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PACU NURSE EDUCATION 1 Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2023 Providing Post Anesthesia Care Unit Nurse Education on Commonly Used Anesthetic Medications Hilda Bartel Marian University Leighton School of Nursing Chair: Bradley Stelflug, DrAP, MBA, CRNA , DrAP, CRNA_____ (Signature) Project Team Members: Leslie Smith, MBA, BSN, RN (Signature) PACU NURSE EDUCATION Date of Submission: 2 Month, Day, Year Table of Contents Abstract .................................................................................................................................................. 4 Introduction ............................................................................................................................................ 5 Background ......................................................................................................................................... 6 Problem Statement ............................................................................................................................. 9 Organizational Gap Analysis of Project Site ..................................................................................... 10 Review of the Literature ........................................................................................................................ 10 Theoretical Framework or Conceptual Model or Evidence-Based Practice Model .................................. 11 Goals, Objectives, and Expected Outcomes ........................................................................................... 11 Project Design/Methods ........................................................................................................................ 12 Project Site and Population................................................................................................................ 12 Measurement Instruments ................................................................................................................ 13 Data Collection Procedures ................................................................................................................ 13 Ethical Considerations/Protection of Human Subjects........................................................................ 14 Data Analysis and Results ...................................................................................................................... 14 Discussion ............................................................................................................................................. 15 Conclusion............................................................................................................................................. 16 References ............................................................................................................................................ 17 Appendix .............................................................................................................................................. 26 Appendix A9 Appendix B.10 Appendix C.10 Appendix D.11 Appendix E.11 Appendix F.13 PACU NURSE EDUCATION 3 PACU NURSE EDUCATION 4 Abstract Medication errors and interactions happen every day in the perioperative setting. It is the responsibility of the post-anesthesia care unit (PACU) nurse to manage pain, nausea, vomiting, and maintain hemodynamics after surgery and prior to discharge. This project aimed to educate and/or re-educate PACU nurses on commonly used anesthesia medications in a rural hospital in southern Indiana. This project was requested by the nurses and the director of perioperative services as their 2023 Anesthesia Competency and had three weeks to complete this training. A pre-test was distributed prior to the educational PowerPoint on commonly used medications by anesthesia providers. After reviewing the PowerPoint, a post-test was distributed for assessment. The tests were distributed to the nurses work email by Qualtrics.com to track individual responses. The average score on the pre-test was 69.2%, the average post-test score was 83.3%, and the commonly missed question was on the medication dexmedetomidine. This project showed the importance of providing educational material on commonly used anesthetic medications for PACU nurses. Keywords: PACU, Post anesthesia care unit, medication errors, recovery, education PACU NURSE EDUCATION 5 Providing PACU Nurse Education on Commonly Used Anesthetic Medications Introduction This project is submitted to the faculty of Marian University Leighton School of Nursing as partial fulfillment of degree requirements for the Doctor of Nursing Practice, Nurse Anesthesia Track. The post-anesthesia care unit (PACU) is a stressful, fast-paced unit caring for patients recovering from anesthesia. Nurses working in these units must be able to recognize early the signs that indicate delayed awakening, bronchospasm, or need for reintubation. Nurses also need to know the medications that can be given safely while anesthetic medications are wearing off to avoid a patient overdose or prolongation of