughout the United States. Three of the programs have a frontloaded structure, where the students participate in at least one year of didactic coursework up-front without clinical involvement. After the majority of didactic coursework is completed, the student begins integrating into the clinical setting. One of the programs had an integrated structure where the classes and clinical experiences run simultaneously within one year of the program start. All SRNA students (cohort of 2023, 2024, and 2025) currently enrolled in these programs will be sent the survey. Measurement Instruments The first section of the survey consisted of questions related to demographic data and the use/availability of stress management programs. The second section of the survey was the DASS-21. The DASS-21 is a clinical assessment that measures the three related states of depression, anxiety, and stress. It has 21 questions and takes about 3 minutes to complete. Students are asked to read each statement and circle a number, from 0 (did not apply to me at all) to 3 (applied to me very much or most of the time) dictating how much the statement applied to them over the past week. The third section contained a list of stressors related to anesthesia PROGRAM STRUCTURES ON SRNA STRESS 18 school. Students were asked to rate the sources of stress on a scale from 1 (no stress) to 5 (extremely stressful). The final section of the questionnaire addressed the use of coping strategies by the students. Seven coping strategies were measured by a scale rating the frequency of use from 1 (always) to 4 (never). The survey (Appendix E) was utilized after validation by two students from the same cohort, two nurse anesthesia faculty member, and one faculty member outside the nurse anesthesia department. Data Collection Procedures An online Qualtrics survey was utilized for the dissemination of this project. Qualtrics meets the highest IRB and security standards in the industry. Survey reminders were sent out every two weeks after the initial request for participation. Data collection was completed in a 12week period. The results from this survey discussed above were collected and analyzed with Qualtrics. Qualtrics automatically runs the right statistical test and visualizations, and then trends the results into simple language that can be put into action. Ethical Considerations/Protection of Human Subjects Students were asked to provide electronic informed voluntary consent allowing those refusing to participate to do so. Participants had the right to withdraw from the study at any time with no penalty and it had no effect on their academic performance. Only the scholarly project team had access to the date which was stored on a password protect computer. Data will be deleted three years following project completion. Data Analysis and Results The survey was sent out through email solicitation with a link that was created through Qualtrics. The survey was sent to SRNAs at Marian University, Clarkson College, National University, and The University of South Florida. Marian University, Clarkson College, and PROGRAM STRUCTURES ON SRNA STRESS 19 National University fall under the category of a front-loaded program. The University of South Florida is an integrated program. Distribution of the survey started on November 21, 2022, and continued through February 19, 2023, for a total of 90 days. There were 114 surveys started and a total of 112 completed surveys. Data collected from the surveys resulted in the following: Marian University, 70 SRNA participants; Clarkson College, 16 SRNA participants; National University, 6 SRNA participants; and University of South Florida with 22 SRNA participants. Each participant was asked to select her year in CRNA school, and there were 47 first year SRNAs, 44 second year SRNAs, and 23 third year SRNAs (Qualtrics, 2022-2023). Demographics of the students were collected. The average age of SRNAs was between 25-35 years old with the 25-30 age group resulting in 42.9% of the total population surveyed and the age category 30-35 making up 32.46% for a total of 75.36%. The gender division of SRNA students resulted in 70 female student and 44 male student respondents. Relationship status showed that majority of SRNA participants were some types of a relationship with 53.51% married and 25.44% in a committed relationship. The other relationship categories resulted in 19.3% of respondents marking single and less than 1% in divorced or other category (Qualtrics, 2022-2023). Students were asked if their CRNA school provided resources and education for mental health. 71.38% of students responded yes, 23.68% selected no, and 4.39% selected unsure. Utilizing the mental health resources provided by the school was only used by 11.40% of students; however, reaching out for mental health or other counseling services were utilized by 26.32% of students. 16.67% of students did not use any mental health services, but recognized that they needed such a service., and 57% of the SRNAs did not utilize any mental health services at all. These results show that a little more than one quarter of the students were PROGRAM STRUCTURES ON SRNA STRESS 20 actively engaged in counseling services during their current enrollment in CRNA school (Qualtrics, 2022-2023). The DASS-21 questionnaire was chosen because of the standardization of the stress scale measuring three categories of anxiety, depression, and stress. The DASS-21 items questionnaire is self-reporting and was included in the survey sent out to students. The DASS-21 can be referenced in Appendix E, section 2. The DASS-21 questionnaire has categorized results of depression, anxiety, and stress, in sections of normal, moderate, severe, and extremely severe. Based on the scoring key, the mean score for each question in the DASS-21 survey was calculated to report the total score and define the category resulting from that total score. This calculation was decided on because of the validity of responses attributed to a standard deviation of <1.0 for each question. For depression, the score was 24.28, which is categorized as severe depression. Anxiety category was a total of 26.08 which is categorized as extremely severe, and the stress category score was 31.76 which is severe. These results show that the