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NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 1 Needs Assessment of Podcast Use for Professional Development and Lifelong Learning in CRNAs Sydney Loesing Marian University Leighton School of Nursing Chair: Bradley Stelflug, DNAP, CRNA DNAP, CRNA Committee Member(s): Christina Pepin, PhD, RN, CNE Date of Submission: December 11, 2020 NEEDS ASSESSMENT OF PODCASTS FOR CRNAS Table of Contents Abstract ................................................................................................................................4 Introduction .........................................................................................................................5 Background and Significance ........................................................................................7 Scope of Nurse Anesthesia Practice ........................................................................7 History of Podcasts ..................................................................................................9 Problem Statement and PICO ......................................................................................10 Review of the Literature ....................................................................................................10 Podcast Use in Advanced Medical Education .............................................................11 Podcast Use for Continued Education .........................................................................13 Practice Gap Analysis ..................................................................................................15 Theoretical Framework ......................................................................................................15 Purpose and Aims ..............................................................................................................18 Project Design ....................................................................................................................19 Setting ..........................................................................................................................19 Population ....................................................................................................................19 Inclusion/Exclusion Criteria ........................................................................................20 Methods..............................................................................................................................20 Measurement Instrument .............................................................................................20 Data Collection Procedure ...........................................................................................22 Data Analysis ...............................................................................................................23 Results ................................................................................................................................24 Interpretation/Discussion ...................................................................................................26 2 NEEDS ASSESSMENT OF PODCASTS FOR CRNAS Timeline .............................................................................................................................27 Ethical Considerations/Protection of Human Subjects ......................................................28 Conclusion .........................................................................................................................28 References ..........................................................................................................................29 Appendices .........................................................................................................................32 Appendix A National Qualification Framework Principles/Definitions .................32 Appendix B Needs Assessment Survey ...................................................................33 Appendix C Participant Recruitment Post ...............................................................38 Appendix D Survey Data Analysis ..........................................................................39 Table 1: Participant Demographics ........................................................................39 Table 2: Podcast Use in CRNAs ............................................................................40 Table 3: Professional Development in CRNAs .....................................................41 Figure 1: Podcasts as a Valuable Component of Professional Development ........42 Appendix ETable 2: Timeline of Project .................................................................43 Appendix FIRB Exemption Form ............................................................................44 Appendix G Committee Membership .......................................................................45 3 NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 4 Abstract In the rapidly evolving world of medical education and content, professional development is not just a choice, it is an obligation. Despite the rising popularity of podcast use over the last 10 years, there is still little-known if they effectively meet the needs of professional development and lifelong learning for anesthesia experts, specifically CRNAs. A needs assessment was performed to determine if anesthesia-focused podcasts are a valuable component to professional development and lifelong learning. The needs assessment survey encompassed 14 questions that looked at participant demographics, overall outlooks and preferences on current anesthesiafocused podcasts, desired modes of professional development, and if they considered podcasts to be a valuable component of professional development and lifelong learning in nurse anesthesia. After data analysis was completed, results from the survey responses indicated that anesthesiafocused podcasts are perceived as a valuable component to professional development and lifelong learning. In-person lectures/professional meetings were the most preferred mode of professional development (75% of responses). Podcasts were the 2nd most preferred mode of professional development (52.27% of responses). Relevant (92.86%), Credible (71.43%), Quality-focused (50%), and accessible (50%) were found to be the most valuable principles of professional development and lifelong learning. Although there is no research on podcast-use as an alternative method to achieving professional development and lifelong learning, this project demonstrates how anesthesia-focused podcasts have the potential to become a valuable component to the future of the nurse anesthesia profession. Keywords: Podcasts, lifelong learning, professional development, nurse anesthesia, continued education (CE), SRNA, CRNA NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 5 Needs Assessment of Podcast Use for Professional Development and Lifelong Learning in CRNAs In the chaotic and complex surgical environment where health care professionals are highly independent, it is obligatory for nurse anesthesia providers to remain updated in knowledge, understanding, and skillset. Regardless of the continual shift in job requirements and expectations, Certified Registered Nurse Anesthetists (CRNAs) uphold credentials which validate just how important it is to engage in professional development and lifelong learning within the anesthesia profession (NBCRNA, 2020). Professional development is a continuous process that verifies the importance of lifelong learning, because by maintaining credentials, individuals are given the opportunity to build on an established set of skills, competencies, and experiences to better navigate their career pathways (Papadakis & Parr, 2019). According to Bradberry & Greaves (2012), a lifelong learner is one who is constantly looking for ways to improve his or her skills as well as develop new ones (p. 11). By engaging in lifelong learning, a mentor and/or leader are using gained knowledge to develop their abilities along many dimensions (Bradberry & Greaves, 2012, p. 11). CRNAs are not only Advanced Practice Registered Nurses who deliver and manage anesthesia in the operating room, but they are also frontline leaders who are recognized for practicing with a high degree of autonomy and professional respect (AANA, 2019). As the expectations of leadership in the workforce continues to rise, it will be imperative for the nursing profession to continue fostering a safe learning environment by promoting individuals who engage in professional development and lifelong learning. Participating in professional development and lifelong learning allows individuals to stay informed of evidence-based research in order to effectively translate the most current research into the clinical setting. NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 6 It is evident that professional development is an essential component to the nursing profession as a whole. According to the ANA professional development is a vital phase of lifelong learning in which nurses engage to develop and maintain competence, enhance professional nursing practice, and support achievement of career goals (Gaines, 2019). Professional development is also known to be the heart of the American Association of Nurse Anesthetists (AANA) mission (AANA, 2020). To maintain professional development, CRNAs are required to be recertified under the Continued Professional Certification (CPC) program in order to safely practice. This program was developed by the National Board of Nurse Anesthetists (NBCRNA) and officially went into effect in 2016 (AANA, 2020). The CPC core modules encompassed in the program are created and designed to provide a dynamic, microlearning environment while also delivering an engaging learning experience that fits the busy schedules of CRNAs (AANA, 2020). Although the CPC Program offers a wide variety of educational activities such as meetings, workshops, and online courses, educational anesthesiafocused podcasts have not been approved and are currently not an option as an activity for completing these CPC core modules. E-learning tools, such as anesthesia-focused podcasts, can be utilized as an educational resource and basic fundamental refresher for clinical skills and knowledge. They also have the aptitude to enhance continuous learning opportunities within the nurse anesthesia profession. To optimize professional development and lifelong learning among CRNAs, it will be imperative to gather information through a needs assessment to identify preferred modes of professional development and lifelong learning, understand what key principles of professional development and lifelong learning are most desired, and determine if anesthesia-focused podcasts are a valuable component of professional development and lifelong learning for CRNAs. NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 7 Background and Significance The market for continuing education, professional development, and lifelong learning within the healthcare profession is continuously emerging through ongoing advancements in technology. Technology, particularly used for educational purposes, has developed rapidly over the years. With that, emerging technologies are becoming an essential asset to our growing culture. In the complex, multifaceted, and intricate world of anesthesia where providers are expected to be highly autonomous, anesthesia-focused podcasts are a technological tool that have the aptitude to meet the current expectations of professional development and lifelong learning within the anesthesia workforce. Scope of Nurse Anesthesia Practice Since 1980, when the Scope of Practice statement was first published as a guideline for the AANA organization, the profession of nurse anesthesia has remarkably evolved (AANA, 2020). CRNAs are partaking in independent, professional judgment, as well as taking accountability by maintaining competency to enhance patient outcomes across all anesthesia services (AANA, 2020). AANAs (2020) most current Scope of Nursing Anesthesia Practice states that the scope of an individual CRNAs practice is determined by education, experience, local, state and federal law, and organization policy (p. 1). This project will allow readers to gain a better understanding on why professional development and lifelong learning are fundamental to the CRNA scope of practice. The growing demands and complexity of patients and procedures, along with the everchanging medical content and healthcare environment, are just a few of the many reasons why professional development and lifelong learning within the nurse anesthesia profession is mandated. The educational process that is required to become a CRNA is an extensive, challenging journey, and one that certainly never ends. From completing NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 8 an undergraduate nursing program and gaining experience in the critical care setting as a Registered Nurse to finishing a comprehensive didactic and clinical practice curriculum at an accredited nurse anesthesia graduate program, the education process has only just begun. According to the AANA (2020), CRNAs are accountable to the public for professional excellence through lifelong learning and practice, continued certification, continuous engagement in quality improvement and professional development, and compliance with the Standards for Nurse Anesthesia Practice and Code of Ethics for the Certified Registered Nurse Anesthetist. (p.1) It is evident that in order for a CRNA to adequately fulfill their scope of practice, they are required to remain updated in knowledge and skillset and maintain the necessary credentials until the very end of their career. To achieve this, engagement in professional development and lifelong learning should be more than just an intrinsic motivation. For a quality nurse anesthesia provider to make ethically sound decisions, they must translate the best evidence-based research into clinical practice. McFadden & Thiemann (2009) rationalize that evidence-based research, provider expertise, patient preferences, and standards of practice are all aspects that back up a clinicians decisions. They also support that establishing an evidence-based nurse anesthesia practice is a means of engaging in lifelong learning to strengthen decision-making skills, which in time, will facilitate quality education onto the next generation of CRNAs (McFadden & Thiemann, 2009). The AANA (2018) Code of Ethics deems that it is a CRNAs ethical responsibility to engage in continuing education and lifelong professional development related to area of nurse anesthesia practice, including clinical practice, education, research, and administration (p. 2). NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 9 There are several professional nurse anesthesia organizations that promote and support the concepts of professional development and lifelong learning. According to the Journal of Nursing Professional Development (2015), commitment to lifelong learning and ongoing personal and professional development is reflected in active membership in nursing professional organizations (p. 57). The NBCRNA is a professional organization that has certified over 54,000 CRNAs. Their overall mission is to protect the public by ensuring that practicing CRNAs have met predetermined qualifications for providing nurse anesthesia services and carry out the knowledge base and skillset required to practice safely and effectively (NBCRNA, 2020). To accomplish this, lifelong learning is highly encouraged through developed credentialing programs, ongoing recertification, and continued education, all of which are vital components to maintaining an active CRNA license. History of Podcasts Podcasts are a technological modality that provide infrastructure while addressing the rapidly changing educational environment and future challenges of medical education (Guze, 2015). Over the last ten years, the percent of the U.S. population who have listened to podcasts has risen from 11% to 40% (Goldberg, 2017). The 2019 Podcast Trends Report focuses on understanding the current podcast market, where people listen to podcasts, and how long they are listening to them for. This report showed that in 2019 82.4% of people listen to podcasts for more than 7 hours each week, compared to 76.8% in 2018 and 66.8% in 2017 (Goldberg, 2019). Data continues to show a rapid growth since the mainstream adoption of podcasts in 2000 (Goldberg, 2019). With ongoing technological advancements, along with the growing population of APRNs, evidence-based anesthesia-focused podcasts have the potential to be a valuable and desirable tool for CRNAs to gain knowledge throughout every stage of their career. NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 10 Although podcasts are still greatly under-explored as an alternative educational modality within the anesthesia community, the increasing popularity and use in medical education suggests that they could be an important adjunct to delivering the most current research through desired anesthesia topics and content. Additionally, promoting anesthesia-focused podcasts to the anesthesia community may enhance CRNA educational resources while bringing evidence-based research into practice much quicker than other modes of professional development and lifelong learning. Since there are no CE activities that are currently being offered in the podcast format, anesthesia-focused podcasts could be offered as an additional avenue for meeting professional development requirements. Problem Statement and PICO Although studies have found podcasts to be an effective educational tool as an alternative learning mode for students in the medical field, there is no literature to support that anesthesiafocused podcasts are a useful adjunct to promoting professional development and lifelong learning for CRNAs. This led to the following PICO question: Can anesthesia-focused podcasts meet the needs for professional development and lifelong learning among CRNAs compared to other current modes of knowledge dissemination? Review of Literature The review of literature was executed from November 2019 to July 2020 to gain a comprehensive understanding on podcast-use as a way to promote professional development and lifelong learning in nurse anesthesia. The initial search utilized CINAHL, Pubmed, MEDLINE Ovid, and ERIC databases. Search terms that were used in various combinations included: podcasts, lifelong learning, professional development, nurse anesthesia, continued education, NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 11 SRNA, and CRNA. Date limitations were set to articles published in the last 5 years. After reviewing the title and abstract of articles, 6 articles were retrieved and included in this literature review. Final article selection was extremely rigorous and only included literature that appeared to be relevant to this project. Article selection criteria included studies that were specific to podcast use as an alternative learning tool for advanced medical education and continued educational opportunities. Literature regarding podcast use among undergraduate students was excluded from this review. Unfortunately, there were a few articles with titles that seemed applicable to this review; however, they were not able to be analyzed or used because they were unable to be accessed. Most of the literature found focused on podcast-use as an alternative learning strategy compared to traditional educational modalities for students in the classroom setting. Despite the growing evidence indicating that podcasts are currently being used as a quality educational adjunct and an effective learning tool (Cho, Cossimini & Espinoza, 2017), there is no research on podcast usage as a means for professional development. There were also no articles found specific to lifelong learning and professional development within the anesthesia profession. Although there is a lack of literature on this desired topic, this review of literature is centered towards podcast use in advanced medical education and continued education. By focusing on these more explored topics, the importance of utilizing anesthesia-focused podcasts as an alternative adjunct to achieving professional development and lifelong learning among CRNAs may be better understood. Podcast Use in Advanced Medical Education NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 12 Anesthesia and Critical Care Reviews and Commentary (ACCRAC) was the one of the first medical podcasts to focus on anesthesia and critical care-related topics. In April of 2017, just one year after being created, the podcast gained over 7,000 anesthesiology learners and providers. Wolpaw & Toy (2018) performed a cross-sectional survey centered towards capturing the demographics and views of ACCRAC podcast listeners. The listeners who participated in the survey included attending physicians, CRNAs, CRNA students, critical care RNs, fellows, medical students, and residents (Wolpaw & Toy, 2018). Results from the study found that a majority of these listeners were anesthesiology residents who preferred podcasts over other forms of learning, therefore, it is assumed that the format of learning this podcast had to offer is strongly desired by them (Wolpaw & Toy, 2018). This study also demonstrated that 79% of those who frequently listened to the podcast found themselves listening to at least 1 episode per week (Wolpaw & Toy, 2018). Additionally, the ability to listen to the podcasts while accomplishing other things (such a working out or commuting) was found to be a main reason why participants preferred podcasts over textbooks (Wolpaw & Toy, 2018). According to Wolpaw & Toy (2018), results suggest that there is a demand for podcasts among learners and that those who listen to podcasts do so frequently and value them because they support multitasking and provide flexible access to pertinent information (p. 4). Overall, the users found the podcast to be extremely useful for learning (Wolpaw & Toy, 2018). Back et al. (2017) designed a randomized controlled trial (RCT) which compared preand post-tests of 2 groups of medical students to evaluate differences in the gain of knowledge with the use of podcasts versus textbooks when learning about orthopedic diseases. The use of podcasts led to not only a significantly higher gain of knowledge but also showed a significantly higher rate of satisfaction and approval than the textbooks did (Back et al., 2017). Despite the NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 13 students who were in favor of podcasts as the learning tool, the podcasts also revealed a higher gain in knowledge to those students who did not have a positive attitude toward them (Back et al., 2017). Podcast Use for Continued Education Qalehsari et al. (2017) performed a systematic review to identify lifelong learning strategies in nursing. Although findings were specific to nursing students, it was found that lifelong learning strategies are a necessity to the nursing profession and will lead to increased quality of education, development of professional competency, and increased quality of patient care (Qalehsari et al., 2017). According to Qalehsari et al. (2017) personal, professional and social development were found to be the strongest motivators for continuing education. Results of this study implied that lifelong learning positively influences the overall growth of employees. Cuppett (2001) executed a 3-part survey study to determine the self-perceived continuing education needs of current certified athletic trainers and the factors that affect those needs (p. 388). According to Cuppett (2001), the mandatory continuing education movement arose out of the perception that professionals need to be committed to lifelong learning to maintain and improve their competence (p. 388). Cuppett (2001) found that the main factors contributing to the increased need of continued education are due to the continuous change in knowledge, the increasing diversity of employment settings, the restructuring of professional requirements, the influence of technology on assessment and treatment procedures, and the everchanging health care system. Additionally, findings from the study allowed Cuppett (2001) to conclude that mandatory continuing education hours required by most professions was not the motivating factor for professionals to attend and participate in continuing education activities and programs. NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 14 Patrick et al. (2019) performed a descriptive study which targeted post-graduate pediatric healthcare providers who had an interest in continuing medical education. They began their study by developing a podcast platform called PediaCast CME where they produced 26 podcast episodes that incorporated quality criteria medical education and offered free accredited continued medical education to the podcast listeners (Patrick et al., 2019). From the production of their first podcast episode in March 2015 to the production of their last podcast episode in May 2017, they had a cumulative total of 91,159-episode downloads (Patrick et al., 2019). They found that overtime, podcast listenership grew, and results from their study showed that audio podcasts appeared to be an effective means of communicating pediatric knowledge content for continuing medical education opportunities (Patrick et al., 2019). The article that was found to be most relevant to this project was a qualitative study that was carried out by Malecki et al. (2019). Through interviews, this study was performed to obtain a better understanding of why individuals incorporate podcasts into ongoing medical education and professional development (Malecki et al., 2019). Listeners of The Rounds Table (TRT), a medical podcast created by physicians who summarize, analyze and contextualize new research in internal medicine, were interviewed to determine the podcasts perceived impact on learning and practice (Malecki et al., 2019). Of the 17 participants that were interviewed, 2 of them were medical students, 8 were residents, and 7 were staff physicians. Thematic analysis yielded 4 main themes in regards to medical podcast usage: (1) TRT optimized efficiency, (2) TRT endorsed individuals to stay up-to-date in medical literature, (3) listeners used TRT as a form of both education and entertainment (edutainment), and (4) listeners felt that TRT expanded their overall knowledge base and allowed them to translate gained knowledge into the clinical setting (Malecki et al., 2019). It was also found that listeners across all stages of practice turn to medical NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 15 podcasts for various reasons, such as giving them the ability to multitask. Additionally, the findings of the study highlight how podcasts, developed for continuing professional development, are oftentimes used as informal adjuncts to promote learning (Malecki et al., 2019). Practice Gap Analysis Podcasts are beginning to address the changing educational environment while providing a foundation that addresses the future challenges of medical education. After performing a literature review, nearly all the studies found were specific to podcast-use as an educational adjunct for medical students and residents, not to anesthesia providers. Although podcasts have become a unique technological advancement to our growing culture and continue to be a spotlight as a newer approach to effectively delivering medical education, there is no research on how podcasts optimize professional development and promote lifelong learning for individuals within the nurse anesthesia profession. By performing a needs assessment on podcast use for professional development and lifelong learning in CRNAs, we can gain a better understanding on how anesthesia-focused podcasts can be a fundamental way to obtaining knowledge, disseminating the most current medical information, and appreciate how podcasts can be an alternative and more desired adjunct to obtaining continued education credits. Theoretical Framework The CRNA scope of practice is constantly evolving to meet the needs of our expanding healthcare system as newer research and technologies continue to emerge. Lifelong learning is a concept that has been discussed as early as 1970. There are several meanings of lifelong learning, however, Longworth (1999) defines it as: NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 16 The development of human potential through a continuously supportive process which stimulates and empowers individuals to acquire all the knowledge, values, skills, and understanding they will require throughout their lifetimes and to apply them with confidence, creativity and enjoyment in all roles, circumstances, and environment. (p.2) Today, lifelong learning is used as a framework to enable individuals to engage in learning wherever, whenever, and however it may align to ones learning styles and needs. According to Vander Ark & Ryerse (2017), professional development is one of the most common types of lifelong learning and happens on a daily basis at work through job training and skill acquisition. Professional development allows individuals to engage in activities that guide them in maintaining competency to enhance their overall professional practice. Tricia Kurtt, an instructional coach and education teacher adds that in order for professional development to influence what matters most, every individual needs to engage in the learning process so they embrace and model what it means to be a lifelong learner (Kurtt, 2016). For this DNP project, The National Qualifications Framework (NQF) was chosen as a guide to determine which principles are most desired and valued in popular anesthesia-focused podcasts, today. The NQF, established in 1995 in South Africa, is a foundation for a system of efficient education and training through lifelong learning. The NQF encompasses eleven key principles which were developed to evaluate if lifelong learning in a workplace and/or profession was achieved. These key principles include credible, coherent, relevant, quality-focused, flexible, accessible, articulation, portable, responsive, reflective, and progressive (Motshekga-Sebolai, 2003). The establishment of this theoretical framework is grounded by these principles. The framework provides a definition for each of these eleven principles, which can be found in Appendix A. NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 17 Although these principles are defined and specific to lifelong learning in South Africas education system, they can be interpreted in a way that articulates how educational podcasts meet the needs of all these principles, and therefore, have the ability to promote professional development and lifelong learning. For example, Motshekga-Sebolai (2003) describes qualityfocused as the willingness to learn and continually update knowledge (p. 23). Newer developed technologies that offer e-learning, such as podcasts, are being used to quickly deliver the most current and up-to-date evidence-based information to health professionals. One study in particular found that healthcare professionals are not only using podcasts to augment knowledge but are also using them as a way to stay current with the newest medical literature (Malecki et al., 2019). Accessibility, another principle from the NQF, emphasizes on expanding open public services in order to promote learning opportunities for everyone (Motshekga-Sebolai, 2003). One of the great things about podcasts is that they are made available to nearly everyone. Today, most medical-related podcasts fall under the concept of Free Open Access Medical (FOAM) education, which enables all individuals to conveniently access podcasts on mobile devices, social media platforms, or through common applications such as Apple iTunes and Spotify (Andrejco et al., 2017). Portability and accessibility are two more principles of the NQF that offer flexibility and convenience, which are both extremely important concepts when it comes to time management (Motshekga-Sebolai, 2003). Work-life balance is not always easy to manage, especially for healthcare professionals who are always pressed for time. With that said, trying to find additional time to engage in professional development and lifelong learning on an already overwhelming workload is not always attainable. Podcasts, however, give individuals the opportunity to NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 18 multitask and listen to them while on the go such as while driving/commuting to and from work, while doing household chores, or even while exercising. Furthermore, relevance is a principle that fosters professional growth and the ability to confidently cope with change and uncertainty, especially since learning is conditional and never stops (Motshekga-Sebolai, 2003). Another principle, responsive, implies that the anesthesia workforce will adequately respond to the needs of the healthcare system and nurse anesthesia providers will acquire all the necessary skills to accommodate ongoing changes in the surgical setting. According to Motshekga-Sebolai (2013) changes in the nature of work mandate different ways of performing your job which can be quite overbearing, however, these challenges can be successfully addressed through lifelong learning. By providing several examples on how the principles comprised in the NQF parallel lifelong learning in nurse anesthesia, it is apparent that these eleven principles could be valuable components to building a foundation for professional development and lifelong learning through anesthesia-focused podcasts. Purpose and Aims Although job expectations are constantly changing, CRNAs are required to stay informed on the most current medical content while maintaining an expert-level skillset to deliver quality patient care within the surgical setting. To overcome these challenges and demands, CRNAs should be given the opportunity to engage in other modalities of continued education and professional development, such as anesthesia-focused podcasts. Podcasts continue to transform the face of medical education and have the capability to enhance knowledge, optimize personal and professional development, and endorse lifelong learning for CRNAs. The purpose of this project is to determine if anesthesia-focused podcasts are a valuable technological alternative to achieving professional development and lifelong learning for nurse anesthesia professionals. The NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 19 aims of this project are: (1) to survey CRNAs on their overall viewpoint on anesthesia-focused podcasts, (2) to identify preferred modes of professional development and continued education (CE) within the nurse anesthesia community, (3) to determine content, length, and essential principles that are most desired in anesthesia-focused podcasts, and lastly, (4) to distinguish if anesthesia-focused podcasts are seen as a valuable component of professional development and lifelong learning in nurse anesthesia. Project Design This needs assessment project targeted professionals within the nurse anesthesia community, specifically CRNAs. A needs assessment was performed to determine what the most desired content, length, and key principles of an anesthesia-focused podcast are currently most desired by CRNAs. This project used a descriptive design and was selected to gain a greater understanding on if anesthesia-focused podcasts are seen or have the potential to be a valuable component of professional development and lifelong learning in nurse anesthesia. This design may also help future projects and/or research studies determine if anesthesia-focused podcasts are a fundamental asset to the nurse anesthesia profession. Setting This needs assessment was carried out as an online survey. The project site varied for all participants in the project, because they were given the opportunity to take the survey on their own time and in any type of setting that they chose to do so. Population The participants of this project were initially targeted towards people within the nurse anesthesia profession, specifically CRNAs and SRNAs. CRNAs are licensed professional who have obtained a masters and/or doctoral degrees in anesthesia delivery and have been providing NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 20 anesthesia care to patients in the United States for more than 150 years (AANA, 2019). According to Merritt Hawkins (2019) there are approximately 49,000 registered CRNAs in active practice the United States, excluding students and those who are not in active patient care roles (p. 3). The population of this project was targeted through a CRNA/SRNA Facebook group. This group, which now has over 27,000 members, was created on October 24, 2010 by a CRNA named Betsy Majma. To gain access to the group, you must provide photographic proof of your CRNA/SRNA identity by sending a picture of your AANA or NCRNA identification badges. Inclusion/Exclusion Criteria Originally, the survey included both CRNAs and SRNAs, who were members of the CRNA/SRNA Facebook group. However, after data collection was completed it was decided that the needs assessment should only include the CRNA respondents. Although literature shows that podcasts are just as effective as other teaching methods in the classroom setting, professional development and lifelong learning are not required or necessary until SRNAs enter the phase of their careers when they are out of school and working as CRNAs. By excluding them, the focus was directed more towards understanding podcast use as a means of professional development and lifelong learning exclusively in CRNAs. Methods Measurement Instrument The survey was created, managed, and analyzed through a statistical analysis software program called Qualtrics Survey Software. This software program was made available through Marian University Center for Teaching and Learning. NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 21 Survey questions were tailored to find trends, patterns, and/or gaps based on demographics, overall outlooks and preferences on current anesthesia-focused podcasts, preferred modes of professional development, and most importantly, if podcasts are perceived as a valuable component of professional development in nurse anesthesia. After the initial survey was created, several alterations were made to enhance the overall quality of the needs assessment survey. Such alterations included modifying the wording and phrasing to make survey questions and answers more succinct and eliminating survey questions that did not correlate to the four aims of the project. The survey was also sent to a well-known anesthesia podcast host, Jon Lowrance, for additional guidance and expertise. In receiving advice from Jon Lowrance, several additional changes were made to achieve content and face validity, and the survey was finalized. This needs assessment survey can be found in Appendix B. The first four questions of the survey were included to obtain participant demographics such as provider status, age range, highest degree obtained, and number of years practicing as a CRNA. To best determine if anesthesia-focused podcasts are a valuable technological alternative to achieving professional development and lifelong learning for nurse anesthesia professionals, ten survey questions were designed to address the four key aims of the project: Aim 1. To gain a better understanding on the participants overall perspective on podcast use as an alternative educational and reinforcement tool for professional development and lifelong learning in nurse anesthesia, five questions (questions 6-8 and 12-13) were asked. One of these was a multiple-response type question asking the participant which anesthesia-focused podcast(s) they currently listen to. The other four were single-response questions covering topics including: how often the participant listens to podcasts, how/when the participant listens to NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 22 podcasts, what would make podcasts more meaningful to the participant, and if the participant would prefer shorter lengths of podcast episodes presented as a series if content is complicated. Aim 2. Question 5 was encompassed to identify the participants preferred modes of professional development and CE within the nurse anesthesia community. This was a multipleresponse type question. The six options of preferred modes of professional development that were given included the common CE activities that are currently offered through NBCRNA, along with Podcasts. Aim 3. Three questions (questions 9-11) were incorporated to determine content, length, and essential principles that are most desired in anesthesia-focused podcasts. Two of these were formatted as multiple-response type questions, whereas the other was a single-response question. Aim 4. The last question (question 14) was asked to determine if anesthesia-focused podcasts are seen as a valuable component of professional development and lifelong learning in nurse anesthesia. A Likert-scale format was used and the participants were given the option to select strongly agree, agree, neutral, disagree, or strongly disagree. Additionally, four of the fourteen questions in the survey were given an other option where participants could choose to add something if it was not included as an option for them to select from the already given response choices. Data Collection Procedures After obtaining approval from the Marian University IRB in December of 2019, participants were recruited through Facebook, which is a social media platform where individuals can connect with family, friends, colleagues, co-workers, etc. Facebook offers users to join public or private groups where people with common interests can communicate, express NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 23 opinions, and interact with one other. A private group on Facebook called CRNAs and SRNAs is where the participants from this project were found and recruited. Prior to recruitment request, permission was obtained from the creator and owner of the group, Betsy Majma through Facebook messenger. As shown in Appendix C, the initial recruitment post included a brief introduction of the researcher, detailed the project that was being performed, and provided thorough instructions on how to access the survey. It was also mentioned that by choosing to select the link and complete the survey, the participants were consenting to participate in the project. Qualtrics offers a feature that allows survey creators to specify a date and time for the survey to open and close, which prevents participants from completing the survey outside the allotted time frame. The survey was made available for all participants to complete on a voluntary and confidential basis over a 2-week period. A reminder message about completing the survey was sent out at the 1-week mark. The survey opened on Wednesday, April 1st at 3:22 pm (EST) and closed on Wednesday, April 15th at 11:59 pm (ET). The Prevent Ballot Box Stuffing option that is given on Qualtrics places a cookie on the respondents browser after they complete the survey (Qualtrics, 2020). This function was used for this survey so that respondents could not skew the results by taking the survey numerous times. Data Analysis To determine if anesthesia-focused podcasts are a valuable technological alternative to achieving professional development and lifelong learning for nurse anesthesia professionals, data analysis was carried out to meet the four aims of this project. Data analysis encompassed descriptive statistics including frequency distributions. Utilizing descriptive statistics for nominal and ordinal data through frequencies and percentages was found to be the best method in NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 24 analyzing the collected data from the survey. Since the project only focused on one population and included a single needs assessment survey, there was no data that needed to be compared. Additionally, there were no continuous variables; therefore, interval and ratio data were unable to be measured, and central tendencies such as mean, median, range, standard deviation, and confidence intervals were not applicable. There were other-specify options included in four of the survey questions. These otherspecify responses that were suggested did not fit into any of the pre-existing categories, and there were not enough similar responses to where they could be grouped into their own separate category. Due to this finding, content analysis was not performed, and these responses were excluded from the dataset and study. Results Approximately half of the respondents were SRNAs; however, since they were excluded, the population sample size was 44 CRNAs. These respondents answered all of the survey questions. After data analysis was performed through Qualtrics, the obtained frequencies and percentages from each survey question were transferred into three separate tables which were created on Microsoft Word software program to identify trends and patterns from the retrieved data. As shown in Table 1, participant demographics were broken down into age range, highest degree obtained, and length of time practicing as a CRNA. Participants that were 51 years and older made up 25% of the study population, and almost 35% of the participants were 35 years and younger, leaving the remaining 40% falling under the ages 36-50 years old. Regarding the highest degree obtained, nearly 70% of the participants have their masters degree, while the remaining 30% have their doctoral degree. Over 20% of the participants within the study have NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 25 been practicing as a CRNA for over 20 years; however, almost 60% of the participants only have been practicing as a CRNA for under 10 years. Table 2 encompasses the survey questions specific to aim 3 to gain a better understanding on the participants overall outlook and use on podcasts. In table 2, there is one select all that apply which displays the percentage of cases, whereas the other single answered questions are displayed as just a percentage. Nearly half (47.73%) of the participants claimed that they listen to podcasts less than once a month, and about 30% of the participants stated that they listen to podcasts anywhere from at least once a week (15.91%) to daily (13.64%). Roughly half (47.73%) of the participants preferred for the duration of a single podcast episode to be 16-30 minutes. When participants were asked how they listened to podcasts, 61.36% were found to listen to them while driving or in the car. Furthermore, intraoperative emergencies (62.79%), pharmacology (60.49%), and anesthesia management and considerations based on co-existing diseases (58.14%) were the top three out of eleven most desired anesthesia-related podcast topics. Lastly, 32 out of the 44 participants (72.73%) stated that having the option to get continued education (CE) credits for podcasts episodes would make podcasts more meaningful to them. Table 3 includes survey questions that are specific to aim 2 and cover topics regarding outlooks on professional development and lifelong learning. The data obtained from the two questions included in this table are retrieved from select all that apply questions, which are displayed as percentage of cases. The participants were given 6 options when asked what their preferred mode of professional development were. In person lectures or professional meetings was the most selected answer, and it was selected 33 times (75% of responses). Videos and online lectures/courses (59.99%) and podcasts (52.27%) were the other two top selected answers NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 26 of the six options that were given. For this project, the chosen theoretical framework was used to determine which principles are most desired and valued in popular anesthesia-focused podcasts today. The NQF embodied eleven key principles to evaluate if lifelong learning in a workplace and/or profession was achieved. In the survey, participants were asked which of these eleven principles regarding lifelong learning and professional development were most valuable to them. Relevant was the most selected principle in 39 out of the 44 responses (92.86%). Credible (71.43%), quality focused (50%), and accessible (50%) were the next most popular choices of the eleven key principles that were listed. Figure 1 is a pie chart that deciphers if the participants of this project find podcasts to be a valuable component of professional development and lifelong learning. The question was asked on a 5-point Likert scale and the respondents were given the options to strongly agree, agree, neutral, disagree, or strongly disagree when asked if they considered podcasts to be a valuable component of professional development and lifelong learning. As demonstrated in Figure 1 of Appendix D, 25% strongly agreed, 36% agreed, 32% remained neutral, and 7% disagreed. There were no respondents that selected strongly disagree. Interpretation/Discussion Findings obtained from the collected survey data showed that anesthesia-focused podcasts have the aptitude to be an alternative and valuable component to professional development and lifelong learning. Overall, the data collected from this needs assessment survey indicate that anesthesia-focused podcasts are perceived as a valuable component to professional development and lifelong learning. As podcast use in the anesthesia community continues to rise, anesthesia podcast platforms and hosts can use the information from this project and adjust their podcasts to better meet the needs of CRNAs who currently use them. If CRNAs were given the NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 27 option to listen to anesthesia-focused podcasts as a means of obtaining CE credits, podcast in the anesthesia community could gain significant popularity as an additional alternative educational adjunct. Additionally, since podcasts were found to be most listened to while driving, CRNAs can make better use of their time and busy schedules by listening to them on their commutes to and from work. Limitations of this study include non-respondent bias, small sample size, and lack of prior research on the topic. Due to the small response rate, non-respondent bias can be assumed which can limit the results of the study. The obtained data may not accurately represent the targeted population, thus, leading to inconclusive research. By recruiting participants through a Facebook group, it is easy to assume that the survey did not reach all members of the targeted sample. If this study was repeated or used for future research implications, participants should be recruited on other social media platforms and/or via email to members of all nurse anesthesia organizations, such as the AANA. By limiting the sample size and only recruiting participants through Facebook, certain age groups may be less likely to participate in the study. By obtaining a larger sample size, it would be interesting to see if the age or number of years an individual has been practicing as a CRNA is correlated to the preferred professional development and lifelong learning modality. Location of employment, duties required in a job, generational learning differences, age range and even hours worked per week may have a significant impact on how an individual would prefer to engage in CE activities. Timeline After getting approval on the proposal of the project, IRB documentation was sent out on December 4, 2019 and exempted on December 13, 2019. Following IRB exemption, the implementation phase of the project began which consisted of creating and sending out the needs NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 28 assessment survey and collecting/analyzing data. Recruitment and data collection occurred from April 2020 to May 2020, while data analysis occurred from May 2020 to August 2020. Ethical Considerations/Protection of Human Subjects The Marian Universitys Institutional Review Board (IRB) approval was obtained prior to initiating this DNP project. On December 13, 2019, the submitted protocol was reviewed and deemed exempt (Appendix F). Additionally, confidentiality regarding survey responses was guaranteed through the Qualtrics Software program that was used to complete the survey. Through the anonymous survey link provided by Qualtrics, participants were not required to provide any personal information in the survey. Conclusion This needs assessment highlights how CRNAs view anesthesia-focused podcasts as an alternative way to engage in professional development and lifelong learning. Although there is no research on podcast-use as an alternative method to achieving professional development and lifelong learning, this project demonstrates how anesthesia-focused podcasts have the potential to become a valuable component to the future of the nurse anesthesia profession. As the popularity of anesthesia-focused podcasts continues to rise to meet the educational needs of a CRNA, it will be interesting to see if podcasts will be offered as a CE activity in order for CRNAs to obtain credits. Understanding how emerging technologies, such as anesthesia-focused podcasts, can optimize continued medical education has the ability to enhance and facilitate better learning opportunities throughout every stage of a CRNAs career. Due to the paucity in this literature, future research can further explore podcast use to better understand this continually emerging topic. NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 29 References American Association of Nurse Anesthetists. [AANA]. (2020). Scope of nurse anesthesia practice. 1-3. https://www.aana.com/docs/default-source/practice-aana-com-webdocuments-(all)/scope-of-nurse-anesthesia-practice.pdf?sfvrsn=250049b1_2 American Association of Nurse Anesthetists. [AANA]. (2019). Certified registered nurse anesthetist fact sheet. https://www.aana.com/membership/become-a-crna/crna-fact-sheet American Association of Nurse Anesthetists. [AANA]. (2018). Code of ethics for the certified registered nurse anesthetists. 1-5. https://www.aana.com/docs/default-source/practiceaana-com-web-documents-(all)/code-of-ethics-for-the-crna.pdf Andrejco, K., Lowrance, J., Morgan, B., Padgett, C., & Collins, S. (2017). Social media in nurse anesthesia: A model of a reproducible educational podcast. American Association of Nurse Anesthetists (AANA) Journal, 85(1), 10-16. www.aana.com/aanajournalonline Back, D. A., von Malotky, J., Sostmann, K., Hube, R., Peters, H. & Hoff, E. (2017). Superior gain in knowledge by podcasts versus text-based learning in teaching orthopedics: A randomized controlled trial. Journal of Surgical Education, 74(1), 154-160. http://dx.doi.org/10.1016/j.jsurg.2016.07.008 Bradberry, T., & Greaves, J. (2012). Leadership 2.0: San Diego, CA: Talent Smart. Cho, D., Cosimini, M., & Espinoza, J. (2017). Podcasting in medical education: A review of the literature. Korean Journal of Medical Education, 22(4), 229. Cuppett, M. (2001). Self-perceived continuing education needs of certified athletic trainers. Journal of Athletic Training, 36(4), 388-395. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC155434/ Gaines, K. (2019). You should join a nursing organization. Heres why. Full Beaker, Inc. NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 30 https://nurse.org/articles/benefits-of-nursing-organizations/ Goldberg, Kevin. (2017). The history of podcasts. Discover Pods. https://discoverpods.com/ history-of-podcasts/ Guze, P. A. (2015). Using technology to meet the challenges of medical education. Transactions of the American Clinical and Climatological Association, 126, 262-270. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4530721/ Journal for Nursing Professional Development. [JNPD]. (2015). The role of nursing professional development in the future of nursing. Wolters Kluwer Health, Inc., 56-57. https://www.nursingcenter.com/pdfjournal?AID=2714576&an=01709760-20150100000015&Journal_ID=54029&Issue_ID=2714125 Kurtt, T. (2016). Professional development for lifelong learning. ASCD In Service. https://inservice.ascd.org/professional-development-for-lifelong-learning/ Longworth, N. (1999). Making lifelong learning work: Learning cities for a learning century. Sterling, VA: Stylus Publishing Inc. Malecki, S. L., Quinn, K. L., Zilbert, N., Razak, F., Ginsburg, S., Verma, A. A. & Melvin, L. (2019). Understanding the use and perceived impact of a medical podcast: Qualitative study. JMIR Medical Education, 5(2). doi:10.2196/12901 McFadden, J. J. & Thiemann, L. J. (2009). Evidence-based practice for lifelong learning. AANA Journal, 77(6), 423-426. https://www.aana.com/docs/default-source/practice-aana-comweb-documents-(all)/evidence-based-practice-for-lifelonglearning.pdf?sfvrsn=a02f44b1_2 Merritt Hawkins. (2019). CRNA supply, demand, and recruiting trends. https://www.merritthawk ins.com/uploadedFiles/Merritt_Hawkins_CRNA_Whitepaper_2019.pdf NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 31 Motshekga-Sebolai, M. E. (2003). Theory of lifelong learning. A Study of Lifelong Learning in Academic Institutions (pp. 20-49). https://repository.up.ac.za/bitstream/handle/2263/26726/ 02chapter2.pdf?sequence=3&isAllowed=y. National Board of Certification and Recertification for Nurse Anesthetists. [NBCRNA]. (2020). Your credential matters. https://www.nbcrna.com/about-us/your-credential-matters Papadakis, E. & Parr, M. (2019). How credential transparency can drive lifelong learning access and impact. https://evolllution.com/programming/credentials/how-credential-transparencycan-drive-lifelong-learning-access-and-impact/ Patrick, M., Stukus, D., & Nuss, K. (2019). Using podcasts to deliver pediatric educational content: Development and reach of of Pediacast CME. Digital Health, 5, 1-9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6393949/ Qalehsari, M. Q., Khaghanizadeh, M. & Ebadi, A. (2017). Lifelong learning strategies in nursing: A systematic review. Electronic Physician, 9(10), 5541-5550. http://dx.doi.org/10.19082/5541 Qualtrics. (2020). Survey protection: Preventing respondents from taking your survey more than once. https://www.qualtrics.com/support/survey-platform/survey-module/surveyoptions/survey-protection/ Vander Ark, C. & Ryerse, M. (2017). 10 reasons why lifelong learning is the only option. Getting Smart. https://www.gettingsmart.com/2017/01/10-reasons-why-lifelong-learningis-the-only-option/ Wolpaw, J. & Toy, S. (2018). Creation and evaluation of an anesthesiology and critical care podcast. The Journal of Education in Perioperative Medicine, 19(4), 1-16. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5991777/pdf/i2333-0406-20-1-1f.pdf NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 32 Appendix A: NQF Principles and Definitions Retrieved from Motshekga-Sebolai, M. E. (2003). Theory of lifelong learning. A study of lifelong learning in academic institutions (pp. 20-49) NEEDS ASSESSMENT OF PODCASTS FOR CRNAS Appendix B: Needs Assessment Survey Needs Assessment of Podcast Content for Professional Development of CRNAs Q1. Please indicate your provider status. o a. Certified Registered Nurse Anesthetist (CRNA) o b. Student Registered Nurse Anesthetist (SRNA) Q2. Please select the age range you fit into. o 20-25 o 26-30 o 31-35 o 36-40 o 41-45 o 46-50 o 51+ Q3. Please select highest degree obtained. o Associates degree o Bachelor's Degree o Master's Degree o Doctoral Degree Q4. Please select number of years you have been practicing as a CRNA. o 1-2 years o 3-5 years o 6-10 years o 11-15 years 33 NEEDS ASSESSMENT OF PODCASTS FOR CRNAS o 16-20 years o 21+ years o I am a SRNA Q5. Please indicate your preferred mode of professional development (Select all that apply) o In person lectures/Professional meetings o Videos/Online lectures or courses o Podcasts o Textbooks o Peer reviewed literature (journals, articles) o PowerPoint slides/notes o Other (Please specify) Q6. How often do you listen to podcasts? o Less than once a month o 1-2 times per month o At least once a week o Daily Q7. How do you typically listen to podcasts? o I don't listen to podcasts o While driving/in car o While doing household chores o While exercising o While doing nothing but solely listening to the podcast o Other (Please specify) 34 NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 35 Q8. What anesthesia-related podcasts do you currently listen to? (Select all that apply) o None o 'Anesthesia and Critical Care Reviews and Commentary' (ACCRAC) hosted by Jed Wolpaw o 'Depth of Anesthesia' hosted by David Has o 'From the Head of the Bed' hosted by Jon Lawrence o 'Apex Live Anesthesia Podcast' hosted by Sass Elisha o 'Anesthesia Deconstructed: Science, Politics, Realities' hosted by Michael MacKinnon o Other (Please specify) Q9. National authorities have recommended eleven key principles to promoting professional development and lifelong learning. When thinking about the anesthesia-related podcasts that you enjoy listening to the most, which of the following principles are most valuable to you? (Select all that apply) o Relevant o Quality-focused o Accessible o Portable o Responsive o Credible o Coherent o Articulation o Reflective o Progressive NEEDS ASSESSMENT OF PODCASTS FOR CRNAS o Flexible Q10. What is the ideal duration of a podcast episode? o 5-15 minutes o 16-30 minutes o 31-45 minutes o 46-60 minutes o 60+ minutes Q11. What anesthesia-related content do you desire most for future podcasts? (Select top 3) o Pharmacology o Anatomy o Physiology o Regional Anesthesia o Airway Management o Fluid Management o Pain Management (Acute & Chronic) o Patient Positioning o Intraoperative Emergencies o Anesthesia management/considerations based on specific populations (Geriatrics, Pediatrics, Obstetrics, Obese, etc). o Anesthesia management/considerations based on co-existing diseases o Other (Please specify) Q12. What would make podcasts more meaningful to you? o Continuing education (CE) credits for podcast episodes 36 NEEDS ASSESSMENT OF PODCASTS FOR CRNAS o Having the option to watch audio recorded podcasts in a video format o Being able to interact and engage with podcast host and guests o Having more didactic review of basic core content Q13. If content is complicated I would you prefer shorter lengths of podcast episodes that are presented as a series. o Strongly agree o Agree o Neutral o Disagree o Strongly disagree Q14. Overall, podcasts are a valuable component of professional development as a CRNA. o Strongly agree o Agree o Neutral o Disagree o Strongly disagree 37 NEEDS ASSESSMENT OF PODCASTS FOR CRNAS Appendix C: Participant Recruitment Post Initial Post on CRNA SRNA Facebook Group Page 38 NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 39 Appendix D: Survey Data Analysis Table 1 Participant Demographics Age range (years) Highest degree obtained Length of time practicing as a CRNA (years) Note. n=44 Characteristics Frequency Percentage 26 30 4 9.09 31 35 10 22.73 36 40 9 20.45 41 45 5 11.36 46 50 5 11.36 51 + 11 25.00 Bachelors 1 2.27 Masters 30 68.18 Doctoral 13 29.55 1-2 6 13.95 35 11 25.58 6 10 7 16.28 11 15 6 13.95 16 20 2 4.65 20 + 11 25.58 NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 40 Table 2 Podcast Use in CRNAs Characteristics How often participants listen to podcasts How do participants listen to podcasts Less than once a month 21 47.73 1 2 times per month 10 22.73 At least once a week 7 15.91 Daily 6 13.64 While doing nothing but solely listening to podcast 7 15.91 While exercising 5 11.36 While driving/in car 27 61.36 Do not listen to podcasts 5 11.36 5 15 minutes 10 22.73 16 30 minutes 21 47.73 31 45 minutes 10 22.73 46 60 minutes 3 6.82 Pharmacology 26 60.47 Anatomy 8 18.60 Physiology 17 39.53 Regional Anesthesia 14 32.56 Airway Management 15 34.88 Fluid Management 11 25.58 Pain Management (Acute & Chronic) 11 25.58 Patient Positioning 3 6.98 Intraoperative Emergencies 27 62.79 Population-specific anesthesia management and considerations (Geriatrics, Pediatrics, Obstetrics, etc). 22 51.16 Anesthesia management and considerations based on co-existing diseases 25 58.14 Having more didactic review of basic core content 5 11.36 Being able to interact and engage with podcast host and guests 3 6.82 Having the option to watch audio recorded podcasts in a video format 4 9.09 Continuing education (CE) credits for podcast episodes 32 72.73 Desired duration of a single podcast episode *Most desired anesthesia-related podcast content What would make podcasts more meaningful Frequency Percentage Note. *=Select all that apply (percentage of cases). n=44 NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 41 Table 3 Professional Development in CRNAS (Select All That Apply) Preferred mode of professional development Most valuable principles of professional development Note. n=44 Characteristics Frequency Percentage of cases In person lectures or professional meetings 33 75.00 Videos/Online lectures or courses 26 59.09 Podcasts 23 52.27 Textbooks 5 11.36 Peer reviewed literature (journals, articles) 19 43.18 PowerPoint slides/notes 7 15.91 Relevant 39 92.86 Quality-focused 21 50.00 Accessible 21 50.00 Portable 12 28.57 Responsive 2 4.76 Credible 30 71.43 Coherent 17 40.48 Articulation 9 21.43 Reflective 4 9.52 Progressive 10 23.81 Flexible 6 14.29 NEEDS ASSESSMENT OF PODCASTS FOR CRNAS Figure 1 Do CRNAs consider podcasts to be a valuable component of professional development? 42 NEEDS ASSESSMENT OF PODCASTS FOR CRNAS Appendix E: Timeline of Project 43 NEEDS ASSESSMENT OF PODCASTS FOR CRNAS Appendix F: IRB Exemption Form 44 NEEDS ASSESSMENT OF PODCASTS FOR CRNAS 45 Appendix G: Committee Membership 12/17/2020 12/17/2020  ...