the anesthetic medications. Medication errors can be detrimental to patients and must be avoided. The Pennsylvania Patient Safety Authority queried medication errors from the Pennsylvania Patient Safety Reporting System (PA-PSRS) database for the year 2017. In their published report of medication errors during the perioperative timeframe, 27% of medication errors occurred in the PACU, of that 22.5% were wrong frequency, 33.2% were analgesics, 53.3% were non-opioids and 44% were opioids (Cierniak et al., 2018). According to Talley et al (2019), 15% of postoperative adverse events were due to communication failures between the OR team and receiving nursing team. To reduce medication errors, there needs to be proper documentation and efficient handoff reports from the Certified Registered Nurse Anesthetist (CRNA) or anesthesia provider and the PACU nurse and education on regularly used anesthesia medications. It has been recommended that handoff should be in both verbal and written communication to promote safety and clarity of what was given (Talley, 2019). Postoperative delirium is associated with major peri-operative complications, prolonged hospital stays, mortality, and morbidity (van Norden, 2021). Signs of delirium may include PACU NURSE EDUCATION extreme disturbances of arousal, attention, orientation, perception, intellectual function, affect, and accompanied by fear and agitation (Nagelhout, 2017). According to Nagelhout (2017), 510% of general surgery patients and 62% after operative hip procedures have been reported to have postoperative delirium. Dexmedetomidine, a highly potent alpha-2 agonist, has benefits that decrease the chance of delirium (van Norden, 2021). Van Norden (2021) used dexmedetomidine for its antisympathetic, co-analgesic, anxiolytic, and sedative effects that do not significantly cause respiratory depression to decrease postoperative delirium in elderly patients. This project aimed to improve PACU staff education on medications frequently used by anesthesia providers to improve patient care needs which improves patient safety in the postanesthesia care setting. Background The CRNA is responsible for giving many medications during a patients anesthetic including pain medication, antiemetics, paralytics, and reversal agents. Many of these medications are not taught in nursing school so can be confusing or not seem like necessary information to the PACU nurses. Information necessary for patients safety about the medications frequently used along with their half-life time, the reason for giving, side effects, and reversals will help reduce overmedication and prolonged stay in recovery (Cierniak et al., 2018, Talley, 2019). Additional medication information may also help the PACU nurse identify delayed awakening and residual neuromuscular blockade which may lead to reintubation. Elisha et al (2021) listed adverse effects of residual neuromuscular blockade for surgical patients as having an increased risk of critical respiratory events in the PACU, symptoms, and signs of profound muscle weakness, and postoperative pulmonary complications such as atelectasis or 6 PACU NURSE EDUCATION pneumonia. Reinsertion of an endotracheal tube after planned extubation (RAP) in the PACU is a rare but serious complication. Haritos, et. al (2019) found the RAP range of 0.06-1.8% along with some contributing factors like no train-of-four (TOF) documentation and neostigmine administration leading to RAP. Neostigmine is a neuromuscular blocker (NMB) reversal agent commonly used by anesthesia providers. However, it is not to be used for moderate to deep neuromuscular blockade that was achieved with Rocuronium (Haritos et al., 2019). Another commonly used reversal agent that providers use is sugammadex which is a selective binding agent that encapsulates the paralytic drug and prevents it from binding to the receptor (Elisha et. al, 2021). Recurarization is rare with sugammadex but can happen due to the dose of reversal being based on the depth of the paralytic block (Elisha et. al, 2021). Delayed awakening can be very challenging for the anesthesia provider and cause the patient to remain in the PACU longer than intended. Many interactions can occur with the medications used preoperatively, intraoperatively, and post-operatively which can prolong the effects and emergence. Volatile anesthetics (VA) and intravenous (IV) medications are metabolized and eliminated differently by the body. According to Nagelhout (2017), VA anesthetics are prolonged due to hypoventilation which limits the exhalation and elimination of the drug. IV medications may be prolonged due to pharmacokinetic alterations from changes in drug distribution, redistribution, and elimination (Nagelhout, 2017). If delayed awakening appears to be caused by electrolyte imbalances, hypothermia, hypo- hyperglycemia, hypocalcemia, hypo- hypermagnesemia, treatment should be aimed at correcting the cause (Nagelhout, 2017). Post-operative delirium (PD) is a common complication in the PACU setting. PD is associated with major peri-operative complications, prolonged hospital stays, mortality, and 7 PACU NURSE EDUCATION morbidity (van Norden, 2021). According to Nagelhout (2017), 5-10% of general surgery patients and 62% after operative hip procedures have been reported to have postoperative delirium. The most common cause of PD in the PACU setting is recovery from inhalation anesthetics (Nagelhout, 2017). According to Nagelhout, Sevoflurane has been associated with emergence delirium in children, Ketamine can increase the chance of delirium in patients between 16 and 65 years of age. Nagelhout (2017) states premedicating with atropine or scopolamine, which both cross the blood brain barrier, can cause unwanted reactions of central anticholinergic syndrome that may be confused with delirium. Other medications have side effects of delirium include naloxone, muscle relaxants, antibiotics included cefazolin, penicillin, streptomycin, antituberculosis drugs, antiviral, anticonvulsant (i.e., phenytoin), and antiparkinsonian agents (i.e., levodopa) (Nagelhout, 2017). Dexmedetomidine, an alpha-2 agonist, is commonly used by anesthesia providers due to its sedative effects that resemble a natural sleep (Nagelhout, 2017). In the previously mentioned study by van Norden (2021), the predicted incidence of PD was 44% however, their study showed only 5% of the patients experienced PD after having an infusion of dexmedetomidine throughout the procedure and in the ICU. According to Flood et. al, (2015), Flumazenil is a selective benzodiazepine antagonist that can reverse benzodiazepine-induced delirium. Flood et. al, (2015), states Naloxone is a nonselective opioid antagonist that can be used to reverse opioid overdose that may be causing hypoventilation contributing to PD and delayed awakening. Both reversal agents should be given in small increments and titrated to the patients response (Flood et. al, 2015). If delirium is caused by metabolic disturbances such as acidosis, alkalosis, electrolyte imbalances, and porphyria the treatment is directed towards the correction of the cause. 8 PACU NURSE EDUCATION 9 Being aware of the half-life, side effects, and reversals is important for PACU nurses to anticipate the correct medication to administer if one is needed. Misal (2016), states that full physiologic recovery can occur in 40 mins in 40% of the patients. This project was completed for a critical access hospital in rural Indiana. Critical access hospitals only have 25 patient rooms and many outpatient/same-day surgeries occur in these facilities (RUIhub, 2021). The need for education and having a quick reference of medications for the PACU nurses is important to keep them vigilant in potential side effects like seizures, allergic reactions, or additive effects of medications causing delayed awakening (Misal et al., 2016). Many anesthetists perform deep extubation which consists of extubating the patient while they are spontaneously breathing, without airway reflexes, and still under VA anesthesia (Juang et al., 2021). This brings the concern of hypoxemia for patients in PACU with contributing factors like sleep apnea or COPD. Many anesthesia providers are comfortable with deep extubation, or it is safer for the patient based on the procedure completed. Such as craniotomy, it is important to avoid coughing and bucking which may increase the risk of bleeding. The PACU nurse should be aware of what a deep extubation means so they can prepare for appropriate interventions. Problem Statement Patients are in a vulnerable state during the perioperative period, with the most vulnerable periods including intraoperative and postoperative. PACU nurses need to be vigilant in identifying complications like hypoxia, bronchospasm, laryngospasm, and appropriate medication interactions with anesthetic medications. The focus of this study was to fulfill the need for education on commonly used anesthetic medication for PACU nurses. To achieve this goal, the project included an educational PowerPoint for PACU nurses with common anesthetic PACU NURSE EDUCATION 10 medications with the reasons for administration, half-life, side effects, and reversals. Along with the PowerPoint, a competency self-exam was completed by the nurses before and after the completion of the education (see Appendix A). Organizational Gap Analysis of Project Site This project was implemented in a rural area of Indiana. This location has employed recently graduated nurses or nurses who have not worked in PACU previously and has requested education on commonly used anesthetic medications. Providing the education on medications they will typically encounter will help identify areas to improve in personal growth and provide safe and effective care for patients recovering from anesthesia. Some comments from nurses at this hospital confirm the need for this education. Comments such as I get the report from anesthesia about meds, but I dont know what they are talking about and they gave 160 mg of Propofol but dont know if it was a lot or in range for this patient. The need for this project came directly from the director of the unit to help fill the gap and improve education on medications which will reduce the chance for poor patient outcomes in the PACU. Review of the Literature