SRNAs who participated in this section of the survey are past the moderate levels of anxiety, stress, and depression and are experiencing much higher-than-normal levels while in CRNA school (Qualtrics, 2022-2023). The next data collected reflected on questions about items and events that have occurred for the students during their time in CRNA school. The highlights of this question show that 27.6% of participants experienced the death of close person or family member. Divorce and marital separation effected 7.41%, and 11.11% had a birth of a child while in CRNA school. Changes in personal habits were experienced by 83.78%, and 83.94% has a change in their financial state. This question and the entire results are in Appendix F Table 1. Further evaluation of specific sources of stress were asked in question 13 of the survey, and the full results of the PROGRAM STRUCTURES ON SRNA STRESS 21 question are in Appendix F Table 2. Stress factors that scored highly were fear of a clinical error with a SD= 1.08 and categorized as highly stressed by 35.14% and as moderate stress by 25.23% of SRNAs. Mental and physical exhaustion resulted in a SD= 1.08 with 25.23% reporting as highly stressed and 28.83% in the moderate stress category (Qualtrics, 2022-2023). Assessment of the use of 6 coping strategies was asked in question 14 (Appendix F Table 3) with the answer selection of always, frequently, seldom, and never. The results showed that only 0.91% always communicated with faculty regarding feelings or frustrations, 7% frequently, 55.45% seldomly. 36.36% of respondents expressed frustrations with classmates, 26.36% always, 53.64% frequently, 18.18% seldom, and 1.82% never. The use of relaxation or meditation techniques to deal with stressful situations was only used by 8.18% always, 33.64% frequently, 40.91% seldom, and 17.27% never. Seek guidance from a professional counselor always was 4.59%, frequently 10.09%, 22.94% seldom, and 62.39% never. The exercise category showed 18.18% always, 33.64% frequently, 43.64% seldom, and 4.55% never. The final coping strategy of relying on personal support systems showed 47.27% selected always, while 39.09% chose frequently, 12.73% seldom, and 0.91% never. The coping strategies show that support systems were the most significantly utilized in the always category, and professional counseling was the highest reported for the never category (Qualtrics, 2022 2023). The University of South Florida (USF) CRNA school is an integrated program and had 22 first year SRNA students participate in the survey. SRNAs gender characteristics were 14 female and 6 male students. Four students were in the 2025-year range, twelve students in the 2530-year range, two students in the 30-35 year range, and four students in the 35-40 year range. The students reported 31.82% single and 68.18% in a relationship or marriage. The PROGRAM STRUCTURES ON SRNA STRESS 22 SRNAs at USF answered 72.73% yes to having resources provided to them for mental health from their school, but 90% have not used the resources. Only 13.64% of the students have reached out for professional counseling services, and another 13.64% answered that they have not but they do need to seek out counseling. The majority, 68.18%, selected that yes, they feel supported by faculty regarding their mental health (Qualtrics, 20222023). Results of the DASS-21 questionnaire has categorized each section of depression, anxiety, and stress, as normal, moderate, severe, and extremely severe. Based on the scoring key the mean score for each question in the DASS-21 survey was calculated to report the total score and define the category to which the total score contributed. This calculation was decided on because of the validity of responses attributed to a standard deviation of <1.07 for each question. For depression, the score was 10.41, which is in the normal category. Anxiety category was a total of 12.87, which is categorized as moderate, and the stress category score was 10.46, which is the normal category. The front-loaded programs had a depression score of 24.28, which is categorized as severe depression. The anxiety category was a total of 26.08 which is categorized as extremely severe, and the stress category was 31.76 which is severe. The coping strategy results for USF SRNAs were like those at other schools in all six categories (Qualtrics, 2022 2023). Further evaluation of specific sources of stress were asked in question 13 of the survey, and the full results of the question for USF SRNAs is in Appendix G. The biggest difference between the front-loaded curriculum and integrated curriculum structure is when SRNAs start clinical. For front-loaded, the implementation of clinical experiences may be done gradually or immediately, full time. Integrated nurse anesthesia programs have classes and clinical experiences running simultaneously. For USF SRNAs, the fear of clinical error was 31.82% for PROGRAM STRUCTURES ON SRNA STRESS 23 extremely stressed, and for Marian SRNAs it was a 38.81% for highly stressed. USF students scored mental and physical exhaustion at 45.45% for moderately stressed, and for Marian SRNAs it was 31.34% for highly stressed. Discussion The survey was sent out through email solicitation with a link that was created through Qualtrics. The survey was sent to SRNAs at Marian University, Clarkson College, National University, and the University of South Florida. Marian University, Clarkson College, and National University fall under the category of a front-loaded program. The University of South Florida is an integrated program. Distribution of the survey started on November 21, 2022, and continued through February 19, 2023, for a total of 90 days. 114 surveys were started and a total of 112 completed surveys were received. Data collected from the surveys was gleaned from Marian University's 70 SRNA participants, Clarkson College's 16 SRNA participants, National University's 6 SRNA participants, and the University of South Floridas 22 SRNA participants. Each participant was asked to select her year in CRNA school, and there were 47 first year SRNAs, 44 second year SRNAs, and 23 third year SRNAs (Qualtrics, 20222023). Demographics of the students were collected, and the average age of SRNAs was between 2535 years old with the 25-30 age group resulting in 42.9% and the age category of 30-35 making up 32.46% for a total of 75.36%. The gender division of SRNA students resulted in 70 female students and 44 male student respondents. Relationship status showed that the majority of SRNA participants were in some type of relationship with 53.51% married, and 25.44% in a committed relationship. The other relationship categories resulted in 19.3% of students labeling themselves as single and less than 1% were in a divorced or other category (Qualtrics, 20222023). PROGRAM STRUCTURES ON SRNA STRESS 24 Students were asked if their CRNA school provided resources and education for mental health, and 71.38% of students responded yes, 23.68% selected no, and 4.39% selected unsure. Utilizing the mental health resources provided by the school was only done by 11.40% of students; however, reaching out for mental health or other counseling services was utilized by 26.32% of students. 