... RUNNING HEAD: EVALUATING THE PREEMPTIVE USE OF OFIRMEV Evaluating the Preemptive Use of Ofirmev to Address Post-Cesarean Pain Kris Huerta Marian University Leighton School of Nursing Chair: Dr. Bradley, Stelflug, CRNA, DNP (Signature) ___________________________ Committee Members: Dr. Dave, Beal, CRNA, DNP (Signature) ___________________________ Dr. Darrell, Nemec, CRNA, DNP (Signature) ___________________________ Date of Submission: 12/23/2020 1 EVALUATING THE PREEMPTIVE USE OF OFIRMEV Table of Contents Abstract ............................................................................................................................page 3 Introduction .....................................................................................................................page 3 Background ................................................................................................................page 4 Problem Statement ....................................................................................................page 4 Organizational Gap Analysis of Project Site .......................................................page 5 Review of the Literature ..................................................................................................page 5 Cesarean Birth Trends . page 6 Theoretical Framework/Evidence Based Practice Model/Conceptual Model............page 10 Goals/Objectives/Expected Outcomes ....................................................................... page 10 Project Design/Methods page 10 Project Site and Population .................................................................................... page 11 Measurement Instrument(s) .................................................................................. page 11 Data Collection Procedure .................................................................................... page 11 Ethical Considerations/Protection of Human Subjects .. page 11 Data Analysis and Results.page 12 Conclusion .................................................................................................................... page 12 References ..................................................................................................................... page 14 Appendix A ................................................................................................................... page 16 2 EVALUATING THE PREEMPTIVE USE OF OFIRMEV 3 Abstract Uncontrolled postpartum pain has been linked to increased opioid use, increased risk for opioid dependency, depression, and the development of persistent pain (Bateman et al., 2016). The purpose of this project is to assess the use of a preemptive dose of Ofirmev (Tylenol, acetaminophen, paracetamol) 1,000 mg IV in decreasing post-cesarean pain and consequently opioid usage within the first 24-hour postoperative period. This project will evaluate documented pain scores charted in the EPIC charting system by the obstetrics nurses at Hendricks Regional Health. The 24-hour postoperative pain scores of cesarean patients who received acetaminophen before cesarean section will be compared to those who did not receive acetaminophen. Reducing post-cesarean pain scores and opioid usage within the first 24-hours may reduce the risk of opioid dependency, persistent pain, and depression. Keywords: preemptive, post-cesarean, Ofirmev, Tylenol, acetaminophen, paracetamol, EPIC charting system Introduction This project is submitted to Marian University Leighton School of Nursing faculty as partial fulfillment of degree requirements for the Doctor of Nursing Practice, Anesthesia track. Cesarean delivery is the most common inpatient surgical procedure among women in the United States, affecting 1.4 million women annually (Holland, Sudhof & Zera, 2020). The national cesarean rate for 2015 was 32% of all births (US National Center, 2017). Despite the standard use of neuraxial (spinal) anesthesia/analgesia intraoperatively, pain is one of the most commonly reported problems after cesarean section (The American College of Obstetricians and Gynecologists [ACOG], 2018). The American College of Obstetricians and Gynecologists (ACOG), and the Society for Maternal-Fetal Medicine (SMFM), recommend maximizing the use EVALUATING THE PREEMPTIVE USE OF OFIRMEV 4 of multimodal non-opioid analgesics, such as non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen when feasible and appropriate (Batemen et al., 2016). Background Postoperative pain is best treated preemptively by using multimodal analgesic (MMA) techniques (Carvalho & Butwick, 2017). With the expanding interest in investigating the incidence of post-cesarean pain and global increase in opioid dependency, the ACOG is recommending that a three-tiered MMA approach comparable to the one created by the World Health Organization (WHO) in 1986 to treat cancer pain be considered in the pain management of post-cesarean patients (The American College, 2018). The WHO analgesic ladder calls for a multilayered approach to pain treatment in which opioids are secondary and not primary; they are not restricted but instead used only when necessary. This stepwise regimen allows for an opioid-sparring approach by preemptively treating pain with first-line drugs like acetaminophen. The optimal approach to pain management in the post-cesarean population remains a topic of ongoing debate despite these recommendations set by the ACOG and SMFM to decrease post-cesarean opioid use. Data regarding the use of a detailed, stepwise, pain protocol in the post-cesarean population is absent. However, there is a significant amount of research utilizing non-opioid analgesics, such as acetaminophen, as rst-line adjuncts in relieving pain while diminishing opioid usage in this population, which will be the focus of this project. Problem Statement Post-cesarean women are experiencing increasing postpartum pain levels, exposing them to a higher risk for opioid dependency, depression, and the development of persistent pain (Bateman et al., 2016). Current suggestions from the ACOG and the SMFM include neuraxial analgesia and non-opioid adjunctive medication as rst-line agents, with oral (PO) and parenteral EVALUATING THE PREEMPTIVE USE OF OFIRMEV 5 (IV) opioids reserved for breakthrough pain (ACOG, 2018). This project addresses this problem by evaluating patients' pain scores, some of whom received a non-opioid, adjunctive, first-line agent (Ofirmev 1,000 mg IV) versus those who did not receive the intervention. Organizational Gap Analysis of Project Site Anesthesia providers at Hendricks Regional Health do not have a standardized way to treat post-cesarean pain. Consequently, some patients are experiencing high levels of pain, frequent occurrences of breakthrough pain, or moderate to high pain at the time of discharge, which results in higher consumption of narcotics during their inpatient stay and upon discharge. This phenomenon places post-cesarean patients at greater risk for persistent or chronic pain and opioid misuse. Review of the Literature The clinical question PICO (population, intervention, comparison, and outcome) guiding the search for evidence is as follows: In patients undergoing elective cesarean surgery at Hendricks Regional Health Hospital, how does the use of preoperative Ofirmev 1,000 mg, compared with no preoperative dosing affect the incidence of post-cesarean pain during the first 24-hours postpartum? A systematic literature search was performed using the following databases (2015 to 2020): PubMed, CINAHL, and Google Scholar. The following keywords, key strings, and mesh terms were used separately or in combination: Ofirmev, Acetaminophen, Paracetamol, multimodal analgesia, cesarean section, c-section, post-surgical pain, cesarean section /adverse effects, pain management, practice guidelines, obstetric anesthesia, analgesics, nonnarcotic/therapeutic use, and opioid use. Additionally, a citation search was performed manually and utilizing Google Scholar to review cited articles of interest. EVALUATING THE PREEMPTIVE USE OF OFIRMEV 6 The following were inclusion criteria: randomized controlled trials (RCTs), practice guidelines, epidemiologic statistics, observational studies, case series, and case reports involving human subjects published in the English language, in peer-reviewed journals in full-text form, or on a professional specialty website addressing the PICO question and studies in which only one dose of Ofirmev 1,000mg was used as an adjunct to standard neuraxial or general anesthesia. The ACOG committee opinion article was utilized to offer a compelling insight into the problem and recommendations from the ACOG and SMFM. The literature was appraised and classified by level according to the method proposed by Melnyk and Fineout- Overholt. The hierarchy of evidence described in this method ranges from level I (systematic review or meta-analysis of randomized controlled trials) to level VII (expert opinion). Fifty sources were found; after reviewing the sources and removing duplicates, 14 met the inclusion criteria. After consideration of all inclusion and exclusion criteria, six articles remained (Table A1). Cesarean Birth Trends According to the US National Center for Health Statistics (2017), cesarean section is the most common operating room procedure in US hospitals, with a national cesarean rate of 32% of all births reported in 2015. The ACOG outlines how pain and fatigue are the most commonly reported problems in the early postpartum period. There is a significant gap in the pain management of the rapidly growing cesarean population in the US and the need for standardization of pain practices to provide adequate pain control in the postpartum period (ACOG, 2018). Despite the standard use of neuraxial anesthesia with opioid adjuncts, research shows an increasing trend in inadequately managed post-cesarean pain and a rising prevalence of EVALUATING THE PREEMPTIVE USE OF OFIRMEV 7 opioid use disorder (OUD), reiterating the need for a multimodal (MMA) approach that provides individual pain control while decreasing the use of opioids (Holland et al., 2020). The gold standard treatment for immediate post-cesarean pain involves neuraxial local anesthetic combined with an opioid, usually morphine. Carvalho and Butwick (2017) report that neuraxial anesthesia is recommended as the preferred anesthetic modality for cesarean section by the American Society of Anesthesiologists and the American Pain Society and that neuraxial opioids provide high-quality post-cesarean pain control. According to Holland et al., (2020), intrathecal or epidural morphine offers 12 to 36 hours of analgesia and is the standard of care for immediate postoperative pain control, as indicated by national obstetric and anesthesia societies guidelines. Despite the thought that neuraxial opioids provide up to 36 hours of pain control, postcesarean pain is still a problem. A meta-analysis of 84 references including cohort studies, practice guidelines, and randomized controlled trials (RCTs) conducted by Holland et al., (2020) concluded that optimal post-cesarean pain control includes a multimodal (MMA) approach combining the use of neuraxial opioids, acetaminophen, and NSAIDs as first-line pain relievers, with PO or IV opioids for breakthrough pain. Additionally, guidelines set by a committee of authors vetted by the Enhanced Recovery After Surgery (ERAS) society describe MMA as a critical component in managing post-cesarean pain as part of an enhanced recovery protocol (Macones et al., 2019). Carvalho and Butwick (2017) add the recommendation of around the clock dosing (ATC) scheduling of acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) as a core principle of multimodal cesarean pain management. A randomized, double-blind, placebo-controlled trial conducted by Baskent University School of Medicine demonstrated that preoperative administration of a single IV dose of EVALUATING THE PREEMPTIVE USE OF OFIRMEV 8 paracetamol offered effective pain control while reducing morphine consumption within the first 24-hour post-cesarean period compared with placebo treatments (Ozmete et al., 2016). The researchers in this study used meticulous search strategies, methods, and design. Pain scores were evaluated in frequent intervals, and additional measures like patient satisfaction and side effects were recorded. They noted no conflict of interests, consented patients, and attained proper IRB approval. The Bazkent study compared the pain of sixty randomized pregnant women having an American Society of Anesthesiologists (ASA) I and II between 18 and 40 years of age scheduled to undergo elective cesarean surgery under general anesthesia. Half received 1,000 mg IV of paracetamol before induction of anesthesia, while the other half received a placebo. Pain was evaluated at 15th, 30th minutes, and 1st, 2nd, 4th, 6th, 12th, 24th hours, and morphine consumption in the first 24 hours postpartum was also tallied. The authors concluded that the use of paracetamol prior to general anesthesia not only decreased pain scores but morphine consumption by 36% (Ozmete et al., 2016). These results offer a compelling insight into the positive effects of using paracetamol as an adjunct in an MMA approach to post-cesarean pain management. Still, it is essential to note that this study's participants received general anesthesia instead of the standard neuraxial anesthesia for cesarean section. A meta-analysis including five randomized, placebo-controlled, double-blind studies conducted by Ng et al., (2019) concluded that preoperative IV paracetamol significantly reduced postoperative pain and opioid consumption in the post-cesarean period. The researchers describe a rigorous inclusion and exclusion process and the use of per-protocol analysis and a randomeffects model in their methods and design section. The authors mention study limitations causing EVALUATING THE PREEMPTIVE USE OF OFIRMEV 9 heterogenicity due to the different types of anesthetics used (two neuraxial vs. three general), medication administration timing (some 15 minutes before incision and some immediately after induction), and age (patient population ranged from 18-40 years old). This meta-analysis had results similar to the Bazkent study. Although the researchers encountered some limitations in this study, the results demonstrate that high-level data support preemptive Ofirmev dosing to decrease pain and opioid consumption post-cesarean. The authors also discuss potential benefits found within the literature, like a blunted hemodynamic response to laryngoscopy and reduced nausea vomiting but imply that these findings require additional studies. Conversely, Towers et al., (2017) determined that a preemptive dose of Ofirmev 1,000mg did not lower postoperative pain score, morphine usage, or overall length of stay. This prospective double-blinded randomized placebo-controlled trial comprised 105 participants, of which 54 received 1,000mg of acetaminophen and 51 the placebo. Comparably these researchers used stringent inclusion and exclusion criteria, statistical testing to validate their results, proper patient consenting, and IRB approval. Dissimilar to the research conducted by Ozmete et al., (2016) and Ng et al., (2019) this study solely evaluated cesarean patients who received neuraxial anesthesia. The participants received a standard protocol for spinal anesthesia that consisted of an intrathecal injection of 20 mcg of fentanyl, 0.2 mg of morphine sulfate, and 12 mg of 0.75% bupivacaine; the acetaminophen infusion was started just before the start of and was continued during the placement of the spinal (Towers et al., 2017). Another difference in this study is that the researchers collected pain data using a visual analog scale instead of a numerical scale to evaluate pain for the first 48 hours postoperatively. Despite concluding that a preemptive dose of EVALUATING THE PREEMPTIVE USE OF OFIRMEV 10 Ofirmev did not decrease pain or morphine usage, the authors discuss the need for further studies to evaluate the use of acetaminophen as a postoperative adjunct. They concede that significant data supports its use in this manner (Towers et al., 2017). Theoretical Framework or Conceptual Model or Evidence Based Practice Model The conceptual model utilized to guide the development of this project is the John Hopkins Nursing Evidence-based Model. This model uses a three-step process focused on the practice question, evidence, and translation to incorporate the latest evidence-based research findings into practice. The lack of implementation and generalizability of a standardized opioidsparing approach to treating post-cesarean pain makes this model ideal for this project. The theoretical framework chosen for this project is Havelocks change theory, comprising of six steps performed cyclically throughout the assessing, planning, implementing, and evaluating the process of an evidence-based intervention. This framework is relevant to this project as it proposes a change in the existing way post-cesarean patients pain is managed at Hendricks Regional Health, with the intent to decrease pain scores and opioid usage in the first 24 hrs. Goals, Objectives, and Expected Outcomes This project aims to evaluate the effectiveness of a preemptive Ofirmev 1,000mg IV on post-cesarean pain scores within the first 24 hours postpartum at Hendricks Regional Health. Pain scores charted by unit nurses were measured using a validated NRS Likert scale (0-10). The expected outcomes were average pain scores lower than 5 out of 10 in the intervention group versus the non-treatment group. Project Design/Methods EVALUATING THE PREEMPTIVE USE OF OFIRMEV 11 A convenience sample of 50 scheduled cesarean patients from Hendricks Regional Health was retrospectively reviewed. Utilizing Havelocks theoretical framework, the numerical results of NRS scores within the first 24 hours postpartum were compared between 18 patients who received the Ofirmev 1,000mg preoperatively and 32 patients who did not receive the intervention. Project Site This project took place at Hendricks Regional Health on the Obstetrics unit, at which 1,330 births occurred in 2018 (About Hendricks, 2019). Hendricks Regional Health is a not-forprofit healthcare organization located in rural Danville, Indiana. Measurement Instrument(s) The intervention was evaluated by gathering the pain scores of 50 scheduled postcesarean patients based on a numerical NRS scale of 0-10, as charted by the obstetric nurses in EPIC over six months. These scores were then averaged and separated into less than five and a score greater than five on the Likert scale. Data Collection Data were collected by reviewing patient charts via the EPIC electronic charting system. The primary practical consideration was how patients were deidentified; this was achieved using the patient's initials and the last four digits of their medical record number. Ethical Considerations/Protection of Human Subjects Hendricks Regional Health Hospital Internal Review Board (IRB) approval was obtained prior to initiating this DNP Project. There were no major ethical considerations or risks involved in this project's participation as standard pain management options are not altered, only retrospectively reviewed. Participant confidentiality was assured by coding the participants using EVALUATING THE PREEMPTIVE USE OF OFIRMEV 12 personal identification numbers. The list of participants and their identifying numbers have been stored electronically in a password-protected laptop, which can only be accessed by the project coordinator. Data Analysis and Results Retrospective NRS pain data were collected over six months and compared between the random intervention and non-intervention groups. After comparing NRS scores between the two groups, the intervention's effectiveness was analyzed by comparing the odds ratio of pain within the first 24 hours postpartum between the two groups. The 24-hour post-cesarean pain scores of 50 patients were collected; of the 50 patients, 18 were in the treatment group while 32 were in the non-treatment group; of the treatment group, two patients' pain results were eliminated due to poor NRS charting. Appraisal of the data collected demonstrates no relationship between the preemptive use of Ofirmev 1,000mg and lower post-cesarean pain scores within the first 24-hours postpartum with an odds ratio of 1.0 (95% CI 0.21 to 4.65, P=1.0); still, this study did have some limitations. One of the main limitations was a small sample size of only 50 patients. Another limitation was the timing of Ofirmev admistration which ranged anywhere from several hours before cesarean to within and hour of incision. Future studies should focus on a larger sample size and specific timeframe of administration. Conclusion The management of post-cesarean pain and the incidence of opioid use and misuse is a rising problem requiring the standardization of an optimal pain regimen. Synthesis of literature regarding current techniques utilized in post-cesarean pain management revealed that MMA regimens are the best approach to addressing post-cesarean pain (Carvalho & Butwick, 2017). EVALUATING THE PREEMPTIVE USE OF OFIRMEV 13 The review of literature demonstrates that a preemptive dose of Ofirmev to manage postcesarean pain may be potentially effective. Still, due to the layered nature of drug administration used in MMA regimens, data regarding only the utilization of one preemptive dose of Ofirmev in conjunction with standard neuraxial cesarean analgesia is limited. Notably, many articles were excluded from the literature review that utilized multiple doses of Ofirmev throughout the pre and postoperative periods and in combination with other PO or IV drugs on a scheduled basis. EVALUATING THE PREEMPTIVE USE OF OFIRMEV 14 References About Hendricks Regional Health. (2019). Retrieved from Hendricks.org Carvalho, B., & Butwick, A. (2017). Postcesarean delivery analgesia. Best Practice & Research Clinical Anaesthesiology, 31, 69-79. doi:10.1016/j.bpa.2017.01.003 Bateman, B. T., Franklin, J. M., Bykov, K., Avorn, J., Shrank, W. H., Brennan, T. A., Choudhry, N. K. (2016). Persistent opioid use following cesarean delivery: Patterns and predictors among opioid-nave women. American Journal of Obstetrics and Gynecology, 215(3), 353.e1353.e18. doi:10.1016/j.ajog.2016.03.016 Holland, E., Sudhof, L. S. & Zera, C. (2020). Optimal pain management for cesarean delivery. International Anesthesiology Clinics, 58(2), 4249. doi:10.1097/AIA.0000000000000272 Macones, G. A., Caughey, A. B., Wood, S. L., Wrench, I. J., Huang, J., Norman, M., Pettersson, K., Fawcett, W. J., Shalabi, M. M., Metcalfe, A., Gramlich, L., Nelson, G., & Wilson, R. D. (2019). Guidelines for postoperative care in cesarean delivery: Enhanced Recovery After Surgery (ERAS) Society recommendations (part 3). American Journal of Obstetrics and Gynecology, 221(3), 247.e1247.e9. https://doi.org/10.1016/j.ajog.2019.04.012 Ng, Q. X., Loke, W., Yeo, W. S., Chng, K., & Tan, C. H. (2019). A meta-analysis of the utility of preoperative intravenous paracetamol for post-caesarean analgesia. Medicina (Kaunas, Lithuania), 55(8), 424. https://doi.org/10.3390/medicina55080424 Ozmete, O., Bali, C., Cok, O. Y., Ergenoglu, P., Ozyilkan, N. B., Akin, S., Kalayci, H., & Aribogan, A. (2016). Preoperative paracetamol improves post-cesarean delivery pain management: a prospective, randomized, double-blind, placebo-controlled trial. Journal of Clinical Anesthesia, 33, 5157. https://doi.org/10.1016/j.jclinane.2016.02.030 EVALUATING THE PREEMPTIVE USE OF OFIRMEV 15 The American College of Obstetricians and Gynecologists. (2018). ACOG Committee Opinion No. 742: Postpartum pain management. Obstet Gynecol, 132(1), e35e43. doi:10.1097/AOG.0000000000002683 Towers, C. V., Shelton, S., van Nes, J., Gregory, E., Liske, E., Smalley, A., Mobley, E., Faircloth, B., & Fortner, K. B. (2018). Preoperative cesarean delivery intravenous acetaminophen treatment for postoperative pain control: a randomized double-blinded placebo control trial. American Journal of Obstetrics and Gynecology, 218(3), 353.e1 353.e4. https://doi.org/10.1016/j.ajog.2017.12.203 US National Center for Health Statistics. (2017). Cesarean Birth Trends in the United States, 19892015. Retrieved from https://www.cdc.gov/nchs/fastats/delivery.htm EVALUATING THE PREEMPTIVE USE OF OFIRMEV 16 Appendix A Table A1 Author/Title/Journal Purpose Design/R eference s Level of Evide nce Result Holland, E., Sudhof, L. S. & Zera, C. (2020). Optimal pain management for cesarean delivery. International Anesthesiology Clinics, 58(2), 42 49. doi: 10.1097/AIA.0000000000000272. 1. Review options for pain management after cesarean delivery for both opioid-naive women and those with opioid dependence. Metaanalysis 84 referenc es Level I 1. Optimal pain control after cesarean delivery includes a multimodal strategy utilizing intrathecal or epidural opioids, acetaminophen, and nonsteroidal anti-inflammatory agents as a first-line, with oral or parenteral opioids reserved for breakthrough pain. 2. Additional options are relatively understudied and should be individualized to patient needs. Women with stable OUD should continue medication-assisted therapy perioperatively; however, data are limited to guide pain control beyond standard approaches. 3. System-wide strategies should include implementing ERAS protocols and maternal safety bundles to achieve optimal pain management, minimize excess opioid prescribing, and provide standardized multidisciplinary care for women with OUD. Systemat ic Review Ref # 93 Level I Metaanalysis Level I 1. It is recommended that women undergoing cesarean delivery receive neuraxial morphine (or equivalent long-acting opioid) withround-theclock NSAIDs and acetaminophen for 2 to 3 days following surgery. 2. Systemic opioids should only be prescribed as needed for considerable pain, not responding to opioid-sparing multimodal analgesics, i.e., NSAIDs and acetaminophen. 3. Oral opioids, such as oxycodone, hydrocodone, and tramadol, are recommended to treat moderate to severe breakthrough pain. Intravenous opioids should be reserved only for patients with extreme pain or who are intolerant of oral intake. 4. Alternate clinical care pathways may be required for women with risk factors for severe postoperative pain, such as general anesthesia, extended vertical skin incisions, and a known history of chronic pain. 1. Applying per-protocol analysis and a random-effects model, there was a significant reduction in postoperative opioid consumption and pain score in the group that received preoperative IV paracetamol, compared to placebo. Carvalho B, Butwick AJ. Postcesarean delivery analgesia. Best Pract Res Clin Anaesthesiol. 2017 Mar;31(1):69-79. doi: 10.1016/j.bpa.2017.01.003. Epub 2017 Jan 12. Review. PubMed PMID: 28625307. Ng QX, Loke W, Yeo WS, Chng KYY, Tan CH. A Meta-Analysis of the Utility of Preoperative Intravenous Paracetamol for Post-Caesarean Analgesia. Medicina (Kaunas). 2019 Jul 31;55(8):424. doi: 10.3390/medicina55080424. PMID: 31370298; PMCID: PMC6723542. 2. Review system-wide approaches to help prevent OUD and improve quality of care for women with OUD. Review literature to determine best post-cesarean analgesia delivery Aimed to investigate the utility of preoperative IV paracetamol for post-caesarean analgesia EVALUATING THE PREEMPTIVE USE OF OFIRMEV Ozmete O, Bali C, Cok OY, Ergenoglu P, Ozyilkan NB, Akin S, Kalayci H, Aribogan A. Preoperative paracetamol improves postcesarean delivery pain management: a prospective, randomized, double-blind, placebocontrolled trial. J Clin Anesth. 2016 Sep;33:51-7. doi: 10.1016/j.jclinane.2016.02.030. Epub 2016 Apr 8. PMID: 27555133. Towers CV, Shelton S, van Nes J, Gregory E, Liske E, Smalley A, Mobley E, Faircloth B, Fortner KB. Preoperative cesarean delivery intravenous acetaminophen treatment for postoperative pain control: a randomized doubleblinded placebo control trial. Am J Obstet Gynecol. 2018 Mar;218(3):353.e1-353.e4. doi: 10.1016/j.ajog.2017.12.203. Epub 2017 Dec 21. PMID: 29274831. ACOG Committee Opinion No. 742: Postpartum Pain Management. (2018). Obstetrics and gynecology, 132(1), e35e43. https://doi.org/10.1097/AOG.0000 000000002683 To evaluate the analgesic effect of preoperative single-dose intravenous paracetamol on postoperative pain and analgesic consumption within 24hours after elective cesarean surgery. The primary study objective was to see if maternal opioid use was significantly less in the postoperative period for the study group that received 1 g of intravenous acetaminophen preoperatively compared with a control group that received a placebo. The secondary objectives were to evaluate the maternal length of stay and pain scores postoperatively and assess the acetaminophen level in cord blood at delivery. Recommendatio ns for postpartum pain. Stepwise approach. Csection recommendatio ns. 17 Randomi zed Controlle d Trial Level I 1. Preoperative use of single-dose intravenous 1g paracetamol was found to be effective in reducing the severity of pain and opioid requirements within 24hours after cesarean section. Randomi zed Controlle d Trial Level I 1. the use of a preoperative 1-g intravenous dose of acetaminophen does not decrease the number of opioid medication doses or the morphine milligram equivalents administered postoperatively, nor does it reduce the length of stay postcesarean. 2. The administration of 1-g intravenous acetaminophen preoperatively does not result in elevated newborn cord blood levels. Expert Opinion Ref #64 Level VII 1. Pain and fatigue most significant issues postpartum. 2. Pain interferes with self-care and baby care. 3. Stepwise, MMA emphasizing non-opioid analgesia is safe and effective. 3. Discharge with fewer opioids  ...