While gathering literature for this study, the databases used were PubMed, CINAHL, and Google Scholar. The phrases searched were post-anesthesia care unit or PACU or recovery and medication errors and education. Adding in the exclusions of full articles, English, publication in the last 5 years, and removing duplicates narrowed it down to 63 articles. Finding articles that only pertained to education on anesthesia medications or common medication errors in the PACU were used and included in the development of this project. There is limited research on this topic which shows there is a need for education on commonly used medications for anesthesia. The literature review matrix with used sources is found in Appendix B. PACU NURSE EDUCATION 11 Theoretical Framework or Conceptual Model or Evidence-Based Practice Model The framework used for this project was The Iowa Model of Evidence-Based Practice to Promote Quality Care (see Appendix C). This model was developed at the University of Iowa Hospitals and Clinics to help the implementation of research into their practice for healthcare professionals (Titler et al., 2001). In this framework, if there is a problem identified, such as the need for education on medications, a literature review is performed. If there is enough evidence showing that there is a need for education and change is needed in their institute, then a quality improvement project can begin. For this project, there are limited studies previously done but evidence to show that complications can be avoided if properly educated. The model then suggests forming a team to implement the assessments and allows for questions if this is still a need in the institute. The team for this project to implement the assessment and education was formed with this researcher, Marian University faculty, and the director of the unit at the institute this was presented. Goals, Objectives, and Expected Outcomes This project aimed to educate and/or re-educate PACU nurses on commonly used anesthesia medications. The education was presented via a PowerPoint presentation with the commonly used medications along with the indications, typical doses, half-life times, side effects, and reversals. The main objectives of this project were to assess the knowledge of PACU nurses on anesthesia medications. The areas that are lacking were reassessed after education is provided. Nurses participating in this project were able to demonstrate knowledge of the medications with a post-assessment. Individuals who scored less than 70% on the posttest will have remediation provided by the director to ensure understanding of medications. With this PACU NURSE EDUCATION 12 education, the expectation is that the nurses will be able to provide medication dosages accurately along with recognizing side effects promptly. The PowerPoint was included in their annual anesthesia competency training that included a pre and post-exam that was completed in two weeks from implementation. Project Design/Methods This was an educational intervention for PACU nurses structured to obtain quantitative data related to frequently used anesthesia medications. Project Site and Population This project was implemented at a critical access hospital in rural Indiana (see Appendix D for site agreement). This was an educational PowerPoint used during employee annual anesthesia competency training. The PACU nurses participated in a brief pre-quiz, the PowerPoint on medications, followed by a post-quiz. The employee compliance was distributed by the director of clinical operations of perioperative services. The elements mentioned in this study were distributed by this researcher and the director. The results of the quizzes were reported via Qualtrics and analyzed by this researcher for education evaluation. As part of required hospital competency training, this education PowerPoint was completed by employees. A barrier that was met during implementation was employee access if the employee is on medical leave or unavailable during the training. Allowing the employee access to the training via a personal email address was an option to complete training. Limited resources were needed to complete this training. Employees were able to access this training via their functioning work email address. SWOT analysis stands for strengths, weaknesses, opportunities, and threats (SWOT) for the project during development (see Appendix E). The strengths of this project included the PACU NURSE EDUCATION 13 current need for education on anesthesia medications as they relate to PACU recovery. The clinical site that was a stakeholder in this study needing this education due to new staff that may not have the experience of working in a PACU prior. Weaknesses were things that I can improve to better this project. These include better time management to meet deadlines appropriately, along with, schedule conflicts within the group. Personal and professional schedules minorly interfered with meeting times and schedule changes at the last minute. Opportunities for this project included better patient outcomes, reduced PACU recovery times, and reduced medication