16.67% of students did not use offered services, but recognized they needed to do so, and 57% of the SRNAs did not utilize any services at all. These results show that a little over a quarter of students were actively engaged in counseling services during their current enrollment in CRNA school (Qualtrics, 20222023). The DASS-21 questionnaire was chosen because of the standardization of the stress scale measuring three categories of anxiety, depression, and stress. The DASS-21 items questionnaire is self-reporting and was included in the survey sent out to students. The DASS-21 can be referenced in Appendix E section 2. The DASS-21 questionnaire has categorized results of depression, anxiety, and stress, into sections of normal, moderate, severe, and extremely severe. Based on the scoring key, the mean score for each question in the DASS-21 survey was calculated to report the total score and define the category to which the total score contributed. This calculation was decided on because of the validity of responses attributed to a standard deviation of <1.0 for each question. For depression, the score was 24.28, which is categorized as severe depression. The anxiety category was a total of 26.08 which is categorized as extremely severe, and the stress category score was 31.76 which is severe. These results show that the SRNAs who participated in this section of the survey are past the moderate levels of anxiety, stress, and depression and are experiencing many higher-than-normal levels while in CRNA school (Qualtrics, 20222023). PROGRAM STRUCTURES ON SRNA STRESS 25 The next data collected reflected on questions about situations and events that occurred for the students during their time in CRNA school. The highlights of this question show that 27.6% of participants experienced the death of a close person or family member. Divorce and marital separation affected 7.41%, and 11.11% had the birth of a child while in CRNA school. Changes in personal habits were reported by 83.78%, and 83.94% had a change in their financial state. This question and the entire results are in Appendix F Table 1. Further evaluation of specific sources of stress was asked in question 13 of the survey, and the full results of the question are in Appendix F Table 2. Stress factors that scored high were fear of a clinical error with an SD= 1.08 and categorized as highly stressed by 35.14% and moderately stressed by 25.23% of SRNAs. Mental and physical exhaustion scored an SD= 1.08 with 25.23% highly stressed and 28.83% in the moderate stress category (Qualtrics, 20222023). Assessment of the use of 6 coping strategies was asked in question 14 (Appendix F Table 3) with the answer selection of always, frequently, seldom, and never. The results showed that only 0.91% always communicated with faculty regarding feelings or frustrations, 7% frequently, and 55.45% seldomly. 36.36% expressed frustrations with classmates: 26.36% always, 53.64% frequently, 18.18% seldomly, and 1.82% never. The use of relaxation or meditation techniques to deal with stressful situations was only used by 8.18% always, 33.64% frequently, 40.91% seldom, and 17.27% never. Seeking guidance from a professional counselor always was 4.59%, frequently 10.09%, 22.94% seldom, and 62.39% never. The exercise category showed 18.18% always, 33.64% frequently, 43.64% seldom, and 4.55% never. The final coping strategy of relying on personal support systems showed 47.27% selected always, 39.09% frequently, 12.73% seldom, and 0.91% never. The coping strategies show that support systems were the PROGRAM STRUCTURES ON SRNA STRESS 26 most significantly utilized in the always category, and professional counseling was the highest reported for the never category (Qualtrics, 20222023). University of South Florida (USF) CRNA school is an integrated program and had 22 first year SRNA students participate in the survey. SRNAs were 14 female and 6 male students with four students in the 2025-year range, twelve students in the 2530-year range, two students in the 3035-year range, and four students in the 3540-year range. The students reported 31.82% were single, and 68.18% were in a relationship or marriage. The SRNAs at USF answered 72.73% yes to having resources provided to them for mental health from their school, but 90% have not used the resources. Only 13.64% of the students have reached out for professional counseling services, and another 13.64% answered that they have not, but they need to seek out counseling. The majority, 68.18%, selected yes that they feel supported by faculty regarding their mental health (Qualtrics, 20222023). Results of the DASS-21 questionnaire have categorized each section of depression, anxiety, and stress as normal, moderate, severe, and extremely severe. Based on the scoring key, the mean score for each question in the DASS-21 survey was calculated to report the total score and define the category to which the total score contributed. This calculation was decided on because of the validity of responses attributed to a standard deviation of <1.07 for each question. For depression, the score was 10.41 which is in the normal category. The anxiety category was a total of 12.87 which is categorized as moderate, and the stress category score was 10.46 which is the normal category. The front-loaded programs had a depression score of 