... PODCASTS IN NURSE ANESTHESIA EDUCATION 2 TABLE OF CONTENTS Abstract4 Introduction......5 Background......5 Problem Statement ..6 Review of Literature6 Podcasts vs. Traditional Learning Modalities..6 Podcasts in Conjunction with Traditional Learning Modalities..8 Alternative Podcast Implementations......8 Practice Gap Analysis......9 Conceptual Framework..............10 Goals and Objectives.11 Project Design12 Method for Translation......12 Stakeholder Assessment.........13 Procedure for Implementation...14 Setting16 Participants.16 Perceived Barriers......17 Methods......18 Instrument..18 Data Collection Procedure.........18 Data Analysis.........19 PODCASTS IN NURSE ANESTHESIA EDUCATION 3 Results19 Discussion......21 Ethical Considerations...22 Conclusion.22 References..........23 Appendices.26 Appendix A - Student Satisfaction with Educational Podcasts Questionnaire (SSEPQ).26 Appendix B - Podcasts as a Learning Adjunct in Nurse Anesthesia Education Satisfaction Survey27 Appendix C - Table 1: Participant Characteristics....35 PODCASTS IN NURSE ANESTHESIA EDUCATION 4 Abstract Educational approaches are constantly evolving due to of influences from technology and improvements in the resources that are available to educators as well as learners. Current literature suggests that utilizing podcasts in addition to conventional educational methods contributes to a higher level of satisfaction among learners. The goal of this translational research project was to provide student registered nurse anesthetists (SRNAs) with educational podcasts as an adjunct to their traditional learning process and then measure their satisfaction after listening to the podcasts. A series of six educational podcasts were recorded and made available on From the Head of the Bed, which is a free podcast platform for the anesthesia community that is available to Apple, Android, Spotify, or Rich Site Summary (RSS) users. The intervention of using educational podcasts was intended to supplement and reinforce customary learning practices in nurse anesthesia education. A post-intervention anonymous online survey was administered to the SRNAs at Marian University. A mixed methods study design was developed to assess the satisfaction of the educational podcasts. Keywords: Podcasts, learning, education, nurse anesthesia, SRNA, CRNA, SSEPQ PODCASTS IN NURSE ANESTHESIA EDUCATION 5 Podcasts as a Learning Adjunct in Nurse Anesthesia Education Introduction Utilizing technology in education has made options like podcasting, a new and popular way to engage learners and provide variety to the educational process. People learn in different styles and settings, and this realization has created a paradigm shift in the delivery of education . This shift also reveals millennial learners preferences toward education, which include stimulating activities as well as the option to multitask while learning. Student Registered Nurse Anesthetists (SRNAs) have demanding schedules between clinicals and didactic responsibilities, leaving little time available to study and review clinical concepts. A previous systematic review of the literature revealed that podcasts improve test scores and are a satisfactory method of disseminating educational information to students in this modern era of learning where they enjoy multitasking and studying with technology (Rouhselang, 2018). Even though educational podcasts do exist, there are very few that are related to anesthesia. Background According to Rainsbury and McDonnell (2006), a podcast is a whole new medium for disseminating news, views, and education as a downloadable audio or video file to store in your pocket and listen to or view at your leisure (p.481). An educational podcast can be developed based on expert content that is then recorded on a computer and uploaded to a service, allowing listeners to download or stream the episodes that they choose (Andrejco, Lowrance, Morgan, Padgett, & Collins, 2017). An overarching advantage of podcasting is the unique ability for learners to multitask by listening to them while driving, cooking dinner, cleaning, or working out, which makes efficient use of time that would otherwise be unavailable for other, more traditional forms of learning (Wolpaw & Toy, 2018). SRNAs experience intense workloads with PODCASTS IN NURSE ANESTHESIA EDUCATION limited time for additional tasks. Current literature suggests podcasts are advantageous for learners who want supplementary information at their fingertips. Problem Statement It is clear that podcasts could be an important, but as of yet under-explored, learning adjunct in nurse anesthesia education. Proposing an intervention to develop, produce, and measure the satisfaction of podcasts focused on SRNA educational content can be a valuable reinforcement tool for traditional learning. Review of Literature This literature review was undertaken to understand the current state of podcasts as possible adjuncts in higher education. Many of the studies reviewed were similar in their purposes to assess whether podcasts are an effective tool as an alternative learning strategy however, their study designs testing that hypothesis varied slightly. Alternative methods of podcast implementation in education were also explored. For the purpose of this literature review, the term traditional learning modalities refers to either in-class lectures or reading a textbook. The chosen articles have been reviewed under three distinct subheadings: podcasts vs. traditional learning modalities, podcasts in conjunction with traditional learning modalities, and alternative podcast implementations. Podcasts vs. Traditional Learning Modalities Four publications, two randomized controlled trials and two quasi-experimental studies analyze data to determine whether test scores are higher after students learn by listening to podcasts or after a combination of classroom lectures and textbook readings. McKinney, Dyck, and Lubar (2009) determined that listening to a podcast lecture is an advantage over attending a traditional lecture (p<0.05). McKinney et al. (2009) also noticed a favorable quality among 6 PODCASTS IN NURSE ANESTHESIA EDUCATION 7 educational podcasts which gave the learner the ability to listen to the podcasts as many times as they wanted. This attribute allows the learner to review any of the content in a purposeful and topic-specific way that traditional lectures do not. Conversely, another early quasi-experimental study published by Vogt, Schaffner, Ribar, and Chavez (2010) found there to be no statistically significant improvement in the scores of three different exams (p=0.22, p=0.06, p=0.11) when administered to two groups of undergraduate nursing students (n=120), one who received a traditional lecture and one who received an audio podcast. A more recent randomized controlled trial published by Back et al. (2017) reviewed the effect of podcasts over textbook readings in a group of medical students (n=130) and found that the group who listened to the educational podcasts scored significantly higher on the post-test than the group who read from textbooks (p<0.021). Another randomized controlled trial compared two groups of second year medical residents (n=49), one who listened to podcasts and one who learned through traditional lectures and found that the podcast arm of the study had statistically higher scores than the control group (p<0.01) (Brust, Cooke, & Yeung, 2015). An additional factor that should be considered is the user satisfaction of the podcast against more traditional learning methods. McKinney et al. (2009) did not test user satisfaction. Vogt et al. (2009) administered a six-question satisfaction survey that found the users to be satisfied with the podcasts, but preferred traditional lectures (63%) over the podcasts. It is possible that lack of familiarity with podcasts influenced satisfaction at a point in time when podcast development was very new. Brust et al. (2015) found no difference in user satisfaction between the podcast learners and traditional lecture learners (p=0.37). Finally, Back et al. (2017) reports an increase in user satisfaction of podcasts over reading textbook chapters. Overall, the satisfaction of podcast use is equal to or higher than traditional learning media. PODCASTS IN NURSE ANESTHESIA EDUCATION 8 Podcasts in Conjunction with Traditional Learning Modalities Two publications, one randomized controlled trial and one quasi-experimental study, analyze data to determine whether test scores are higher after students learn by listening to podcasts in addition to a combination of classroom lectures and textbook readings. Kalludi, Punja, Pai, and Dhar (2013) conducted a quasi-experimental study involving dental students (n=80) that assessed the efficacy of podcasts as a supplement to classroom lectures and textbook readings. The authors reported that the students who had access to the podcasts scored higher on the post-test than the students who did not receive the podcasts until after the exam (p=0.00). A randomized controlled trial published by Morris (2015) assessed how podcasts and mobile selfassessments affected learning in two groups of healthcare students (n=85) by describing that supplementary podcasts and mobile assessments positively affected the learners (p<0.05). It is valuable to include a review of the theme of user satisfaction of podcasts in conjunction with traditional learning methods. The learners in Kalludi et al. (2013) felt very strongly (91%) that the biggest advantage of podcasts was the ability to listen to them repeatedly, a common theme that has been discussed in this review. In a survey provided to the students in Morriss study, 86% felt strongly that having podcasts as a supplement to traditional learning methods enriched their learning. Alternative Podcast Implementations Two publications, both quasi-experimental studies, will be discussed for their unique attributes. In a one-arm, quasi-experimental study published by Miesner, Lyons, and McLoughlin (2017), medical residents (n=23) took pre-tests, listened to the educational podcasts, and then took post-tests which yielded a significant improvement in test scores (p=0.001). Lien, Chin, Helman, and Chan (2018) compared two groups of medical students (n=61), one who PODCASTS IN NURSE ANESTHESIA EDUCATION 9 learned by using podcasts and the other who used blog posts, finding that knowledge was increased with both the podcast (p<0.01) and blog post learning (p<0.01), but no significant difference existed between the two (p>0.05). Satisfaction among learners in these alternative forms of educational podcast implementation is a key point to consider in this review, especially related to the recency of these two studies. In Lien et al. (2018) students liked that the podcast taught us how to approach a clinical presentation and walked us through steps for differential and management, was easy to listen to and kept a constant volume level, and was good for consolidating information (p. 7). In the post-assessment survey done in the study by Miesner et al. (2017), no evaluation of satisfaction was performed, however students provided unanimously positive comments about the podcast. Another theme that is helpful to analyze is that of the activity of students while they listen to podcasts. In Lien et al. (2018) 79% (n=22/28) of the students in the podcast arm of the study took part in different activities such as working out, driving, and eating while simultaneously listening to the podcasts. This is an interesting finding, as learning while multitasking can be perceived as an advantage to educational podcasts. The literature supports the efficacy and satisfaction of educational podcasts, in addition to highlighting the lack of available research that exists regarding educational podcasts geared toward anesthesia education. Practice Gap Analysis The literature review established that podcasts can be a useful adjunct in education, however, research does not exist to support the satisfaction of an educational podcast created for SRNAs. While Andrejco et al. (2017) set the foundation for the creation and implementation of educational anesthesia podcasts, research was not conducted to measure the effects of the PODCASTS IN NURSE ANESTHESIA EDUCATION 10 podcast. This gap presented an opportunity to create educational podcasts for SRNAs and then measure their satisfaction after the intervention was implemented. Conceptual Framework The Keller Attention, Relevance, Confidence, and Satisfaction (ARCS) Model of Instructional Design was the framework chosen to guide the process of creating podcasts as a learning adjunct in nurse anesthesia education. The ARCS Model of Instructional Design is a method that was developed by John Keller in order to enhance the motivational interest of educational resources (Keller, 1987). While the model is made up of three different components, only the first component that involves four conceptual conditions to distinguish learners motivation will be used as a framework in this translational research. The four conceptual conditions, including attention, relevance, confidence, and satisfaction, must be achieved in order to create and sustain motivation in the learner (Keller, 1987). The first condition suggests using methods to capture users attention including active participation, variability, humor, incongruity, specific examples, and inquiry (Keller, 1987). Using anecdotes, different styles of presentation, and allowing the learner to choose the educational topics are all ways to garner and hold attention (Keller, 1987). Relevance is a condition used to motivate the learner by presenting the material in a way that the learner can connect to personal experiences and encourages them to relate the material to future applicability (Huang, Huang, Diefes-Dux, & Imbrie, 2006). Some strategies to promote relevance include using examples of previous experiences, relating instruction to future usefulness, giving learners choices, using modeling and need matching, and relating the instruction to the worth of future goals (Keller, 1987). The third condition of confidence pertains to the learners perceived ability to be successful with the learning task (Huang et al., 2006). Factors that can increase confidence include providing the learner with PODCASTS IN NURSE ANESTHESIA EDUCATION 11 goals and expectations, ensuring they understand performance requirements and evaluation criteria, giving them encouragement and support, and attributing success to effort (Keller, 1987). Lastly, satisfaction is based on the learners perceived sense of achievement and utility, as well as using the newly acquired knowledge and positive feedback as reinforcements for motivation (Huang et al., 2006). Some strategies of satisfaction include natural consequences of learning, receiving unexpected rewards, giving verbal praise, scheduling reinforcement, and avoiding negative threats or influences during learning (Keller, 1987). Together, these four conditions create a foundation for successful learning motivation. The ARCS Model was selected because it was presented in Andrejco et al. (2017) as a guide for nurse anesthesia educators to create educational podcasts. According to Andrejco et al. (2017), the use of the Keller ARCS Model and the logic model outlined in this article provide a guide for nurse anesthesia educators who wish to develop effective educational podcasts for the field of nurse anesthesia (p. 17). Andrejco et al. researched, outlined, and established a podcast for the anesthesia community, in addition to publishing a blueprint for the re-creation and further development of educational anesthesia podcasts in the future (2017). The ARCS Model guided the work of Andrejco and colleagues in their development of podcasts for the nurse anesthesia community. Goals and Objectives The significance of creating educational anesthesia podcasts for SRNAs is to provide them with flexibility and engagement in alternative forms of studying. The goal of this project is to explore whether educational anesthesia podcast content provides an alternative medium in a way that will give SRNAs variety in their study plans and enrich the traditional study methods they are using already. PODCASTS IN NURSE ANESTHESIA EDUCATION 12 The overall purpose of this project is to determine the level of satisfaction that SRNAs have toward educational podcasts as a supplement to their traditional education. In a more detailed perspective, the four aims of this DNP project are: (1) to record and disseminate a series of educational podcasts that are interesting and helpful to SRNAs, (2) to motivate SRNAs to seek out and utilize alternative, relevant forms of education that are available to reinforce previously learned topics, (3) to give SRNAs confidence in their knowledge by supporting their learning with anesthesia-based educational podcasts, and finally (4) to measure the levels of satisfaction that SRNAs have toward the podcasts. Project Design Method for Translation The ARCS Model of Instructional Design guided the project plan to create educational podcasts for SRNAs. In accordance with the conceptual components of the ARCS model, podcast creation was guided utilizing attention, relevance, confidence, and satisfaction strategies. The condition of attention was the basis for podcast production. Creating a learning tool that provided variability to the learning environment by reinforcing familiar concepts through a podcast platform that offers flexibility to the learners study plan is the foundation of the project (Keller, 1987). Other methods such as active participation through role play, personal stories, and access to references were used to capture listeners attention and participation (Keller, 1987). The relevance of anesthesia topics for the SRNA participants is extremely important to the studys design as the podcasts topics were chosen to appeal to those interested in introductory anesthesia content. The material presented can assist the study participants in future exams, clinical experiences, and professional endeavors, making them very pertinent to a student. The information produced in the podcast consisted of foundational anesthesia content, PODCASTS IN NURSE ANESTHESIA EDUCATION 13 along with relevant personal experiences and practice recommendations. In addition, Andrejco et. al. (2017) explains that relevance is not only related to the content material but how it is presented, showcasing that podcasts are delivered in a relevant and accessible manner for SRNAs. The condition of confidence was incorporated by allowing the study participants to control their own learning through the podcasts. Motivation can be increased by allowing the study participant control over which podcast(s) and how much of the podcast(s) they listened to, that way success is a direct result of the effort that was put in (Keller, 1987). Andrejco et. al. (2017) also suggests that confidence is related to the validity of the podcasts, which can be accomplished through providing show notes with references as an aide to the discussion. Also, podcasts can provide a low-risk learning environment of the listeners choosing, which can enhance confidence (Andrejco et al., 2017). Lastly satisfaction was addressed by providing a post-intervention survey to study participants, evaluating their perceived satisfaction with the podcasts. Satisfaction may be based on personal achievement and mastery of the content presented or can stem from feedback and reinforcement (Keller, 1987). The study participants satisfaction may continue to evolve as the learner attempts to use the newly acquired knowledge on exams or in clinical practice. Stakeholder Assessment The SRNAs at Marian University in the class of 2020 and class of 2021 are the key stakeholders in this project. Their interest in the project stems from their desire to expand and reinforce their foundational anesthesia knowledge for the purposes of improved test scores and clinical skills and knowledge. The implementation and evaluation of the intervention is dependent on other stakeholders as well. Drs. Alarcn, Bendayan, and Blanca are additional PODCASTS IN NURSE ANESTHESIA EDUCATION 14 stakeholders as their validated tool, Student Satisfaction with Educational Podcasts Questionnaire (SSEPQ) (Appendix A), is being used to evaluate the satisfaction of the podcasts in this translational research project (Alarcn, Bendayan, & Blanca, 2017). Lastly, Jon Lowrance, MSN, CRNA has provided his podcast platform, From the Head of the Bed, as a repository for the podcast series, and therefore is another stakeholder in this project. Procedure for Implementation After reading the article Social Media in Nurse Anesthesia: A Model of Reproducible Educational Podcasts, and listening to several podcasts on the show, From the Head of the Bed, contributing author and producer, Jon Lowrance, MSN, CRNA was contacted for advice on podcast production (Andrejco et al., 2017). Lowrance obtained his Master of Science in Nursing after attending the nurse anesthesia program at Western Carolina University (Lowrance, 2019). He is a current practicing CRNA of four years in Portland, Maine as well as a faculty member with Landmark Learning, Cornerstone Anesthesia Conferences, and National Outdoor Leadership School (NOLS) Wilderness Medicine. Lowrance and three other CRNAs created From the Head of the Bed as a research project while in nurse anesthesia school. He has since continued the free, open access podcast channel independently and continues to update and create additional episodes which are accessible on Apple, Android, Spotify, and RSS (Lowrance, 2019). Mr. Lowrance generously contributed to this project by voluntarily offering his podcast platform to host the series of educational podcasts, in addition to editing the scripts and recording and editing the podcasts. Focusing on foundational anesthesia content applicable to SRNAs, it was decided that a series of six podcasts would be created. The six podcast episodes included: Clinical Flow: from OR set up through intubation, The Anesthesia Machine, Pharmacokinetics of Volatile PODCASTS IN NURSE ANESTHESIA EDUCATION 15 Anesthetics, Pharmacodynamics of Volatile Anesthetics, IV Induction Agents, and Local Anesthetics. The process of creating the podcasts began with writing scripts using several common anesthesia textbooks as a reference. All scripts were then reviewed by Lowrance and any necessary edits were made to ensure clarity and accuracy. The podcasts were recorded using Facetime Audio on Apple devices. Lowrance used his own recording equipment to capture the audio and used editing software to make necessary adjustments to the recordings. References to the concepts discussed were provided in the show notes which can be accessed on fromtheheadofthebed.com. A post-intervention satisfaction survey (Appendix B) was created using Qualtrics Survey Software. The survey included a required consent agreement in order to gain access, which was listed as question 1, but has been left out of Appendix B at this time. Demographic information was collected in the survey in addition to using the SSEPQ validated tool (Appendix A) in order to measure satisfaction (Alarcn et al., 2017). Once produced, an email was sent to all Marian University SRNAs in classes 2020 and 2021, requesting their participation in this study, along with instructions on how to access the podcasts and post-intervention survey. In addition, some of the members of the class of 2020 and 2021 were visited in person to introduce the study and to answer any questions if needed. Lowrance released all six podcasts on his platform, making them available to the public at the same time the instructions were given. While the podcasts are accessible for free to the public, only the Marian University SRNAs were provided with instructions on how to access the postintervention survey. After the podcasts and survey were released, the SRNAs were given 45 days to listen to any or all of the podcast series and submit their satisfaction surveys. PODCASTS IN NURSE ANESTHESIA EDUCATION 16 Setting The setting of the podcast series is complex, as it exists in a virtual medium. As stated, the podcasts were made available on Apple, Android, Spotify, and RSS under the From the Head of the Bed platform. Due to the virtual nature of the podcasts, there is little ability to control the setting. Control cannot be exercised in regard to when the podcasts are listened to, where they are listened to, how much of the podcast is listened to, which episodes are listened to, and how the podcasts are listened to. The setting is primarily determined by the study participants. Podcasts could have been listened to on a phone, tablet, or computer and with or without headphones. A podcast episode also could have been listened to in one setting or split up over time. The setting of where the podcasts were listened to could vary, including the gym, car, while doing chores, while sitting down at home, and so on. The survey inquired about the setting in which the participants listened to the podcasts. A participant could have listened to one podcast episode, multiple episodes, or none at all before completing the survey. The only control is where, electronically, the podcasts and survey are accessed, as well as the time frame of 45 days that the participants had to listen to the podcasts and take the survey. Participants The study participants included Marian University SRNAs in the classes of 2020 and 2021. These participants were chosen based on their presence in the nurse anesthesia program at Marian University. Only SRNAs from Marian University were selected as participants in order to maintain control over who had access to the post-intervention satisfaction survey. The class of 2020 consisted of 12 SRNAs entering their third year of the program and the class of 2021 consisted of 21 SRNAs entering their second year of the program. Participants were recruited through an email detailing the study, along with instructions on how to access the podcast series PODCASTS IN NURSE ANESTHESIA EDUCATION 17 and the post-intervention satisfaction survey. In addition, several members of both classes were visited in person during a school meeting to promote participation in the study, as well as to answer any questions. Participants were not offered any reward or compensation for participation in this study. Perceived Barriers Perceived barriers associated with this study include time commitment, technology, and motivation. The podcast episodes ranged from 28 to 55 minutes. A study conducted with anesthesia residents measuring podcast use and content, found that the preferred length of podcasts was less than 30 minutes, and a podcast was less likely to be listened to if it exceeded 45 minutes (Matava, Rosen, Siu, & Bould, 2013). Therefore, the increased length of five out of the six podcasts is a barrier to getting listeners to stay engaged through the entire episode. The series of six podcasts totaling 260 minutes and 44 seconds, is an extensive time commitment for SRNA students. However, it is anticipated that a desire to acquire educational anesthesia content in a non-traditional format will be embraced by the study participants. Technology is also a barrier due to predicted differences in experience with podcasts in regard to accessing the platform and either downloading or streaming the content. Access to technology required to listen to podcasts is not barrier, as all students in the nurse anesthesia program at Marian University are provided with an iPad at the start of the program. Lastly, motivation is the most significant perceived barrier, because this study relies heavily on intrinsic motivation from the participants and is not within the control of the study design. PODCASTS IN NURSE ANESTHESIA EDUCATION 18 Methods Instrument The SSEPQ tool (Appendix A) addressed satisfaction related to the podcast series through a 10-question Likert-type scale with four response options (Alarcn et al., 2017). Based on the SSEPQ, satisfaction is measured in relation to perceived content adequacy, ease of use, and usefulness and benefits. This tool was developed by Alarcn, Bendayan, and Blanca (2017) in order to create a brief and simple questionnaire evaluating satisfaction with educational podcasts in higher education and has standardization data. The creators of the tool are considered to be experts, as they all are doctoral recipients and have experience with teaching or supporting teaching in undergraduate research method courses. In order to standardize this tool, 376 students in a psychology course were enrolled in a study and presented with 11 educational podcasts created by the authors of the psychology course. The podcast could be freely accessed throughout the year, and on the last day of the course, the SSEPQ was administered to the students. The SSEPQ tool was standardized using Cronbachs alpha to determine internal consistency and was created with a one-factor structure in order for the total score of the questionnaire to provide an overall index of students satisfaction with podcasts. The four response options per question pertain to a score of 1-4 resulting in an overall max score of 40 (Alarcn et al., 2017). Permission was obtained via email from Dr. Alarcn to use the SSEPQ tool in this study. Data Collection Procedure Based on the Keller ARCS Model of Instructional Design and the condition of satisfaction, the data collection involved creating a post-intervention satisfaction survey using the SSEPQ (Appendix A) (Alarcn et al., 2017; Andrejco et al., 2017). Information regarding PODCASTS IN NURSE ANESTHESIA EDUCATION 19 how to access the survey and when to take it was included in the email used to recruit participants for the study. While the podcast is on a free, open access platform available to the public, the post-intervention satisfaction survey access was only shared with Marian University SRNAs. It should be noted that this method does not allow the experimenter to control at what point during the 45-day period the participant takes the survey. It is suggested to the study participants that the survey should be completed after the participant has listened to all the podcast episodes that they plan on listening to within the 45-day period. Data collected will then be analyzed and also compared to the results from Alarcn et al. (2017), which was used to validate the SSEPQ tool (Appendix A), in order to evaluate the effectiveness of the study. Data Analysis The analysis plan for this study included utilizing descriptive statistics to analyze the data as the sample size was not large enough to warrant parametric analysis. While this study does not lend itself to parametric comparisons, comparisons will be made with the results of Alarcn et al. (2017), which was used to validate the SSEPQ tool. The SSEPQ portion of the survey was scored in the same manner as the SSEPQ tool used in Alarcn et al. (2017). Each item was scored by rating the answers from 1-4: Strongly disagree (1), Disagree (2), Agree (3), and Strongly Agree (4). The average of the responses for each question along with the total mean score was calculated and compared to Alarcn et al. (2017). Results The data collected from the post-intervention survey included demographic information and the SSEPQ instrument (Alarcn et al., 2017). The classes of 2020 and 2021 were equally represented with about 50% (n=26) of participants from each class. The majority of the sample ranged from ages 26-35 with only a small percentage age 36 and above. About 50% of the PODCASTS IN NURSE ANESTHESIA EDUCATION 20 sample had between 6-10 years of experience as a registered nurse, the remaining sample had anywhere from 3 years to over 21 years of experience. Forty percent of participants stated that they already listened to podcasts 1-2 times per week, with only 8% reporting they never listen to podcasts. The participants were asked which additional educational modalities are mostly beneficial to them besides traditional didactic learning, the three top rated modalities were YouTube/videos online, recorded video lectures, and podcasts, respectively. Of the 6 podcasts that were released for this study, 88% of participants stated they listened to all 6 podcasts and 12% listened to 3 podcasts. The majority stated that they listened to the podcasts while in the car, followed by cooking and cleaning, sitting and listening, other, and exercising. The other responses entered included: while getting ready in the morning; giving my child a bath; and mowing the lawn. See Table 1 Participant Characteristics for a complete overview of the sample (Appendix C). The table below depicts the results from this study (SRNA Results) compared to Alarcn et al. (Standardized Results) utilizing the SSEPQ tool (2017). Table 2 SSEPQ Mean Comparisons SSEPQ Question 1. The podcasts are easy to access 2. The podcasts are useful for learning about this subject 3. The podcasts motivate me to learn about this subject 4. The podcasts make it easier to learn about this subject 5. I am satisfied with the podcasts as a learning tool for this subject 6. The podcasts provide clear information about the theoretical content of the topic 7. The podcasts provide clear information about the practical content of the topic 8. The content of the podcasts is well organized Standardized Results (mean) n=376 3.49 3.34 DNP Project Results (mean) 3.71 (n=24) 3.88 (n=24) Difference 2.84 3.87 (n=23) 1.03 3.28 3.91 (n=23) 0.63 3.44 3.87 (n=23) 0.43 3.27 3.78 (n=23) 0.51 3.16 3.91 (n=23) 0.75 3.18 3.96 (n=23) 0.78 0.22 0.54 PODCASTS IN NURSE ANESTHESIA EDUCATION SSEPQ Question 9. The information contained in the podcasts is academically rigorous 10. The design of the podcasts makes them appealing 21 Standardized Results (mean) n=376 3.03 DNP Project Results (mean) 3.74 (n=23) Difference 2.85 3.87 (n=23) 1.02 0.71 Discussion Overall, the results depict a general satisfaction with the podcast series created. Compared to Alarcn et al. (2017), all of the results from the SSEPQ scored higher, with the greatest difference being that the podcasts motivated the SRNAs to learn about the subject and that the design of the podcasts makes them appealing. The increase in mean scores could be due to multiple factors, the most prevalent being Alarcn et al. (2017) had a sample size of 376, while the sample size for this study was 26. It should be noted that while 26 participants began the survey, only 23 participants fully completed the survey. The higher incidence of satisfaction could also be attributed to Marian University SRNAs bias toward classmates research. The creators of the study are a part of the class of 2020 and this project was created as a Doctor of Nursing Practice (DNP) research project. The participants could have reported overall better scores as a way to support their classmates. The higher satisfaction scores could also be attributed to motivation. SRNAs at Marian University, and across the country, undergo a rigorous graduate program that requires balance between didactic and clinical education. The goal upon graduation is to pass a standardized board exam in order to obtain a Certified Registered Nurse Anesthetist license. The stress of the program coupled with limited spare time forces students to seek out additional educational resources. This podcast series was created to directly appeal to SRNAs seeking out foundational anesthesia concepts. PODCASTS IN NURSE ANESTHESIA EDUCATION 22 Due to the study design, a relationship cannot be inferred from any of the demographic information collected and the SSEPQ instrument (Alarcn et al., 2017). It would be interesting to know whether age, familiarity with podcasts, or matriculation in the program had any correlation to satisfaction with the podcasts. Ethical Considerations The Marian Universitys Institutional Review Board determined the project was exempt from the need of human subjects protections; therefore, the project was approved by the Leighton School of Nursing. Conclusion Demanding schedules along with intense workloads create a conundrum for SRNAs who have to balance their time between didactic and clinical obligations. Educational podcasts solve a problem for SRNAs in which they can add more studying into their busy schedules without sacrificing time needed for the responsibilities of daily life. There is an evident lack of modern supplemental educational modalities related to anesthesia, including podcasts aimed towards SRNAs. The purpose of this project was to address this void and develop, produce, and measure the satisfaction of educational podcasts created for SRNAs. The study revealed that SRNAs at Marian University were satisfied with the podcast series created and believed that the podcasts made it easier for them to learn about the subject, motivated them to learn, and were a useful for anesthesia education. As educational approaches continue to evolve, it is likely the popularity of podcasts as an additional study modality will become more widely accepted and utilized in anesthesia education. PODCASTS AS A LEARNING ADJUNCT 23 References Alarcn, R., Bendayan, R., & Blanca, M. J. (2017). The student satisfaction with educational podcasts questionnaire. Psychological Writings, 10(2), 126-133. http://dx.doi.org/10.5231/psy.writ.2017.14032 Andrejco, K., Lowrance, J., Morgan, B., Padgett, C., & Collins, S. (2017). Social media in nurse anesthesia: A model of reproducible educational podcasts. American Association of Nurse Anesthetists, 85(1), 10-16. Retrieved from https://www.aana.com/docs/defaultsource/aana-journal-web-documents-1/social-media-0217-pp1016.pdf?sfvrsn=89cd48b1_4 Back, D. A., von Malotky, J., Sostmann, K., Hube, R., Peters, H., & Hoff, E. (2017). Superior gain in knowledge by podcasts versus text-based learning in teaching orthopedics: A randomized controlled trial. Journal of Surgical Education, 74(1), 154-160. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/27651055 Brust, T., Cooke, L., & Yeung, M. (2015). A randomized-controlled trial comparing efficacy and user satisfaction of audio podcasts versus a traditional lecture on multiple sclerosis in family medicine resident education. Neurology, 84(14). Retrieved from http://n.neurology.org/content/84/14_Supplement/P4.195 Huang, W., Huang, W., Diefes-Dux, H., & Imbrie, P. K. (2006). A preliminary validation of attention, relevance, confidence, and satisfaction model-based instructional material motivational survey in a computer-based tutorial setting. British Journal of Educational Technology, 37, 243-259. http://dx.doi.org/10.1111/j.1467-8535.2005.00582.x PODCASTS AS A LEARNING ADJUNCT 24 Kalludi, S., Punja, D., Pai, K., & Dhar, M. (2013). Efficacy and perceived utility of podcasts as a supplementary teaching aid among first-year dental students. Australian Medical Journal, 6(9), 450-457. http://dx.doi.org/10.4066/AMJ.2013.1786 Keller, J. M. (1987). Development and use of the ARCS model of instructional design. Journal of Instructional Development, 10(3), 2-10. Retrieved from http://www.jstor.org.forward.marian.edu/stable/30221294 Lien, K., Chin, A., Helman, A., & Chan, T. (2018). A randomized comparative trial of the knowledge retention and usage conditions in undergraduate medical students using podcasts and blog posts. Cureus, 10(1). http://dx.doi.org/10.7759/cureus.2065 Lowrance, J. (2019). From the head of the bed...a podcast for the anesthesia community. Retrieved from https://www.fromtheheadofthebed.com/about/ Matava, C. T., Rosen, D., Siu, E., & Bould, D. M. (2013). eLearning among Canadian anesthesia residents: A survey of podcast use and content needs. BMC Medical Education, 1-8. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3648490/pdf/1472-692013-59.pdf McKinney, D., Dyck, J., & Lubar, E. (2009). iTunes university and the classroom: Can podcasts replace professors? Computers and Education, 52(3), 617-623. http://dx.doi.org/10.1016/j.compedu.2008.11.004 Miesner, A. R., Lyons, W., & McLoughlin, A. (2017). Educating medical residents through podcasts developed by PharmD students. Currents in Pharmacy Teaching and Learning, 9, 683-688. http://dx.doi.org/10.1016/j.cptl.2017.03.003 Morris, N. (2015). Podcasts and mobile assessment enhance student learning experience and academic performance. Bioscience Education, 16(1). http://dx.doi.org/10.3108/beej.16.1 PODCASTS AS A LEARNING ADJUNCT 25 Pashler, H. McDaniel, M., Rohrer, D., & Bjork, R. (2008). Learning style: Concepts and evidence. Psychological Science in the Public Interest, 9(3), 105-119. Retrieved from https://www.psychologicalscience.org/journals/pspi/PSPI_9_3.pdf Rainsbury, J. W. & McDonnell, S. M. (2006). Podcasts: An educational revolution in the making? Journal of the Royal Society of Medicine, 99, 481-482. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1557886/pdf/0481.pdf Rouhselang, S. (2018). The efficacy of educational podcasts: A literature review. Unpublished manuscript, Marian University. Vogt, M., Schaffner, B., Ribar, A., & Chavez, R. (2010). The impact of podcasting on the learning and satisfaction of undergraduate nursing students. Nurse Education in Practice, 10, 38-42. Doi:10.1016/j.nepr.2009.03.006 Wolpaw, J. & Toy, S. (2018). Creation and evaluation of an anesthesiology and critical care podcast. The Journal of Education in Perioperative Medicine, 19(4), 1-16. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5991777/pdf/i2333-0406-20-11f.pdf PODCASTS AS A LEARNING ADJUNCT Appendix A Student Satisfaction with Educational Podcasts Questionnaire (SSEPQ) (Alarcn et al., 2017) 26 PODCASTS AS A LEARNING ADJUNCT Appendix B Podcasts as a Learning Adjunct in Nurse Anesthesia Education Satisfaction Survey Q1 Consent (Details omitted) Q2 Please select the year of your expected graduation date from Marian Universitys nurse anesthesia program o 2020 (1) o 2021 (2) Q3 Please select the age range you fit into o 20-25 years old (1) o 26-30 years old (2) o 31-35 years old (3) o 36-40 years old (4) o 41-45 years old (5) o 46-50 years old (6) o 51+ years old (7) 27 PODCASTS AS A LEARNING ADJUNCT Q4 Please select your gender o Male (1) o Female (2) o Neither (3) o Combo of male and female (4) o Prefer not to answer (5) Q5 Please select the number of years youve been a registered nurse o 1-2 years (1) o 3-5 years (2) o 6-10 years (3) o 11-15 years (4) o 16-20 years (5) o 21 + years (6) Q6 How often do you listen to podcasts? o Never (1) o Rarely (less than 1-2 times per month) (2) o Sometimes (1-2 times per month) (3) o Regularly (1-2 times per week) (4) o Daily (1 or more per day) (5) 28 PODCASTS AS A LEARNING ADJUNCT 29 Q7 Outside of traditional didactic learning, which additional educational modalities are most beneficial to you? (Select all that apply) Recorded video lectures (1) YouTube/videos online (2) Podcasts (3) Textbooks (4) Slide presentation notes (5) Other (Please specify) (6) ________________________________________________ None (7) Q8 How many podcasts did you listen to out of the 6 total that were recorded with Ashley Scheil and Skyler Rouhselang on From the Head of the Bed? o 0 (1) o 1 (2) o 2 (3) o 3 (4) o 4 (5) o 5 (6) o 6 (7) PODCASTS AS A LEARNING ADJUNCT Q9 Please select the podcasts that you listened to #44 Clinical Flow: From OR Set Up Through Intubation Ashley Scheil (1) #45 The Anesthesia Machine Ashley Scheil (2) #46 Pharmacokinetics of Volatile Anesthetics Skyler Rouhselang (3) #47 Pharmacodynamics of Volatile Anesthetics Skyler Rouhselang (4) #48 IV Induction Agents Ashley Scheil (5) #49 Local Anesthetics Skyler Rouhselang (6) None (7) Q10 How did you listen to the podcasts? (Select all that apply) While driving/In the car (1) While cooking or cleaning (2) While exercising (3) While sitting and focusing solely on the podcasts (4) Other (Please specify) (5) ________________________________________________ Did not listen to any podcasts (6) 30 PODCASTS AS A LEARNING ADJUNCT Q11 The podcasts are easy to access o Strongly agree (1) o Agree (2) o Disagree (3) o Strongly disagree (4) Q12 The podcasts are useful for learning about this subject o Strongly agree (1) o Agree (2) o Disagree (3) o Strongly disagree (4) Q13 The podcasts motivate me to learn about this subject o Strongly agree (1) o Agree (2) o Disagree (3) o Strongly disagree (4) 31 PODCASTS AS A LEARNING ADJUNCT Q14 The podcasts make it easier to learn about this subject o Strongly agree (1) o Agree (2) o Disagree (3) o Strongly disagree (4) Q15 I am satisfied with the podcasts as a learning tool for this subject o Strongly agree (1) o Agree (2) o Disagree (3) o Strongly disagree (4) Q16 The podcasts provide clear information about the theoretical content of the topic o Strongly agree (1) o Agree (2) o Disagree (3) o Strongly disagree (4) 32 PODCASTS AS A LEARNING ADJUNCT Q17 The podcasts provide clear information about the practical content of the topic o Strongly agree (1) o Agree (2) o Disagree (3) o Strongly disagree (4) Q18 The content of the podcasts is well organized o Strongly agree (1) o Agree (2) o Disagree (3) o Strongly disagree (4) Q19 The information contained in the podcasts is academically rigorous o Strongly agree (1) o Agree (2) o Disagree (3) o Strongly disagree (4) 33 PODCASTS AS A LEARNING ADJUNCT Q20 The design of the podcasts makes them appealing o Strongly agree (1) o Agree (2) o Disagree (3) o Strongly disagree (4) End of Block: Consent 34 PODCASTS AS A LEARNING ADJUNCT 35 Appendix C Table 1 Participant Characteristics DNP Participant Characteristics Frequency (n) Expected Graduation Date n=26 2020 12 (46%) 2021 14 (54%) Age n=26 26-30 16 (61%) 31-35 6 (23%) 36-40 1 (4%) 41-45 2 (8%) 45-50 0 51+ 1 (4%) Gender n=25 Male 5 (20%) Female 19 (76%) Prefer not to answer 1 (4%) Years as an RN n=25 3-5 years 9 (36%) 6-10 years 12 (48% 11-15 years 1 (4%) 16-20 years 2 (8%) 21+ years 1 (4%) How often do you listen to podcasts? n=25 Never 2 (8%) Rarely (less than 1-2 times per month) 5 (20%) Sometimes (1-2 times per month) 6 (24%) Regularly (1-2 times per week) 10 (40%) Daily (1 or more per day) 2 (8%) Outside of traditional didactic learning, which additional educational modalities are most beneficial to you? n=84 Recorded video lectures 18 (21%) YouTube/Videos online 21 (25%) Podcasts 15 (18%) Textbooks 14 (17%) Slide presentation notes 14 (17%) Other (Hands-on/simulation) 2 (2%) How many podcasts did you listen to out of the 6 total that were recorded with Ashley Scheil and Skyler Rouhselang on From the Head of the Bed? n=25 0 0 DNP Participant Characteristics Frequency (n) PODCASTS AS A LEARNING ADJUNCT 1 2 3 4 5 6 36 0 0 0 3 (12%) 0 22 (88%)  ...