interactions. Threats were external factors that are not in my control. The threats to this project included COVID-19, staff resistance, and IRB approval. Measurement Instruments To measure the outcomes of this DNP project the following instrument was used: pre and post-test surveys on anesthesia medication questions (see Appendix A). There are no measures or tools developed to guide the understanding of anesthesia medications for PACU nurses. The questions formulated for the pretest/ posttest were validated by Dr. S. Ditty MDA, Dr. R. Sorrell MDA, Dr. K. Lake DNP-CRNA, and Dr. P. Strube DNAP, CRNA, MBA, APNP, APRN, LTC. Data Collection Procedures Data was collected utilizing a survey created in Qualtrics (see Appendix A). Participants completed the pre-and post-test in their educational PowerPoint during anesthesia competency training. The participants received full credit for completing and participating in this educational training regardless of score. Individuals who scored less than 70% on the posttest will have remediation provided by Leslie Smith to ensure understanding of the medications. Their identity and results are protected by password protected access that is only available to the committee of PACU NURSE EDUCATION 14 this project. Questions pertained to medications commonly used in the OR by anesthesia providers that may affect the patient in PACU. Other questions evaluated their knowledge of the use, side effects, and interactions of commonly used anesthetic medications. The participants had two weeks to complete the training. After one week, a reminder email was sent out asking for the remaining employees to complete the training. After the two-week timeframe was completed, the results of the pre and post-test were reviewed by this writer for further review and analysis. Ethical Considerations/Protection of Human Subjects Marian University Institutional Review Board (IRB) approval was obtained before initiating the DNP Project (see Appendix F). No patients participated in this study which eliminated any patient harm. Participant confidentiality was assured by using a one-time only link to complete the tests. The results are protected and only available to the project coordinators utilizing a password-protected document. Only the project coordinators will have access to the passwords. Data Analysis and Results Quantitative data was gathered from the survey instrument Qualtrics. The pre-test survey was distributed prior to the educational PowerPoint presentation. After verification that the nurse had completed the pre-test survey, the educational presentation was given, followed by the posttest survey sent after viewing time allowed. This project was presented to the PACU nurses as part of their annual compliance training. The number of participants that completed the training was eight. The average score for the pretest was 69.2% with the average years of experience ranging from 3-5 years. The commonly missed questions were those asking for half-life and side effects of dexmedetomidine. After the presentation, 83.3% was the average score recorded. The commonly missed question was the side effects of dexmedetomidine. This was reported to the PACU NURSE EDUCATION 15 director that had requested this training to request background if it was a poorly written question or information was not clearly presented. See appendix A for test questions provided to participants. Looking at the results for the side effects of dexmedetomidine question, there is not one reason that stands out to why the question is missed. One participant chose three options instead of two, another only chose one option, and two participants chose the wrong answers. This may have been due to time restrictions and not fully reviewing the presentation. Discussion The limitations of this project included staff resistance/compliance and group scheduling conflicts. One limitation that was prominent in this project was scheduling conflicts for the participants who were working while also requested to complete the training. This project was set to be completed within two weeks but needed to be extended an extra week, so the participants had adequate time. The presentation had a lot of information included which may have been too much to review while working. The strengths of this project included being online, being part of education compliance within their facility, and better patient outcomes. The overall score improved after the presentation to show a refresher on commonly used medications is needed for PACU nurses. In addition, no participant needed to have remediation with the director as part of their compliance training. Based on the results of this study there is a need for education on anesthesia medications for all PACU nurses. Anesthesia providers need to give a brief but complete PACU hand-off for patient safety. PACU nurses need to know commonly used anesthetic medications including their reversals, half-life, interactions, and side effects to prevent prolonged recovery time. PACU NURSE EDUCATION 16 Conclusion Commonly used medications by anesthesia providers can have interactions with PACU medications. It