24.28, which is categorized as severe depression. The anxiety category was a total of 26.08 which is categorized as extremely severe, and the stress category was 31.76 which is severe. The coping strategy PROGRAM STRUCTURES ON SRNA STRESS 27 results for USF SRNAs were similar to those at other schools in all six categories (Qualtrics, 20222023). Conclusion Analyzing the findings from the survey and the relevant literature, a recommendation for wellness programs in nurse anesthesia graduate training programs became apparent. It is crucial for programs to provide a clear pathway in policy and procedure for students to have access to mental health resources. However, programs need to do more than just provide instructions for mental health and wellness assistance. It is essential to have an ongoing assessment of students well-being during their journey in CRNA school The stress that SRNAs experience during their time in school changes with each year of the program and varies based on program structure such as front-loaded versus integrated programs. Multiple studies over the last thirty years have proven that CRNA school is challenging not only academically but on the mental and emotional health of the SRNAs. Currently, there is no data supporting one particular approach to improving SRNA wellness over another, but nurse anesthesia educational programs must improve their wellness efforts and prioritize the mental health of their students. Further research may develop curricular innovation for nurse anesthesia education and, possibly, for graduate programs in other professional clinical disciplines. PROGRAM STRUCTURES ON SRNA STRESS 28 References Bozimowski, G., CRNA, DNP, Groh, C., RN, PhD, Rouen, P., RN, PhD, & Dosch, M., CRNA, PhD. (2014). The prevalence and patterns of substance abuse among nurse anesthesia students. AANA, 82(4), 277283. Caplan, R. D. (1983). Person-environment fit: Past, present, and future. In C. L. Cooper (Ed.), Stress research (pp. 35-78). Caplan, R. D., Cobb, S., French, J. R. P., Jr., Harrison, R. V., & Pinneau, S. R. (1980). Job demands and worker health: Main effects and occupational differences. Chipas, A., CRNA, PhD, & McKenna, D., CRNA, MSNA. (2011). Stress and burnout in nurse anesthesia. AANA, 79(2), 122128. Chipas, A., Cordrey, D., Floyd, D., Grubbs, L., Miller, S., & Tyre, B. (2012, August). Stress: Perceptions, manifestations, and coping mechanisms of student registered nurse anesthetists. American Association of Nurse Anesthetists Journal, 80(4), 49- 55. Retrieved from https://pdfs.semanticscholar.org/28ab/95c2955219073a5cc9ae6913156b83334c0f. pdf Conner, M. (2015, April). Self-efficacy, stress, and social support in retention of student registered nurse anesthetists. American Association of Nurse Anesthetists Journal, 83(2), 133-138. Retrieved from https://www.aana.com/docs/default-source/aana- journal-webdocuments-1/self-efficacy-stress-0415-pp133- 138.pdf?sfvrsn=2bcd48b1_6 PROGRAM STRUCTURES ON SRNA STRESS 29 Council on Accreditation of Nurse Anesthesia Educational Programs. (2019). Standards for accreditation of nurse anesthesia programs - practice doctorate. https://www.coacrna.org/ Edwards, J. R., & Cooper, C. L. (2013). The impacts of positive psychological states on Physical Health: A Review and theoretical framework. Stress to Wellbeing , 1, 6690. https://doi.org/10.1057/9781137310651_4 Edwards, J. R., Caplan, R. D., & Van Harrison, R. (1998). Person-environment fit theory. Theories of organizational stress, 28(1), 67-94. Elisha, S., & Rutledge, D. N. (2011). Clinical education experiences: perceptions of student registered nurse anesthetists. AANA Journal, 79(4 Suppl), S35S42. Farina, C., Hranchook, A. M., Bittinger, A. C., & Aebersold, M. (2021). The Flipped Classroom with Case-Based Learning in Graduate Nurse Anesthesia Education. AANA Journal, 89(3), 254260. Fernandez, V., & Klopfenstein, M. (2020). Reducing Stress Among SRNAs: Implementation of a Pre-Matriculation Wellness Module (thesis). Flynn, F. M., Bing-Jonsson, P. C., Falk, R. S., Tnnessen, S., & Valeberg, B. T. (2022). Educating for Excellence: A Cohort Study on Assessing Student Nurse Anesthetist Non-Technical Skills in Clinical Practice. AANA Journal, 91(1), 715. Foley, T., DNP, CRNA, & Lanzillotta-Rangeley, J., PhD, CRNA. (2021). Stress reduction through mindfulness meditation in student registered nurse anesthetists. AANA, 89(4), 284289. PROGRAM STRUCTURES ON SRNA STRESS 30 French, J. R. P., Jr., Rodgers, W. L., & Cobb, S. (1974). Adjustment as person-environment fit. In G. Coelho, D. Hamburg, & J. Adams (Eds.), Coping and adaptation (pp. 316-333). Griffin, A., PhD, CRNA, APN, Yancey, V., PhD, CHPN, HNC-A, RN, & Dudley, M., PhD. (2017). Wellness and thriving in a student registered nurse anesthetist population. AANA, 85(5), 325330. Harrison, R. V. (1978). Person-environment fit and job stress. In C. L. Cooper and R. Payne (Eds.), Stress at work (pp. 175-205). Harrison, R. V. (1985). The person-environment fit model and the study of job stress. In T. A. Beehr & R. S. Bhagat (Eds.), Human stress and cognition in organizations (pp. 23-55). Imus, F. S., & Burns, S. (2015). What to Consider Before Beginning Graduate Education: A Pilot Study. AANA Journal, 83(5), 345350. Imus, F. S., Burns, S. M., Fisher, R., & Ranalli, L. (2015). Students perceptions on pre-clinical experience in a front-loaded nurse anesthesia program. Journal of Nursing Education and Practice, 5(10). https://doi.org/10.5430/jnep.v5n10p22 Kent, S. (2021). Wellness programs for healthcare graduate students: a literature review with recommendations for nurse anesthesia programs (thesis). Khetarpa, R., Chatrath, V., Kau, J., & Verma, A. (2015). Occupational stress in anesthesiologists and coping strategies. International Journal of Scientific Study, 3(6), 188192. https://doi.org/10.17354/ijss/2015/420 Mesisca, J., DNP, CRNA, & Mainwaring, J., DNP, MS CRNA. (2021). Stress, anxiety, and wellbeing in nurse anesthesia doctoral students. AANA, 89(5), 396402. PROGRAM STRUCTURES ON SRNA STRESS 31 Pervin, L. A. (1989). Persons, situations, interactions: The history of a controversy and a discussion of theoretical models. Academy of Management Review, 14, 350-360. Perez, E. C., CRNA, MS, & Carroll-Perez, I., CRNA, MS. (1999). A national study: stress