... AIRWAY MANAGEMENT 2 Abstract It is a requirement of perianesthesia nurses to be competent in caring for patients who are sedated or anesthetized for procedures in a hospital setting. Oftentimes, when patients are sedated, they are unable to maintain their own airways. This can lead to respiratory decompensation of the patient if interventions are not employed. Therefore, perianesthesia nursing requires expert advanced airway assessment and management skills or training to achieve competency. A review of related studies on continuing education of nurses reveals that trainings are beneficial in the realms of knowledge acquisition, practice change, and perceived self-efficacy. The primary purpose of this project was to evaluate the efficacy of such an educational training on knowledge gained utilizing a pre/post-test method of assessment. A secondary aim was to measure if there was a reduction in skill-related anxiety of the nurses following the training utilizing a short-form of the State-Trait Anxiety Inventory for Adults. Long-term follow up of both knowledge gained and anxiety levels was performed at a six-month interval after the initial training. The findings between the initial knowledge and anxiety pre- and post-tests were both statistically significant (p<0.001). However, at the six-month interval, neither the knowledge gained nor reduction of anxiety remained significantly better compared to the initial pre-test. Nurse training and education is effective in increasing knowledge and self-efficacy, but long-term continuing education may be necessary to maintain familiarity and competence with material. Keywords: nurse education, nurse training, airway management, perianesthesia nurse AIRWAY MANAGEMENT 3 Table of Contents Abstract....2 Table of Contents.....3 Background and Significance of Problem.......5 Project Aims and Problem Statement..........6 Literature Review.....6 Conceptual Model......19 DNP Project Plan Practice Gap and Organizational Readiness..23 Stakeholder Assessment.....24 Method for Translation Setting & participants....25 Procedure for implementation...........26 Ethics and human subjects permission.........28 Method of Evaluation Instruments used................29 Outcome data.....30 Analysis plan......31 Results Initial..31 Long-Term (Six-Month)33 Discussion......34 Limitations.35 Conclusion.....38 AIRWAY MANAGEMENT 4 References.....39 Appendices Appendix A....44 Appendix B....45 Appendix C....46 Appendix D....47 Appendix E....50 AIRWAY MANAGEMENT 5 Background and Significance of Problem Perianesthesia nurses are members of a nursing specialty that cares for patients who are undergoing anesthesia for anything from minor procedures to major surgery. This type of care usually occurs in the pre-operative and post-operative post-anesthesia care setting. These periods are commonly referred to as the perianesthesia phases of care. Depending on the type of procedure, the patient may be hospitalized as an inpatient, or he/she will go home the same day following nurse observation and after meeting recovery criteria. Often, these nurses are tasked with caring for patients before, during, and after the administration of sedation and pain medications for these procedures. Occasionally, these nurses are the ones responsible for administering the sedation medications and monitoring the patient throughout these procedures or diagnostic tests. When patients receive these types of medications, it is not uncommon for them to become sedated enough that they cannot safely maintain their airway. Therefore, adequate training in airway assessment and management is essential for nurses who are caring for these patients. They must know how to recognize when a patient is not oxygenating and ventilating well on their own, and how to assist these patients properly. The Institute of Medicine (IOM) acknowledges that, although undergraduate education provides baseline knowledge needed to enter the nursing profession, it does not generally address in depth acute, complex, or specialized care (2010). There is a recognized need for continuing education that can assist nurses in acquiring specialized knowledge and skills so that they are well-equipped to deliver safe, quality, patient-centered care across all settings, and manage the complex patients that are encountered in todays healthcare system (IOM, 2010, p. 35). The American Nurses Association (ANA) Code of Ethics (2015) states that it is the duty of individual nurses to maintain continuing acquisition of knowledge in order to maintain competence. AIRWAY MANAGEMENT 6 However, the ANA also believes it to be the duty of nurse managers and educators to assist nurses in their facilities to gain knowledge and skills when baseline knowledge is not adequate for specialized care (ANA, 2015). In their review of staff training, Forghany et al. (2018) made the connection that it is reasonable to assume the quality of staff training will have an impact on the type of care that is received by patients. Project Aims and Problem Statement A review of related studies on in-service nurse training reveals that continuing education is beneficial in the realms of knowledge gained, practice change, and perceived self-efficacy. The aim of this project was to evaluate the efficacy of such an educational training on knowledge gained utilizing a pre/post-test method of assessment. A secondary aim was to measure if there was a reduction in anxiety of the nurses following the training utilizing a short-form of the StateTrait Anxiety Inventory for Adults (Spielberger, 1977; Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983). The problem PICOT [population, intervention, comparison, outcome, and timeframe] statement for the project was: In perianesthesia nurses, does a didactic airway management training, compared to no formal training, result in increased knowledge and decreased anxiety immediately following and six-months after training? Literature Review Education serves many purposes on units throughout a facility and include: get all nurses to a minimum level of proficiency (i.e., homogenize competence levels), provide the most up-todate knowledge to staff, decrease nurses anxiety about particular components of care by increasing their competence, improve nurse satisfaction through the acquisition of new knowledge and improve patient outcomes. Continuing education occurs in various ways, such as through unit-based staff training including educational workshops, self-directed study, computer- AIRWAY MANAGEMENT 7 based modules, simulations, and off-site professional meetings. The purpose of the literature review was to determine the efficacy of educational training on knowledge acquisition, behaviors, and psychosocial metrics, such as anxiety, stress, or satisfaction in nurses. Methods A review of the literature was conducted regarding nurse training and continuing education using the online databases PubMed, Cumulative Index to Nursing & Allied Health Literature (CINAHL), and Cochrane Collaboration. A search of relevant evidence-based articles was conducted using various combinations of the following keywords and phrases, utilizing Boolean operators: in-service training, in-service education, nurse training, nurse staff development, educational workshop, nurse competency, in-service training AND nurse, inservice education AND nurse, educational workshop AND nurses, continuing education AND nursing AND staff development. A 25-year search limit was placed in order to cover a breadth of traditional education modules, with the chosen articles ranging from 1995 to 2018. Pre-set inclusion criteria were that the articles were in the English language, used human subjects, and were not duplicates. Additional inclusion criteria were that the articles involved nurses (not nursing students), that studies were conducted in the US or countries with a similar Westernized healthcare model, and that didactic or autodidactic training methods were utilized. Articles were excluded if they were level IV, V, or VI evidence according to Melnyk and Fineout-Overholts (2015) level of evidence classification, such as case reports, reviews, consensus, or opinion pieces. Articles that involved simulation or other highly technical training were also excluded as the review is focused on traditional didactic education methods. Evaluation of resultant articles was done by abstract review to determine which related best to the topic of interest in which the reviewer was trying to investigate. A final twelve studies were AIRWAY MANAGEMENT 8 selected for review: three randomized-control trials (RCTs) (level 2 evidence), and nine quasiexperimental studies (level 3 evidence). Themes The literature revealed three major themes for consideration: post-intervention outcomes, method of education delivery, and length of study. Regarding outcomes, all of the studies found favorable results in at least one of the following categories: participant gain of knowledge, behavior change, or perceived self-competence post-intervention. The primary goal for an educational intervention is that there will be a knowledge gain by the participants. As previously discussed, it is an assumption by most in the healthcare community that education will lead to knowledge acquisition resulting in better practice and patient outcomes (ANA, 2015; Forsetlund, 2009; IOM, 2010). Ten of the reviewed studies directly state this belief that education will result in better care by nurses, which will lead to improved patient outcomes (Attard et al., 2014; Cone et al., 1996; Corcoran, 2016; Day et al., 2001; Daly et al., 2009; Goudy-Egger et al., 2018; Hemingway et al., 2015; Melnyk et al, 2010; Murray & Dunn, 2017; Turner-Parker et al., 1995). Post-intervention outcomes. The purpose of both the experimental RCTs and the quasi-experimental studies was to determine the efficacy of an educational training by performing a type of pre-test, survey, or chart-audit; providing the training; and then doing a post-test, survey, or chart-audit to measure outcomes. Only one study done by Cone et al. (1996) did not perform a pre-test; training was provided, followed only by a post-training assessment of documentation. Seven of the studies directly measured knowledge gain, six of the studies measured behavior or practice changes, six of the studies assessed participant perception of self-gain in knowledge, competence, or skills; and seven of the studies reported on more than one of these dependent variables. AIRWAY MANAGEMENT 9 Knowledge gained. The primary goal for an educational intervention is that there will be knowledge gained by the participants. As previously discussed, it is an assumption by most in the healthcare community that education will lead to knowledge acquisition resulting in better practice and patient outcomes (ANA, 2015; Forsetlund, 2009; IOM, 2011). Ten of the reviewed studies found that education will result in better care by nurses, which will lead to improved patient outcomes (Attard et al., 2014; Cone et al., 1996; Corcoran, 2016; Day et al., 2001; Daly et al., 2009; Goudy-Egger et al., 2018; Hemingway et al., 2015; Melnyk et al, 2010; Murray & Dunn, 2017; Turner-Parker et al., 1995). Furthermore, in nine of the studies reviewed, there was a hypothesis, in line with previously discussed findings from the IOM (2010), that nurses baseline knowledge is often inadequate to provide quality care to the patients they serve (Attard et al., 2014; Corcoran, 2016; Day et al., 2001; Du Mont et al., 2018; Goudy-Egger et al., 2018; Hemingway et al., 2015; Melnyk et al, 2010; Murray & Dunn, 2017; Turner-Parker et al., 1995). According to TurnerParker et al. (1995), changes in current care recommendations, new technology, and a low percentage of nurses seeking continuing education on their own contribute to a lack of knowledge. This lack of baseline knowledge is a large motivator for nurse educators to create educational workshops or in-service training. Of the seven studies that collected data on knowledge gained, six showed significant results (p<0.05) for the treatment group. Du Mont et al. (2018) had the greatest statistically significant increase in staff knowledge (p<0.001). Though this was a quasi-experimental study and therefore level 3 evidence (Melnyk & Fineout-Overholt, 2015), the study sample was large, n=1366, which can provide a stronger level of external validity and generalizability. Murray and Dunn (2017) had a reported significance level of (p=0.00), but the sample size was only 49. Thus, while the results were AIRWAY MANAGEMENT 10 positive, generalizability is limited due to the small sample size. Hemingway et al. (2015) also achieved a high level of significance, (p=0.004), but the sample size was also lower, n=48. Furthermore, the sample was a non-randomized convenience sample without a control group and included 22 nursing students. Turner-Parker et al. (1995) found a significance level of (p=0.006) for knowledge gain compared to the comparison group (p=0.57). Although the sample size for this study was only 35, this was one of the only RCTs, giving it a higher level of evidence (level 2) than nine of the other studies. Day et al. (2001) also utilized an RCT design that showed statistically significant (p<0.01) knowledge gain in the treatment group after the training. However, the major limitation of this study was its very small sample size of 16 nurses. Though one of the studies with the highest level of evidence (2), it is also the study with the lowest number of participants, and therefore questionable external validity. Authors did note that the study was meant to be a pilot study for larger-scale implementation if results were favorable (Day et al., 2001, p. 694). Lower levels of statistical significance related to increased knowledge were reported by Goudy-Egger et al. (2018), with (p<0.05) and a sample size of 31. Even though the results just met significance and the sample size was small, the authors felt that their findings were strong enough to support a need for continued education. One limitation that was discussed by the authors was that only knowledge was tested, but changes in clinical practice were not. Therefore, one can assume that there would be some crossover, but this was not proven (GoudyEgger et al., 2018, p. 458). One study performed by Attard et al. (2014) did not find a significant difference in scores post-training (p=0.054); however, overall scores post-training were higher. Though not significant, this did show some benefit to having a training. AIRWAY MANAGEMENT 11 Behavior or practice change. As discussed, there is an assumption that knowledge acquisition will lead to better patient outcomes. However, knowledge gain in itself is not an accurate measure of whether nurses will have a change in behavior or practice. For example, though Turner-Parker et al. (1995) found a significant gain in knowledge, they noted no effect on behavioral changes, and that a lack of behavioral effect supports follow-up reinforcement sessions. Similarly, Melnyk et al. (2010) also found no statistical difference for implementation of the evidence-based practices (EBP) by participants that were taught in their training session. However, the authors provided a survey to participants to identify barriers to implementation, and many confounders were identified such as time constraints, competing interests, and a unit remodel (Melnyk et al., 2010). Therefore, a limitation of this study is that there may have been adequate knowledge gain, but that outside factors made it difficult for participants to have a practice change. Other study authors, such as Du Mont et al. (2018) did not specifically study behavioral effects, but they also concluded that more research is needed to determine the impact of knowledge gain on practice change. Conversely, some studies that measured behavior change did note positive effects on practice following the education module. For example, though Cone et al. (1996) did not perform a pre-training chart audit of study subjects vs. control subjects, they did conduct an initial needs assessment of 100 random charts to determine compliance levels with assessment documentation. Their resultant assessment describes a failure to meet documentation standards set by regulatory bodies. However, they found a significant difference (p<0.001) in the documentation behaviors of the treatment group vs. comparison group following an in-service education. The small sample size of 20 does limit the ability to infer external validity. AIRWAY MANAGEMENT 12 Poulsen et al. (2015) also found statistical significance (p=0.006) in the ability of participants to recover from job stress compared to the control group. Though the sample size for this study was slightly larger at 70, only 33 of the participants were nurses. A further limitation of this study was that by allowing participant data to remain anonymous, missing data was lost to follow-up (Poulsen et al., 2015, p. 496). However, allowing for anonymity was also likely a strength in getting participants to record stress levels honestly. Also, the participants chose to be in the study, which could lead to bias and decreased internal validity, as they were likely interested in the proposal of the study (to reduce job stress). The RCT performed by Day et al. (2001) found that, at baseline, none of the participants demonstrated complete competency with endotracheal suctioning. However, they found a significant increase (p<.01) in the experimental groups utilization of research-based practices while performing endotracheal suctioning after the training. A unique aspect of this study was the actual observation of learned behaviors of the subjects by the researchers. This is the only study that reported this type of observational result, and therefore the only study that had a direct measurement of how the training impacted patient care. A limitation of this study is that subjects were likely aware that there was a study being done on their unit, as well as the small sample size (Day et al., 2001). The small sample size of 16 limits the external validity and generalizability of the studies. In contrast to the groups with small sample size, Daly et al. (2009) used a large sample size of 308 participants across eleven hospitals, lending good external validity to the study. The authors compared an in-service training to a self-directed competency training to determine via chart audits if there was increased compliance with assessment and management standards for alcohol withdrawal. They found increased overall compliance rates across all nine measured AIRWAY MANAGEMENT 13 standards but found greater statistical significance (p=.000 in 4/9 standards and p=.001 in 1/9 standards; mean compliance scores p=.000) in the self-directed training group. Mean compliance scores revealed a percent change from pre- to post-test in the in-service group of 9%, and of 25% in the competency group. However, a few limitations to this study exist. First, the study did not have a control group. Second, relying on medical record audits to measure a change in nurse knowledge is somewhat confounded by the orders and activity of medical staff (Daly et al., 2009). For example, prescribing diazepam was a standard, but this may have been influenced by physicians prescribing practices more than the nurses adherence to protocols. Participants perceived self-gain. As knowledge acquisition and behavior change are often the most desired results of an educational workshop or training, an occasionally overlooked aspect of education is the potential increase in self-efficacy of the participants. As previously mentioned, nine of the studies reported inadequate baseline knowledge resulting in nurses being unprepared to provide adequate care for their patients. Just as this knowledge gap is a motivator for nurse educators to create educational in-services, it is also a source of anxiety for many nurses. Du Mont et al. (2018) found through open-ended comments on their surveys that one nurse felt better equipped to respond to certain situations as a result of the training, and another would not have known how to go about a situation had it arisen before taking the course (pp. 127-128). This implies that inadequate baseline knowledge can lead to feelings of incompetence, fear, or anxiety In Corcorans (2016) study of EOL care, she relates a novice nurses feelings of fear and helplessness when dealing with a dying patient or their family (p. 103). However, following an educational workshop, her findings showed significant (p<.001) improvements in caregivers comfort with providing EOL care. One limitation to this study was that the pre- AIRWAY MANAGEMENT 14 test/post-test tool, though a validated tool, was not validated for this type of study design (Corcoran, 2016, p. 108). Also of note, the pre-test may have had a negative influence on the internal validity of the post-test scores. In their study, Hemingway et al. (2015), concluded that a lack of confidence on the part of the provider could impact his/her ability to meet the needs of the clients (p. 31). This is congruent with findings from the Murray and Dunn (2017) study in which, prior to a workshop on spiritual care practices, 80% of nurses surveyed reported feeling inadequately prepared to provide this type of care for their patients (p. 120). As a result of being inadequately prepared, only 49% of those surveyed felt that they were usually able to meet [their] patients spiritual needs (Murray & Dunn, 2017, p. 119). Daly et al. (2009) also surveyed participants following the study and found a perceived increase in confidence and ability to provide non-judgmental care to patients (p. 103). Further, the participants believed that through increased self-confidence and knowledge, there would be improved patient care and decreased risks (Daly et al., 2009, p. 104). One study that had ambiguous results on participant self-efficacy was performed by Melnyk et al. (2010). The authors of the study report that statistical significance (p=.069) was achieved for an increase in EBP beliefs after the training. They report using a statistical value of p=.10 due to small sample size; however, the sample size was larger than eight of the other included studies. The other studies maintained a significance value of p=.05. Not only was the significance of the results questionable, the impact it had on participants perceived ability to implement EBP remains unknown. AIRWAY MANAGEMENT 15 Delivery method of education. Education can take many different forms. Even when exploring only traditional methods of didactic education, the design of the workshop or in-service can vary. Many modes of delivery were used in the studies reviewed, such that it is difficult to determine the most efficacious of the delivery methods as there are multiple other confounding variables. Also, of note, though simulation is a well-established form of education, it involves a greater degree of resources such as time, money, and instructor competency. Therefore, studies involving this type of training were purposefully excluded in order to focus on more feasible methods. More than half (seven) of the studies reviewed used some variation of a lecture format (usually a PowerPoint lecture) with or without written materials (Cone et al., 1996; Corcoran, 2016; Day et al., 2001; Goudy-Egger et al., 2018; Murray & Dunn, 2017; Poulsen et al., 2015; Turner-Parker et al., 1995). In addition to this format, three of the studies also had an interactive discussion session (Murray & Dunn, 2017; Goudy-Egger et al., 2018; Poulsen et al., 2015), and one had the addition of a bedside demonstration (Day et al., 2001). Poulsen et al. (2015) found a significant difference (p=.006) in providing this type of workshop over written materials alone. Interestingly, Corcoran (2016) also provided breakfast, lunch, a small gift bag, a CE credit (1), and had prize giveaways both days of her workshop in an effort to encourage participation. This is important as getting participants to give up time (paid or unpaid) to attend a workshop is often a difficult challenge. However, the downside to this is related to cost and a decreased feasibility by most institutions to provide these incentives. As all of these studies had significant gains in knowledge, behavior, or self-efficacy as previously discussed, it can be concluded that this is an effective means of education delivery. AIRWAY MANAGEMENT 16 As previously discussed, Daly et al. (2009) conducted self-directed and in-service training. They concluded that self-directed training had better results than in-service training and was favored by participants. The authors believed this to be related to the lack of time many participants have during or after their shift, and the fact that they may be too tired to concentrate on the education module (Daly et al, 2009, p. 100). However, this is in contrast to findings from Du Mont et al. (2018): they provided one group an in-person training consisting of a PowerPoint presentation, case studies, and quizzes; and another group was provided with online training. Their results showed that participants preferred in-person training. However, the authors note that this is more time-consuming, and can be challenging due to the operational demands of the unit (Du Mont et al., 2018, p. 129). This is in agreement with the conclusions made by Daly et al. (2009) about why their participants preferred the self-directed training. Two studies did not fit into the style of those previously mentioned. One study did not elaborate on how the workshop was conducted, but merely called the training a study unit (Attard et al., 2008). However, the authors conclude that multiple reflective teaching methodologies, such as discussion groups, journaling, and self-reflection are important for knowledge transfer (Attard et al., 2008, p. 1464). This makes replication of this type of study, significant as its results may be (p=.006) for behavioral changes, difficult. The other study by Hemingway et al. (2015) used multiple teaching methods (multiple choice questionnaire, clinical equipment demonstration, video demonstration, and guided reading package), and found that participants preferred the video demonstration (highest mean ranking score of 4.28/5). Though it is likely that a variety of learning methods is preferred by learners, it is also more labor intensive for those creating the training. Alternatively, as the results of this study showed that video AIRWAY MANAGEMENT 17 demonstrations and clinical equipment demonstrations were ranked highest, the focus could be placed on those two forms of education delivery. Study length. Length of sessions. There were significant discrepancies among the studies regarding the length of the workshops, with sessions lasting from 20 minutes to two days; thus making it difficult to draw any conclusions about what the best length of training may be. However, all studies had generally favorable results with regard to knowledge acquisition. The articles reviewed showed that some utilized shorter sessions (two hours or less) in order to decrease the time that nurses were away from their units or had to come in off-duty, and thus result in better attendance (Day et al., 2001; Du Mont et al., 2018; Turner-Parker et al., 1995). Other studies with short sessions offered multiple times for nurses to attend in order to increase attendance (Cone et al., 1996; Murray & Dunn, 2017). It is also important to note that at least two of the studies utilizing short sessions (Cone et al., 1996; Turner-Parker et al., 1995), delivered multiple contiguous sessions over a period of time. Five of the studies presented a longer, eight-hour/one-day workshop (Corcoran, 2016; Goudy-Egger et al., 2018; Hemingway et al., 2015; Melnyk et al., 2010; Poulsen et al., 2015). Some that delivered longer workshops cited an inability to deliver the necessary content in a shorter session (Melnyk et al., 2010; Poulsen et al., 2015). Still others, such as Hemingway et al. (2015) were looking to increase the length of the training even further based on feedback from participants who felt that there was not enough time for the training. In line with the thought that one-day training is not long enough, Poulsen et al. (2015) questioned the support of a short training on long-term gains and felt that repeated exposure to an educational training might be more important than the length of a training session (p. 496). AIRWAY MANAGEMENT 18 Timing of post-tests. Though all of the studies reviewed performed some version of a post-test, no consistency or set standard for when these tests should be administered was revealed in this review. Five of the reviewed studies collected post-test data immediately after the conclusion of the workshop (Du Mont et al., 2018; Goudy-Egger et al., 2018; Hemingway et al., 2015; Murray & Dunn, 2017; Poulsen et al., 2015). A benefit of immediate post-testing is the determination of short-term gains from the training. The main limitation of these studies that performed post-testing immediately after the workshop is that there is no measure of long-term gain; making the results of these studies suspect for whether or not they can result in a sustainable change in practice. Therefore, it is difficult to draw conclusions about the ability of the training to affect long-term patient outcomes based on these particular articles. However, the study by Poulsen et al. (2015) differed from the others that performed immediate testing; they collected a series of post-tests once a week for six weeks. This longerterm investigation in series allowed those authors to show long-term gains or regression of behavior change and self-efficacy. They were able to support the efficacy of their workshop on behavior as the treatment group was better able to recover from stress at the six-week follow-up time. Additionally, participants in the workshop felt that the workshop met their needs and increased their confidence in self-care abilities (Poulsen et al., 2015). The next subset of data collection was performed by Corcoran (2016) at three weeks, and then by Day et al. (2001) at four weeks post-training. Following this, three studies (Cone et al., 1996; Melnyk et al., 2010; Turner-Parker et al., 1995) used a three-month follow-up timeframe to collect their post-test data. The study with the longest follow-up period was done by Daly et al. (2009), and it is unique in that it started a post-training chart audit that lasted for two-three years (years for the audit are provided, but the months are not, making the exact timeframe AIRWAY MANAGEMENT 19 difficult to determine). The Attard et al. (2014) study did not put a timeframe for post-testing, but instead allowed anyone who had taken the training at some point be involved in the study. The limitation to this is that all participants had a different follow-up timeframe, making it impossible to make conclusions based on the timing of the training and results. Much like the length of the training sessions, there are significant variations in the time to follow-up (if any time was given at all). Limitations of immediate follow-up have been discussed. However, waiting long periods, such as three months to perform post-testing can result in attrition of participants. Long follow-up times can also allow for confounding variables to be interjected, thus interfering with results. Though it is possible that a three, four, or sixweek timeframe is reasonable to assess long-term gains and avoid attrition, further studies are required to come to a definite conclusion. Discussion Though education is an important mainstay of nursing, the lack of standardization of training programs is likely a cause for regional and inter-systems discrepancies in both knowledge and care. Though all the reviewed studies provided evidence that education is beneficial, it remains inconclusive that an increase in knowledge leads to long-term behavioral changes. Therefore, it is also impossible without long-term evaluation or review of patientspecific outcomes to claim that educational training will improve patient care. Conversely, education remains the best weapon against inadequate knowledge, lack of skills, and poor practice that the healthcare community has. It is critical to continue to search for what leads to effective training and better participant engagement. Various training modalities should be employed to encourage knowledge retention and subject participation. However, those factors must also be balanced with cost, time, and best-practice. AIRWAY MANAGEMENT 20 Conclusion Given that 10 of the 12 reviewed studies showed a favorable statistical significance (p .05) regarding gains in either knowledge, practice changes, or perceived self-efficacy following an education module, it is reasonable to conclude from this review of literature that educational workshops, among other forms of delivery, are beneficial. Though newer technology has allowed for more in-depth and high-fidelity modes of education, the feasibility (cost/time) of delivering traditional didactic and workshop-style training helps it to remain a reasonable mode of delivery for most units. There is also strong support provided directly via study results, or indirectly through author commentary, that repeat sessions of education will result in better outcomes for both nurses and their patients. The lack of studies demonstrating this type of long-term application is a major limitation to identifying the true ability for education to influence patient outcomes, which is the ultimate goal of education. However, the lack of strong long-term evidence suggests that follow-up training should occur. Conceptual Model Synergy Model The Institute of Medicine (IOM) recognizes that nurses are central members of the healthcare team and have an essential role in coordinating complex care of patients (IOM, 2010). As such, in the current age of accountability and transparency, it is a reasonable expectation by the consumers of healthcare, i.e., patients and their families, that nurses are knowledgeable and competent to provide such care. Unfortunately, without continuing education, or specialized training in some cases, nurses may be unprepared to provide certain types of patient care. This practice may lead to poor patient outcomes, as well as a lack of confidence on the part of the AIRWAY MANAGEMENT 21 provider and consumers. Therefore, to support the implementation of this project, the American Association of Critical-Care Nurses (AACN) Synergy Model for Patient Care was utilized (Appendix A), which links nursing competence and practice to patient characteristics and needs (Curley, 2007). As the name of the model implies, it involves synergistic transactions of reciprocity, equity, and interdependence (Curley, 2007). In order for this type of interaction to occur in the healthcare setting, assumptions must be made about each of the three key players: patients, nurses, and systems. To begin, patients, their families, and nurses must be active participants in the relationship in order to have a reciprocal relationship that is synergistic. Patients (and their families) are tasked with defining their optimal level of wellness and acceptable outcomes; while nurses are tasked with guiding and assisting patients in achieving their goals with regards to these outcomes (Curley, 2007). In her model, Curley (2007) describes the synergistic effect that occurs when nursing care meets the needs of patients and their families (p. 2). Most importantly, when synergy exists, patient outcomes are optimal (Curley, 2007). As the synergy model works to improve patient outcomes by linking nursing care to the patients needs within a supportive system, it is logical to use it as a framework for the utilization of specialized nurse training and continuing education to increase nursing competency. Another component of the Synergy Model is that the most complex patients will have the greatest need, and therefore will require care from the nurses with the highest competency (Curley, 2007). According to the model, the pathway to increased competency is through a three-tiered approach that includes academic education, staff development, and continuing education (Curley, 2007). AIRWAY MANAGEMENT 22 There already exists an assumption by the healthcare community that continuing education will improve knowledge, enhance practice and competence, and lead to improved patient outcomes (Forsetlund et al., 2009; IOM, 2010). Therefore, the concept that a systembacked training of nurses to increase their competence and self-confidence would, in-turn better meet patient needs, thus leading to improved outcomes is logical. During the development of the project, a concept map for continuing education/in-service training was created (Appendix B). Though there are many more sub-components to this map than the Synergy Model, when simplified, it too lines up with the core components of the model: the relationship of nursepatient, nurse-nurse, and nurse-system (Curley, 2007). Curley (2007) describes the characteristics of both patients and nurses that span a continuum and can result in linkages when the characteristics of both participants are in alignment. These characteristics are highly individual and fall on different areas of the spectrum for each patient and nurse. For the patients, these characteristics include stability, complexity, vulnerability, predictability, resiliency, participation in decision-making, participation in care, and resource availability (Curley, 2007). On the part of the nurse, the characteristics include clinical judgement, clinical inquiry, caring practices, advocacy/moral agency, facilitation of learning, collaboration, systems thinking (Curley, 2007). The system is incorporated into the reciprocal nature of the nurse-patient relationship because the system must supply the resources, determine the environment (for both the nurses and patients), and support the nature of the mutual goals and outcomes between patients and nurses. On the receiving end, when optimal outcomes are achieved by the patients and nurses, the system benefits. Going back to the literature review, Du Mont et al. (2018) found through open-ended comments on surveys evaluating nurses training module that they felt better equipped to AIRWAY MANAGEMENT 23 respond to certain situations as a result of their training, and another would not have known how to go about a situation had it arisen before taking the course (pp. 127-128). In Corcorans (2016) study of end-of-life (EOL) care, she relates a novice nurses feelings of fear and helplessness when dealing with a dying patient or their family (p. 103). However, following an educational workshop, her findings showed significant improvements in caregivers comfort with providing EOL care (p<.001). In their study, Hemingway et al. (2015) concluded that a lack of confidence on the part of the provider could impact his/her ability to meet the needs of the clients (p. 31). This lack of confidence is consistent with findings from Murray and Dunn (2017) in which, prior to a workshop on spiritual care practices, 80% of nurses surveyed reported feeling inadequately prepared to provide this type of care for their patients (p. 120). As a result of being inadequately prepared, only 49% of those surveyed felt that they were usually able to meet [their] patients spiritual needs (Murray & Dunn, 2017, p. 119). Daly et al. (2009) also surveyed participants following their training module and found that the participants believed that through increased self-confidence and knowledge, there would be improved patient care and decreased risks (Daly et al., 2009, p. 104). Again, this implies that inadequate baseline knowledge can lead to feelings of incompetence, fear, or anxiety. When this occurs, there is a breakdown in the level of care that a nurse can provide a patient, and in turn, a lack of synergy in the nurse-patient relationship. DNP Project Plan Practice Gap and Organizational Readiness At the facility where the training occurred, the peri-operative nurses care for patients before, during, and after the administration of sedation and pain medications for diagnostic tests, AIRWAY MANAGEMENT 24 minor procedures, or major surgery. Occasionally, the pre-operative nurses are called upon to provide sedation to patients for minor procedures such as bronchoscopies. As previously stated, it is not uncommon for patients to lose their own ability to maintain a patent airway. With proper training, nurses will be exposed to the assessment skills needed to recognize airway compromise and appropriately intervene. Generally, this will require basic and non-invasive maneuvers such as bag-mask ventilation, applying a nasal cannula, or inserting an oral or nasal airway. However, if the nurse has not undergone such training, patient airway compromise can go unnoticed with potentially catastrophic results. A situation that could have required a basic airway intervention can quickly become an emergency resulting in cardiac or respiratory compromise, severe hypoxic brain injury, or even death (American Society of Anesthesiologists [ASA], 2018). The clinical nurse educator and the perianesthesia nursing staff of the facility where the study occurred expressed the need for, not only airway management training, but also sedation medication training. This type of training is also recommended by the two nationally recognized anesthesia organizations in the US, the American Association of Nurse Anesthetists (AANA), and the American Society of Anesthesiologists (ASA), for anyone providing patient sedation (AANA, 2016; ASA, 2018). Anesthesia providers are considered experts in airway management and procedural sedation; therefore, the anesthesia department was approached by the clinical nurse educator to request that they lead the training. The ability of non-anesthesia trained providers to administer sedation to patients remains controversial (AANA, 2016; ASA, 2018; OMalley & Poling, 2015). The anesthesia providers at the hospital, certified registered nurse anesthetists (CRNAs) and physician anesthesiologists (MDAs) were unwilling to provide the training, as they felt that it would be an endorsement of AIRWAY MANAGEMENT 25 this practice. Time constraints of these medical professionals was also a limiting factor since they are generally all in the operating room. However, it was felt that the airway management training was important for all perianesthesia nurses to know regardless of whether or not they provided the sedation. Patients can lose their ability to maintain their airway at any point in the course of their stay, and again, it is imperative that the nurses caring for them are able to assess and intervene when necessary. A student nurse anesthetist (SRNA) was willing to provide the training and deemed competent in airway assessment and management. In an effort to avoid the controversy of nurses providing sedation, no discussion of specific sedation medications occurred, and this type of training was avoided during this particular module. Stakeholder Assessment Key stakeholders for this project came from all levels of the peri-operative and anesthesia departments of the organization. Those in favor of training the pre-operative and post-operative nurses in airway assessment and management included unit managers, the units clinical nurse educator, as well as the nurses themselves. Nursing leadership and educators supported project objectives of creating an airway assessment and management training to positively impact patient outcomes and improve the overall quality of care, as well as to decrease the anxiety that nurses were feeling regarding the care of sedated patients. Though initially many in the anesthesia department expressed concern about teaching sedation training to registered nurses, once the project objectives were disclosed, many, including the chief of anesthesia, were in support of such a training. Outside of the organization, nurse anesthesia faculty members were also supportive of the project. Not only was this project undertaken to increase knowledge and decrease anxiety, another aspect of interest to the stakeholders existed: the fact that this was the inaugural DNP AIRWAY MANAGEMENT 26 project at this site. The organization and university had only recently entered into a partnership and started training nurse anesthesia students. Furthermore, many at the organization were unfamiliar with the scope of a Doctorate of Nursing Practice (DNP) student and his/her capacity for translating evidence to best practice. This project gave those involved an opportunity to see how such a partnership could work and evolve, thus making a connection for future students to implement projects at this site. Method for Translation Setting and participants. Completion of the proposed project occurred at a small Midwestern, urban teaching hospital with 191 beds (Lopez-Gonzalez, Pickens, Washington, & Weiss, 2014). The selection of the institution was due to both a recognized need at the site and because it was, at the time, the current clinical site of the SRNA responsible for the training. The students who attended the training were perianesthesia (pre-operative and post-operative) nurses who currently worked at the facility. At the time of the study, there were 43 perianesthesia nurses including those at the main hospital, those at the associated ambulatory surgery center (ASC), resource nurses, and as needed or PRN workers. Nurses who specifically worked only in the operating rooms were not included in the training, as there are airway experts, specifically anesthesia providers, available at all times. A limited amount of demographic data were collected including the unit in which the nurse primarily works and how many years of nursing experience the nurse had to enable the researcher to describe the sample (Appendix E). Participants were told that the collection of all data was optional. Thirty-four participants attended the training, producing a 79% response rate. However, only thirty-one participants completed all necessary knowledge- AIRWAY MANAGEMENT 27 related data, thirty completed knowledge and anxiety data, and only twenty-nine completed the demographic portion of the survey. Of the twenty-nine participants who completed that portion of the survey, demographic data is displayed in Figure 1 and Figure 2. As displayed in Figures 1 and 2, the majority of the sample (72%) had 6 or more years of nursing experience. The primary work setting of this group was PACU ASC (31%), with only 7% drawn from the Resource group. Perianesthesia Area Worked Years of Nursing 10 Years 8 6 4 2 PACU main PACU ASC Pre-op ASC Resource Pre-op Main 0 0-5 yrs 6-10 yrs 11-20 yrs >20 yrs Figure 1 and 2: Breakdown of the area nurses who attended an airway assessment and management training work and how many years of nursing each had at the time of the training. Procedure for implementation. The proposed intervention module was composed of face-to-face didactic education delivered via PowerPoint presentation and followed by a question and answer session. The SRNA developed the content of the PowerPoint presentation and overall objectives (Appendix C). Three faculty content experts, three peer SRNAs, and the clinical educator reviewed the proposed content and objectives. The knowledge portion of the exam (Appendix D) consisted of a total of 15 questions taken directly from the created content and objectives. The same panel AIRWAY MANAGEMENT 28 also reviewed these. A six-question, modified version of a validated was used to evaluate the participants anxiety regarding airway management of sedated patients. A handout of the PowerPoint slides was given to the nurses to follow and keep as a reference. Multiple trainings were done throughout the day to accommodate any nurse who attended with groups as small as two and as large as six at a time. These nurses are required to maintain competencies throughout the year, typically through continuing education and inservice training. Usually, these trainings are created and delivered by the units clinical nurse educator. The difference for this project was that an SRNA created and provided the training rather than the clinical educator at the site. As mentioned, this was requested due to the fact that those in anesthesia routinely perform airway assessment and management skills, and the clinical educator is less familiar with these topics. The nurses were encouraged, but not required to attend the training. There was no punitive action for not attending, nor was a certain score on testing required. Participation credit towards the amount of attended competencies was noted regardless of whether or not the participants completed the tests. Prior to the training, participants were assigned a color by the clinical educator to ensure blinding of the investigator. Participants then used their color for both the knowledge portion and anxiety portion of the test as a method of de-identification. The knowledge portion of the exam was used as part of unit-based quality improvement, and therefore, the scores to this portion were released to the clinical educator. However, all participants were notified before the training that all portions of data collection were optional and that they could opt out anytime. In addition, the clinical educator was blinded to the anxiety portion of data collection to allow participants to feel more comfortable in answering. This portion was done on a separate sheet (taken at the same time) and was collected by the investigator. As previously mentioned, demographic data AIRWAY MANAGEMENT 29 including the unit in which the nurse works and how many years of nursing experience were also collected. The institution does not employ the investigator, and therefore she did not have access to the demographic data of the nurses trained (i.e., would not be able to identify participants based on their demographic data). The investigator collected the blinded results of all data using only the color coding. The knowledge and anxiety post-tests were then re-administered at a sixmonth interval to determine long-term increases in knowledge and confidence. Aggregate results of the knowledge portion were used to assist the clinical educator in creating future review sessions and trainings. No individual was required to undertake remediation based on any missed questions. Ethics and human subjects permission This project was reviewed by the Marian University Institutional Review Boards (IRB) Social-Behavioral Subcommittee and deemed to be exempt from the need for human subjects protections. As the nature of the project was quality improvement, the procedures proposed were appropriate for exemption under the federal regulations. The principle investigator was not an employee of the institution and did not have access to the demographic data of the nurses being trained. Further, the demographic portion was an optional component which was explicitly explained to participants. The results of the knowledge-gained portion were seen by the clinical educator, in support of quality improvement. Blinded results of this portion of the test was collected using only color coding. Additionally, all participants were told of the nature of the project, and verbal consent was received from all participants for data usage in the project. According to the IRB, given the low-risk of your [the] study, and the blinding that youve explained the study is exempt from IRB review. The project was therefore approved by the Leighton School of Nursing. AIRWAY MANAGEMENT 30 Method of Evaluation Instruments used. A quasi-experimental pre-test/post-test design was used to evaluate the effectiveness of the educational training. A knowledge-based pre-test that contained fifteen