perception by nurse anesthesia students. AANA, 67(1), 7986. Qualtrics. (2022-2023). SRNA stress in CRNA school [Unpublished raw data]. Qualtrics results. https://marian.co1.qualtrics.com/reportingdashboard/web/63fcedd6e2b16600086acf0b/pages/Page_ccf90298-0102-4be3-81457aa5872ac54a/view?surveyId=SV_6QzR7l5iu0PuWTY Stillwell, S. B., Vermeesch, A. L., & Scott, J. G. (2017). Interventions to Reduce Perceived Stress Among Graduate Students: A Systematic Review with Implications for EvidenceBased Practice. Worldviews on evidence-based nursing, 14(6), 507513. https://doi.org/10.1111/wvn.12250 Warner, D. O., Berge, K., Sun, H., Harman, A., & Wang, T. (2020). Substance use disorder in physicians after completion of training in anesthesiology in the United States from 1977 to 2013. Anesthesiology, 133(2), 342349. https://doi.org/10.1097/aln.0000000000003310 PROGRAM STRUCTURES ON SRNA STRESS 32 Appendix A Citation Research Design & Level of Evidence Population / Sample size n=x Major Variables Instruments / Data collection Results Bozimowski, G., Groh, C., Rouen, P., & Dosch, M. (2014). The prevalence and patterns of substance abuse among nurse anesthesia students. AANA Journal, 82(4), 277283. Retrospective study N= 2,439 Study has limited the analysis to descriptive data, the addition of correlative data could have provided more insight and no psychometric assessments were performed to ensure validity or reliability Surveys were sent via email to the program directors of 111 CRNA schools to send to their students to collect over a 5-year period. The result of the surveys included 2,439 students that participated. The surveys were analyzed by statistical software. The result in 0.65% prevalence of substance abuse among SRNAs while in school from the study. This study was used to assess the frequency, prevalence, outcomes, and preventative measures for substance abuse among SRNAs over a 5year period from 2008 to 2012. Wellness promotion and mental health education were the most frequent prevention strategies needed to decrease substance abuse among SRNAs. 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), S49S55. Descriptive Study Level VI N = 1,282 Gender, race/ethnicity, program type, semester in school, depression, suicidal ideation, symptoms, exercise, coping mechanisms An online SurveyMonkey questionnaire composed of 54 study-specific questions was developed to assess stress in the SRNA population. Statistical procedures used to analyze data included independent t-tests for response levels in various domains and Pearson correlation coefficient. Internal consistency was determined by calculating the average of split-half correlations using statistical analysis software. SRNAs have a substantially higher level of stress than practitioners. This high level may not be fully appreciated by educators, clinical staff, or the AANA. It is essential that this community understand the issues contributing to the high levels of stress within this population so we can work toward implementing solutions that reduce the stress. The academic community and the AANA have a role in helping students cope with stress. Level III PROGRAM STRUCTURES ON SRNA STRESS Chipas, A., CRNA, PhD, & McKenna, D., CRNA, MSNA. (2011). Stress and burnout in nurse anesthesia. AANA, 79(2), 122128. Elisha, S., & Rutledge, D. N. (2011). Clinical education experiences: perceptions of student registered nurse anesthetists. AANA Journal, 79(4 Suppl), S35 S42. A descriptive study using a crosssectional survey method 33 N=5,737 Survey sent to CRNAs and SRNAs and did not differentiate between level of experience or year in program. A survey was sent to emails in the ANNA database to all CRNAs and SRNAs 5,737 surveys were completed to be used for data for this study. The respondents were 85% practicing CRNAs and 15% were SRNAs. The results were analyzed and distributed into different categories. SRNAs reported to be more stressed than CRNAs with 90% of the stress coming from school. Of the CRNAs that were stressed majority of them were educators that reported a higher level of stress. Results concluded that the anesthesia profession is a stressful job, and that stress management should start during anesthesia school. N=696 Survey sent via email and no validation of reported experiences, invalid email addresses SRNAs received informational email message to inform them that they would receive an invitation to participate in a study and a brief explanation of the study. A 54-item questionnaire was sent 52 questions that required closed-ended responses and 2 were open-ended. Data were analyzed using the SPSS statistical software program. The study's focus was to examine SRNA experiences during clinical education rotations. SRNA participants report high numbers of verbal abuse (69%), sexual harassment (13%), physical abuse (14%), or racial discrimination (12%) was experienced by less than 15% of the SRNAs. Learning can be enhanced by a reduction in perceived mistreatment of all types. The results of this study show that this information could be used to create educational modules and standards of conduct for preceptors in the clinical setting. Level VI A descriptive study using a crosssectional survey method Level VI PROGRAM STRUCTURES ON SRNA STRESS Farina, C., Hranchook, A. M., Bittinger, A. C., & Aebersold, M. (2021). The Flipped Classroom with Case-Based Learning in Graduate Nurse Anesthesia Education. AANA Journal, 89(3), 254260. RCT - Pilot study Flynn, F. M., BingJonsson, P. C., Falk, R. S., Tnnessen, S., & Valeberg, B. T. (2022). Educating for Excellence: A Cohort Study on Assessing Student Nurse Anesthetist Non-Technical Skills in Clinical Practice. AANA Journal, 91(1), 7 15. Cohort Study Foley, T., DNP, CRNA, & LanzillottaRangeley, J., PhD, CRNA. (2021). Stress reduction Level II N=36 Certain groups of students were not exposed to a flipped classroom model and limited to a small cohort of nurse anesthesia students to try the model of a flipped classroom. Other limitations related to curriculum limitations regarding deadlines and length of the course Level II Academic performance and course satisfaction were compared using a precourse, and post-course satisfaction survey from a neuro anesthesia graduate course comparing two different first-year cohorts one with a traditional teaching method (n=19) and one that incorporated a flipped classroom model (n =17) that had case studies. The data was analyzed using a mixed methods model that also measured demographic data to compare the two cohorts for similarities regarding age, and prior nursing experience. The satisfaction scores between the two cohorts were not significantly different. However, there was an increase in satisfaction scores in both cohorts between the pre-course survey and post course survey. The study results that there is potential for flipped base classroom model to be used in graduate anesthesia school and that there is a need for further research and studies on this topic. N=22 size of the sample, recruitment method was for convenience sample, a possible threat to the studys objectivity was the first author is a clinical supervisor, but no invalidation was found A cohort of SRNAs was prospectively followed over a 12- months during anesthesia education, SRNAs were assessed at 3 different time points, 9 weeks into clinical rotations, 20 weeks after clinical rotation, and 37 weeks in clinical practice. Data was collected using the assessment instrument NANTS-no to assess the SRNAs non-technical skills in clinical practice between January 2018 to January 2019. Non-technical skills should be rated according to what is expected of a qualified CRNA Of the SRNAs that participated in this study only seventeen SRNAs nontechnical skills were rated at all 3-time points, while 3 SNAs non-technical skills were rated at 2 of the time points. Descriptive statistics were presented for the SRNAs showing an improvement of the SRNAs non-technical skills and the SRNAs scored themselves significantly lower in all 4 categories compared to the expert groups of clinical educators and mentors. This study shows the lack of confidence the SRNA has in their own skill level and performance of nontechnical skills. N=33 Limited sample size n=33, small sample size of students that completed preintervention and postintervention survey (n=33) compared to the The preintervention and postintervention survey answers were paired together with unique user identifier code and compared. A singletailed t test was used to analyze decreases in the categories of The results of this study showed a decrease in depression after completing the course on wellness and mediation and completing ten days of practicing meditation. Students reported wanting to continue the use Level IV RCT -Cohort study 34 PROGRAM STRUCTURES ON SRNA STRESS number of students that enrolled in the course (n=71). depression, anxiety, and stress Results of the DASS-21 questionnaire was analyzed by a Wilcoxon signed rank test that resulted in a significant decrease in depression and anxiety of the participants that participated in the mindfulness meditation management. of a meditation method and incorporate time for mindfulness into their daily routine. N=75 Different cohorts, different class levels, demographics such as gender, age, marital status, and previous nursing experience Salutogenic Wellness Promotion Scale (SWPS), Perceived Self-Efficacy Scale (PSE), and Academic Achievement. To measure a student's academic success - GPA. Data analysis using multiple regression analysis, and SWPS was selected as the predictor variable. 16 months of following 3 cohorts demonstrated that there is a strong correlation between self-efficacy and higher perceived wellness scores. There is a need for further evidence to study the relationship between these two factors and student nurse anesthetists during CRNA school. Increased levels of stress and decreased wellness were shown in programs with a doctoral curriculum versus a master's program. N=66 Age, gender, academic year, previous years of experience as a nurse, number of clinical cases, call hours, and years since attending an academic program General Self-Efficacy Scale (GSE), a survey sent to the students and data were collected with electronic data tool, analyzed with descriptive and correlational statistics (Pearson R) The self-efficacy results are prominent predictors of a student nurse anesthetist clinical performance and that SRNAs have decreased self-efficacy compared to the students only enrolled in didactic courses N = 29 Open ended questions, benefits of clinical training, An online surgery was used to collect data related to the perception of the pre-clinical All students found that the pre-clinical experience helped reinforce their didactic curriculum. Many of the students through mindfulness meditation in student registered nurse anesthetists. AANA, 89(4), 284 289. Griffin, A., PhD, CRNA, APN, Yancey, V., PhD, CHPN, HNC-A, RN, & Dudley, M., PhD. (2017). Wellness and thriving in a student registered nurse anesthetist population. AANA, 85(5), 325330. RCT pilot study Imus, F. S., & Burns, S. (2015). What to Consider Before Beginning Graduate Education: A Pilot Study. AANA Journal, 83(5), 345350. Descriptive Pilot study Imus, F. S., Burns, S. M., Fisher, R., & Ranalli, L. (2015). Descriptive Study Level II Level III Level VI 35 PROGRAM STRUCTURES ON SRNA STRESS Students' perceptions on preclinical experience in a front-loaded nurse anesthesia program. Journal of Nursing Education and Practice, 5(10), 2227. https://doi.org/10.5 430/jnep.v5n10p22 36 study habits, lab time, anxiety, and confidence. experience. It was a 21-item Likert scale style survey. additionally stated that this experience encouraged and motivated them to want to learn and study. There is a benefit to early integration into the clinical arena. Continued research is recommended regarding the benefits of preclinical education affecting students' confidence and anxiety levels. Mesisca, J., DNP, CRNA, & Mainwaring, J., DNP, MS CRNA. (2021). Stress, anxiety, and wellbeing in nurse anesthesia doctoral students. AANA, 89(5), 396402. Crosssectional mixedmethods study Level I N=76 Class levels, open-ended questions, previous nursing experience, demographics Data was collected and dispersed with an online survey. Three validated measurement tools used Perceived Stress Scale-10 (PSS-10), Penn State Worry Questionnaire (PSWQ), and Medical Student Well-Being Index (MSWBI) CRNA programs result in SRNAs having low well-being, high stress, and high anxiety levels. Students