questions based on the training objectives and content was administered to the participants anywhere from a week before the training, up to immediately before the training depending on participants availability to take the pre-test. Answers to the pre-test were not given to participants, so they did not know if they missed any questions, how many they missed, or which questions. Participants were also not permitted to work on the pre-test with any other participant. The post-test had the same fifteen questions and was administered immediately after the training. Again, participants were also not permitted to work with any other participant. No commercially available validated tool measuring airway assessment and management existed at the time of the study. Therefore, the investigator developed an evaluation tool. To establish construct validity, three former faculty content experts, three peer SRNAs, and the clinical educator reviewed the proposed content and objectives. Additionally, a validated, shortened form of the State-Trait Anxiety Inventory (Spielberger et al., 1983) was used to measure the nurses state anxiety level with regards to caring for a sedated patient during or after a procedure. The original inventory, developed by Spielberger and colleagues consisted of two 20-item self-report questionnaires, one created in 1970, the other in 1983 (Marteau & Bekker, 1992). Due to time constraints of study participants, shortened versions of the inventory have been developed, including the six-item form utilized for this project developed by Marteau and Bekker (1992). According to Tluczek, Henriques, and Brown (2009), the six-item scale has favorable internal consistency, reliability, and validity AIRWAY MANAGEMENT 31 when correlated with the parent 20-item State scale (p. 23). Marteau and Bekker (1992) used Pearson correlation coefficients between the 20-item form and their six-item form to determine that the 20-item form had a reliability coefficient value of =.91 and for their six-item form, =.82 (p. 303). However, Tluczek et al. (2009) found the Marteau & Bekker short-form to have even higher reliability correlations (>.9) when compared to the long-form (p. 22). Participants took the State-Trait pre- and post-tests at the same time as the knowledge tests. Copyright laws prohibit the reprinting of the tool in part or in its entirety, but an allowed question sample to give the reader a feel for the type of dyad questions includes: I feel at ease; I feel upset. (Spielberger, 1977). Answers choices to those questions include: not at all, somewhat, moderately so, or very much so. Copyright permission to utilize the tool for this project was obtained. Post-tests of both knowledge and anxiety were re-administered to participants who completed the training, an original pre-test, and original post-test. This was done six months after the initial training in order to determine long-term increases in knowledge and selfconfidence, i.e., the efficacy of the training. Conclusions made following the review of the literature determined that long-term follow-up is rare following educational training. Therefore, the ability to measure long-term gains is lost. However, this can provide a vital component in the evaluation of trainings and the future directions of providing efficacious continuing education. Outcome data. The analysis of the data collected consists of the comparison of means in the knowledge of participants regarding airway assessment and management before and after an in-service training, and again at a six-month interval. The two-tailed, paired (dependent) t-test was the statistical test used to compare the data at p <0.05. The same analysis was done with the results AIRWAY MANAGEMENT 32 of the State-Trait Inventory. These results were scored using the scoring key provided with the copyright permission from the owner of the copyrights to the survey (Mind Garden, Inc.). Analysis plan. Both the investigator and educator have kept all test scores in password-protected, encrypted files. Original copies of all materials including completed tests are kept in locked filing-cabinets by the investigator. Original materials kept by the educator were used for grading only, and after scores were recorded in the password-protected, encrypted files, they were shredded in hospital-approved devices. Incomplete pre-and post-tests were not included in the study, but all data was treated in the same sensitive manner. Data analysis occurred using the Microsoft Office, Version 16.20 Excel software (2018). All pre-test scores were entered in Excel and paired with the same colors post-test scores. The statistical formulas function built into the software was utilized to generate the pvalue using a paired, two-tailed t-test. This function was used for both the initial pre- and posttests of knowledge and anxiety, as well as the six-month follow up tests. Pre-test and initial post-test data was compared, and then pre-test data was later compared to the six-month followup data. In addition, initial post-test data was compared to six-month post-test data. This comparison is used to show immediate differences in knowledge and self-confidence (initial preto post- data); any sustained long-term changes from pre-training to six-months post; and any sustained long-term changes from immediate post-training to six-months post-training. Results Initial As discussed previously, thirty-one participants completed all necessary knowledgebased data, and thirty completed all anxiety-related assessment data. As part of the ethical AIRWAY MANAGEMENT 33 conduct of the study, participants were allowed to opt-out of any or all portions of the study in which they did not want to participate. Participants completed pre-tests within the week prior to the training, and initial post-tests were completed immediately following the training. However, answers to the questions on the pre-test, which were the same questions found on the post-test, were not explicitly given to participants to prevent a threat to internal validity. Change in knowledge. The fifteen-item knowledge assessment tool was assigned a point of one for each correct answer and zero for each incorrect answer. Then, total scores were averaged among all thirty-one participants to create a mean measure of change in knowledge. The mean number of correct answers increased from a pre-test mean of 12.35 (SD=1.60) to a post-test mean of 14.48 (SD=0.71). These results are not only meaningful from the stance that participants on average increased their scores by 2.13 points, the results were also statistically significant after the paired t-test was conducted (p <0.001). Change in anxiety. As discussed in the Method of Evaluation section, a shortened form of the State-Trait Anxiety Inventory was used to measure anxiety levels of the nurse participants (Spielberger et al., 1983). The inventory utilizes a four-point frequency scale, with a score of one (1) indicating absent anxiety, to a score of four (4) indicating a presence of high levels of anxiety about a particular situation (state) (Spielberger et al., 1983). For the thirty participants who completed the anxiety portion of the assessment, the mean scores decreased from 1.61 (SD= 0.65) on the pre-test to 1.35 on the post-test (SD= 0.46). These results show a statistically significant decrease in anxiety of the participants (p<0.001). Anecdotally, participants reached out to the investigator following the training to verbalize their gratitude for the training. Some of the nurses stated that AIRWAY MANAGEMENT 34 they had felt anxiety about providing care to sedated patients before having any formal training, but this anxiety had been somewhat relieved by attending the training. Long-Term (Six-Month) Change in knowledge. Of the thirty-one initial participants in the knowledge assessment, fifteen completed a six-month follow-up post-test, yielding a response rate of 48%. The average score on the sixmonth post-test was 12.8 (SD=1.42), with a mean decrease of 1.6 points, which was a statistically significant decrease from the initial post-test scores (p<.001). From the pre-test to the six-month post-test, there was a mean increase in scores of 0.5 points, which was not statistically significant (p=.388). (See Figure 3). Figure 3: Comparison of mean scores between initial pre-test, initial post-test, and six-month post-test knowledge scores. Change in anxiety. Of the thirty original participants in the anxiety portion of the assessment, eleven completed the six-month post-test, for a return rate of 37%. The mean score on the six-month post-test was 1.49 (SD=0.49), with a mean increase of only 0.16 points from the initial post-test mean (1.33). This result was not statistically significant (p=.289). From the pre-test to the sixmonth post-test, there was a mean decrease in scores of 0.06, which was also not statistically significant (p=.705). (See Figure 4). AIRWAY MANAGEMENT 35 Figure 4: Comparison of mean scores between initial pre-test, initial post-test, and six-month post-test anxiety inventory (State-Trait) scores. Discussion The primary purpose of this study was to evaluate the efficacy of an educational training on knowledge gained utilizing a pre/post-test method of assessment. A secondary aim was to measure if there was a reduction in anxiety of the nurses following the training utilizing a shortform of the State-Trait Anxiety Inventory for Adults. The nurse learners completed a priming didactic training module as a unit-based quality improvement endeavor. Long-term follow up of both changes in knowledge and anxiety levels was performed at a six-month interval after the initial training. The didactic training module was shown to be an effective short-term tool for both knowledge acquisition and a reduction in anxiety on the part of participant perianesthesia nurses. The findings between the initial knowledge and anxiety pre- and post-tests were both statistically significant (p<.001). Furthermore, many nurses who attended the training, particularly those with less than five years of experience expressed gratitude at being provided with an airway management training. AIRWAY MANAGEMENT 36 At the six-month interval, neither the knowledge gained, nor reduction of anxiety results were significantly different compared to the initial pre-test. Unfortunately, this showed that there was no statistically measurable long-term gain from the training. However, this is still an important finding, as the review of the literature shows that there is little long-term follow-up of study subjects following educational training. It is important to know that long-term gains will trend downward over time based on the findings of this study because it can help guide educators to determine education intervals. It can also lead educators to recognize that there may be a need to build upon didactic education with demonstration, simulation, and perhaps more frequent didactic training. For example, following didactic training, the participants could have participated in return demonstration of how to insert oral or nasal airways, how to bag mask a patient, or how to do an effective jaw thrust with feedback could have been an important adjunct. Additionally, getting the nurses into the OR to practice these skills with an anesthesia provider could have been more beneficial than didactic training alone. It is difficult to know if repeated exposure to the knowledge provided in training would have an additive effect on knowledge acquisition or anxiety reduction, as there was no repeat of the didactic training done at the six-month interval. A future training module may include an initial training and a six-month re-training with the same information to see if the results have a more substantial effect, i.e., the results of the six-month post-test show even greater gains in knowledge and further decreases in anxiety from the initial post-test. The additional adjunct previously mentioned could also be employed at the initial training and at the six-month interval to reinforce the didactic material. As learning is done in a multi-modal fashion, trainings should also be done in ways that address multiple learning styles. AIRWAY MANAGEMENT 37 Limitations Limitations to Learning A few limitations and barriers to the training did exist, the largest of which was related to time constraints of the nurses attending the training. Typically, nurses are not willing to come in on a day off or an unscheduled weekend day, such as a Saturday. These constraints were understandable, and it was not the intention of the investigator to burden nurses by doing so. Furthermore, unless already scheduled, nurses were not approved for paid time to attend the training. Thus, preventing some nurses, such as those who are only used as needed (PRN) or those on vacation, from being able to attend. Another issue related to time was that neither the investigator, clinical educator, nor the nurses wanted the nurses to attend the training during a lunch break or after a scheduled shift. The training itself took approximately 25-30 minutes to deliver, with additional time needed for questions or if clarification of a topic was needed. Therefore, the training was typically completed for the PACU nurses first thing in the morning before they had started receiving patients from the OR. The pre-operative nurses attended a training throughout the day as timepermitted in between getting patients ready for surgery. Unfortunately, the result was that some nurses were pulled away from, or came late to the training, in order to attend the needs of a patient. In some instances, this meant that either a pre- or post-test was not completed, and therefore, the data could not be used. In the operative setting, getting nurses to be able to leave the patients to attend a training is not often feasible, and there are not enough nurses scheduled to cover for one anothers patients. Furthermore, paying the nurses for any extra time was not approved by management for this training. Interestingly, when Corcoran (2016) did her training, she also provided AIRWAY MANAGEMENT 38 breakfast, lunch, a small gift bag, a CE credit (1), and had prize giveaways both days of her workshop to encourage participation. This type of incentive is important, as getting participants to give up time (paid or unpaid) to attend a workshop is often a difficult challenge. However, the downside to this is related to cost and a decreased feasibility by most institutions to provide these incentives. Limits to Implementation When the training was in its conception stage, it was to include a demonstration component. Unfortunately, the clinical educator was unable to gain access to a big enough room and appropriately-sized mannequins. Given the time constraints already discussed, it was also determined to be too large of an undertaking, and the didactic primer was deemed the most critical initial component of training. However, a demonstration component utilizing the objectives learned from the training would have likely added a rich layer to the learning process. The setting for the training was also a barrier, as it was difficult securing a conference room close enough to the unit and large enough for the trainees. Some conference rooms were available throughout the hospital, but the clinical educator did not feel that the nurses would be able to go far from the unit in case a patient needed them. This meant that the training ended up being done either at the nurses station if space permitted, or in an empty PACU bay or preoperative room. This led to many distractions in the form of noise, interruptions, and at times, the nurses not being able to give their full attention for fear that they would be needed on the unit. Although the participation rate for the unit was reasonably high (79%), the actual sample size of nurses (n=31), is not a large enough sample size to be able to generalize the results to a large population. Additionally, there was a marked drop off in both interest and participation from the initial training to the six-month re-evaluation. Many nurses who attended the initial AIRWAY MANAGEMENT 39 training did not complete the six-month post-test due to being absent (not scheduled, illness, or vacation), unable, unwilling, or through termination of employment. Therefore, attrition of subjects was another limitation, albeit an expected limitation of allowing a six-month interval to elapse between tests. The last major limitation was related to the long-term evaluation of the anxiety portion of the assessment. According to Spielberger et al. (1983), as the S-Anxiety scale monitors anxiety resulting from situational stress, the re-test coefficient is somewhat low. However, the internal consistency of the Form Y S-Anxiety scale was high, with a median Cronbach alpha coefficient of .93 (Spielberger et al., 1983). Therefore, it is difficult to correlate the situational stress one is feeling towards a particular event/stressor given a six-month time interval. Conclusion Nurse training and education is effective in the short-term at increasing knowledge and reducing anxiety, but long-term continuing education is likely necessary to maintain familiarity and competence with the material. It may also be beneficial to include different types of training such as simulation, in addition to didactic methods. As was concluded with the review of literature, this study also concludes that repeat sessions of education will likely result in better outcomes for both nurses and their patients. AIRWAY MANAGEMENT 40 References American Association of Nurse Anesthetists (AANA). (2016). 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The Journal of Continuing Education in Nursing, 48(3), 115-122. doi:10.3928/00220124-20170220-07 OMalley, P. A., & Poling, L. (2015). Finding a way through the sedation labyrinth: Is it conscious, moderate, deep, or procedural sedation? Emerging evidence for CNS practice. Clinical Nurse Specialist, 29(1), 12-18. doi: 10.1097/NUR.0000000000000092 Poulsen, A. A., Sharpley, C. F., Baumann, K. C., Henderson, J., & Poulsen, M. G. (2015). Evaluation of the effect of a 1-day interventional workshop on recovery from job stress for radiation therapists and oncology nurses: A randomized trial. Journal of Medical Imaging and Radiation Oncology, 59, 491-498. doi:10.1111/1754-9485.12322 Spielberger, C. D. (1977). State-Trait Anxiety Inventory. Retrieved from http://www.mindgarden.com/products/staisad.htm AIRWAY MANAGEMENT 44 Spielberger, C. D., Gorsuch, R. L., Lushene, R., Vagg, P. R., & Jacobs, G. A. (1983). Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press, Inc. Tluczek, A., Henriques, J. B., & Brown, R. L. (2009). Support for the reliability and validity of a six-item state anxiety scale derived from the State-Trait Anxiety Inventory. Journal of Nursing Measurement, 17(1), 19-28. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/19902657 Turner-Parker, M., Leggett-Frazier, N., Vincent, P. A., & Swanson, M. S. (1995). The impact of an educational program on improving diabetes knowledge and changing behaviors of nurses in long-term care facilities. The Diabetes Educator, 21(6), 541-545. AIRWAY MANAGEMENT 45 Appendix A The Synergy Model Figure 1. The Synergy Model: Optimal patient outcomes occur when the nurses competencies, which are supported by the system, match the patients needs. Used with permission. Curley, M. A. Q. (1998). Patient-nurse synergy: Optimizing patients outcomes. American Journal of Critical Care, 7(1), 64-72. PMID: 9429685 AIRWAY MANAGEMENT 46 Appendix B Continuing Education/In-Servicing Concept Map Figure 2. Depiction of relationships between education, students (learners), instructors, and the system and their impact on outcomes. Engelman, M. (2018). DNP concept map: Continued education/in-servicing. Unpublished raw figure. AIRWAY MANAGEMENT 47 Appendix C Lesson Objectives: 1. 2. 3. 4. 5. Identify high risk patients based on his/her ASA classification. Interpret a patients OSA risk from his/her STOPBANG score Review current NPO guidelines for patients preparing to undergo procedures. Identify patient assessment findings that can lead to difficulty with mask ventilation Discuss how positioning a patient can result in either increased or decreased airway patency. 6. Explain the proper use of oral and nasal airways, and when they should be employed as an airway adjunct. 7. State minimum monitoring recommendations for patients undergoing procedures outside the operating room. 8. Explain the uses of capnography as a monitoring parameter. 9. Define the depth continuum and explain how this relates to airway management. 10. List the minimum necessary equipment that should be available for a patient undergoing a procedure outside of the operating room 11. Report potential complications related to the airway that can occur during bronchoscopies AIRWAY MANAGEMENT 48 Appendix D Patient Assessment and Airway Management Pre/Post-test Assigned color _____________________________ (Please circle one) Pre-test Post-test 1. Which of the following can contribute to difficulty in being able to mask-ventilate a patient? a. A patients allergies b. The patient having a beard and no teeth c. The patient had recent abdominal surgery d. The patient is a known alcoholic 2. The most common cause of airway obstruction when a patient is sedated is: a. The tongue and soft palate b. The uvula and hard palate c. The teeth d. A foreign body 3. A 47-year-old female that has well-controlled diabetes mellitus, a BMI of 33, and who drinks an occasional glass of wine would be an ASA Class: a. 1 b. 2 c. 3 d. 4 4. A 46-year-old male with a history of snoring, a BMI of 40, and a neck circumference of 48 cm would be at high risk for obstructive sleep apnea based on STOP BANG scoring: a. True b. False 5. The most effective position for bag-mask ventilating a patient is the: a. Chin-to-chest maneuver b. Pulling the face up while grabbing the soft tissue under the mandible c. Head-tilt-chin-lift with jaw thrust d. All positions are effective with proper squeezing of the Ambu bag 6. According to the most recent NPO guidelines, a patient who has eaten a light meal, without anything fried, should have a minimum fasting period of: a. 2 hours b. 4 hours c. 6 hours d. 8 hours AIRWAY MANAGEMENT 49 7. Nasopharyngeal airways are better tolerated than oral airways in patients who: a. are not deeply unconscious b. have trauma to the mid-face region or significant head trauma c. have a platelet count of <50,000 d. are completely unconscious 8. Signs of effective bagmask ventilation include all of the following EXCEPT: a. Adequate chest rise b. Gastric distension c. Improved color d. Oxygen saturation of 98-99% 9. Potential complications of bronchoscopy include: a. Pneumothorax or pneumomediastinum b. Bleeding and dental damage c. Laryngospasm or bronchospasm d. All of the above 10. If you cannot ventilate your patient after repositioning the mask and airway, the FIRST thing you should do is: a. Squeeze the bag-valve mask (BVM) harder b. Put your patient on their left side c. Call for assistance d. Initiate CPR 11. Continuous physiologic monitoring or assessment of the patient before, during, and after a procedure should include which of the following? a. Ventilation and oxygenation b. Cardiovascular status and neuromuscular function c. Patient positioning and body temperature d. All of the above 12. All of the following about end-tidal CO2 (ETCO2) are true EXCEPT: a. Normal values are 35-45 mmHg b. It is a measure of ventilation c. It is a delayed measurement, not real-time d. It can aid in the assessment of respiratory effort 13. According to the Medical Licensing Board of Indiana, during procedures, there must be a reliable source of: a. Oxygen, Lighting, Emergency drugs, Resuscitation equipment b. Oxygen, Suction, Lighting, Emergency drugs c. Suction, Lighting, Resuscitation equipment, Emergency drugs d. Oxygen, Suction, Resuscitation equipment, Emergency drugs AIRWAY MANAGEMENT 50 14. During a procedure, your patient is responsive to tactile stimulation, is maintaining her own airway and is adequately spontaneously ventilating with well-maintained cardiovascular function. She is in which stage of the Depth of Sedation Continuum? a. Minimal Sedation b. Moderate Sedation c. Deep Sedation d. General Anesthesia 15. When it comes to potential airway difficulties, which of the following patients would make you the most vigilant? a. A 45-year-old, obese man with a thick neck, whose wife says he snores and sometimes stops breathing at night b. A 6-month-old with no prior medical history who is being observed after ingesting four aspirin tablets c. A 61-year-old who smoked 1 pack-per-day for 10 years, but quit 35 years ago d. A 21-year-old who is presenting today for repair of an inguinal hernia and states he had a cold about 3 weeks ago AIRWAY MANAGEMENT 51 Appendix E Demographic Data Assigned color _____________________________ Pre-test 1. Which unit do you primarily work on? (please circle only one) a. PACU i. Main OR ii. ASC b. Pre-op i. Main OR ii. ASC c. Other: Please list ____________________ 2. How many years have you been a nurse? a. 0-5 years b. 6-10 years c. 11-20 years d. > 20 years  ...

... AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 2 Table of Contents Abstract ............................................................................................................................... 5 Section II: Introduction ....................................................................................................... 6 Background and Significance of Practice ....................................................................... 6 Provider Shortages ...................................................................................................... 6 Expansion of Medical Knowledge .............................................................................. 7 Millennial Learning Style ........................................................................................... 7 Problem Purpose/Specific Aim ....................................................................................... 8 Problem Statement .......................................................................................................... 8 Organizational Gap Analysis of Project Site ............................................................... 9 Section III: Literature Review and Framework .................................................................. 9 Literature Review............................................................................................................ 9 Methods....................................................................................................................... 9 Synthesis of Findings. ............................................................................................... 10 Limitations ................................................................................................................ 20 Conclusion. ............................................................................................................... 20 Framework .................................................................................................................... 21 Section IV: DNP Project Plan ........................................................................................... 22 Practice Gap Analysis Recommendation ...................................................................... 22 Method for Translation ................................................................................................. 22 AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 3 Stakeholder Assessment ................................................................................................ 23 Organizational Readiness .............................................................................................. 23 Setting ........................................................................................................................... 23 Participants .................................................................................................................... 24 Ethics and Human Subjects Permission ........................................................................ 24 Procedure for Implementation ...................................................................................... 24 Barriers .......................................................................................................................... 26 Instrument, Data, and Evaluation.................................................................................. 26 Analysis......................................................................................................................... 27 Relevance. ................................................................................................................. 28 Attention. .................................................................................................................. 28 Confidence. ............................................................................................................... 28 Satisfaction ................................................................................................................ 29 Global ........................................................................................................................ 29 Limitations .................................................................................................................... 29 Conclusion .................................................................................................................... 30 Section V: References ...................................................................................................... 31 Section VI: Appendices ..................................................................................................... 35 Appendix A. Evidence Evaluation Table ...................................................................... 36 Appendix B: SWOT Analysis ....................................................................................... 39 AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 4 Appendix C: Instructional Materials Motivation Survey Modified for AR ............... 40 Appendix D: IMMS Results Mean Sample Population ............................................. 41 AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 5 Abstract Research shows that the addition of extended reality (XR) in healthcare education is advantageous as it enhances the learning experience and improves students knowledge and motivation to learn. Its use has been documented in nearly all areas of healthcare education but is much less explored in the realm of anesthesia. This research project focuses on a branch of XR known as augmented reality (AR) and its use as an adjunct learning tool in the curricula for nurse anesthesia. Kellers Attention, Relevance, Confidence, and Satisfaction (ARCS) Model of Motivation guided the design of this project to understand the impact AR technology had on second year student registered nurse anesthetists (SRNA) motivation towards learning. Students used an AR mobile application to interact with a realistic anatomical structure of the human larynx and completed a related worksheet. A post-assessment Likert-type Instructional Materials Motivation Survey (IMMS) was used to assess ARs impact on learner motivation as it relates to each of the four ARCS model constructs. Each construct yielded a high average score amongst participants, thereby indicating a positive learning experience. The results imply that AR enhances current learning modalities and may directly influence students motivation to learn. The evidence is supportive for the use of AR as an adjunct learning tool in nurse anesthesia education. Future studies are needed to evaluate the efficacy of AR as a result of its integration into curricula. AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION Keywords: Anesthesia, Augmented Reality, Extended Reality, Virtual Reality, Student Registered Nurse Anesthetist, Healthcare, Technology Augmented Reality in Nurse Anesthesia Education Section II: Introduction Extended reality (XR) utilizes computer technology as a platform to create real-andvirtual combined environments with which a user can interact. Extended reality is a generic umbrella term that encompasses both virtual reality (VR users are immersed into a computergenerated environment) and augmented reality (AR cyber images are superimposed over the real-world environment). The use of this technology in healthcare education has proven to increase motivation for learning and enhance traditional learning styles. Background and Significance of Practice The need for XR in healthcare education is multi-faceted due to factors such as worsening provider shortages, rapid expansion of medical knowledge, and alternative learning styles of healthcare students. Provider Shortages. A projected healthcare shortage of more than 100,000 providers is anticipated in the United States by 2030 (Dall, West, Chakrabarti, Reynolds, & Lacobucci, 2018). By this time, there will have been a 50% increase in the number of individuals reaching 65 years of age or older, making the aging population a primary determinant of this impending shortage (Dall et al., 2018). Since advancing age tends to be accompanied by an increased requirement for healthcare related services, not only will it be difficult to meet the needs of patients, meeting the educational and training demands of students will also present a challenge. An anticipated concern is that this provider deficiency will equate to a lack of available educators to efficiently train todays healthcare students (Dall et al., 2018). Therefore, it is of 6 AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 7 paramount importance to employ alternative and effective teaching strategies that meet current education demands and requirements for the learner population. Expansion of Medical Knowledge. The U.S. Bureau of Labor Statistics has projected healthcare to be the largest and fastest growing industry of the decade (U.S. Bureau of Labor Statistics, 2015). Emerging technologies, complex multimorbidity and the aging population contribute to the obligatory growth of existing medical knowledge. A study in 2011 calculated an average time of 3.5 years for todays knowledge to double, dropping as low as 73 days by the year 2020 (Densen, 2011). For historical comparison, doubling of medical knowledge took more than 50 years in 1950 and seven years in 1980; a time when todays educators were in the student role (Densen, 2011). Conventional education strategies are challenged to up with the accelerated expansion of knowledge, calling for curricular innovation that is culturally relevant to meet the current challenges of healthcare education (Piper, 2012). Millennial Learning Style. Millennials (defined as individuals born between 1981 and 1996) have begun to saturate the healthcare industry, currently occupying the largest portion of its learner population. As these students graduate, they will account for 75% of the workforce, providing them with a crucial role in the transformation of future healthcare (U.S. Bureau of Labor Statistics, 2015). Being digitally native and having grown accustomed to a rapidly changing environment, the Millennial generation may be best equipped to manage the accelerated learning demands seen with healthcare today. The generational yearn for participating in contemporary learning opportunities challenges the mainstream infrastructure of education to discover new ways of teaching that will maximize use of modern resources and adapt to revolutionary changes. AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 8 The demands of Millennial learners necessitate diversity in teaching strategies that support innovative ways of thinking and student engagement (Taekman & Shelley, 2010). This idea of active learning, however, is not new. Edgar Dale introduced his learning pyramid over 50 years ago, emphasizing that learners retain 90% of what they do and only 10% of what they read (Dale, 1969). Restructuring modern curricula to adopt active, learner-centered didactic strategies will foster meaningful learning and quality education for the Millennial healthcare student. Additionally, programs who adopt such models are likely to experience improved rates of retention and student satisfaction, a key factor in managing the current trends of American healthcare (Giddens, 2008). Problem Purpose/Specific Aim Extended reality is a cost-effective resource that creates a non-threatening, realistic environment in which one can repeatedly practice his/her skills (Badash, Burtt, Solorzano, & Carey, 2016). This constant exposure shortens the learning curve, allowing faster transitions to occur from classroom to clinical environments (Munro, 2012). It is evident that XR employed for healthcare education and training has overwhelming benefits, however, its advantages in the realm of anesthesia have not been fully explored. Problem Statement In order to investigate best teaching modalities to meet the demands of todays healthcare education, a PICOT question was formulated. The question includes the population of interest, a proposed intervention, the desired outcome, and the project timeframe. The PICOT question is: does the use of extended reality enhance motivation for learning in the education and training of student registered nurse anesthetists. AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 9 Organizational Gap Analysis of Project Site Marian University in Indianapolis, IN has been identified as the site for implementation of this project. The organizations nurse anesthesia program is in its infancy and does not currently utilize XR for learning purposes. The institution shows great potential in adapting new teaching modalities as it continues to develop the ideal curricula for optimal performance. Section III: Literature Review and Framework A review of the literature was conducted to identify how XR is being utilized in healthcare education and evaluate the perceived benefits among its users (see Appendix A). This project drew on the ARCS (Attention, Relevance, Confidence, and Satisfaction) model to further explore student motivation for learning through the use of AR in anesthesia education (Keller, 1987). Literature Review Methods. Initial review of the literature was completed using the database, PubMed. The terms extended reality, XR, immersive technology, mixed reality, haptic learning, augmented reality AND education, extended reality AND healthcare students, and virtual reality AND millennials were searched to ensure inclusion of any synonymous terms that may have developed throughout its evolution. Due to the rapid changes associated with emerging technology and healthcare and for the purpose of maintaining validity, a five-year limit was applied to exclude literature published prior to 2013. Results were further restricted to only randomized control trials (RCTs) (level 2 evidence) and quasi-experimental studies (level 3 evidence) utilizing Melnyk and Fineout-Overholts classification system (Melnyk & FineoutOverholt, 2015). To confirm saturation of data, an additional manual search of the articles references was conducted in the database Google Scholar. No new relevant articles were AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 10 identified confirming saturation point had been met. A total collection of nine articles were chosen for this review, five of which were randomized control trials (RCTs) and four quasiexperimental studies. Synthesis of Findings. Study samples included within the reviewed articles were currently enrolled medical students, nursing students obtaining a bachelors degree in nursing (BSN) or an associate degree in nursing (ADN), and pharmacy students. The control or comparison groups in all nine studies represented different forms of conventional learning methods including one or more of the following: mannequin simulation, computer-based learning (CBL), classroom lecture, written material, and problem-based learning (PBL). Computer-based learning was identified throughout the literature to include web-based educational material of two-dimensional images, video demonstrations, and/or online textbooks. Problem-based learning employs a facilitator that leads a discussion for a small group of students on a patient-case scenario in which several therapy options are discussed and each clinical decision made by the group alters the subsequent therapy choices (Al-Dahir, Bryant, Kennedy, & Robinson, 2014). The experimental group was assigned various modalities of XR technology including virtual, augmented, and high-fidelity simulation. Critical appraisal was done, in isolation, by two graduate researchers with near-identical levels of content expertise. For sake of homogeneity and analogous evaluation, generic categorization of studies into major themes was necessary. After full analysis was complete and each study was categorized under a major theme, analytic discussion commenced, and findings were revealed. The outcomes identified within the literature can be aggregated into the following themes: cognition, psychomotor performance, and perceived experience. AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 11 Cognition. Cognition was assessed by the researchers in five studies (two RCT and three quasi-experimental) to evaluate knowledge acquisition or retention by administering pre-tests and post-tests before and after the training. Pre-tests were employed to determine students baseline knowledge and identify any cognitive differences that existed between the groups. A difference in pre-test results was found in only one study by Smith et al. (2016) that compared efficacy of XR to written instruction for teaching nursing students the skill of decontamination. In this study, unsupervised pre-tests were administered to 108 BSN students. The pre-test scores were significantly lower in the XR group which indicated a baseline cognitive advantage existed in the comparison group (Smith et al., 2016). Despite the XR groups inherent handicap, mean post-training scores were numerically superior compared to the control group. Therefore, it is implied that XR training was an effective method for improving learning outcomes among nursing students for teaching the skill of decontamination (Smith et al., 2016). The XR groups in all five of the studies measuring cognition showed an improvement from their pre-test to post-test scores. However, when comparing the post-test scores between the study groups, one RCT by Al-Dahir et al. (2014) reported that the XR group scored significantly lower (p = .001) than the control group. This study assessed clinical decision-making in a patient case scenario utilizing either PBL or XR as the teaching method among 108 pharmacy students. Participants allocated to the PBL group were further divided into groups of six to eight students and were tasked with navigating through a patient case scenario by participating in a discussion exercise. Each student in the XR group independently completed a virtual computer-based simulation of the same patient case scenario. Knowledge application of the case subject matter was assessed after the experience, which revealed significantly lower scores in the XR group (p = .001). The authors postulate that this finding could be attributed to the fact that the students AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 12 had previously participated in PBL scenarios as part of their curriculum and were therefore accustomed to it. Another limitation of this study was that more students assigned to the PBL group were enrolled in an internal medicine rotation and therefore may have had prior exposure to a similar patient case (p < .001). The study concludes that both learning methods were effective (Al-Dahir et al., 2014). Two quasi-experimental studies compared XR simulation with a high-fidelity mannequin simulation to evaluate learning outcomes between the two activities (Cobbett & SnelgroveClarke, 2016; Haerling, 2018). The study by Cobbett & Snelgrove-Clarke (2016) compared two maternal clinical scenarios experienced by 56 BSN students randomly assigned to either a highfidelity mannequin simulation or the XR simulation. This study had the experimental and comparison groups switch after the first scenario so that the mannequin group would be assigned to the XR simulation for the second scenario, and vice versa. The authors concluded that since the post-tests scores demonstrated no significant difference between the groups with each scenario, that neither educational approach was more advantageous than the other in terms of cognitive outcomes. The limitations of this study include its small sample size and use of unvalidated pre-test and post-test assessments (Cobbett & Snelgrove-Clarke, 2016). Haerling (2018) compared cognitive outcomes among 81 ADN students assigned to participate in either a professionally facilitated group simulation or an independent web-based XR scenario of a patient presenting to the hospital with respiratory complications. A debriefing session was then provided via the students respective training method. This was noted as a limitation of the study given that the differences in feedback were not controlled for, potentially impacting the learning outcomes and obscuring the validity of the data. Following the debriefing, students took a post-test which showed no differences in results between the XR group or the AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 13 control group, however, both methods contributed to significant improvement in pre-testing knowledge (p < .05) (Haerling, 2018). An RCT by Stepan et al. (2017) was the only study that did not utilize a simulated patient scenario to measure cognition. Instead, computed tomography (CT) and magnetic resonance imaging (MRI) were used to create a three-dimensional digital model of the brain. A VR headmounted display (HMD) was used to view these images which allowed 64 medical students to experience an immersive and interactive environment to learn neuroanatomy. While the XR group used the HMD, the control group was given traditional online textbooks to study anatomical structures of the brain. A post-test found that both educational methods resulted in equivalent learning outcomes. However, a post-experience survey found that students felt they devoted a substantial amount of their allotted training time on familiarizing themselves with the XR technology. Recognizing that there was a learning curve disadvantage for the XR group, the authors acknowledged that cognitive tests scores may have been higher if the students had received a satisfactory orientation period. Additionally, the researchers assessed students knowledge retention by administering a quiz eight weeks after the training, to which the researchers did not discover a significant difference between the groups. This study was well randomized and the authors report that the sample size met their recruitment goal (Stepan et al., 2017). Psychomotor Performance. The theme of psychomotor performance relates to outcomes that evaluated overall skill performance, dexterity, skill completion time, skill retention, and proficiency in advanced communication techniques. Skill performance was measured in four RCTs and two quasi-experimental studies by using a checklist or performance rubric. Five of the six studies reported better performances demonstrated by the XR group when compared to the AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 14 control group (De Oliveira, Glassenberg, Chang, Fitzgerald, & McCarthy, 2013; Aebersold et al., 2017). An RCT by Kron et al. (2016) measured the most unique outcome of advanced communication skills by conducting a study in which 421 medical students were taught interprofessional communication principles by means of a CBL module or a XR human interaction scenario. Initially, each student in the XR group completed an intercultural scenario, received personalized feedback, and subsequently repeated the same scenario once more to evaluate performance improvement. They repeated this process with the interprofessional communication scenario. A major limitation of this study is that the control group was not provided an intercultural scenario as part of their training. The authors noted that this could have impacted the overall performance scores. Performance between the study groups was evaluated by having students demonstrate interprofessional communication in an objective structured clinical exam (OSCE) scenario with trained standardized patient individuals (SPIs) that scored them based on their verbal responses and nonverbal behaviors. Although the SPIs were blinded to the students exposure, this grading method could have resulted in scoring variations. Considering these limitations, results concluded that students in the XR group showed significant improvement in their advanced communication skills after receiving feedback in both scenarios (p < .0001). The OSCE grading scale used to measure performance had a small effect size and was therefore less likely to detect a statistical significance. As a result, the authors created a global composite score and conducted an analysis of variance to compare results between groups. This showed that performance in the XR group was significantly better when compared with the control group (p = .014) (Kron et al., 2016). AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 15 An RCT performed by De Oliveira et al. (2013) examined whether virtual upper endoscopic airway training improved dexterity among students operating a fiberoptic scope. All students received didactic training, but only the XR group had an additional 30 minutes of training using a virtual airway simulator on a mobile device. Students were then given 10 consecutive attempts to complete the skill on a mannequin in the presence of an instructor blinded to the study groups. In addition to a skills checklist, a global assessment score was used to evaluate the students performance on their ability to manipulate the fiberoptic scope. The researchers found that students in the XR group performed the skill faster (p = .001), received higher skills checklist scores (p = .014) and had better global assessment scores. To eliminate potential bias related to skill experience, none of the participants in this study had prior exposure to this skill. The authors concluded that XR airway simulation improved the dexterity of novice medical students in upper airway endoscopy performed with a fiberoptic scope (De Oliveira et al., 2013). Smith and Hamilton (2015) also reported better performance scores among the XR group. In this RCT, all students received didactic instruction on urinary catheter insertion and were given times to practice the skill on a non-human model for one week prior to a skills evaluation. The experimental group additionally had remote access to computer-based XR. The study reports that an expert supervisor used a Fundamentals of Nursing Simulated Skills Evaluation Placement grading tool to assess student performance with catheter insertion on the non-human model. It is unknown if this instrument is validated or if the supervisors were blinded to the study groups. Results showed that performance scores were higher in the XR group compared to the control group, however, the difference was not significant. The authors also state that students in the XR group spent fewer time practicing with both the non-human model and XR combined (156.1 minutes) compared to the control group (182.5 minutes). However, the AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 16 XR minutes were self-reported which could alter the validity of the results. Another limitation of this study is its small sample of only 20 ADN participants, three of which were reassigned to the control group due to technical difficulties downloading the XR (Smith & Hamilton, 2015). Aebersold et al. (2017) reported similar findings after conducting a quasi-experimental study that examined the use of XR as a training tool for teaching procedural skills to 69 BSN students. Nasogastric tube (NGT) insertion was taught to participants by providing them with either an iPad anatomy-augmented XR training or a module with didactic material and an animated video. Skill competency was evaluated by having students demonstrate successful NGT insertion on a mannequin. Two raters blinded to the students exposure scored them using a validated skills checklist. Inter-rater reliability was determined at 0.95 prior to the skill demonstration. Results showed that the XR group scored significantly better than the control (p = .01). The authors disclose that the students had exposure to the skill prior to the study, and therefore, they suggest more studies are needed to determine effectiveness of XR for skills training among students with no previous experience. Nevertheless, the authors concluded that XR technology is an effective method for training nursing student on procedural skills (Aebersold et al., 2017). Two quasi-experimental trials used a simulated patient case scenario to evaluate the efficacy of XR training (Smith et al., 2016; Haerling, 2018). Smith et al. (2016) evaluated BSN students performance in a decontamination scenario following training with either XR or written instruction. The authors state that a performance rubric was completed by trained raters that were responsible for supervising the skill demonstration, but it does not affirm if they were blinded to the students method of training. Although the XR group showed an initial performance advantage, their repeat evaluation at five months to measure skill retention demonstrated lower AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 17 performance scores than the control group (p = .041). However, the XR group performed the skill faster in both the immediate and five-month retention testing periods (p = .015) (Smith et al., 2016). The quasi-experimental study by Haerling (2018) that used SPIs to evaluate the students performance after training with XR or a high-fidelity simulation showed that there were no significant differences noted between the groups. However, due to resource limitations, only 28 of the 81 students were selected to participate in the SPI portion of the study. The author recognized that due to the small sample size, the analyses would be less likely to identify a significant difference (Haerling, 2018). Perceived Experience. Students perceived experiences were commonly reported throughout the literature as measures of anxiety, self-confidence, motivation, and preparedness. Perceptions of the technology itself were stated as application preference, ease of use, and interactivity. There were seven studies to report on one or more of these outcomes as a means of analyzing the students experience respective to their assigned learning method, four of which were RCTs and three were quasi-experimental studies. Overall, the results were variable with three studies reporting a significantly enhanced experience in the XR group (Kron et al., 2016; Aebersold et al., 2017; Stepan et al., 2017), two studies found no difference between the groups (Smith & Hamilton, 2015; Haerling, 2018), and two others reported worse experiences in the XR group (Al-Dahir et al., 2014; Cobbett & Snelgrove-Clarke, 2016). Only one study evaluated motivation as an outcome (Stepan et al., 2017). After students experience with either the XR or CBL teaching modalities, the students completed an Instructional Materials Motivation Survey (IMMS), a validated measurement tool that provided a total score encompassing results related to attention, relevance, confidence, and satisfaction. The AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 18 results revealed that the XR group had a greater sense of motivation with significantly higher overall IMMS score compared to the control group (p < .001). This study also administered a subjective user experience survey using a visual analog scale to quantify the students perceptions on how easy to use, enjoyable, and engaging the learning tool was, if they found it useful for learning, and whether they would recommend it to another student. The average responses exposed that the XR group had a better perceived experience in all domains (p < .01) except for ease of use, which revealed no significant difference (Stepan et al., 2017). Results from one study using an attitudinal survey validated for internal consistency revealed students reported an overall more positive experience in the XR group (p < .0001) (Kron et al., 2016). Another study examined students perception of clinical preparedness by utilizing a visual analog scale administered to the students after they completed the skill demonstration (Smith & Hamilton, 2015). The researchers found that students in the XR group felt more prepared for the skill demonstration compared to the control group (Smith & Hamilton, 2015). The difference was not statistically significant which may be attributed to the studys small sample size (Smith & Hamilton, 2015). Self-confidence was measured in two studies (Cobbett & Snelgrove-Clarke, 2016; Haerling, 2018). The study by Haerling (2018) had participants complete a Satisfaction and SelfConfidence in Learning survey with a Cronbachs alpha measurement that validated internal consistency for both satisfaction (0.92) and self-confidence (0.83). The survey was completed before and after the intervention. Although the scores of the XR group did not differ significantly from the comparison group, both groups achieved better post-intervention scores, indicating that XR was as effective as high-fidelity simulation in improving students satisfaction and selfconfidence. Student feedback was obtained by the researchers indicating that more students in AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 19 the control group (33%) experienced feelings of anxiety or nervousness compared to the XR group (11%) (Haerling, 2018). The second study to have reported on self-confidence levels obtained findings contrary to the positive trends found in most of the studies analyzing perceived experiences (Cobbett & Snelgrove-Clarke, 2016). Although there was no difference found between groups related to their level of self-confidence, the XR group conveyed higher anxiety levels (p = .002) using the Nursing Anxiety and Self-Confidence with Clinical Decision-Making Scale. This instruments Cronbachs alpha measurement validated high internal consistency for measuring anxiety (0.96) and self-confidence (0.97). These results could be partially attributed to the lack of orientation period provided to the students prior to the XR scenario, a significant limitation of the study reported by the authors (Cobbett & Snelgrove-Clarke, 2016). The study comparing XR to PBL administered a survey using a Likert-type scale to evaluate students experiences (Al-Dahir et al., 2014). An adequate Cronbachs alpha measurement (0.864) reported by the authors indicated that the survey was a reliable tool to analyze students opinion of either teaching modality. More students assigned to the control group reported that the PBL learning method provided knowledge reinforcement (p = .034), as well as contributed to additional knowledge within the subject area (p = .01). However, both groups reported that they would recommend their assigned learning method to another student. Additionally, although not statistically significant, less students in the XR group felt they had adequate time to complete the task (p = .065). Students perception on the adequacy of orientation to the XR technology was not assessed by the survey. This would have been useful to distinguish if the lack of time perceived by the students was attributed to an increased amount of time spent familiarizing themselves with the technology. Additionally, PBL is incorporated into AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 20 the students curriculum and therefore students were more familiar with this learning method, potentially influencing their overall reported experience (Al-Dahir et al., 2014). Limitations. Perhaps the largest limitation to this literature review manifests in the identification of the authors as Millennial healthcare students. Unanticipated bias may be evident despite attempts to remain impartial. Another limitation lies in the infancy of the concept as it is still emerging for its use in educational training. By excluding articles written outside of North America, themes may have been missed that could benefit US healthcare. Additionally, although a five-year limit was placed in order to capture the most recent evidence of the concept, this tight of a time constraint may have resulted in missed relevant studies. Many of the studies report insufficient sample sizes thereby serving as a potential factor for the inability to reach statistical significance. Lastly, the studies in this review utilized convenience sampling and measured single, specific outcomes, thus limiting generalizability. Conclusion. With Millennials comprising the majority of healthcare students, and the complexity of healthcare steadily increasing, an obvious call for restructuring traditional curricula is mandated. Extended reality is noted as one of the most innovative pieces of emerging technology today and is expected to proliferate throughout healthcare education. Defining features of Millennials and trends of population growth have targeted this generation to be the most impacted by XR. Many institutions have already begun to incorporate this modern technology into their curricula. This literature review uncovered some of the most common themes that have emerged through XR use in healthcare education: psychomotor performance, knowledge acquisition, and personal experience. Seven of the nine studies found that XR had a significant, positive influence on healthcare learners education and training. The modernized curricula in these studies proved AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 21 superior to traditional education strategies; therefore, its use as an adjunct learning tool is recommended. Some studies found no difference in outcomes when XR was utilized, suggesting its equivalence to conventional learning modalities. The addition of XR can expand the armamentarium of medical learners therefore persistent recommendation for its use exists. Two studies reported fewer desirable results and criticized the use of XR in education (Al-Dahir et al., 2014; Cobbett et al., 2016). However, multifactorial causes related to participant characteristics may have influenced results and further research is warranted. Overall, XR demonstrates the potential to enhance clinical preparation, improve motivation, and shorten the learning curve among healthcare students. The articles in this review provide data supportive of the use of XR in the education and training of healthcare students and revealed comparable outcomes to conventional teaching methods. Framework This project was developed through John Kellers ARCS Model of Motivational Design Theory to better understand the impact AR technology had on student anesthetists motivation towards learning (Keller, 1987). The ARCS Model is a method used for improving the motivational appeal of instructional material (Keller, 1987). Based on this model, the AR project was optimally designed to grasp students attention, be relevant to their learning, promote confidence with its use, and elicit feelings of satisfaction after completion (Khan, Johnston, and Ophoff, 2019). Presumably, the presence of these four factors will encourage students to become and remain motivated to learn. The increase in motivation to learn will promote self-employed erudition, which demonstrates a positive correlation with improved test scores and clinical performance (Stepan et al., 2017, p7). AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 22 Section IV: DNP Project Plan The main objective of this project was to provide SRNAs with supplemental learning material using AR technology for the purpose of enhancing motivation and increasing authenticity of the learning experience. Practice Gap Analysis Recommendation The investigators hypothesized that incorporation of XR technology into SRNA education would enhance educational experiences, encourage active learning participation, and improve didactic motivation. This hypothesis was grounded in the ARCS Model of Motivation, which suggests learner motivation is enhanced when users engage in something that piques their interest, is pertinent to their studies, offers assurance, and leaves feelings of gratification. The AR application utilized in this study entertains kinesthetic and spatial instructional strategies that appeal to learners with informational processing styles to enhance the learning experience and improve motivation to learn (White, Dudley-Brown, and Terhaar, 2016). Method for Translation The need for this project was identified by the investigators through their personal experience and recognition of gaps in current education practice. Access to clinical resources is scarce and hands-on learning opportunities are limited. Extended reality is engaging and allows for knowledge reinforcement through repetition, and can be conveniently completed in the comfort of ones own home. Based on the stakeholder assessment and supported by the ARCS model of motivation, the need for complementary modalities to traditional learning has been expressed. AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 23 Stakeholder Assessment Stakeholders who hold a vested interested with this project involve university healthcare students, faculty, and information technologists (IT). The primary interest of the student population is personal attainment of enhanced knowledge and increased interest and motivation for educational learning. Members of healthcare faculty are designated with the responsibility of incorporating these modern teaching modalities into their curriculum. Additionally, IT focuses mainly on the impact of service quality and its usability. Information technologists are available as expert resources to assist users in troubleshooting the AR application and promote efficiency and efficacy for student use. Organizational Readiness An analysis of the organizations strengths, weaknesses, opportunities, and threats (SWOT) was complete (see Appendix B). Internal strengths consisted of the novelty of the program and fluidity of its adaptive curriculum, the receptive nature of faculty to incorporate XR technology into current curriculum, and presence of a manageable class size. Internal weaknesses consisted of busy and demanding school schedules and elevated stressors associated with several recent program changes. External opportunities exist as AR can be applied to many areas of the Universitys health science students, especially those with kinesthetic and spatial learning styles. Threats concerning the project that may impede its progression include the scarcity of program funding for equipment that support the use of AR and lack of expert resources. Setting Implementation of this project took place on Marian University Indianapolis campus, specifically in the Evans Center for Health Sciences. Reservations for the clinical lab room were AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 24 made in advance so students were able to participate on a day in which they were scheduled to be on campus for class. Participants Participants for this project were student registered nurse anesthetists (SRNAs) currently enrolled in their second year of didactics at Marian University Indianapolis with a target sample of n=21. Participants were recruited via email and given a verbal reminder from their professor during class. All necessary information regarding the projects purpose was provided prior to the day of implementation. Participation was completely voluntary, and subjects were free to withdraw at any point throughout the study. Anonymity during participation was limited since subjects and researchers were familiar with one another due to being enrolled in the same program and hands-on assistance was mandatory. Ethics and Human Subjects Permission This project was reviewed by the Marian University Institutional Review Board (IRB) and deemed not to require human subjects protection; therefore, the project was endorsed by the Leighton School of Nursing (LSON). Informed consent was obtained from all participants prior to project implementation. No forms were collected, electronically or physically, that elicited identifiable information in order to ensure confidentiality and anonymity of feedback. Procedure for Implementation The investigators for this project explored multiple AR applications to determine which one was most relevant and attention grabbing for the target population. The chosen application, Human Anatomy Atlas 2019, allowed users to engage in an augmented reality experience that enabled manipulation, dissection, and interaction with life-like anatomical structures of the human body (Visible Body, 2019). A unit closely related to anesthesia practice, laryngeal AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 25 muscles, was chosen and a PDF worksheet was created for students to complete during their learning session. The objectives for this activity involved correct identification of key laryngeal structures and knowledge of their functions and nerve innervation. The activitys structures, functions, and nerve innervations were chosen after thorough review of course learning objectives to be sure the experience was relevant and beneficial in student learning. The application was installed on both investigators mobile devices and multiple trials were employed to ensure user comfort with the technology for training purposes. Due to monetary constraints and limited availability of IOS devices that support AR, only two devices were utilized throughout the process of this project. In order to confirm relevance and increase likelihood of user satisfaction, the activity was informally introduced to other members in the investigators third year cohort. Positive feedback from the senior students regarding the perceived benefits of the AR application and its use throughout the second-year Anesthesia Principles II course attested to the significance of this chosen unit and PDF for this project. Second year SRNAs currently enrolled in Anesthesia Principles II signed up in groups of two or three for one 30-minute session with the investigators. A brief introductory tutorial was provided at the beginning of each session for the purpose of familiarizing users with the technology and educating them on how to navigate through the application. Participants spent approximately 15 minutes completing the exercise while investigators were available to answer questions and assist in troubleshooting. Following the learning exercise, students were provided an anonymous survey link via email regarding their experience and asked to complete it upon exiting the lab room. Any additional questions/comments/concerns were addressed, and the session was concluded as the following group arrived. This cycle continued, uninterrupted, until all available participants completed the activity. AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 26 Barriers The actualization of this project presented barriers which were dealt with accordingly and able to be overcome without altering the general concept. The first challenge was met in the initial phase of project design related to the lack of funding and negligible access to desired materials. To overcome this, the project design was restructured to use the researchers personal devices with smaller groups of participants. Despite prolonging the overall time period for implementation, this design eradicated financial barriers and enabled the intended project plan to proceed. Another roadblock arose after an unexpected alteration was made to the researchers clinical schedules. The addition of more remote locations increased devotion of time to travel and required distant lodging outside of Indianapolis. Consequently, this limited the researchers availability to convene on Marians campus during the week and required remodeling of the proposed implementation plan. Fortunately, early communication and collaboration between the researchers, faculty, and clinical coordinators enabled amendments to be made in scheduling and allowed the project to ensue as planned. Lastly, no expert in the field of AR technology was available to assist in troubleshooting or teaching the application. In preparation, the researchers partook in self-education through use of online videos and hands-on familiarization. All questions and issues were able to be readily resolved by the researchers and the need for an expert was not evident. Instrument, Data, and Evaluation The instrument utilized in measuring this research projects main outcome of interest was the modified Instructional Materials Motivation Survey (IMMS). Prior research suggested that the IMMS items be modified to accommodate the situational features of the projects purpose in AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 27 order to remain applicable (Huang, Huang, Diefes-dux, and Imbrie, 2006). Therefore, this project ultimately utilized the modified version that has been previously been altered to evaluate the use of augmented reality. The instrument ranked 36 items on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree) to evaluate ARs ability to promote and sustain motivation among users based on the four domains that correspond with the ARCS model (Keller, 1987). Of those 36 items, 12 measured attention, 9 measured confidence, 6 measured satisfaction, and 9 measured relevance (Di Serio, Ibez, & Kloos, 2013). Ten of the items required a reversed ranking which the investigators adjusted for during data analysis (see Appendix C for specific items). The mean score for each of the four domains was evaluated to determine which constructs were rated highly among the users, thereby indicating a positive learning experience. A comparison of scores among each construct was then evaluated to determine areas of strength and weakness and identify where improvements are needed. The sample populations mean global score was also calculated to evaluate the overall effect AR had on the class motivation for learning. These results will be used to help guide and make recommendations for future use of XR as a complementary teaching modality in SRNA education. Analysis Of the 21 potential participants, 18 partook in the study and 16 completed the IMMS. The investigators echoed previous study evaluation methods guided by the ARCS model to define score ranges (Brits, 2016). A low score was considered 2.5 whereas a high score was 3.5. Scores that fell between these values (2.6 3.4) were considered inconclusive. Constructs that yielded a low score assumed the population had a negative AR experience whereas high scores were considered positive. AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 28 Qualtrics analysis was used to evaluate the response scores for each individual survey question. The researchers then re-organized the questions by grouping them into their respective category following the ARCS model: attention, relevance, confidence, and satisfaction to improve visual format for interpretation (see Appendix D). The mean score of each construct was calculated for the total sample population and deemed to be either high or low based on the numerical range it fell in. Each of the four constructs yielded a high-level score with relevance being the highest followed by attention, confidence, and satisfaction respectively. All individual survey questions scored highly as well as the overall mean score of the sample population. Relevance. The highest scoring construct was relevance with a mean sample score of 4.25 and a standard deviation (SD) of 1.08. This category also held the highest scoring individual question (4.56) stating that participants felt the content was relevant to their interests. These results indicate a positive experience with AR as it relates to the relevancy of their learning and interests. A positive contribution to motivation can be inferred from this construct. Attention. Trailing just behind relevance, the construct, attention, yielded a high score of 4.24 with a SD of 1.03. The two highest scoring questions in this category (4.5) strongly imply that participants found the AR activity appealing and feel it held their attention. The two lowest scoring questions (3.87) suggested that participants were not extremely surprised by what they learned nor very stimulated by the audio content associated with the application. A positive correlation exists between ARs attention-grabbing capabilities and the perception of a learning experience. Likewise, this construct may contribute to feelings of increased motivation to learn. Confidence. The concept, confidence, scored next highest at 4.18 with a SD of 1.00. The highest scoring question within this construct (4.47) implies that participants were able to easily understand the content presented within the AR application. Contrarily, the lowest scoring AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 29 individual question from the survey (3.56) lies within this domain and suggests hesitance exists in participants initial impressions regarding the ease of its use. The high mean score is affirmative for positively influencing students levels of confidence, implying a similar association with motivation exists. Satisfaction. Though scoring lower than the other constructs, satisfaction was still rated highly (4.13) with a mean SD of 1.05. Numerically, this category had the fewest amount of questions and was the only one that did not include a reversed ranking question embedded within. The top scoring question within this construct stated that participants really enjoyed completing this lesson (4.33) whereas the lowest scoring question (3.87) implies there was not as strong of a sense of reward for completing it. This construct follows suit with the previous three and implies AR has a positive influence on learner satisfaction and ultimately may enhance motivation to learn. Global. The global mean score from the sample population was high at a value of 4.21 with a SD of 1.05. This result implies that the AR activity positively influenced the students overall airway anatomy learning experience. Therefore, it is presumable that the use of AR in nurse anesthesia education directly impacts students motivation to learn. Limitations There are several limitations of this study. The inherent relationship that exists between anesthesia cohorts may have caused bias among peers and produced falsely elevated outcomes. Additionally, the small sample size limits generalizability to other SRNAs that are enrolled in different programs. Another limitation was the unintentional pressure placed onto students who were not readily eager to participate. Despite reassuring no academic penalties or consequences would ensue, feelings of forced participation may have influenced levels of engagement and AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 30 consideration in IMMS responses. Furthermore, reversed IMMS questions required readers to be extra attentive in choosing their intended numerical responses. Lastly, the researchers are classified as Millennials and may have inadvertently influenced participants perceptions. Conclusion Todays healthcare presents with many challenges including provider shortages, increased care complexities, and rapidly expanding medical knowledge. The current generation of healthcare students who are faced with these challenges should ideally be presented with educational strategies that are up-to-date, adhere to their alternative learning style, and motivate them to learn. The use of extended reality (XR) as an adjunct learning tool in healthcare education has proven to be advantageous, however its use in the realm of anesthesia has been much less explored compared to other medical specialties. This study sought to evaluate whether the use of AR in nurse anesthesia education would lead to improved learner motivation. The results indicated that AR had a positive influence on all constructs of the ARCS model: attention, relevance, confidence, and satisfaction for SRNAs. The evidence validates previous literature findings and implies there may be a direct relationship between the use of AR in nurse anesthesia education and improved motivation for learning. The concept of improving student motivation is vital for accepting and conquering the increasingly difficult challenges that present with healthcare today. Additionally, motivation increases rate of retention which also helps alleviate the imminent shortage of providers. Therefore, this study supports the use of AR as an adjunct learning tool in nurse anesthesia education. Future studies are needed to explore additional ways in which AR can be incorporated into anesthesia curricula and to determine its effectiveness on sustaining learner motivation. AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 31 Section V: References Aebersold, M., Voepel-Lewis, T., Cherara, L., Weber, M., Khouri, C., Levine, R., & Tait, A. R. (2017). Interactive anatomy-augmented virtual simulation training. International Nursing Association for Clinical Simulation and Learning, 15, 34-41. http://dx.doi.org/10.1016/j.ecns.2017.09.008 Al-Dahir, S., Bryant, K., Kennedy, K. B., & Robinson, D. S. (2014). Online virtual-patient cases versus traditional problem-based learning in advanced pharmacy practice experiences. American Journal of Pharmaceutical Education, 78(4), 76. Doi:10.5688/ajpe78476 Badash, I., Burtt, K., Solorzano, C. A., & Carey, J. N. (2016). Innovations in surgery simulation: a review of past, current, and future techniques. Annals of Translational Medicine, 4(23), 1-10. Http://dx.doi.org/10.21037/atm.2016.12.24 Brits, L. (2016). The perceived motivational impact of voice-over-powerpoint on part-time adult learners in a distance learning environment. Retrieved from https://repository.up.ac.za/bitstream/handle/2263/60523/Brits_Perceived_2017.pdf?seque nce=1&isAllowed=y Cobbett, S., & Snelgrove-Clarke, E. (2016). Virtual versus face-to-face clinical simulation in relation to student knowledge, anxiety, and self-confidence in maternal-newborn nursing: A randomized controlled trial. Nurse Education Today, 45, 179-184. http://dx.doi.org/dx.doi.org/10.1016/j.nedt.2016.08.004 Dale, E. (1969). Audio-visual methods in teaching. New York: Dryden Press. Dall, T., West, T., Chakrabarti, R., Reynolds, R., & Lacobucci, W. (2018). The complexities of physician supply and demand: Projections from 2016 to 2030. Retrieved from https://aamc-black.global.ssl.fastly.net/production/media/filer_public/85/d7/85d7b689- AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 32 f417-4ef0-97fbecc129836829/aamc_2018_workforce_projections_update_april_11_2018.pdf De Oliveira, G. S., Glassenberg, R., Chang, R., Fitzgerald, P., & McCarthy, R. J. (2013). Virtual airway simulation to improve dexterity among novices performing fiberoptic intubation. Anaesthesia, 68, 1053-1058. http://dx.doi.org/10.1111/anae.12379 Densen, P. (2011). Challenges and opportunities facing medical education. Transactions of the American Clinical and Climatological Association, 122, 48-58. Di Serio, ., Ibez, M. B., & Kloos, C. D. (2013). Instructional Materials Motivation Survey Modified Version. PsycTESTS. https://doi-org.forward.marian.edu/Full; Full text; 999926416_full_001.pdf Giddens, J. F. (2008). Achieving diversity in nursing through multicontextual learning environments. Nursing Outlook, 56(2), 7883. Doi:10.1016/j.outlook.2007.11.003 Haerling, K. A. (2018). Cost-utility analysis of virtual and mannequin-based simulation. Society for Simulation in Healthcare, 13(1), 34-41. http://dx.doi.org/10.1097/SIH.0000000000000280 Huang, W., Huang, W., Diefes-Dux, H., & Imbrie, P.K. (2006). A preliminary validation of attention, relevance, confidence, and satisfaction model-based instructional material motivational survey in a computer-based tutorial setting. British Journal of Educational Technology, 37(2), 243-259. doi:10.1111/j.1467-8535.2005.00582.x Keller, J. M. (1987). Development and use of the ARCS model of instructional design. Journal of Instructional Development, 10(3), 210. Doi:10.1007/bf02905780 AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 33 Khan, T., Johnston, K., & Ophoff, J. (2019). The impact of an augmented reality application on learning motivation of students. Advances in Human-Computer Interaction, 1 14. Doi:10.1155/2019/7208494 Kron, F. W., Fetters, M. D., Scerbo, M. W., White, C. B., Lypson, M. L., Padilla, M. A., Becker, D. M. (2016). Using a computer simulation for teaching communication skills: A blinded multisite mixed methods randomized controlled trial. Patient Education and Counseling, 100, 748-759. http://dx.doi.org/10.1016/j.pec.2016.10.024 Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia: Lippincott, Williams & Wilkins. Munro, M. G. (2012). Surgical simulation: Where have we come from? Where are we now? Where are we going? Journal of Minimally Invasive Gynecology, 19, 272-283. Retrieved from https://www-clinicalkey-com.forward.marian.edu/#!/content/playContent/1-s2.0S1553465012000131 Piper, L. E. (2012). Generation Y in healthcare: leading millennials in an era of reform. Frontiers of Health Services Management, 29(1), 1628. Doi:10.1097/01974520-201207000-00003 Smith, P. C., & Hamilton, B. (2015). The effects of virtual reality simulation as a teaching strategy for skills preparation in nursing students. Clinical Simulation in Nursing, 11, 5258. http://dx.doi.org/10.1016/j.ecns.2014.10.001 Smith, S. J., Farra, S., Ulrich, D. L., Hodgson, E., Nicely, S., & Matcham, W. (2016). Learning and Retention Using Virtual Reality in a Learning and retention using virtual reality in a decontamination simulation. National League for Nursing, 210-214. http://dx.doi.org/10.1097/01.NEP.0000000000000035 AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 34 Stepan, K., Zeiger, J., Hanchuk, S., Del Signore, A., Shrivastava, R., Govindaraj, S., & Iloreta, A. (2017). Immersive virtual reality as a teaching tool for neuroanatomy. International Forum of Allergy & Rhinology, 7(10), 10061013. Doi:10.1002/alr.21986 Taekman, J. M., & Shelley, K. (2010). Virtual environments in healthcare: immersion, disruption, and flow. International Anesthesiology Clinics, 48(3), 101121. Doi:10.1097/aia.0b013e3181eace73 U.S. Bureau of Labor Statistics. (2015). Projections of industry employment, 2014-24. Career Outlook. Retrieved from: https://www.bls.gov/careeroutlook/2015/article/projectionsindustry.htm Visible Body. (2019). Anatomy Atlas 2019 [Mobile application software]. Retrieved from https://www.visiblebody.com/news/visible-body-releases-human-anatomy-atlas-2019-forios-and-android-1 White, K. M., Dudley-Brown, S., & Terhaar, M. F. (2016). Translation of evidence into nursing and health care. Springer Publishing Company. AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION Section VI: Appendices 35 AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 36 Appendix A. Evidence Evaluation Table Author/ Year De Oliveira, 2013 Design/ Level of Evidence RCT (II) Theme Sample Intervention PP n= 20 Fiberoptic intubation Dependent Variable Task time-toperform Errors Manual proficiency Results of XR Group AlDahir, 2014 RCT (II) C n=119 Simulation PE Knowledge Critical thinking Self-directed learning skills Motivation for learning Smith, 2015 RCT (II) PP PE n=20 Urinary catheter insertion Task time-toperform Preparedness Overall performance Reduced time (p = .001) Fewer failed attempts (p < .005) Improved dexterity (p = .004) Improved MCT scores pre- to postsimulation (p < .001) Inferior to postintervention MCT scores (p = .001) Reinforcement of previous knowledge (p = .034) Comprehension of new information (p = .01) No significant difference in level of preparedness (p > .05) No significant difference in timeto-perform (p > .05) No significant difference in performance score (p > .05) AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION Cobbett, 2016 Quasiexperime ntal (III) C n= 56 Simulation PE Knowledge Selfconfidence Anxiety 37 Kron, 2016 RCT (II) PP n = 421 Simulation Smith, 2016 Quasiexperime ntal (III) PP n = 108 Simulation C Interprofessional team skills Multicultural team dynamics Knowledge Knowledge retention Time-toperform Stepan, 2017 RCT (II) C PE n=64 Neuroanatomy lesson Knowledge Knowledge Retention Engagement & Motivation No difference in post-experience MCT scores (p = .09) No difference in self-confidence (p = .059) Worsened performance anxiety (p = .002) XR improved interprofessional communication (p < .0001) XR improved intercultural communication (p < .0001) No significant difference in MCT scores (p = .0238) Improved time-toperform skills task (p < .001) Near identical retention scores (p = .238) No significant difference in MCT scores (p = .087) Improved engagement (p < .001) Improved attention, confidence & satisfaction (p < .01) AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION Aebersold, Quasi2018 experime ntal (III) Haerling, Quasi2018 experime ntal (III) PP n= 69 NGT insertion PE PP n= 81 Simulation C PE 38 Manual proficiency Landmark Identification skill Knowledge Satisfaction SelfConfidence Performance scores Improved performance skill ( p = .011) Improved ability to identify landmarks of structures ( p < .01) Improved MCT scores when compared to preintervention scores (p < .05) No significant difference in satisfaction (p = .476) No significant difference in selfconfidence (p = .126) No significant difference in performance (p = .660) Note: PP = Psychomotor Performance, C = Cognition, PE = Perceived Experience, MCT = Multiple Choice Test, RCT = Randomized Control Trial, XR = Extended Reality, NGT = Nasogastric Tube, AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION Appendix B: SWOT Analysis 39 AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION Appendix C: Instructional Materials Motivation Survey Modified for AR 40 AUGMENTED REALITY IN NURSE ANESTHESIA EDUCATION 41 Appendix D: IMMS Results Mean Sample Population Construct Relevance 4.25 Attention 4.24 Confidence 4.18 Satisfaction 4.13 Survey Question # Mean Score 6 9 10 16 18 23 26 30 33 2 8 11 12 15 17 20 22 24 28 29 31 1 3 4 7 13 19 25 34 35 5 14 21 27 32 36 4.19 4.44 4.00 4.56 4.19 4.20 4.13 4.25 4.27 4.13 4.31 4.25 4.06 4.50 4.50 4.38 4.20 3.87 3.87 4.33 4.47 3.56 4.31 4.25 4.06 4.25 4.44 4.00 4.47 4.33 4.00 4.19 4.33 3.87 4.13 4.27  ...

... 2 CAPNOGRAPHY MONITORING EDUCATION Table of Contents List of Tables .......................................................................................................................4 List of Figures ......................................................................................................................5 Abstract ................................................................................................................................6 Introduction .........................................................................................................................7 Significance ...................................................................................................................7 Background ....................................................................................................................8 Problem Statement .......................................................................................................10 Organizational Gap Analysis of Project Site............................................................10 Review of the Literature ...................................................................................................11 Literature Methods .......................................................................................................11 Literature Synthesis and Discussion ............................................................................12 Gap and Constraint of Literature .................................................................................14 Evidence Based Practice: Verification of Chosen Option .................................................17 Theoretical Framework ......................................................................................................18 Goals/Objectives/Expected Outcomes ...............................................................................19 Project Design 20 Project Site and Population ..........................................................................................20 Setting Facilitators and Barriers...................................................................................21 Methods of Evaluation ...............21 Measurement Instrument(s) and Data Collection Procedure ......................................21 Ethical Considerations/Protection of Human Subjects ................................................23 Data Analysis ..............................................................................................................24 3 CAPNOGRAPHY MONITORING EDUCATION Results ................................................................................................................................24 Participants Characteristics ..........................................................................................24 Pre-test and Post-test Results .......................................................................................27 Pre-test and Post-test Scores ...................................................................................27 Combined Participants demographic results and Pre/Posttest Results ...................27 Means of Pre-test and Post-test ...............................................................................29 Power Analysis .......................................................................................................29 Discussion .........................................................................................................................30 Limitations .........................................................................................................................31 Conclusion ........................................................................................................................32 References ..........................................................................................................................34 Appendix ...........................................................................................................................40 Appendix A. Confirmation Letter from IU Health Arnett Hospital ............................40 Appendix B. Participants Informed Consent ..............................................................41 Appendix C. Pre-test/Post-test Questionnaires ...........................................................42 Appendix D. Demographic Survey ..............................................................................45 Appendix E. PowerPoint Presentation .........................................................................46 Appendix F. Marian University IRB Review Letter ....................................................53 4 CAPNOGRAPHY MONITORING EDUCATION List of Tables Table 1. Gap Analysis Tool ...................................................................................11 Table 2. Literature Review Matrix.........................................................................16 5 CAPNOGRAPHY MONITORING EDUCATION List of Figures Figure 1. Simple Logic Model ...............................................................................19 Figure 2. Adaptation of LFA to the Project steps ..................................................20 Figure 3. Implementation Procedure......................................................................23 Figure 4. Nursing, PACU and ICU experience......................................................25 Figure 5. Additional Nursing Certification ............................................................26 Figure 6. Prior Capnography education .................................................................26 Figure 7. Pretest and Posttest Scores .....................................................................27 Figure 8. Combined Participants Demographic Survey and Pre/post test Result .................................................................................28 Figure 9. The Means of Pre-test and Post-test .......................................................29 Figure 10. Ranked Values of Pre-test and Post-test ...............................................30 6 CAPNOGRAPHY MONITORING EDUCATION Abstract Background: Respiratory compromise is one of the most common complications that occur in the Post Anesthesia Care Unit (PACU) and accounts for half of the closed claims involving death in the PACU. However, with appropriate monitoring like capnography, identification of respiratory depression or apnea can occur prior to the adverse respiratory events (ARE). Although capnography is not currently considered a standard monitor in the PACU, it retains many advantages when used in conjunction with pulse oximetry and other standard monitors. Current research supports its use, and many organizations have created position statements and clinical practice recommendations for the use of capnography when patients are given any pharmacotherapeutic that alters sensorium. A knowledge deficit regarding capnography has been found among the perianesthesia nurses of the Indiana University Health Arnett Hospital, and inservice training was deemed a necessity in improving the quality of care provided to the patients. Aim: This project aims to evaluate a knowledge deficit about the utilization and interpretation of capnography among the perianesthesia nurses and subsequently provide in-service training. Methods and Procedure: A repeated measures, pre/post-test design was utilized to evaluate perianesthesia nurses (n = 23). A dependent paired samples t-test was used to compare mean score differences between the pre-and post-test scores. A 15 minutes in-service session was provided in the PACU to a group of 2-5 perianesthesia nurses at the time for three days. Results: Post-test scores were significantly higher than the pre-test scores following the educational intervention (p < 0.001), based on a two-tailed Wilcoxon ranked test. Conclusion: Providing education on the use and interpretation of capnography resulted in better post-test scores indicating an increased acquisition of knowledge pertaining to capnography. Keywords: capnography monitoring, PACU monitoring, respiratory depression in PACU. 7 CAPNOGRAPHY MONITORING EDUCATION Capnography Monitoring Education for the Perianesthesia Nurses Introduction Significance In 2010, there was an estimated 51.4 million inpatient and 53.3 million outpatient surgical procedures performed in the United States (National Quality Forum, 2019). After surgery requiring sedation or anesthesia, patients are transferred to the Post Anesthesia Care Unit (PACU) for intensive evaluation of any potential adverse outcomes that can occur as the result of the surgery or the anesthesia they received. The overall PACU complication rate ranges from 5% to 30% and includes cardiovascular, respiratory complications, and medication errors (Bothner, Georgieff, and Schwilk, 1999). Of the total complications, adverse respiratory events (AREs) account for 43% of the events. These events mostly occur in patients who present with no or minor preexisting conditions (Kluger & Bullock, 2002; Faraj et al., 2012). The patient is at risk for an ARE due respiratory compromise that can occur as the result of residual anesthetic effects, opioid-induced respiratory depression or patient-related factors (Kellner, Urman, Greenberf, & Brovman, 2018). Furthermore, obesity, obstructive pulmonary disease states, diabetes, advanced age, and male sex are some of the factors that can contribute to respiratory compromise in the PACU (Pederson, Viby-Mogensen, & Ringsted, 1992; Faraj et al., 2012). Compounding the problems are the requirements for opioids, known respiratory depressants, to treat somatic pain resulting for surgical insult. More than 80% of patients undergoing surgical procedures require opioids to manage their pain (Luo & Min, 2017). However, the opioids used in the PACU, especially with 8 CAPNOGRAPHY MONITORING EDUCATION Patient Controlled Analgesia (PCA) infusion, contributed to significant respiratory depression without appropriate monitoring (Luo & Min, 2017; Makoyi, 2018). It was also noted that postoperative AREs extended the length of stay in the hospital by nine days, added more than $53,000 to the hospital costs and increased rate of mortality by 22% (Zhan & Miller, 2003; Fleisher & Linde-Zwirble, 2014). Nevertheless, the advancement of technology and the introduction of new drugs with safer profiles have improved patient care in the perioperative setting (Kellner, Urman, Greenberf, & Brovman, 2018). Capnography monitoring is one such technology when used in conjunction with other monitors, can provide the nurse with real-time ventilator monitoring of the patient in PACU to ameliorate AREs (Kellner, Urman, Greenberf, & Brovman, 2018). Numerous studies have demonstrated that capnography monitoring detects respiratory depression earlier than pulse oximetry and can potentially prevent catastrophic events (Zhang et al., 2017; Foulapdpour, Jesudoss, Bolden, Shaman & Auckley, 2016). Geralemou, Probst, and Gan (2016) mentioned that capnography could detect the change in patients ventilation anywhere between 12 and 271 seconds before pulse oximetry or respiratory rate. According to Haret, Kneeland, and Ho (2012), the purpose of the PACU is to allow centralization of care by a group of specially trained nurses who are expert in interpreting and responding to the events of the brief but intense period immediately following a procedure requiring anesthesia (p. 57). Knowing that AREs are the primary cause of morbidity in the PACU as well as the costs associated with negative outcomes, it is paramount for perianesthesia nurses to be educated on capnography monitor use and interpretation, which will help promote timely interventions that will hopefully prevent respiratory compromise leading to an ARE. 9 CAPNOGRAPHY MONITORING EDUCATION Background As part of the curriculum for the Nurse Anesthesia program, Marian University Student Registered Nurse Anesthetists (SRNAs) are required to rotate to different clinical sites around the state of Indiana to acquire knowledge, skills, and competencies in the field. During the clinical rotation at Indiana University Health Arnett Hospital (IU Health Arnett) at Lafayette, Indiana, this SRNA encountered a potential issue as a large number of perianethesia nurses lacked the necessary knowledge regarding capnography monitoring. This issue was identified during informal observations and ultimately confirmed through dialogue with the peri-operative services educator and anesthesia personnel (L. Sherman, personal communication, September 13, 2018). Due to the amalgamation of the exchanges between the SRNA and the staff and the informal observations, the information demonstrated an apparent deficit in knowledge regarding capnography monitoring among the perianesthesia nurses. The knowledge deficit was the reason for the need to develop and implement this Doctor of Nursing Practice (DNP) project. During different dialogues with the peri-operative services educator, it was revealed a lack of an educational plan regarding capnography monitoring for the PACU might contribute to the knowledge deficit; and the monitors in this unit could not detect the end-tidal CO2 via capnography (L. Sherman, personal communication, September 20, 2018). At the same time, the unit possessed only one portable capnography monitor, and most of the perianesthesia nurses are not aware of its utility. The American Society of PeriAnesthesia Nurses (ASPAN) provides standards and practice guidelines for the PACU, and the perianesthesia nurses should be familiar with these recommendations in order to provide the highest quality of care possible. ASPAN recognized that capnography monitoring improves quality of care and prevents untoward outcomes 10 CAPNOGRAPHY MONITORING EDUCATION (ASPAN, 2017). With the effort to improve patient outcomes related to AREs, the value of capnography monitoring has been recognized by other healthcare organizations that have a vested interest in the PACU. The Anesthesia Patient Safety Foundation (APSF) encouraged the healthcare workers to use continuous oxygenation (pulse oximetry) and ventilation monitoring (capnography) when patients received a postoperative PCA infusion or a neuraxial opioid (Stoelting & Weinger, 2009). The American Society of Anesthesiologists (ASA) emphasized the importance of using capnography monitoring outside of the operating room (Kodali, 2013). They also suggested that particular attention towards monitoring ventilation and perfusion during emergencies in the postoperative period. (Apfelbaum et al., 2013). Pulse oximetry, considered a standard monitor in the PACU, measures the amount of oxygen transported by hemoglobin (oxygenation); however, it has limited ability to identify respiratory depression when patients utilize supplemental oxygen (Hutchison and Rodriguez, 2008). On the other hand, capnography provides real-time ventilator data by measuring expired end-tidal carbon dioxide (EtCO2) which can further be used to evaluate ventilation patterns, perfusion, and specific lung disease (Hutchison and Rodriguez, 2008; Makoyi, 2018). As a result, the peri-operative services educator recognized the importance of educating perianesthesia nurses regarding capnography since the unit had plans to purchase and institute a capnography monitoring in the PACU (L. Sherman, personal communication, January 18, 2019). Currently, both the Ambulatory Surgery Center (ASC) and the main hospital have capnographic monitoring capabilities, and the educational project will complement the planned deployment. 