want more support from programs and education and managing their mental health. There is a need for more research on this subject matter. Perez EC, & Carroll-Perez I. (1999). A national study: stress perception by nurse anesthesia students. AANA Journal, 67(1), 7986. Level II N= 1,504 Surveys were mailed to the addresses of student nurse anesthetists and could have been filled out with other individuals' opinions involved (spouse, children, and friends or classmates). Survey questionnaires were mailed to the national list of student nurse anesthetists and of the 2,200 questionnaires sent out only 1,504 were filled out and returned and 1,400 of those surveys were analyzed for the data collected through the questionnaire. Results of this study showed that 76% of the students reported that their program did not have a stress management program. Of the remaining students that reported a stress management program only 7.9% participated in it. For the life crisis portion of the survey, 26% of students fell into the moderate life crisis category and 73% were in the major life crisis category. In conclusion, this study showed the need for CRNA programs to RCT -Cohort study PROGRAM STRUCTURES ON SRNA STRESS 37 create or better implement a stress management program for SRNAs. Stillwell, S. B., Vermeesch, A. L., & Scott, J. G. (2017). Interventions to Reduce Perceived Stress Among Graduate Students: A Systematic Review with Implications for Evidence-Based Practice. Worldviews on evidence-based nursing, 14(6), 507513. https://doi.org/10.1 111/wvn.12250 Systematic review Level 1 N= 373 Stress, stress management course, yoga, meditation, deep breathing, mindfulness training, anxiety Data was collected from the following databases: CINAHL plus, MEDLINE, PsycINFO. The search terms used included study, intervention, experiment, research, selfcare, stress, coping, anxiety, and mindfulness. Two authors completed an asynchronous review of the articles and one expert evidence-based practice mentor and one wellness expert conducted rigorous appraisal of the eight identified studies. Evidence was evaluated and synthesized, and recommendations for practice were determined. Self-care interventions reduced the perceived stress levels in graduate health science students. Implementing a selfcare mind-body stress reduction (MBSR) program may be encouraging for students. MBSR includes yoga, breath work, meditation and mindfulness. More research needs to be done to develop a standardized MBSR protocol. PROGRAM STRUCTURES ON SRNA STRESS 38 Appendix B STRENGTHS WEAKNESSES Two students working on a larger research project Project chair has a background on this topic Director of program is co-chair for the project . Ability to reach different programs to increase data collection Use of technology to distribute and analyze data Inabiltiy to meet in person with project chair Heavy reliability on technology for communication Indirect comminication with other CRNA programs through faculty teachers Relying on faculty to distribute the survey at other programs OPPORTUNITIES THREATS Large sample size from several CRNA programs Increased data collection Impact CRNA course curriculum to benefit students Gain insight into the need for better mental health resources Present data to the AANA Miscommunication through virtual communication Lack of access to the other programs participating in the survey Relying on others to distribute survey lead to delayed timeline Not receiving IRB approval Technology issues with survey being accessed or completed Similar themes in other DNP projects PROGRAM STRUCTURES ON SRNA STRESS Appendix C 39 PROGRAM STRUCTURES ON SRNA STRESS 40 PROGRAM STRUCTURES ON SRNA STRESS Appendix D 41 PROGRAM STRUCTURES ON SRNA STRESS Appendix E Section 1 Demographics 1. Please select age category a. 20-25 b. 25-30 c. 30-35 d. 40+ 2. Please select your gender a. Male b. Female c. Other d. Decline to answer 3. Relationship status a. Single b. Married c. Relationship d. Divorced e. Other 4. Please select the CRNA school that you attend a. Marian University b. Clarkson College c. National University d. Webster University e. Southern Illinois State University f. Midwestern University g. University of South Florida h. Kaiser Permanente School of Anesthesia 5. Please select your year in anesthesia school a. First b. Second c. Third 6. Does your CRNA school provide education or resources for mental health? a. Yes b. No c. Not sure 7. Have you used the resources for mental health from your CRNA program? a. Yes b. No 42 PROGRAM STRUCTURES ON SRNA STRESS c. No resources available 8. Have you reached out for mental health/counseling services while in CRNA school? a. Yes b. No c. Have not needed services 9. Do you feel supported by your CRNA school faculty regarding your mental health and wellbeing? a. Yes b. No c. Sometimes d. Never 43 PROGRAM STRUCTURES ON SRNA STRESS Section 2 DASS 21 44 PROGRAM STRUCTURES ON SRNA STRESS 45 PROGRAM STRUCTURES ON SRNA STRESS Section 3 Sources of Stress Please select the items that have occurred since your admission to nurse anesthesia school 1. Death of spouse 2. Divorce 3. Marital separation 4. Death of close family member 5. Personal injury/illness 6. Marriage 7. Marital reconciliation 8. Change in health 9. Pregnancy 10. Change in financial state 11. Death of a close friend 12. Change in number of arguments with spouse 13. Change in living conditions 14. Change in personal habits 15. Change in residence 16. Change in church activities 17. Change in social activities 18. Change in sleeping habits 19. Change in eating habits 20. Change in number of family gatherings Use the rating scale below to answer the following questions 1- No stress 2- Mild stress 3- Moderate stress 4- Highly stressed 5- Extremely stressed 1. Fear of dismissal a. 1 b. 2 c. 3 d. 4 e. 5 2. Fear of academic failure a. 1 b. 2 c. 3 d. 4 e. 5 3. Fear of instructors perception of being incompetent 46 PROGRAM STRUCTURES ON SRNA STRESS a. b. c. d. e. 1 2 3 4 5 4. Fear of clinical error a. 1 b. 2 c. 3 d. 4 e. 5 5. Written clinical evaluations of performance a. 1 b. 2 c. 3 d. 4 e. 5 6. Ongoing personal conflict with a specific instructor a. 1 b. 2 c. 3 d. 4 e. 5 7. Ongoing personal conflict with peers a. 1 b. 2 c. 3 d. 4 e. 5 8. Mental and physical exhaustion a. 1 b. 2 c. 3 d. 4 e. 5 9. Ineffective time management a. 1 b. 2 c. 3 d. 4 47 PROGRAM STRUCTURES ON SRNA STRESS e. 5 10. Adjusting to different styles of instruction a. 1 b. 2 c. 3 d. 4 e. 5 11. Lack of time for leisure or social activates a. 1 b. 2 c. 3 d. 4 e. 5 12. Lack of autonomy and control over schedule and assignments a. 1 b. 2 c. 3 d. 4 e. 5 13. Successful completion of the national certification examination a. 1 b. 2 c. 3 d. 4 e. 5 14. Preparedness for graduation as a competent practitioner a. 1 b. 2 c. 3 d. 4 e. 5 15. Expected vigilance despite increased fatigue and workload a. 1 b. 2 c. 3 d. 4 e. 5 48 PROGRAM STRUCTURES ON SRNA STRESS Section 4 Utilizing Coping Strategies Please indicate the frequency with which you use the following strategies based on the scale below 1- Always 2- Frequently 3- Seldom 4- Never 1. Communicate your feelings and/or frustrations to the faculty a. 1 b. 2 c. 3 d. 4 2. Ventilate your frustrations to your fellow classmates a. 1 b. 2 c. 3 d. 4 3. Use relaxation techniques to deal with stressful situations a. 1 b. 2 c. 3 d. 4 4. Seek guidance from a professional counselor a. 1 b. 2 c. 3 d. 4 5. Exercise a. 1 b. 2 c. 3 d. 4 6. Reliance on personal support systems a. 1 b. 2 c. 3 d. 4 49 PROGRAM STRUCTURES ON SRNA STRESS 50 Appendix F Table 1 - Question 12 (all schools included) #12 Please select the items that have occurred since your admission to nurse anesthesia school 1 Death of a spouse 2 Death of close family member 3 Death of close friend 4 Marriage 5 Marital separation 6 Divorce 7 Personal injury/illness 23.85% 26 76.15% 83 109 8 Change in health 35.78% 39 64.22% 70 109 9 Pregnancy 6 94.44% 102 108 10 Birth of new child 11.11% 12 88.89% 96 108 11 Change in financial state 83.93% 94 16.07% 18 112 12 Change in living conditions 54.13% 59 45.87% 50 109 13 Change in personal habits 83.78% 93 16.22% 18 111 14 Change in residence 64.22% 70 35.78% 39 109 15 Change in church activities 33.94% 37 66.06% 72 109 16 Change in social activities 82.73% 91 17.27% 19 110 17 Change in sleeping habits 79.28% 88 20.72% 23 111 18 Change in exercise habits 90.09% 9.91% 11 111 19 Change in eating habits 79.28% 88 20.72% 23 111 20 Change in the number of family gatherings 83.78% 93 16.22% 18 111 Yes 1.85% 19.27% 6.48% 13.89% No Total 2 98.15% 106 21 80.73% 108 88 109 7 93.52% 101 108 93 108 4.63% 5 95.37% 103 108 2.78% 3 97.22% 105 108 5.56% 15 86.11% 100 PROGRAM STRUCTURES ON SRNA STRESS 51 Table 2 - Question 13 (all schools included) 2mild stress 3moderate stress 4highly stressed 5extremely stressed #13 Question 1 - No stress 1 Fear of dismissal 14.41% 16 27.03% 30 24.32% 27 15.32% 17 18.92% 21 111 6.31% 7 18.92% 21 24.32% 27 29.73% 33 20.72% 23 111 5.45% 6 24.55% 27 21.82% 24 27.27% 30 20.91% 23 110 3.60% 4 11.71% 13 25.23% 28 35.14% 39 24.32% 27 111 18.92% 21 19.82% 22 34.23% 38 18.02% 20 9.01% 10 111 63.96% 71 14.41% 16 9.01% 10 6.31% 7 6.31% 7 111 68.47% 76 19.82% 22 7.21% 8 1.80% 2 2.70% 3 111 4.50% 5 12.61% 14 28.83% 32 28.83% 32 25.23% 28 111 7.27% 8 38.18% 42 29.09% 32 16.36% 18 9.09% 10 110 9.09% 10 30.00% 33 31.82% 35 15.45% 17 13.64% 15 110 5.41% 6 17.12% 19 33.33% 37 26.13% 29 18.02% 20 111 8.11% 9 26.13% 29 32.43% 36 17.12% 19 16.22% 18 111 8.18% 9 19.09% 21 30.91% 34 20.91% 23 20.91% 23 110 7.21% 8 20.72% 23 33.33% 37 15.32% 17 23.42% 26 111 7.21% 8 18.92% 21 34.23% 38 22.52% 25 17.12% 19 111 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Fear of academic failure Fear of instructors perception of being incompetent Fear of clinical error Written evaluation of performance Ongoing personal conflict with a specific instructor Ongoing personal conflict with peers Mental and physical exhaustion Ineffective time management Adjusting to different styles of instruction Lack for time for leisure or social activities Lack of autonomy and control over schedule and assignments Successful completion of the national certification exam Preparedness for graduation as a competent practitioner Expected vigilance despite increased fatigue and workload Total PROGRAM STRUCTURES ON SRNA STRESS 52 Table 3 - Question 14 (all schools included) #14 1 2 3 4 Question Communicate your feelings and/or frustrations to the faculty Express your frustrations to your fellow classmates Use relaxation/meditation techniques to deal with stressful situations Seek guidance from a professional counselor 1Always 2Frequently 3Seldom 4Never Total 0.91% 1 7.27% 8 55.45% 61 36.36% 40 110 26.36% 29 53.64% 59 18.18% 20 1.82% 2 110 8.18% 9 33.64% 37 40.91% 45 17.27% 19 110 4.59% 5 10.09% 11 22.94% 25 62.39% 68 109 5 Exercise 18.18% 20 33.64% 37 43.64% 48 4.55% 5 110 6 Reliance on personal support systems 47.27% 52 39.09% 43 12.73% 14 0.91% 1 110 PROGRAM STRUCTURES ON SRNA STRESS 53 Appendix G Table 1 Question 13 (USF student responses only) 2mild stress 3moderate stress 4highly stressed 5extremely stressed #13 Question Sources of Stress 1 - No stress 1 Fear of dismissal 13.64% 3 36.36% 8 18.18% 4 13.64% 3 18.18% 4 22 0.00% 0 22.73% 5 18.18% 4 36.36% 8 22.73% 5 22 0.00% 0 42.86% 9 14.29% 3 28.57% 6 14.29% 3 21 0.00% 0 9.09% 2 27.27% 6 31.82% 7 31.82% 7 22 13.64% 3 9.09% 2 54.55% 12 18.18% 4 4.55% 1 22 90.91% 20 4.55% 1 0.00% 0 0.00% 0 4.55% 1 22 81.82% 18 13.64% 3 0.00% 0 0.00% 0 4.55% 1 22 4.55% 1 9.09% 2 45.45% 10 22.73% 5 18.18% 4 22 13.64% 3 31.82% 7 40.91% 9 13.64% 3 0.00% 0 22 9.09% 2 31.82% 7 36.36% 8 9.09% 2 13.64% 3 22 4.55% 1 13.64% 3 36.36% 8 22.73% 5 22.73% 5 22 13.64% 3 40.91% 9 18.18% 4 9.09% 2 18.18% 4 22 4.55% 1 18.18% 4 36.36% 8 27.27% 6 13.64% 3 22 0.00% 0 22.73% 5 45.45% 10 18.18% 4 13.64% 3 22 9.09% 2 9.09% 2 59.09% 13 9.09% 2 13.64% 3 22 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Fear of academic failure Fear of instructors perception of being incompetent Fear of clinical error Written evaluation of performance Ongoing personal conflict with a specific instructor On going personal conflict with peers Mental and physical exhaustion Ineffective time management Adjusting to different styles of instruction Lack for time for leisure or social activities Lack of autonomy and control over schedule and assignments Successful completion of the national certification exam Preparedness for graduation as a competent practitioner Expected vigilance despite increased fatigue and workload Total  ...