11 CAPNOGRAPHY MONITORING EDUCATION Problem Statement The primary aim of this DNP project was to address the possible knowledge deficit regarding capnography monitoring among perianesthesia nurses in a single level 2 Midwest hospital affiliated surgical center. The objective was to provide in-service training regarding capnography to the perianesthesia nurses. The in-service intervention was intended to increase knowledge regarding capnography use. The ultimate goal of this project is to provide perianesthesia nurses with the knowledge needed to interpret capnography in order to decrease morbidity with AREs. The following problem statement was used to guide this project: Among the perianesthesia nurses (P), does an in-service education on capnography monitoring (I) compared to the lack of in-service education (C) result in increased knowledge in the PACU (O)? Organizational Practice Gap Analysis A gap analysis tool adapted from the U.S Department of Health & Human Services, Agency for Healthcare Research and Quality, was used to provide a better understanding of the current practice compared to the best practice (Table 1). 12 CAPNOGRAPHY MONITORING EDUCATION Table 1. Gap Analysis Tool Best Practice Best Practice Strategies The use of capnography in the PACU Provide education regarding capnography to the perianesthesia nurses implementation in capnography to the PACU How Your Practices Barriers to Best Differ from Best Practice Practices implementation Nurses do not usually use capnography monitoring. Knowledge deficit Will Implement Best Practice (Yes/No; why not) Yes. The current practice guidelines at IU Health Arnett do not require the use of capnography monitoring in the PACU, and there is not a nursing protocol that emphasizes the use of capnography. In the past, IU Health Arnett PACU monitors did not capture the end-tidal CO2, and the unit used to possess only one portable capnography monitoring for both the main hospital and the Ambulatory and Surgery Center. As previously mentioned, research has demonstrated that the implementation of continuous capnography monitoring in the PACU permits early detection of respiratory depression and improves patient safety and decreases healthcare costs (Geralemou, Probst & Gan, 2016). Although the hospital has updated its PACU monitors, which can measure capnography, the majority of the nursing staff has some knowledge deficit regarding capnography monitoring. Therefore, an in-service training regarding the value and the basic understanding of capnography in the PACU was paramount. 13 CAPNOGRAPHY MONITORING EDUCATION Review of the Literature Literature Methods A search of the literature was performed using Medline, Cochrane Collaboration, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Google Scholar databases. Medical Subject Headings (MeSH) incorporating Boolean phrasing was used in the search and included: capnography, CO2 monitoring, end-tidal carbon dioxide monitoring, post-anesthesia care unit (PACU), recovery room, postoperative, obstructive sleep apnea, sleep apnea, pulse oximetry, hypoventilation syndrome, and obesity (Makoyi, 2018). There was not a limitation on the year search since capnography monitoring has not been routinely utilized in the PACU setting. Therefore, increasing the search length was expected to increase the available evidence. Only the articles related to the PACU and all age groups and sexes were part of the literature review. Four articles met the requirement for utilization in this DNP project because these articles provide information regarding the value of the capnography monitoring among children, adolescents, and adult patients (Table 2). The frequency of hypoventilation, apnea, oxygen desaturation, postoperative respiratory depression, bradypnea, and nursing observation and intervention were the outcomes of interest. The knowledge gained from these articles triggers the accomplishment of this project. Literature Synthesis and Discussion A randomized controlled trial and cross-sectional study discussed the importance of capnography in identifying hypoventilation and apneic events among children in the PACU. In the cross-sectional study, it was reported that the occurrence of hypoventilation and apnea was observed in 45.5% (95% CI 38.5%, 52.5%) of children, while oxygen desaturation was identified in 19% (95% CI 13%, 24%) of children (Langhan, Li, & Lichtor, 2016). The same authors 14 CAPNOGRAPHY MONITORING EDUCATION mentioned that hypoventilation (OR 2.3, 95% CI 1.02, 5.3) and apneic events (OR 2.7, 95% CI 1.1, 7) were more noticeable in children who received opioid medication postoperatively. Hypoventilation was mostly noticed in children who received supplemental oxygen (OR 3.1, 95% CI 1.1, 12). Therefore, the same authors encouraged the use of capnography among children when the opioid and supplemental oxygen are utilized postoperatively (Langhan et al., 2016). In the randomized controlled trial, the participants were randomly selected in order to evaluate if the PACU nurses would be able to view the capnography monitoring (intervention group) or not (control group) (Langhan et al., 2017). The alarm settings were disabled in the control group while the intervention group alarm settings were arranged to alert the staff in case of hyperventilation, hypoventilation, or apnea events. It was reported that capnography monitoring increased the intervention of the nursing staff, which eventually led to decreased adverse events (hypopnea and apnea) among children in the PACU (Langhan et al., 2017). The incidence of hypopneic hypoventilation [ 5% (95%CI: 2-8%) per minute vs 1 % (95% CI:-1% to 3%) per minute; P = 0.04] and apneic episodes [ 11% (95% CI:8-14%) per minute vs 1.5% ( 95% CI:-2% to 5%; P = < 0.001] decreased dramatically in the intervention group as opposed to the control group (Langhan et al., 2017). However, the rates of oxygen desaturation between both groups seemed not to be different (Langhan et al., 2017). Among the adult patients, there was one meta-analysis and one prospective observational study that evaluated the importance of capnography monitoring in the PACU. The meta-analysis consisted of nine studies, where five of them examined capnography monitoring. A pooled data from three capnography studies concluded that continuous capnography monitoring detected 8.6% more postoperative respiratory episodes than continuous pulse oximetry (P< .00001). The probability of detecting postoperative respiratory episodes with the use of capnography 15 CAPNOGRAPHY MONITORING EDUCATION monitoring was 5.8 times higher than the pulse oximetry monitoring (OR:5.83, 95% CI, 3.549.63, P < .00001) (Lam et al., 2017). A conclusion was drawn in the meta-analysis study that continuous capnography, together with continuous pulse oximetry yielded information about ventilation. Continuous capnography monitoring identified respiratory events sooner than oxygen desaturation when supplemental oxygen was used (Lam et al., 2017). The same authors emphasized the importance of nursing staff education related to capnography monitoring and the recognition of postoperative respiratory events (Lam et al., 2017). Although the prospective observational study showed that apneic alert events did not correlate with the hourly nursing observations and the respiratory rate after a cesarean section, the authors suggested further investigation of the value of capnography among high-risk obstetric patients who received opioid (Weiniger et al., 2018). In all studies reviewed, capnography monitoring detected postoperative adverse events sooner than the pulse oximetry. Also, the incidences of respiratory events were less frequent, and the intervention of nursing staff increased when capnography monitoring was used. Capnography monitoring facilitates the job of perianesthesia nurses during the titration of opioid in the PACU because capnography monitoring can detect opioid-induced respiratory depression (Lam et al., 2017). Therefore, the necessity of education regarding capnography in the PACU appears to be necessary. In sum, the review provides evidence that capnography monitoring is vital in PACU, and nursing staff education is also essential to promote immediate nursing intervention and improve patient outcomes. Gap and Constraint of the Literature The primary constraint of the literature was the limited number of selected studies and different level of evidence. Numerous studies with the highest level of evidence had confirmed 16 CAPNOGRAPHY MONITORING EDUCATION the value of capnography monitoring in the various healthcare settings except for PACU, which limited the applicability of capnography in the PACU (Makoyi, 2018). The necessity to have more studies with the highest level of evidence was noted in the review. Although the selected articles contained different levels of evidence, half of those articles were at the highest end of the spectrum. Therefore, those articles responded to the purpose of this project as they confirmed the importance of capnography in the PACU. The literature review is summarized in Table 2. Table 2. Literature Review Matrix Author/ Methodology Purpose Year /Sample Langham Observational et al, 2016 n = 194 To determine the frequency of hypoventilation and apnea by capnography among children in the PACU. Results Conclusions Capnography detected hypoventilation or apnea in 45.5% of patients (95% CI 38.5%, 52.5%) O2 desaturation occurred in 19% of patients (95% CI 13 %, 24%) Routine monitoring with capnography may improve recognition of respiratory depression and enhance patient safety in the PACU. Education of PACU staff is recommended. Evidence Rating 3 17 CAPNOGRAPHY MONITORING EDUCATION Author/ Year Methodology /Sample Purpose Lam et al, 2017 Meta-analysis Review the effectiveness of continuous capnography monitoring with or without pulse oximetry for detecting postoperative respiratory depression (PORD) and preventing postoperative adverse events. To identify if children monitored with capnography would have more frequent staff interventions and fewer adverse events than children monitored with pulse oximetry alone. 1 RCT & 4 observational Langham RCT et al, 2017 n =201 Weiniger Prospective et al, 2018 observational n = 80 Estimate the number of apneas events Results Conclusions Evidence Rating Capnography group identify more PORD events than pulse oximetry group P < .00001 Odds of recognizing PORD = higher in the capnography versus pulse oximetry group. OR: 5.83, 95% CI, 3.54 -9.63; P < .00001 Capnography provides early warning of PORD before oxygen desaturation. However, improved education and further research with high-quality studies are recommended. 1 Change in rate of hypopneic hypoventilation was faster in the intervention group (p = .04) Change in rate of apnea was significantly different from the control group (p < .001) Bradypnea rates decreased faster in the control group (p=.05) No differences in rates of hypoxemia between groups over time. 198 apnea alert events were detected Children had fewer episodes of hypoventilation or apnea due to more effective interventions by nursing staff. 2 Apneic events were not confirmed by 4 18 CAPNOGRAPHY MONITORING EDUCATION Author/ Year Methodology /Sample Purpose while using continuous capnography after cesarean delivery with intrathecal morphine. Results Conclusions Nurse observation of RR = OR > 14 R =0.05 between capnography and nurse observation. the intermittent hourly nursing observations. Future studies are needed to examine the role of capnography in at- risk subjects and during at risk periods when receiving sedatives or systematic narcotics. Evidence Rating Legend: O2= Oxygen, O2 Sat= Oxygen saturation, PACU= Post-Anesthesia Care Unit, PORD= postoperative respiratory depression, RR= respiratory Rate Evidence-Based Practice: Verification of Chosen Option Due to the increased complexity in healthcare and with the effort to improve the quality of care and safety of patients, many healthcare organizations strive to foster quality improvement projects. Based on the review of the literature, an educational intervention was developed as a quality improvement measure. Perianesthesia nurses can be the frontline staff in detecting adverse events that occur in the PACU; therefore, education is a fundamental component in this setting. Theoretical Framework A logic model or Logical Framework Approach (LFA) (Figure 1) focuses on a chain of causation or if-then connections that lead to intended outcomes (Hayes, Parchman, & Howard, 2011). This framework links the desired results with the different actions taken and the underlying assumptions of the project (Hayes, Parchman & Howard, 2011). The LFA 19 CAPNOGRAPHY MONITORING EDUCATION maximizes the possible effort of the project team in their planning, implementing, and evaluating with the goals to reach the desired outcomes (Goeschel, Weiss, & Pronovost, 2012). The LFA has been successfully used in healthcare for various quality improvement projects. The LFA was used in the planning, implementation, and evaluation of a Comprehensive Unit-Based Safety Program (CUSP) and Central Line-Associated Bloodstream Infections (CLABSI) program in some intensive care units (ICU) (Goeschel, Weiss, & Pronovost, 2012). The framework was also successfully used in a primary care practice-based research network. In this setting, the process for the development of this framework consists of identifying the target audience, identifying and describing assumptions, inputs, and activities, and finally identifying outputs, outcomes and outcome indicators (Hayes, Parchman, & Howard, 2011). The LFA contains four main components, such as inputs, activities, outputs, and outcomes (Centers for Disease Control and Prevention [CDC], 2014). The inputs, activities, and outputs are considered the process components or planning elements of the model; while the outcomes component of the model consists of the intended effects (CDC, 2014). The LFA also identified three different outcomes, such as short-term, intermediate, and long-term outcomes (CDC, 2014). The CDC also developed and used the LFA to evaluate the program for heart disease and stroke prevention activities (2017). 20 CAPNOGRAPHY MONITORING EDUCATION Figure 1. Simple Logic Model adapted from http://click4it.org/index.php/Logic_Model Goals/ objectives/ expected outcomes From these underlying assumptions and actions of the LFA framework, the purpose of this DNP project aligns with the LFA as it recognizes the knowledge deficit regarding capnography monitoring among the perianesthesia nurses at IU Health Arnett Hospital. This knowledge deficit required an in-service or training session with the short-term goal of improving the knowledge of the perianesthesia nurses regarding capnography monitoring. The long-term goal will consist of changing behavior, practices, and policies (Figure 2). 21 CAPNOGRAPHY MONITORING EDUCATION Knowledge Situation Deficit IU Arnett staff/ Capnography Equipment Inputs Training Outputs Session PeriAnesthes Audience ia Nurses Short term outco me Knowledge Gained Practices/ policies and PACU environment change medium and long term outcomes Figure 2. Adaptation of the LFA to the Project Steps DNP Project Design Project Site and Population The educational intervention was performed at Indiana University Health Arnett Hospital (IU Health Arnett). IU Health Arnett is a 191-bed hospital that serves the population of Lafayette, Indiana. This urban acute tertiary center provides diverse general medical and surgical services such as cancer, neurology, orthopedics, heart and vascular, neurosurgery, primary care, sports medicine, geriatrics, pulmonary and lung surgery, gastroenterology and gastrointestinal (GI) surgery, urology, and womens health (Indiana University Health [IU health], 2019). The hospital accounts for 40 specialties and 23 outpatient clinics (IU Health, 2019). Due to its bed capacity and affiliation with IU, IU Health Arnett is considered an urban academic hospital. The main hospital has eight PACU beds, not including the Phase II beds, which are also used as preoperative rooms for admissions and GI recoveries. The Ambulatory Surgery Center (ASC) has a total of 15 beds for both the Phases I and II of PACU and is located in a separate building, which could be an issue to access the equipment. Currently, IU Arnett hospital has changed all the 22 CAPNOGRAPHY MONITORING EDUCATION monitors, all with the capacity to monitor capnography. Therefore, the educational project will complement the planned deployment of the new monitoring as the perianesthesia nurses will have access to the monitoring at the bedside and will be required to use the monitor after this educational intervention. Setting Facilitators and Barriers The surgical department has a total of 30 perianesthesia nurses who are cross-trained to work in the PACU for both Phases I and II. Web-based and on-the-job training are the main types of education provided at PACU. However, perianesthesia nurses do not receive formal training in capnography waveform use and interpretation. They are required to have Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) training and preference of one year of nursing experience to be hired in the PACU (L. Sherman, personal communication, January 18, 2019). The perioperative nurse educator was involved in the development of this project by approving this project and acting as a liaison between the SRNA and perianesthesia nurses. IU Arnett hospital in general, and particularly the surgery department staff (perianesthesia nurses and the anesthesia department), and any patients who undergo any surgical procedure are stakeholders who have vested interest in this project. Methods of Evaluation Measurement Instruments and Data Collection Procedures This DNP project consisted of providing education about capnography monitoring to the perianesthesia nurses. The in-service training was provided on April 22nd, April 23rd, and April 29th, 2019 from 8 a.m. 12 p.m. to capture most of the perianesthesia nurses who may benefit from the education (Appendix A). 23 CAPNOGRAPHY MONITORING EDUCATION The educational intervention was presented in a small group of two to five nurses at the time with each session lasting 15 minutes. First, a participant informed consent (Appendix B) that discusses the terms of the study was distributed. After the informed consent was obtained, the participants were assigned a random numeric identifying code that was used for all other documents associated with the study. Second, a pre-test questionnaire of ten items (Appendix C) along with the demographic survey of five items (Appendix D) were distributed. Next, paper copies of the presentation in the form of PowerPoint (Appendix E) were provided at the beginning of the education to reinforce teaching. Interactions during the teaching were also encouraged. Before the post-test, there was a brief time for questions and answers. Finally, a post-test with ten items was distributed (Figure 3). The demographic survey, which consists of five items, was solely created for this project to address the experience level of each perianesthesia nurse (nursing, Intensive care unit and PACU experience), others nursing certification and any previous capnography education. The survey was also useful to evaluate if there is any relationship between the demographic survey results and the pre-test and post-test results. The pre-test and post-test consist of identical items that were adapted to determine if there is an improvement in knowledge regarding capnography after the in-service training. The test contains information that was discussed during the PowerPoint presentation. All items were multiple-choice questions. The learning objectives were composed based on level 1 to 3 of the Blooms taxonomy model of educational learning. Each learning objective matched with the material provided in the PowerPoint presentation. The pre-test and post-test were adapted from Covidien and Northwest Community EMS system. Covidien is a global medical products manufacturer that was purchased by Medtronic. Medtronic is one of the healthcare products 24 CAPNOGRAPHY MONITORING EDUCATION company that manufactures and supplies capnography monitoring; it also provides clinical education and training regarding their innovation. The Northwest Community EMS system is emergency medical service that provides services to the communities and continuing education materials. The PowerPoint was adapted from the content found in the textbook endorsed by Marian Universitys Nurse Anesthesia Program, titled Millers Anesthesia 8th edition by Miller, Cohen, Eriksson, Fleisher, Wiener-Kronish, and Young (Miller et al., 2015). The PowerPoint presentation was also adapted from the Association of Radiology and Imaging Nursing Journal, the Alameda County Public Health Department website, the WebMD website, the PubMed website, Community Health Hospital and McHenry Western Lake County EMS presentation. Informed Consent Demographic Survey & PreTest PowerPoint Presentation Post-Test Figure 3. Implementation Procedure Ethics Considerations/ Protection of Human Subjects The Institutional Review Board (IRB) of Marian University reviewed the project proposal and judged it exempt from the need for human subjects protection (Appendix F). Also, the Leighton School of Nursing at Marian University and Indiana University Health Arnett Hospital (IU Health Arnett) have approved the project before its development and implementation. Written informed consent to participate in this project freely was obtained before the intervention. The perianesthesia nurses were able to opt-out of the research but still received the in-service training without any penalty or reprimand. A random numeric code was assigned to each participant to maintain their confidentiality and privacy. 25 CAPNOGRAPHY MONITORING EDUCATION Data Analysis The educational intervention was evaluated by the pre and post-tests, and statistical analysis was performed using a dependent samples t-test. The dependent samples t-test is known as the paired t-test, or paired samples t-test, which provides a comparison of the mean of two related groups to establish the statistically significant differences that can exist between the mean of these groups (Laerd, 2019). With a dependent t-test, the participants responses were examined on two different occasions and were part of a single group, i.e., paired (Laerd, 2019). The information collected before and after the education met the requirement for the dependent samples t-test and was considered as an appropriate method of evaluation for this project. The DNP project examined the knowledge gained regarding the capnography monitoring (dependent variable) by providing a pre-test and post-test to the same perianesthesia nurses on two separate occasions. The descriptive statistics were also used to describe the data collected from the demographic survey. These data were useful to establish a relationship between the results of the pre/post-test and the participants characteristics. It was determined that further statistical analysis of this data would not alter the finding of this project. Results Participants Characteristics All perianesthesia nurses at IU Arnett hospital had at least one year of nursing experience. Two nurses had between one to three years of nursing experience, three nurses had between three to five years of nursing experience, and eighteen nurses had more than five years of experience (Figure 4). Among the perianesthesia nurses, five nurses had less than one year of PACU experience, eight nurses had between one to three years of PACU experience, one nurse 26 CAPNOGRAPHY MONITORING EDUCATION had three to five years of PACU experience, and nine nurses had more than five years of PACU experience (Figure 4). Fourteen nurses had zero ICU experience, six nurses had one to three years of ICU experience, one nurse had three to five years of ICU experience, and two nurses had more than five years of ICU experience (Figure 4). Nurses Experience 20 18 18 Number of Nurses 16 14 14 12 10 9 8 8 4 2 6 5 6 2 3 1 0 1 2 0 Nursing experience None PACU experience 1-3 years 3-5 years ICU experience More than 5 years FIGURE 4. Nursing, PACU and ICU Experience Five perianesthesia nurses possessed an additional nursing certification, while eighteen nurses did not possess any certifications at all (Figure 5). One nurse reported attending a prior capnography education (Figure 6) 27 CAPNOGRAPHY MONITORING EDUCATION Nursing certification (CCRN/ CPAN/CNOR) 22% No yes 78% FIGURE 5. Additional Nursing Certification Prior capnography education 4% yes No 96% FIGURE 6. Prior Capnography Education 28 CAPNOGRAPHY MONITORING EDUCATION Pre-test and Post-test Results Pre-test and Post-test Scores. Twenty-nine pre-tests and post-tests were distributed to the perianesthesia nurses at IU Arnett Hospital. Out of the twenty-nine distributed tests, six pretests were excluded due to the lack of post-test (Figure 7). However, the mean pre-test of those excluded did not differ from the mean pre-test of those participants who were included. Pre and Post-Test Scores 12 10 8 6 4 2 0 RN RN RN RN RN RN RN RN RN RN RN RN RN RN RN RN RN RN RN RN RN RN RN 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Pre test Post Test difference FIGURE 7. Pre-test and Post-test Scores Combined Participants Demographic Results and Pre/ Post-test Results The level of nursing, ICU, or PACU experience, as well as any additional nursing certification and prior capnography education, did not have any impact on the pre/ post-test result. After carefully analyzing the results gathered from both the pre-test and post-test, it is safe to assume that regardless of ones experience, the difference that was yielded were virtually scattered. Just by merely taking a glimpse at the data highlighted on the chart, many nurses who had a higher level of PACU experience seemed to perform worse than those who had little to no experience (Figure 8). At the same time, there were also nurses involved that had minimal 29 CAPNOGRAPHY MONITORING EDUCATION experience and still performed poorly on either or both the pre-test and post-test. Due to this, one can conclude that there is virtually no relationship between the level of experience or additional nursing certification one holds and their level of knowledge in regard to capnography monitoring. RN Participants YEAR of Prior YEAR ICU YEAR PACU NURSING POST RN capno PRETEST DIFFERENCE EXPERIENCE EXPERIENCE CERTIFICATION TEST experience education 1 >5 0 1 3 No No 2 >5 2 >5 No No 3 >5 >5 3 5 No No 4 >5 0 0 Yes No 5 3- 5 0 <1 No No 6 >5 13 >5 No No 7 >5 0 >5 No No 8 35 0 1 3 No No 9 35 0 0 No No 10 > 5 35 >5 No yes 11 >5 >5 >5 Yes No 12 >5 0 >5 No No 13 > 5 0 >5 No No 14 >5 0 1 3 No No 15 >5 13 >5 No No 16 > 5 0 >5 No No 17 2 3 0 1- 3 Yes No 18 >5 0 1 3 No No 19 2 3 0 0 No No 20 >5 13 0 Yes No 21 >5 13 1 3 No No 22 >5 0 1 3 No No 23 >5 13 1 3 No No FIGURE 8. Combined Participants Demographic and Pre/Post-tests Results 4 2 9 3 8 6 8 9 5 6 7 5 6 5 3 8 7 7 3 8 8 8 7 5 10 10 5 9 6 8 9 7 7 9 9 10 8 7 9 9 9 8 9 9 9 10 1 8 1 2 1 0 0 0 2 1 2 4 4 3 4 1 2 2 5 1 1 1 3 30 CAPNOGRAPHY MONITORING EDUCATION Means of Pre-test and Post-test. The mean of pre-test was significantly lower than the mean of the post-test (Figure 9). Figure 9. The Means of Pre-test and Post-test. Power Analysis. The University of British Columbia online program was used to determine the minimally appropriate sample size of the study. Using the power of 0.80 of alpha of 0.05 and assuming a normal distribution, the minimum required sample size per group was eight. However, subsequent results of the Shapiro-Wilk test were significant, indicating a violation of the normality assumption. Therefore, the non-parametric two-tailed Wilcoxon signed rank test was conducted. The Intellectus Statistical online program was used. The results were statistically significant (alpha = 0.05, v = 0.00, z = -3.96, p < .001), demonstrating that the differences in pretest and post-test scores are significant with the median pre-test scores (Median = 7.00) lower than the median post-test scores (Median = 9). This indicates it is likely the education 31 CAPNOGRAPHY MONITORING EDUCATION intervention led to a statistically significant improvement in the subjects test scores. Figure 10 provides the box-plot of the ranked score for the Wilcoxon test. Figure 10. Ranked Values of Pre-test and Post-test Discussion Although the participants demographic survey information did not mirror the results of both the pre and posttest, the in-service training was considered successful, because this educational intervention responded to the self-reported needs of the perianesthesia nurses. An assumption can be made that capnography was a topic that was not adequately highlighted in the PACU orientation. Despite this lack of relationship, the perianesthesia nurses demonstrated an enhancement of knowledge regarding capnography monitoring after the educational intervention. The educational model and subsequent project addressed the project PICO question: 32 CAPNOGRAPHY MONITORING EDUCATION Among the perianesthesia nurses (P), does an in-service education on capnography monitoring (I) compared to the lack of in-service education (C) result in increased knowledge in the PACU (O)? The intervention yielded a positive response to the educational project and may potentially lead to improved safety and quality of care for patients at IU Arnett Hospital. Continuous capnography education should be a part of the required training in the PACU. This quality improvement project would also be more beneficial if other stakeholders, such as the perianesthesia nurses managers and perianesthesia nurses could better facilitate training. Implementation of the educational model would likely have been more effective, if the nurses had been able to take a break to solely focus on education rather than being distracted by patient care during the training. The education was provided at the nursing station, where nurses had their attention divided. Therefore, web-based training in which nurses participate during periods when they do not have patient assignments or other clinical loads may be more beneficial. Based on the framework used, the short-term goal of improving the level of knowledge regarding capnography was achieved; however, the long-term goal of changing practices and behaviors requires a multifaceted and longer-term approach. To examine the validity of the data, the nonparametric Wilcoxon signed rank test was also performed. The results of the two-tailed Wilcoxon signed rank test were significant, which indicates that the differences between these test scores were unlikely due to random variation. This may suggest learning occurred. Limitations The limited time to present the project was considered a significant drawback due to its potential effect on some of the data gathered. Per request of the peri-operative services educator, 33 CAPNOGRAPHY MONITORING EDUCATION the time for the pretest, presentation, and post-test was reduced from 20-30 minutes to approximately 15 minutes due to the inability of the nurses to fully participate in the education. Furthermore, due to the high nursing turnover rates, nurses were unable to leave their station to solely focus on education. This issue only allowed nurses who were not responsible for patients at that particular juncture to be able to actively participate in the capnography module. Some nurses were able to do the pre-test, but were unable to participate in the PowerPoint presentation or the post-test. Due to these issues, the pre-tests for those inactive nurses were unfortunately not included in the analysis. To mitigate this issue, the SRNA was able to add an extra day for training in order to capture the majority of the perianesthesia nurses as much as possible. Regardless of the efforts of the SRNA to capture all of the PACU nurses, a small portion of nurses that participated in the pre-test and PowerPoint presentations were allowed to return the post-test to the perianesthesia nurse educator. Continuing on, another foreseen limitation in the midst of this capnography, was a lack of institutional structure that supported the in-service. With the education not being provided in the learning environment needed for this type of education, and instead, at one of the nursing stations, there is an alarming amount of potential that this negatively affected a lot of the data that was gathered. Conclusion AREs are the most common complication encountered in the PACU, and capnography monitoring can facilitate the detection of respiratory complications. Therefore, it is deemed a necessity for expert perianesthesia nurses to identify this issue appropriately and immediately. In summary, the goal of this project was to evaluate if an in-service training on capnography monitoring will improve the knowledge of the perianesthesia nurses. The educational intervention and the design of which was guided by a logic model, facilitated the 34 CAPNOGRAPHY MONITORING EDUCATION achievement of this project. The short-term goal was accomplished as the perianesthesia nurses demonstrated an increase in knowledge regarding capnography monitoring. Although the shortterm goal was attained, it is far too soon to assess long-term retention of the knowledge. Continuing education as part of the basic training for the perianesthesia nurses will be beneficial in the long-term sustainability of this quality improvement project. Therefore, the stakeholders should continue to support this quality improvement project by continuously providing a formal education regarding capnography monitoring. Furthermore, the dissemination of this project at Marian Universitys Leighton school of nursing can promote sustainable changes as future SRNAs may be interested in continuing to provide the education at the same facility. 35 CAPNOGRAPHY MONITORING EDUCATION References American Society of PeriAnesthesia Nurses (ASPN). (2017). Frequently asked questions. Retrieved from http://www.aspan.org/Clinical-Practice/FAQs. Apfelbaum, J L., Silverstein J.H., Chung, F.F., Connis, R.T., Fillmore, R.B., Hunt, S.E., . . . Schreiner M.S. (2013). Practice guidelines for postanesthetic care: An updated report by the American Society of Anesthesiologists Task Force on postanesthetic care. Anesthesiology, 118(2):291-307. doi: 10.1097/ALN.0b013e31827773e9. Retrieved from http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1918686#66513659 Bothner, U., Georgieff, M., & Schwilk, B. (1999). The impact of minor perioperative anesthesia related incidents, events and complications on post anesthesia care unit complications. Anesthesia & Analgesia, 89, 514-519. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/?term=The+impact+of+minor+perioperative+anes thesiarelated+incidents%2C+events%2C+and+complications+on+postanesthesia+care+u nit+utilization Centers for Disease Control and Prevention. (2014, August 8). Identifying the components of a logic model. Retrieved from https://www.cdc.gov/std/Program/pupestd/Components%20of%20a%20Logic%20Model .pdf Centers for Disease Control and Prevention. (2017, May 23). State heart disease and stroke prevention program evaluation guide: Developing and using a logic model. Retrieved from https://www.cdc.gov/dhdsp/docs/logic_model.pdf 36 CAPNOGRAPHY MONITORING EDUCATION Faraj, J. H., Vegesna, A. R., Mudali, I. N., Khairay, M. A., Nissar, S., Alfarhan, M., Go, T. (2013). Survey and management of anaesthesia related complications in PACU. Qatar medical journal, 2012(2), 6470. doi:10.5339/qmj.2012.2.15 Fleisher, L.A & Linde-Zwirble, W.T. (2014). Incidence , outcome, and attributable cause resource use associated with pulmonary and cardiac complications after major small and large bowel procedures. Perioperative Medicine, 7. Retrieved from https://perioperativemedicinejournal.biomedcentral.com/articles/10.1186/2047-0525-3-7. Fouladpour, N., Jesudoss, R., Bolden, N., Shaman, Z., & Auckley, D. (2016). Perioperative complications in obstructive sleep apnea patients undergoing surgery: A review of the legal literature. Anesthesia & Analgesia, 122(1):145-51. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/26111263/. Geralemou, S., Probst, S., & Gan, T. J. (2016). The role of capnography to prevent postoperative respiratory adverse events. Retrieved from https://www.apsf.org/article/the-role-ofcapnography-to-prevent-postoperative-respiratory-adverse-events/ Goeschel, C.A., Weiss, W.M., & Pronovost, P. J. (2012). Using a logic model to design and evaluate quality and patient safety improvement programs. International Journal for Quality in Health Care. Retrieved from https://academic.oup.com/intqhc/article/24/4/330/1795580 Haret, D., Kneeland, M., & Ho, E. (2012). Chapter 14: Postanesthesia care units. In 2012 operating room design manual (pp. 44-56). American Society of Anesthesiologists. Retrieved from file:///Users/bobettemakoyi/Downloads/CHAPTER%2014%20POSTANESTHESIA%20 CARE%20UNITS%20(1).pdf 37 CAPNOGRAPHY MONITORING EDUCATION Hayes. H., Parchman, M.L., & Howard, R. (2011). A logic model framework for evaluation and planning in a primary care practice-based research network (PBRN). Journal of the American Board of Family Medicine. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/21900441 Hutchison, R., & Rodriguez, L. (2008). Capnography and respiratory depression. American Journal of Nursing. Retrieved from https://www.trianim.com/anesthesia/Pain%20Control%20Capnography%20and%20Respiratory%20Dep ression.pdf Indiana University Health. (2019). IU health Arnett Hospital. Retrieved from https://iuhealth.org/find-locations/iu-health-arnett-hospital Kellner, D.B., Urman, R.D. Greenberg, P. & Brovman, E. (2018). Analysis of adverse outcomes in the post-anesthesia care unit based on anesthesia liability data. Journal of Clinical Anesthesia. Retrieved from https://www-clinicalkeycom.forward.marian.edu/service/content/pdf/watermarked/1-s2.0S0952818018303076.pdf?locale=en_US Kluger, M.T., & Bullock, M.F. (2002). Recovery room incidents: A review of 419 reports from the anaesthetic incident monitoring study (AIMS). Retrieved from https://onlinelibrary.wiley.com/doi/epdf/10.1046/j.1365-2044.2002.02865.x Kodali, B.S. (2013). Capnography outside the operating rooms. Anesthesiology,118(1):192-201. doi: 10.1097/ALN.0b013e318278c8b6. Retrieved from http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2034665#68021764 Laerd. (2018). Dependent t-test for paired samples. Laerd Statistics. Retrieved from https://statistics.laerd.com/statistical-guides/dependent-t-test-statistical-guide.php 38 CAPNOGRAPHY MONITORING EDUCATION Lam, T., Nagappa, M., Wong, J., Singh, M., Wong, D., & Chung, F. (2017). Continuous pulse oximetry and capnography monitoring for postoperative respiratory depression and adverse events. Anesthesia & Analgesia,125(6), 2019-2029. doi:10.1213/ane.0000000000002557. Retrieved from https://journals.lww.com/anesthesiaanalgesia/fulltext/2017/12000/Continuous_Pulse_Oximetry_and_Capnography.31.aspx Langhan, M. L., Li, F., & Lichtor, J. L. (2016). Respiratory depression detected by capnography among children in the postanesthesia care unit: A cross sectional study. Pediatric Anesthesia, 26, 1010-1017. doi:10.1111/pan.12965. Retrieved from https://onlinelibrary.wiley.com/action/showCitFormats?doi=10.1111%2Fpan.12965 Langhan, M. L., Li, F., & Lichtor, J. L. (2017). The impact of capnography monitoring among children and adolescents in the postanesthesia care unit: A randomized controlled trial. Pediatric Anesthesia, 27, 385-393. doi:10.1111/pan.13077. Retrieved from https://onlinelibrary.wiley.com/doi/abs/10.1111/pan.13077 Logic Model. (n.d). Retrieved from http://click4it.org/index.php/Logic_Model Luo, J. & Min, S. (2017). Postoperative pain management in the postanesthesia care unit: an update. Journal of Pain Research. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5695271/ Makoyi, B. (2018). Literature review paper. Portions of this unpublished assignment were submitted to NSG 706. Leighton school of nursing, Marian university, Indianapolis, Indiana. Miller, R.D, Eriksson, L.I., Fleisher, L. A., Weiner-Kronish, J. P., Cohen, N.H., Young, W.L.( 2015). Millers anesthesia 8th edition. Philadelphia, PA: Elsevier. 39 CAPNOGRAPHY MONITORING EDUCATION National Quality Forum (2019). Surgery project 2015-2017.Retrieved from http://www.qualityforum.org/ProjectDescription.aspx?projectID=80864 Pedersen, T., Viby-Mogensen, J. & Ringsted, C. (1992). Anaesthetic practice and postoperative pulmonary complications. Anaesthesiologica Scandinavica. Retrieved from https://onlinelibrary.wiley.com/doi/abs/10.1111/j.13996576.1992.tb03570.x?sid=nlm%3Apubmed StatisticsSolutions (2019). Paired sample t-test. Retrieved from https://www.statisticssolutions.com/manova-analysis-paired-sample-t-test/ Stoelting, R.K. & Weinger, M.B. (2009). Dangers of postoperative opioids-is there a cure? Journal of The Anesthesia Patient Safety Foundation. Retrieved from https://www.apsf.org/article/dangers-of-postoperative-opioids-is-there-a-cure/ U.S Department of Health and Human Services. Agency for Healthcare Research and Quality. Instruction gap analysis. (n.d). Retrieved from https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit /d5-gapanalysis.pdf. Weiniger, C.F., Akdagli, S., Turvall, E., Deutsch, L., & Carvalho, B. (2018). Prospective observational investigation of capnography and pulse oximetry monitoring after cesarean delivery with intrathecal morphine. Anesthesia-Analgesia, 4. Retrieved from http://ovidsp.tx.ovid.com.forward.marian.edu/sp3.32.0a/ovidweb.cgi?WebLinkFrameset=1&S=BHCJFPIMHKDDGPNHNCDKMGJCCI JLAA00&returnUrl=ovidweb.cgi%3f%26TOC%3djb.search.31%257c1%257c50%26FO RMAT%3dtoc%26FIELDS%3dTOC%26S%3dBHCJFPIMHKDDGPNHNCDKMGJCC IJLAA00&directlink=http%3a%2f%2fovidsp.tx.ovid.com%2fovftpdfs%2fFPDDNCJCM 40 CAPNOGRAPHY MONITORING EDUCATION GNHHK00%2ffs046%2fovft%2flive%2fgv025%2f00000539%2f00000539-90000000096629.pdf&filename=Prospective+Observational+Investigation+of+Capnography+and+ Pulse+Oximetry+Monitoring+After+Cesarean+Delivery+With+Intrathecal+Morphine.& PDFIdLinkField=%2ffs046%2fovft%2flive%2fgv025%2f00000539%2f0000053990000000096629&link_from=jb.search.31%7c1&pdf_key=B&pdf_index=jb.search.31&D=ovft Zhan C. & Miller M.R. (2003). Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. JAMA. (14).290: 18681874. Retrieved from https://jamanetwork.com/journals/jama/fullarticle/197442 Zhang, X., Kassem, M. A. M., Zhou, Y., Shabsigh, M., Wang, Q., & Xu, X. (2017). A brief review of non-invasive monitoring of respiratory condition for extubated patients with or at risk for obstructive sleep apnea after surgery. Frontiers in Medicine, 4, 26. http://doi.org/10.3389/fmed.2017.00026 (Links to an external site.)Links to an external site.. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5340767/ (Links to an external site.)Links to an external site. 41 CAPNOGRAPHY MONITORING EDUCATION Appendix A: IU HEALTH ARNETT HOSPITAL Confirmation letter 42 CAPNOGRAPHY MONITORING EDUCATION Appendix B: Participants Informed Consent PARTICIPANTS INFORMED CONSENT This in-service session has been developed as partial fulfillment of the requirements for the Doctor of Nursing Practice (DNP) degree in Nurse Anesthesia at Marian University (MU). This research project is titled: Capnography Monitoring for the PeriAnesthesia Nurses. The purpose of this project is to enhance the knowledge of the perianestheisa nurses regarding capnography monitoring, which will eventually improve the patient outcomes. If you agree to take part in this project, you will be completing a five-item demographic survey and a ten-item pretest, then you will be attending a PowerPoint presentation on capnography monitoring, and you will be provided a ten-item posttest. The completion of all of these steps may last 10-15 minutes. There are no anticipated risks associated with participating in this project. Your records will be kept confidential, and your name will be kept private. Your decision to take part in this research project is entirely voluntary, and you may refuse to participate, or you may withdraw from this project at any time without penalty or reprimand. You may also opt out of the research project but still receive the in-service training. By agreeing to be part of this project, you have the right to have the results of the information gathered from this research project. Your consent to participate in this project is indicated by your voluntary response to the items provided. The Institutional Review Board (IRB) of MU has reviewed and approved this project proposal, but if you have any questions regarding your rights as a research subject, feel free to contact MU IRB committee at 317-955-6115. If you have any questions about the research now or during the study, please contact the member of the research team : Bobette Makoyi, bmakoyi@marian.edu, Dr. Stacie Hitt, sfhitt@marian.edu, or Dr. Allison Luellen , aluellen@marian.edu Your participation is truly appreciated. 43 CAPNOGRAPHY MONITORING EDUCATION Appendix C: Pre and Post-Test Questionnaire Capnography Monitoring in the PACU (Pre/Posttest) 1. Choose the best definition for capnography: a. Non-invasive continuous measurement of excreted carbon dioxide in perspiration b. Invasive measurement of exhaled oxygen and carbon dioxide in the breath c. Non-invasive continuous measurement of carbon dioxide in the breath d. Measurement of arterial carbon dioxide Answer C 2. Capnography can provide information about which of the three physiological functions? a. Metabolism, perfusion, and ventilation b. Oxygenation, ventilation, and metabolism c. Perfusion, neurological, and ventilation d. None of the above Answer A 3. What information does a capnography sensor obtain? a. CO level b. O2/CO2 ratio c. Oxygen level d. CO2 waveform Answer D 4. What is a cause of a low ETCO2 level? a. Fever b. Hyperventilation c. Pain d. Hyperoxia Answer B 5. What is an elevated ETCO2 a sign of? a. Alkalosis b. Hypoxia c. Respiratory failure d. Carbon monoxide poisoning Answer C 6. What is a consequence of hyperventilation? a. Hypercarbia b. Decreased cardiac output c. Increased cerebral perfusion d. Increased coronary perfusion Answer B 7. What ETCO2 reading would you expect in a patient who is hypoventilating from shivering? a. Decreased 44 CAPNOGRAPHY MONITORING EDUCATION b. Normal c. Elevated Answer C 8. Identify this waveform: ETCO2= 25 a. Hyperventilation b. Hypoventilation c. Normal Answer A 9. Identify this waveform: ETCO2= 42 a. Hyperventilation b. Hypoventilation c. Normal Answer C 10. Identify this waveform: ETCO2= 55 a. Hyperventilation b. Hypoventilation c. Normal Answer B 45 CAPNOGRAPHY MONITORING EDUCATION References http://www.nwcemss.org/assets/1/continuing_education/feb_12_-_capnography_PTSQ.pdf. http://alanbatt.net/wp-content/uploads/2017/02/10_EMS-PreTest-11-25.pdf. 46 CAPNOGRAPHY MONITORING EDUCATION Appendix D: Demographic Survey DEMOGRAPHIC SURVEY ID number: 1. How many years of nursing experience do you have? a. < 1 year b. 2 - 3 year c. 3 - 5years d. More than 5 years 2. How many years of ICU experience to you have? a. None b. 1-3 years c. 3-5 years d. More than 5 years 3. How many years of PACU experience do you have? a. None b. 1-3 years c. 3-5 years d. More than 5 years 4. Do you have any nursing certification such as CCRN, CPAN? a. Yes b. No c. Other not listed? Please specify_________ 5. Have you ever taken a class regarding capnography monitoring in the past? a. Yes b. No 47 CAPNOGRAPHY MONITORING EDUCATION Appendix E: PowerPoint presentation 48 CAPNOGRAPHY MONITORING EDUCATION 49 CAPNOGRAPHY MONITORING EDUCATION 50 CAPNOGRAPHY MONITORING EDUCATION 51 CAPNOGRAPHY MONITORING EDUCATION 52 CAPNOGRAPHY MONITORING EDUCATION 53 CAPNOGRAPHY MONITORING EDUCATION 54 CAPNOGRAPHY MONITORING EDUCATION Appendix F: Marian University IRB Review Letter DATE: TO: FROM: RE: TITLE: SUBMISSION TYPE: ACTION: DECISION DATE: Institutional Review Board January 29, 2019 Bobette Makoyi Marian University IRB IRB Protocol # S19.003 Capnography monitoring in the Post Anesthesia Care Unit (PACU) New Project Determination of Exempt Status January 28, 2019 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. However, the Institutional Review Board would like for you to state in your study that nurses will be able to opt out of the research but still receive the in-service training. 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. 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 or 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 Karen Spear at (317) 955-6115 or kspear@marian.edu 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. 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 web-site: http://www.marian.edu/academics/institutional-review-board Karen L. Spear, Ph.D., Interim-Chair, Marian University Institutional Review Board Cc: Dr. Stacie Hitt.  ...

... PODCASTS IN NURSE ANESTHESIA EDUCATION 2 Table of Contents Abstract ........................................................................................................................................... 4 Introduction ..................................................................................................................................... 5 Background ................................................................................................................................. 5 Problem Statement ...................................................................................................................... 6 Review of Literature ....................................................................................................................... 6 Podcasts vs. Traditional Learning Modalities ............................................................................. 6 Podcasts in Conjunction with Traditional Learning Modalities ................................................. 8 Alternative Podcast Implementations ......................................................................................... 8 Practice Gap Analysis ................................................................................................................. 9 Conceptual Framework ................................................................................................................. 10 Goals and Objectives .................................................................................................................... 11 Project Design ............................................................................................................................... 12 Method for Translation ............................................................................................................. 12 Stakeholder Assessment............................................................................................................ 13 Procedure for Implementation .................................................................................................. 14 Setting ....................................................................................................................................... 16 Participants ................................................................................................................................ 16 Perceived Barriers ..................................................................................................................... 17 Methods......................................................................................................................................... 18 PODCASTS IN NURSE ANESTHESIA EDUCATION 3 Measurement Instrument .......................................................................................................... 18 Data Collection Procedure ........................................................................................................ 18 Data Analysis ............................................................................................................................ 19 Results ........................................................................................................................................... 20 Interpretation/Discussion .............................................................................................................. 22 Ethical Considerations/Protection of Human Subjects ................................................................. 24 Conclusion .................................................................................................................................... 24 References ..................................................................................................................................... 26 Appendices .................................................................................................................................... 29 Appendix A: Student Satisfaction with Educational Podcasts Questionnaire (SSEPQ) .......... 29 Appendix B: Podcasts as a Learning Adjunct in Nurse Anesthesia Education - Satisfaction Survey ....................................................................................................................................... 30 Appendix C: Table 1. DNP SRNA Participant Characteristics ................................................ 38 PODCASTS IN NURSE ANESTHESIA EDUCATION 4 Abstract Educational techniques are constantly evolving because of influences from technology and improvements in the resources that are available to educators as well as learners. An educational adjunct, such as a podcast, may help students study by listening and using repetition as a way to strengthen previously learned concepts. Current literature suggests that utilizing podcasts in addition to conventional educational methods contributes to a higher level of satisfaction among learners. The goal of this translational research project was to provide student registered nurse anesthetists (SRNAs) with educational podcasts as an adjunct to their traditional learning process and then measure their satisfaction after listening to the podcasts. A series of six educational podcasts were recorded and made available on From the Head of the Bed, which is a free podcast platform for the anesthesia community that is available to Apple, Android, Spotify, or Rich Site Summary (RSS) users. The intervention of using educational podcasts was intended to supplement and reinforce traditional learning practices in nurse anesthesia education. A mixed methods study design was developed to assess the qualities of the learners as well as their satisfaction with the educational podcasts. A post-intervention anonymous online survey was administered to the SRNAs at Marian University. The results of this project provide additional support for the value of podcasts as a learning adjunct for SRNAs. Keywords: Podcasts, learning, education, nurse anesthesia, SRNA, CRNA, SSEPQ PODCASTS IN NURSE ANESTHESIA EDUCATION 5 Podcasts as a Learning Adjunct in Nurse Anesthesia Education Introduction Utilizing technology in education has made options like podcasting, a new and popular way to engage learners and provide variety to the educational process. People learn in different styles and settings, and this realization has created a paradigm shift in the delivery of education. This shift also reveals millennial learners preferences toward education, which include stimulating activities as well as the option to accomplish concurrent activities while learning. Student Registered Nurse Anesthetists (SRNAs) have demanding schedules between clinicals and didactic responsibilities, leaving little time available to study and review clinical concepts. A previous systematic review of the literature revealed that podcasts improve test scores and are a satisfactory method of disseminating educational information to students in this modern era of learning where they enjoy multitasking and studying with technology (Scheil, 2018). Even though educational podcasts do exist, there are very few that are related to anesthesia. Background According to Rainsbury and McDonnell (2006), a podcast is a whole new medium for disseminating news, views, and education as a downloadable audio or video file to store in your pocket and listen to or view at your leisure (p. 481). An educational podcast can be developed based on expert content that is then recorded on a computer and uploaded to a service, allowing listeners to download or stream the episodes that they choose (Andrejco, Lowrance, Morgan, Padgett, & Collins, 2017). An overarching advantage of podcasting is the unique ability for learners to multitask by listening to them while driving, cooking dinner, cleaning, or working out, which makes efficient use of time that would otherwise be unavailable for other, more traditional forms of learning (Wolpaw & Toy, 2018). SRNAs experience intense workloads with PODCASTS IN NURSE ANESTHESIA EDUCATION 6 limited time for additional responsibilities. Current literature suggests podcasts are advantageous for learners who want supplementary information at their fingertips. Problem Statement It is clear that podcasts could be an important, but as of yet underexplored, learning adjunct in nurse anesthesia education. Proposing an intervention to develop, produce, and measure the satisfaction of podcasts focused on educational anesthesia content can be a valuable reinforcement tool for traditional learning. Review of Literature This literature review was undertaken to understand the current state of podcasts as possible adjuncts in higher education. Many of the studies reviewed were similar in their purposes to assess whether podcasts are an effective tool as an alternative learning strategy however, their study designs testing that hypothesis varied slightly. Alternative methods of podcast implementation in education were also explored. For the purpose of this literature review, the term traditional learning modalities refers to either in-class lectures or reading a textbook. The chosen articles have been reviewed under three distinct subheadings: podcasts vs. traditional learning modalities, podcasts in conjunction with traditional learning modalities, and alternative podcast implementations. Podcasts vs. Traditional Learning Modalities Four publications, two randomized controlled trials and two quasi-experimental studies analyze data to determine whether test scores are higher after students learn by listening to podcasts or after a combination of classroom lectures and textbook readings. McKinney, Dyck, and Lubar (2009) determined that listening to a podcast lecture is an advantage over attending a traditional lecture (p<0.05). McKinney et al. (2009) also noticed a favorable quality among PODCASTS IN NURSE ANESTHESIA EDUCATION 7 educational podcasts which gave the learner the ability to listen to the podcasts as many times as they wanted. This attribute allows the learner to review any of the content in a purposeful and topic-specific way that traditional lectures do not. Conversely, another early quasi-experimental study published by Vogt, Schaffner, Ribar, and Chavez (2010) found there to be no statistically significant improvement in the scores of three different exams (p=0.22, p=0.06, p=0.11) when administered to two groups of undergraduate nursing students (n=120), one who received a traditional lecture and one who received an audio podcast. A more recent randomized controlled trial published by Back et al. (2017) reviewed the effect of podcasts over textbook readings in a group of medical students (n=130) and found that the group who listened to the educational podcasts scored significantly higher on the post-test than the group who read from textbooks (p<0.021). Another randomized controlled trial compared two groups of second year medical residents (n=49), one who listened to podcasts and one who learned through traditional lectures and found that the podcast arm of the study had statistically higher scores than the control group (p<0.01) (Brust, Cooke, & Yeung, 2015). An additional factor that should be considered is the user satisfaction of the podcast against more traditional learning methods. McKinney et al. (2009) did not test user satisfaction. Vogt et al. (2010) administered a six-question satisfaction survey that found the users to be satisfied with the podcasts, but preferred traditional lectures (63%) over the podcasts. It is possible that lack of familiarity with podcasts influenced satisfaction at a point in time when podcast development was very new. Brust et al. (2015) found no difference in user satisfaction between the podcast learners and traditional lecture learners (p=0.37). Finally, Back et al. (2017) reports an increase in user satisfaction of podcasts over reading textbook chapters. Overall, the satisfaction of podcast use is equal to or higher than traditional learning media. PODCASTS IN NURSE ANESTHESIA EDUCATION 8 Podcasts in Conjunction with Traditional Learning Modalities Two publications, one randomized controlled trial and one quasi-experimental study analyze data to determine whether test scores are higher after students learn by listening to podcasts in addition to a combination of classroom lectures and textbook readings. Kalludi, Punja, Pai, and Dhar (2013) conducted a quasi-experimental study involving dental students (n=80) that assessed the efficacy of podcasts as a supplement to classroom lectures and textbook readings. The authors reported that the students who had access to the podcasts scored higher on the post-test than the students who did not receive the podcasts until after the exam (p=0.00). A randomized controlled trial published by Morris (2015) assessed how podcasts and mobile selfassessments affected learning in two groups of healthcare students (n=85) by describing that supplementary podcasts and mobile assessments positively affected the learners (p<0.05). It is valuable to include a review of the theme of user satisfaction of podcasts in conjunction with traditional learning methods. The learners in Kalludi et al. (2013) felt very strongly (91%) that the biggest advantage of podcasts was the ability to listen to them repeatedly, a common theme that has been discussed in this review. In a survey provided to the students in Morriss study, 86% felt strongly that having podcasts as a supplement to traditional learning methods enriched their learning (2015). Alternative Podcast Implementations Two publications, both quasi-experimental studies, will be discussed for their unique attributes. In a one-arm, quasi-experimental study published by Miesner, Lyons, and McLoughlin (2017), medical residents (n=23) took pre-tests, listened to the educational podcasts, and then took post-tests which yielded a significant improvement in test scores (p=0.001). Lien, Chin, Helman, and Chan (2018) compared two groups of medical students (n=61), one who PODCASTS IN NURSE ANESTHESIA EDUCATION 9 learned by using podcasts and the other who used blog posts, finding that knowledge was increased with both the podcast (p<0.01) and blog post learning (p<0.01), but no significant difference existed between the two (p0.05). Satisfaction among learners in these alternative forms of educational podcast implementation is a key point to consider in this review. In Lien et al. (2018), [Students liked that the podcast taught us how to approach a clinical presentation and walked us through steps for differential and management, was easy to listen to and kept a constant volume level, and was good for consolidating information. (p. 7)]. In the post-assessment survey done in the study by Miesner et al. (2017), no evaluation of satisfaction was performed, however students provided unanimously positive comments about the podcast. Another theme that is helpful to analyze is that of the activity of students while they listen to podcasts. In Lien et al. (2018) 79% (n=22/28) of the students in the podcast arm of the study took part in different activities such as working out, driving, and eating while simultaneously listening to the podcasts. This is an interesting finding, as learning while multitasking can be perceived as an advantage to educational podcasts. The recent publication of both of these articles reveals the current feelings that learners have about educational podcasts. Literature supports the efficacy and satisfaction of educational podcasts, in addition to highlighting the lack of available research that exists regarding educational podcasts geared toward anesthesia education. Practice Gap Analysis The literature review established that podcasts can be a useful adjunct in education, however, research does not exist to support the satisfaction of an educational podcast created for SRNAs. While Andrejco et al. (2017) set the foundation for the creation and implementation of educational anesthesia podcasts, research was not conducted to measure the effects of the PODCASTS IN NURSE ANESTHESIA EDUCATION 10 podcast. This gap presented an opportunity to create educational podcasts for SRNAs and then measure their satisfaction after the intervention was implemented. Conceptual Framework The Keller Attention, Relevance, Confidence, and Satisfaction (ARCS) Model of Instructional Design was the framework chosen to guide the process of creating podcasts as a learning adjunct in nurse anesthesia education. The ARCS Model of Instructional Design is a method that was developed by John Keller in order to enhance the motivational interest of educational resources (Keller, 1987). While the model is made up of three different components, only the first component that involves four conceptual conditions to distinguish learners motivation will be used as a framework in this translational research. The four conceptual conditions, including attention, relevance, confidence, and satisfaction, must be achieved in order to create and sustain motivation in the learner (Keller, 1987). The first condition suggests using methods to capture users attention including active participation, variability, humor, incongruity, specific examples, and inquiry (Keller, 1987). Using anecdotes, different styles of presentation, and allowing the learner to choose the educational topics are all ways to garner and hold attention (Keller, 1987). Relevance is a condition used to motivate the learner by presenting the material in a way that the learner can connect to personal experiences and encourages them to relate the material to future applicability (Huang, Huang, Diefes-Dux, & Imbrie, 2006). Some strategies to promote relevance include using examples of previous experiences, relating instruction to future usefulness, giving learners choices, using modeling and need matching, and relating the instruction to the worth of future goals (Keller, 1987). The third condition of confidence pertains to the learners perceived ability to be successful with the learning task (Huang et al., 2006). Factors that can increase confidence include providing the learner with PODCASTS IN NURSE ANESTHESIA EDUCATION 11 goals and expectations, ensuring they understand performance requirements and evaluation criteria, giving them encouragement and support, and attributing success to effort (Keller, 1987). Lastly, satisfaction is based on the learners perceived sense of achievement and utility, as well as using the newly acquired knowledge and positive feedback as reinforcements for motivation (Huang et al., 2006). Some strategies of satisfaction include natural consequences of learning, receiving unexpected rewards, giving verbal praise, scheduling reinforcement, and avoiding negative threats or influences during learning (Keller, 1987). Together, these four conditions create a foundation for successful learning motivation. The ARCS Model was selected because it was presented in Andrejco et al. (2017) as a guide for nurse anesthesia educators to create educational podcasts. Andrejco et al. (2017) encouraged future researchers by stating that, the use of the Keller ARCS Model and the logic model outlined in this article provide a guide for nurse anesthesia educators who wish to develop effective educational podcasts for the field of nurse anesthesia (p. 17). The authors researched, outlined, and established a podcast for the anesthesia community, in addition to publishing a blueprint for the re-creation and further development of educational anesthesia podcasts in the future (Andrejco et al., 2017). The ARCS Model guided the work of Andrejco and colleagues in the development of podcasts for the anesthesia community. Goals and Objectives The significance of creating educational anesthesia podcasts for SRNAs is to provide them with flexibility and engagement in different forms of studying. The goal of this project is to explore whether educational anesthesia podcast content provides an alternative medium in a way that will give SRNAs variety in their study plans and enrich the traditional study methods they are using already. PODCASTS IN NURSE ANESTHESIA EDUCATION 12 The overall purpose of this project is to determine the level of satisfaction that SRNAs have toward educational podcasts as a supplement to their traditional education. In a more detailed perspective, the four aims of this DNP project are: (1) to record and disseminate a series of educational podcasts that are interesting and helpful to SRNAs, (2) to motivate SRNAs to seek out and utilize alternative, relevant forms of education that are available to reinforce previously learned topics, (3) to give SRNAs confidence in their knowledge by supporting their learning with anesthesia-based educational podcasts, and finally (4) to measure the levels of satisfaction that SRNAs have toward the podcasts. Project Design Method for Translation The ARCS Model of Instructional Design guided the project plan to create educational podcasts for SRNAs. In accordance with the conceptual components of the ARCS model, podcast creation was managed utilizing attention, relevance, confidence, and satisfaction strategies. The condition of attention was the basis for podcast production. Creating a learning tool that provided variability to the learning environment by reinforcing familiar concepts through a podcast platform that offers flexibility to the learners study plan is the foundation of the project (Keller, 1987). Other methods such as active participation through role play, personal stories, and access to references were used to capture listeners attention and participation (Keller, 1987). The relevance of anesthesia topics for the SRNA participants is extremely important to the studys design, as the podcasts topics were chosen to appeal to those interested in introductory anesthesia content. The material presented can assist the study participants in future exams, clinical experiences, and professional endeavors, making them very pertinent to a PODCASTS IN NURSE ANESTHESIA EDUCATION 13 student. The information produced in the podcast consisted of foundational anesthesia content, along with relevant personal experiences and practice recommendations. In addition, Andrejco et. al. (2017) explains that relevance is not only related to the content material but how it is presented, showcasing that podcasts are delivered in a relevant and accessible manner for SRNAs. The condition of confidence was incorporated by allowing the study participants to control their own learning through the podcasts. Motivation can be increased by allowing the study participant control over which podcast(s) and how much of the podcast(s) they listened to, that way success is a direct result of the effort that was put in (Keller, 1987). Andrejco et. al. (2017) also suggests that confidence is related to the validity of the podcasts, which can be accomplished through providing show notes with references as an aide to the discussion. In addition, podcasts can provide a low-risk learning environment of the listeners choosing, which can enhance confidence (Andrejco et al., 2017). Satisfaction was addressed by providing a post-intervention survey to study participants, evaluating their perceived satisfaction with the podcasts. Satisfaction may be based on personal achievement and mastery of the content presented or can stem from feedback and reinforcement (Keller, 1987). The study participants satisfaction may continue to evolve as the learner attempts to use the newly acquired knowledge on exams or in clinical practice. Stakeholder Assessment The SRNAs at Marian University in the class of 2020 and class of 2021 are the key stakeholders in this project. Their interest in the project stems from their desire to expand and reinforce their foundational anesthesia knowledge for the purposes of improved test scores and clinical skills and knowledge. The implementation and evaluation of the intervention is PODCASTS IN NURSE ANESTHESIA EDUCATION 14 dependent on other stakeholders as well. Drs. Alarcn, Bendayan, and Blanca are additional stakeholders as their validated tool, Student Satisfaction with Educational Podcasts Questionnaire (SSEPQ) (Appendix A), is being used to evaluate the satisfaction of the podcasts in this translational research project (Alarcn et al., 2017). Lastly, Jon Lowrance, MSN, CRNA has provided his podcast platform, From the Head of the Bed, as a repository for the podcast series, and therefore is another stakeholder in this project. Procedure for Implementation After reading the article Social Media in Nurse Anesthesia: A Model of Reproducible Educational Podcasts, and listening to several podcasts on the show, From the Head of the Bed, contributing author and producer, Jon Lowrance, MSN, CRNA was contacted for advice on podcast production (Andrejco et al., 2017). Mr. Lowrance generously contributed to this project by voluntarily offering his podcast platform to host the series of educational podcasts, in addition to editing the scripts and recording and editing the podcasts. Lowrance obtained his Master of Science in Nursing after attending the nurse anesthesia program at Western Carolina University (Lowrance, 2019). He is a current practicing CRNA of four years in Portland, Maine as well as a faculty member with Landmark Learning, Cornerstone Anesthesia Conferences, and National Outdoor Leadership School (NOLS) Wilderness Medicine. Lowrance and three other CRNAs created From the Head of the Bed as a research project while in nurse anesthesia school. He has since continued the free, open access podcast channel independently and continues to update and create additional episodes which are accessible on Apple, Android, Spotify, and RSS (Lowrance, 2019). While focusing on foundational anesthesia content applicable to SRNAs, it was decided that a series of six podcasts would be created. The six podcast episodes included: Clinical Flow: PODCASTS IN NURSE ANESTHESIA EDUCATION 15 From OR Set Up Through Intubation, The Anesthesia Machine, Pharmacokinetics of Volatile Anesthetics, Pharmacodynamics of Volatile Anesthetics, IV Induction Agents, and Local Anesthetics. The process of creating the podcasts began with writing scripts while using several common anesthesia textbooks as a reference. All scripts were then reviewed by Lowrance and any necessary edits were made to ensure clarity and accuracy. The podcasts were recorded using Facetime Audio on Apple devices. Lowrance used his own recording equipment to capture the audio and used editing software to make necessary adjustments to the recordings. References to the concepts discussed were provided in the show notes which can be accessed on fromtheheadofthebed.com. A post-intervention satisfaction survey (Appendix B) was created using Qualtrics Survey Software. The survey included a required consent agreement in order to gain access, which was listed as question one. The details of the consent have been left out of Appendix B at this time. The survey asked participants for demographic information in addition to the questions in the SSEPQ (Appendix A) that measure satisfaction (Alarcn et al., 2017). Once the podcasts were published and the survey was open, an email was sent to all Marian University SRNAs in classes 2020 and 2021, requesting their participation in this study. The email included instructions on how to access the podcasts and post-intervention survey. In addition, some of the members of the class of 2020 and 2021 were visited in person to introduce the study and to answer any questions if needed. On April 17, 2019, Lowrance released all six podcasts on his platform, making them available to the public at the same time the instructions were given. While the podcasts are accessible for free to the public, only the Marian University SRNAs were provided with instructions on how to access the post-intervention survey. After the PODCASTS IN NURSE ANESTHESIA EDUCATION 16 podcasts and survey were released, the SRNAs were given 45 days to listen to any or all of the podcast series and submit their satisfaction surveys by June 1, 2019. Setting The setting of the podcast series is complex, as it exists in a virtual medium. As stated, the podcasts were made available on Apple, Android, Spotify, and RSS under the From the Head of the Bed platform. Due to the virtual nature of the podcasts, there was little ability to control the setting. Control could not be exercised in regard to when the podcasts were listened to, where they were listened to, how much of the podcast was listened to, which episodes were listened to, and how the podcasts were listened to. The setting was primarily determined by the study participants. Podcasts could have been listened to on a phone, tablet, or computer and with or without headphones. A podcast episode may have also been listened to in one setting or split up over time. The setting of where the podcasts were listened to could have varied, including the gym, car, while doing chores, while sitting down at home, and so on. The survey inquired about the setting in which the participants listened to the podcasts. A participant may have listened to one podcast episode, multiple episodes, or none at all before completing the survey. The only control was where, electronically, the podcasts and survey were accessed, as well as the time frame of 45 days that the participants had to listen to the podcasts and take the survey. Participants The study participants included Marian University SRNAs in the classes of 2020 and 2021. These participants were chosen based on their enrollment in the nurse anesthesia program at Marian University. Only SRNAs from Marian University were selected as participants in order to maintain control over who had access to the post-intervention satisfaction survey. The class of 2020 consisted of 12 SRNAs entering their third year of the program and the class of 2021 PODCASTS IN NURSE ANESTHESIA EDUCATION 17 consisted of 21 SRNAs entering their second year of the program. Participants were recruited through an email detailing the study, along with instructions on how to access the podcast series and the post-intervention satisfaction survey. In addition, several members of both classes were visited in person during a school meeting to promote participation in the study, as well as to answer any questions. Participants were not offered any reward or compensation for participation in this study. Perceived Barriers Perceived barriers associated with this study include time commitment, technology, and motivation. The podcast episodes ranged from 28 to 55 minutes. One particular study of anesthesia residents measured podcast use and content and found that the preferred length of podcasts was less than 30 minutes, and a podcast was less likely to be listened to if it exceeded 45 minutes (Matava, Rosen, Siu, & Bould, 2013). Therefore, the increased length of five out of the six podcasts is a barrier to getting listeners to stay engaged through the entire episode. The series of six podcasts totaling 260 minutes and 44 seconds, is an extensive time commitment for SRNAs, however, it is anticipated that a desire to acquire educational anesthesia content in a non-traditional format will be embraced by the study participants. Technology is also a barrier due to predicted differences in experience with podcasts in regard to accessing the platform and either downloading or streaming the content. Access to technology required to listen to the podcasts is not barrier, as all students in the nurse anesthesia program at Marian University are provided with an iPad. The iPad is capable of downloading and playing the podcasts with an adequate Wi-Fi connection which is also provided at Marian University. Lastly, motivation is the most significant perceived barrier, because this study relies heavily on intrinsic motivation from the participants and is not within the control of the study design. PODCASTS IN NURSE ANESTHESIA EDUCATION 18 Methods Measurement Instrument The SSEPQ tool (Appendix A) addressed satisfaction related to the podcast series through a 10-question Likert-type scale with four response options (Alarcn et al., 2017). Based on the SSEPQ, satisfaction is measured in relation to perceived content adequacy, ease of use, and usefulness and benefits. This tool was developed by Alarcn, Bendayan, and Blanca (2017) in order to create a brief and simple questionnaire evaluating satisfaction with educational podcasts in higher education and has standardization data. The creators of the tool are considered to be experts, as they all are doctoral recipients and have experience with teaching or supporting teaching in undergraduate research method courses. In order to standardize this tool, 376 students in a psychology course were enrolled in a study and presented with 11 educational podcasts created by the authors of the psychology course. The podcast could be freely accessed throughout the year, and on the last day of the course, the SSEPQ was administered to the students. The four response options per question pertain to a score of 1-4 resulting in an overall max score of 40 (Alarcn et al., 2017). The SSEPQ tool was standardized using Cronbachs alpha to determine internal consistency and was created with a one-factor structure in order for the total score of the questionnaire to provide an overall index of students satisfaction with educational podcasts (Alarcn et al., 2017). Permission was obtained via email from Dr. Alarcn to use the SSEPQ tool in this study. Data Collection Procedure Based on the Keller ARCS Model of Instructional Design and the condition of satisfaction, the method for evaluation involved creating a post-intervention satisfaction survey (Appendix B) using the SSEPQ (Appendix A) (Alarcn et al., 2017; Andrejco et al., 2017). PODCASTS IN NURSE ANESTHESIA EDUCATION 19 Demographic information was also elicited to further hypothesize on the results of the satisfaction survey. Information regarding how to access the survey and when to take it was included in the email used to recruit participants for the study. While the podcast is on a free, open access platform available to the public, the post-intervention satisfaction survey access was only shared with Marian University SRNAs. It should be noted that this method does not allow the experimenter to control at what point during the 45-day period the participant takes the survey. It was suggested to the study participants that the survey should be completed after the participant had listened to all the podcast episodes that they planned on listening to within the 45-day period. Data collected was then analyzed and also compared to the results from Alarcn et al. (2017), which was used to validate the SSEPQ tool (Appendix A), in order to evaluate the effectiveness of the study. After the post-intervention satisfaction survey window had closed, the data were gathered from the Qualtrics Survey Software and analyzed. The survey consisted of 20 questions where one was the consent to participate in the research, nine were demographic questions, and 10 were the SSEPQ items. The results from the demographic questions were entered into Table 1C (Appendix C) to be analyzed for patterns related to the DNP survey results from the SSEPQ. The SSEPQ was scored identically to the standardized results from Alarcn et al. (2017) so that direct comparisons between the results could be made. The mean scores from the SSEPQ and the standardized data were entered into a table (Table 2) so that the differences in the scores could be analyzed. Data Analysis The qualitative and quantitative data obtained from the post-intervention satisfaction survey (Appendix B) was arranged to create two tables, Table 1C and Table 2. While this study PODCASTS IN NURSE ANESTHESIA EDUCATION 20 does not lend itself to parametric comparisons, results were compared with the SSEPQ standardization data (Alarcn et al., 2017). The quantitative data were scored by giving each of the 10 questions a point value from 1-4 depending on how the participant answered the question. The corresponding scores for the response were: strongly agree for 4 points, agree for 3 points, disagree for 2 points, and strongly disagree for 1 point. The mean scores for each question appear in Table 2 alongside the standardized scores from the SSEPQ, as well as the difference in the two scores which demonstrate a comparison. Results Partially completed surveys were counted in addition to the completed ones, and because of that the sample size ranged from 23 to 26 participants depending on the particular question. The demographic data can be found in Table 1C. The participants were rather equally represented between the classes of 2020 (46%, n=12) and 2021 (54%, n=14). Females made up 76% (n=19) of the sample size, and more than 80% (n=22) of the participants were between the ages of 26 and 35. 84% (n=21) of the students have been registered nurses between 3 and 10 years. Close to half (48%, n=12) of the SRNAs reported listening to podcasts 1-2 days per week or more. When participants were asked which additional learning modalities were helpful for studying, YouTube and online videos (25%) and recorded video lectures (21%) were both indicated as more useful than podcasts (18%). Twenty-two Marian University SRNAs listened to all 6 podcasts and 3 SRNAs listened to 4 podcasts total. More than half of the students reported listening to the podcasts in the car or while driving (53%), 19% listened while cooking or cleaning, 7% listened while exercising, and 12% listened to the podcasts while sitting and focusing only on the podcasts. PODCASTS IN NURSE ANESTHESIA EDUCATION 21 The SSEPQ mean comparisons can be found in Table 2. For the SRNA group, the highest mean score was 3.96 for a question that asked if the content of the podcast was well organized. The highest mean standardized score was 3.49 and measured the opinion of the ease of access of the podcasts, which happened to be the question with the lowest mean score for the SRNA group (3.71). The lowest score in the standardized group was in regard to the opinion on whether the podcasts motivate learners (2.84). The SRNA group means, out of the ten total questions, were all higher than the standardized means by a difference of at least 0.22, however statistical significance was not assessed. The range of the means in the SRNA group is very narrow, spanning a difference of only 0.25 between the highest and lowest means, where the range in the standardized results is a difference of 0.65. Typically, the results in a study with a larger sample size are less variable when compared to one with a smaller sample size, however the opposite effect can be appreciated in this study. This may be attributed to acquiescence and sponsor bias. Table 2 Mean SSEPQ Comparisons SSEPQ Question 1. The podcasts are easy to access 2. The podcasts are useful for learning about this subject 3. The podcasts motivate me to learn about this subject 4. The podcasts make it easier to learn about this subject 5. I am satisfied with the podcasts as a learning tool for this subject 6. The podcasts provide clear information about the theoretical content of the topic 7. The podcasts provide clear information about the practical content of the topic 8. The content of the podcasts is well organized 9. The information contained in the podcasts is academically rigorous 10. The design of the podcasts makes them appealing Standardized Results (mean) n=376 3.49 3.34 DNP Project Results mean Difference 3.71 (n=24) 3.88 (n=24) +0.22 +0.54 2.84 3.87 (n=23) +1.03 3.28 3.91 (n=23) +0.63 3.44 3.87 (n=23) +0.43 3.27 3.78 (n=23) +0.51 3.16 3.91 (n=23) +0.75 3.18 3.03 3.96 (n=23) 3.74 (n=23) +0.78 +0.71 2.85 3.87 (n=23) +1.02 PODCASTS IN NURSE ANESTHESIA EDUCATION 22 Additionally, mean scores were analyzed based on years of experience as a registered nurse, age of the students, and between participants who listened to all six podcasts and those who listened to less than six. Nurses with 11 or more years of experience (n=4) were overall more satisfied than nurses with less than 10 years of experience (n=21). The nurses with the lowest mean satisfaction scores had between six and ten years of experience (n=12). Considering the typical relationship where age is proportional to years of experience in a profession, the results of the analysis of age compared to satisfaction scores are not surprising. The overall least satisfied students were ages 26-30 (n=16), and the most satisfied were 36 years old and older (n=4). There was no noticeable difference in satisfaction between those who listened to all six podcasts (n=22) and those who listened to less than six (n=3). Interpretation/Discussion Almost half (48%) of the SRNAs reported listening to podcasts regularly, which may reflect on the result that 88% of the SRNAs listened to all 6 of the podcasts for this study. The SRNAs may have also been motivated to listen to the podcasts since the information in them focused on core anesthesia concepts that are discussed in clinical situations and will appear on the licensing exam required after graduation. Prior to administering the post-intervention survey, it was speculated that the podcasts would be useful for multitasking. 88% of SRNAs reported listening to the podcasts in the car or while driving, while exercising, while cooking or cleaning, or doing other activities such as bathing their child, getting ready in the morning, and mowing the lawn. Only 12% of the SRNAs reported listening to the podcasts as their sole focus. These statistics support the assumption that podcasts are a learning modality that allow students to multitask. It could be difficult to utilize other non-podcast educational tools, such as YouTube or video lectures, while participating in any of the common activities of daily living reported in the PODCASTS IN NURSE ANESTHESIA EDUCATION 23 survey. The non-podcast alternative learning modalities require the learner to view learning material as opposed to the audio-only approach that the podcasts have. SRNAs appear to listen to podcasts in addition to performing other activities simultaneously. These activities would otherwise consume time, making it unavailable for studying or using alternative, non-podcast forms of educational adjuncts. Overall, the SRNAs had higher mean satisfaction scores than the standardized results. It is conceivable that the SRNAs were very enthusiastic about receiving an educational tool that could be used during activities that would otherwise not be spent studying. The standardized studys participants totaled 376, where the sample size in this study was much smaller, possibly accounting for the differences in mean scores. Prior to administering the satisfaction survey, it was speculated that the youngest and least experienced of the SRNAs would have been the most satisfied with the podcasts as they are likely the range of students most accustomed to learning with technology. The exact opposite was true, however, and the 26-30-year-old SRNAs and those with 6-10 years of experience as a nurse were the least satisfied. These results could also be affected by the difference in sample size between the groups compared with one another. There were several limitations in this study. The number of possible study participants was already low at 33. The results showed that 26 participants began the satisfaction survey, but only 23 completed it. Because of the very low sample size, parametric comparisons were not able to be made. Comparisons were made against the validated SSEPQ, but the low sample size in addition to possible acquiescence and sponsor bias may have affected the results. It is also possible that the topics of the podcasts targeted a specific group of people with exactly the information they wanted to consume. This high specificity may have left the SRNAs more satisfied than the participants from the comparison study who may not have been as interested in PODCASTS IN NURSE ANESTHESIA EDUCATION 24 the topics of the educational podcasts they listened to. Although the survey retrieved data from few participants, it should be noted that in the first 45 days of the podcasts free public access, they received 11,732 listens combined. Considering there are roughly 53,000 Certified Registered Nurse Anesthetists (CRNAs) and SRNAs in the United States, it is speculated that the educational podcasts were listened to by a large portion of the nurse anesthesia community (American Association of Nurse Anesthetists, 2019). Although no formal study was performed to assess the opinions of the public who have listened to the podcasts, the large number of listens in a relatively short period of time may suggest that podcasts are a popular way for CRNAs and SRNAs to consume educational anesthesia content. Ethical Considerations/Protection of Human Subjects Marian Universitys Institutional Review Board determined the project was exempt from the need of human subjects protections; therefore, the project was approved by the Leighton School of Nursing. Conclusion Appealing SRNAs attention by creating relevant educational podcasts has provided these learners with confidence in their abilities to learn and grow through using an alternative didactic adjunct. This opinion is formed based on the mean satisfaction scores obtained from the postintervention survey that was taken by the Marian University SRNAs after they listened to the podcasts. The SRNAs mean satisfaction scores are supported by the control mean satisfaction scores described in Alarcn et al. (2017). It is also evident that SRNAs enjoy repurposing time that would otherwise be unavailable for studying, by listening to podcasts in addition to performing other necessary activities of daily living. PODCASTS IN NURSE ANESTHESIA EDUCATION 25 Although these six educational anesthesia podcasts have sought to help close the gap around the deficit of complementary educational resources, there is an infinite amount of room left to continue to develop different types of learning modalities geared toward enhancing nurse anesthesia education. PODCASTS IN NURSE ANESTHESIA EDUCATION 26 References Alarcn, R., Bendayan, R., & Blanca, M. J. (2017). The student satisfaction with educational podcasts questionnaire. Psychological Writings, 10(2), 126-133. http://dx.doi.org/10.5231/psy.writ.2017.14032 American Association of Nurse Anesthetists. (2019). About us. Retrieved from https://www.aana.com/about-us Andrejco, K., Lowrance, J., Morgan, B., Padgett, C., & Collins, S. (2017). Social media in nurse anesthesia: A model of reproducible educational podcasts. American Association of Nurse Anesthetists, 85(1), 10-16. Retrieved from https://www.aana.com/docs/defaultsource/aana-journal-web-documents-1/social-media-0217-pp1016.pdf?sfvrsn=89cd48b1_4 Back, D. A., von Malotky, J., Sostmann, K., Hube, R., Peters, H., & Hoff, E. (2017). Superior gain in knowledge by podcasts versus text-based learning in teaching orthopedics: A randomized controlled trial. Journal of Surgical Education, 74(1), 154-160. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/27651055 Brust, T., Cooke, L., & Yeung, M. (2015). A randomized-controlled trial comparing efficacy and user satisfaction of audio podcasts versus a traditional lecture on multiple sclerosis in family medicine resident education. Neurology, 84(14). Retrieved from http://n.neurology.org/content/84/14_Supplement/P4.195 Huang, W., Huang, W., Diefes-Dux, H., & Imbrie, P. K. (2006). A preliminary validation of attention, relevance, confidence, and satisfaction model-based instructional material motivational survey in a computer-based tutorial setting. British Journal of Educational Technology, 37, 243-259. http://dx.doi.org/10.1111/j.1467-8535.2005.00582.x PODCASTS IN NURSE ANESTHESIA EDUCATION 27 Kalludi, S., Punja, D., Pai, K., & Dhar, M. (2013). Efficacy and perceived utility of podcasts as a supplementary teaching aid among first-year dental students. Australian Medical Journal, 6(9), 450-457. http://dx.doi.org/10.4066/AMJ.2013.1786 Keller, J. M. (1987). Development and use of the ARCS model of instructional design. Journal of Instructional Development, 10(3), 2-10. Retrieved from http://www.jstor.org.forward.marian.edu/stable/30221294 Lien, K., Chin, A., Helman, A., & Chan, T. (2018). A randomized comparative trial of the knowledge retention and usage conditions in undergraduate medical students using podcasts and blog posts. Cureus, 10(1). http://dx.doi.org/10.7759/cureus.2065 Lowrance, J. (2019). From the head of the bed...a podcast for the anesthesia community. Retrieved from https://www.fromtheheadofthebed.com/about/ Matava, C. T., Rosen, D., Siu, E., & Bould, D. M. (2013). eLearning among Canadian anesthesia residents: A survey of podcast use and content needs. BMC Medical Education, 1-8. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3648490/pdf/1472-692013-59.pdf McKinney, D., Dyck, J., & Lubar, E. (2009). iTunes university and the classroom: Can podcasts replace professors? Computers and Education, 52(3), 617-623. http://dx.doi.org/10.1016/j.compedu.2008.11.004 Miesner, A. R., Lyons, W., & McLoughlin, A. (2017). Educating medical residents through podcasts developed by PharmD students. Currents in Pharmacy Teaching and Learning, 9, 683-688. http://dx.doi.org/10.1016/j.cptl.2017.03.003 Morris, N. (2015). Podcasts and mobile assessment enhance student learning experience and academic performance. Bioscience Education, 16(1). http://dx.doi.org/10.3108/beej.16.1 PODCASTS IN NURSE ANESTHESIA EDUCATION 28 Rainsbury, J. W. & McDonnell, S. M. (2006). Podcasts: An educational revolution in the making? Journal of the Royal Society of Medicine, 99, 481-482. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1557886/pdf/0481.pdf Scheil, A. (2018). Educational podcasts in higher learning: A literature review. Unpublished manuscript, Marian University. Vogt, M., Schaffner, B., Ribar, A., & Chavez, R. (2010). The impact of podcasting on the learning and satisfaction of undergraduate nursing students. Nurse Education in Practice, 10, 38-42. doi:10.1016/j.nepr.2009.03.006 Wolpaw, J. & Toy, S. (2018). Creation and evaluation of an anesthesiology and critical care podcast. The Journal of Education in Perioperative Medicine, 19(4), 1-16. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5991777/pdf/i2333-0406-20-11f.pdf PODCASTS IN NURSE ANESTHESIA EDUCATION Appendices Appendix A: Student Satisfaction with Educational Podcasts Questionnaire (SSEPQ) 29 PODCASTS IN NURSE ANESTHESIA EDUCATION 30 Appendix B: Podcasts as a Learning Adjunct in Nurse Anesthesia Education - Satisfaction Survey Q1 Consent (Details omitted) Q2 Please select the year of your expected graduation date from Marian University's nurse anesthesia program o 2020 (1) o 2021 (2) Q3 Please select the age range you fit into o 20-25 years old (1) o 26-30 years old (2) o 31-35 years old (3) o 36-40 years old (4) o 41-45 years old (5) o 46-50 years old (6) o 51+ years old (7) PODCASTS IN NURSE ANESTHESIA EDUCATION Q4 Please select your gender o Male (1) o Female (2) o Neither (3) o Combo of male and female (4) o Prefer not to answer (5) Q5 Please select the number of years you've been a registered nurse o 1-2 years (1) o 3-5 years (2) o 6-10 years (3) o 11-15 years (4) o 16-20 years (5) o 21 + years (6) 31 PODCASTS IN NURSE ANESTHESIA EDUCATION 32 Q6 How often do you listen to podcasts? o Never (1) o Rarely (less than 1-2 times per month) (2) o Sometimes (1-2 times per month) (3) o Regularly (1-2 times per week) (4) o Daily (1 or more per day) (5) Q7 Outside of traditional didactic learning, which additional educational modalities are most beneficial to you? (Select all that apply) Recorded video lectures (1) YouTube/videos online (2) Podcasts (3) Textbooks (4) Slide presentation notes (5) Other (Please specify) (6) ________________________________________________ None (7) PODCASTS IN NURSE ANESTHESIA EDUCATION Q8 How many podcasts did you listen to out of the 6 total that were recorded with Ashley Scheil and Skyler Rouhselang on From the Head of the Bed? o 0 (1) o 1 (2) o 2 (3) o 3 (4) o 4 (5) o 5 (6) o 6 (7) Q9 Please select the podcasts that you listened to #44 Clinical Flow: From OR Set Up Through Intubation - Ashley Scheil (1) #45 The Anesthesia Machine - Ashley Scheil (2) #46 Pharmacokinetics of Volatile Anesthetics - Skyler Rouhselang (3) #47 Pharmacodynamics of Volatile Anesthetics - Skyler Rouhselang (4) #48 IV Induction Agents - Ashley Scheil (5) #49 Local Anesthetics - Skyler Rouhselang (6) None (7) 33 PODCASTS IN NURSE ANESTHESIA EDUCATION Q10 How did you listen to the podcasts? (Select all that apply) While driving/In the car (1) While cooking or cleaning (2) While exercising (3) While sitting and focusing solely on the podcasts (4) Other (Please specify) (5) ________________________________________________ Did not listen to any podcasts (6) Q11 The podcasts are easy to access o Strongly agree (1) o Agree (2) o Disagree (3) o Strongly disagree (4) Q12 The podcasts are useful for learning about this subject o Strongly agree (1) o Agree (2) o Disagree (3) o Strongly disagree (4) 34 PODCASTS IN NURSE ANESTHESIA EDUCATION Q13 The podcasts motivate me to learn about this subject o Strongly agree (1) o Agree (2) o Disagree (3) o Strongly disagree (4) Q14 The podcasts make it easier to learn about this subject o Strongly agree (1) o Agree (2) o Disagree (3) o Strongly disagree (4) Q15 I am satisfied with the podcasts as a learning tool for this subject o Strongly agree (1) o Agree (2) o Disagree (3) o Strongly disagree (4) 35 PODCASTS IN NURSE ANESTHESIA EDUCATION Q16 The podcasts provide clear information about the theoretical content of the topic o Strongly agree (1) o Agree (2) o Disagree (3) o Strongly disagree (4) Q17 The podcasts provide clear information about the practical content of the topic o Strongly agree (1) o Agree (2) o Disagree (3) o Strongly disagree (4) Q18 The content of the podcasts is well organized o Strongly agree (1) o Agree (2) o Disagree (3) o Strongly disagree (4) 36 PODCASTS IN NURSE ANESTHESIA EDUCATION Q19 The information contained in the podcasts is academically rigorous o Strongly agree (1) o Agree (2) o Disagree (3) o Strongly disagree (4) Q20 The design of the podcasts makes them appealing o Strongly agree (1) o Agree (2) o Disagree (3) o Strongly disagree (4) End of Block: Consent 37 PODCASTS IN NURSE ANESTHESIA EDUCATION 38 Appendix C: Table 1. DNP SRNA Participant Characteristics DNP Participant Characteristics Expected Graduation Date n=26 2020 2021 Age n=26 26-30 31-35 36-40 41-45 45-50 51+ Gender n=25 Male Female Prefer not to answer Years as an RN n=25 3-5 years 6-10 years 11-15 years 16-20 years 21+ years How often do you listen to podcasts? n=25 Never Rarely (less than 1-2 times per month) Sometimes (1-2 times per month) Regularly (1-2 times per week) Daily (1 or more per day) Outside of traditional didactic learning, which additional educational modalities are most beneficial to you? n=84 Recorded video lectures YouTube/Videos online Podcasts Textbooks Slide presentation notes Other (Hands-on/simulation) How many podcasts did you listen to out of the 6 total that were recorded with Ashley Scheil and Skyler Rouhselang on From the Head of the Bed? n=25 0 1 2 3 4 5 6 How did you listen to the podcasts? n=43 While driving/in the car While cooking or cleaning Frequency n 12 (46%) 14 (54%) 16 (61%) 6 (23%) 1 (4%) 2 (8%) 0 1 (4%) 5 (20%) 19 (76%) 1 (4%) 9 (36%) 12 (48% 1 (4%) 2 (8%) 1 (4%) 2 (8%) 5 (20%) 6 (24%) 10 (40%) 2 (8%) 18 (21%) 21 (25%) 15 (18%) 14 (17%) 14 (17%) 2 (2%) 0 0 0 0 3 (12%) 0 22 (88%) 23 (53%) 8 (19%) PODCASTS IN NURSE ANESTHESIA EDUCATION While exercising While sitting and focusing solely on the podcasts Other (getting ready in the morning, bathing child, mowing lawn) 39 3 (7%) 5 (12%) 4 (9%)  ...

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