is important to know when the last dose of a narcotic is given, the half-life of the narcotic, reversals for paralytics, and the side effects of medications. Some anesthetic medications providers give are not discussed in detail while in training as a nurse. Continuing to provide a detailed hand-off report to PACU nurses in the future and allowing for questions is crucial for patient safety. Providing PACU nurses this educational PowerPoint improved their knowledge on anesthetic medications. PACU NURSE EDUCATION 17 References Banik, R. K., MD, Ph.D., Honeyfield, K., BA, Qureshi, S., MD, & Reddy, S. G., MD, FASA. (2021). Incidence and Mortality Rate of Perioperative Reintubation: Case Series of 196 Patients. AANA, 89(6), 476479. www.aana.com/aanajournalonline Cierniak, K. H., PharmD, MS, BCPS, Gaunt, M. J., PharmD, & Grissinger, M., RPh, FISMP, FASCP. (2018, December 19). Perioperative medication errors: Uncovering risk from behind the drapes [PDF]. http://patientsafety.pa.gov/ADVISORIES/Documents/201812_Perioperative.pdf. Dahlberg, K., Sundqvist, A.-S., Nilsson, U., & Jaensson, M. (2022). Nurse competence in the post-anaesthesia care unit in Sweden: A qualitative study of the nurses perspective. BMCNursing, 21(1). https://doi.org/10.1186/s12912-021-00792-z Elisha, S., Nagelhout, J. J., & Heiner, J. S. (2021). Current Anesthesia Practice. Elsevier. Flood MD MA, Pamela, Rathmell MD, James P., & Steven, S. M. (2015). Stoelting's pharmacology & physiology in anesthetic practice (Fifth ed.). Haritos, G., DNAP, CRNA, Smith, C. A., DNAP, CRNA, Hass, R. E., Ph.D., CRNA, PHRN, & Becker, A., MSN, CRNA. (2019). Critical events leading to endotracheal reintubation in the postanesthesia care unit: A retrospective inquiry of contributory factors. AANA Journal, 87(1), 5963. Juang, J., Cordoba, M., Xiao, M., Ciaramella, A., Goldfarb, J., Bayter, J., & Macias, A. (2021). Post-anesthesia care unit desaturation in adult deep extubation patients. BMC Research Notes, 14(1). https://doi.org/10.1186/s13104-021-05560-5 Miller, L. M. (2011). Emergence delirium in the post-operative adult. International Student Journal of Nurse Anesthesia, 10(2), 4649. PACU NURSE EDUCATION 18 Misal, U., Joshi, S., & Shaikh, M. (2016). Delayed recovery from anesthesia: A postgraduate educational review. Anesthesia: Essays and Researches, 10(2), 164. https://doi.org/10.4103/0259-1162.165506 Mraovic, B., Timko, N. J., & Choma, T. J. (2021). Comparison of recovery after sugammadex or neostigmine reversal of rocuronium in geriatric patients undergoing spine surgery: A randomized controlled trial. Croatian Medical Journal, 62(6), 606 613. https://doi.org/10.3325/cmj.2021.62.606 Nagelhout CRNA PhD FAAN, John J., Elisha EdD CRNA FAAN, Sass, & Elisha EdD CRNA FAAN, Sass. (2017). Nurse anesthesia (6th ed.). Saunders. Robert, C., Soulier, A., Sciard, D., Dufour, G., Alberti, C., Boizeau, P., & Beaussier, M. (2021). Cognitive status of patients judged fit for discharge from the post-anaesthesia care unit after general anaesthesia: A randomized comparison between desflurane and propofol. BMC Anesthesiology, 21(1). https://doi.org/10.1186/s12871-021-01287-9 Rural Health Information Hub. (2021, September 3). Critical access hospitals. https://www.ruralhealthinfo.org. https://www.ruralhealthinfo.org/topics/critical-accesshospitals Talley, D. A., Dunlap, E., Silverman, D., Katzer, S., Huffines, M., Dove, C., Anders, M., Galvagno, S. M., & Tisherman, S. A. (2019). Improving postoperative handoff in a surgical intensive care unit. Critical Care Nurse, 39(5), e13 e21. https://doi.org/10.4037/ccn2019523 Titler, M. G., Kleiber, C., Steelman, V. J., Rakel, B. A., Budreau, G., Everett, L. Q., ... Goode, C. J. (2001, December). The Iowa model of evidence-based practice to promote quality care. Critical Care Nursing Clinics of North America, 13(4), 497-509. PACU NURSE EDUCATION 19 van Norden, J., Spies, C. D., Borchers, F., Mertens, M., Kurth, J., Heidgen, J., Pohrt, A., & Mueller, A. (2021). The effect of perioperative dexmedetomidine on the incidence of postoperative delirium in cardiac and noncardiac surgical patients: A randomised, doubleblind placebocontrolled trial. Anaesthesia, 76(10), 1342 1351. https://doi.org/10.1111/anae.15469 Zhu, B., Sun, D., Yang, L., Sun, Z., Feng, Y., & Deng, C. (2020). The effects of neostigmine on postoperative cognitive function and inflammatory factors in elderly patients a randomized trial. BMC Geriatrics, 20(1). https://doi.org/10.1186/s12877-020-01793-4 PACU NURSE EDUCATION 20 Appendix A Pre-and post-test How many years of experience do you have as a PACU nurse? Which of the following medications is used to treat an overdose of Fentanyl? 0-1 year Naloxone 1-3 years Nalbuphine 3-5 years Buprenorphine 5+ years Methadone What is the indication for Propofol? What is the indication for use of midazolam? Hyperactivity Paralytic Apnea Reversal agent Anesthesia/Sedation Pain Hypertension Anxiolysis What is the duration of action of Propofol? 30 seconds 30 minutes 3-5 minutes 3-5 hours Which medication can reverse the effects of midazolam? Flumazenil Narcan Methadone Fluconazole What is the duration of action of Fentanyl? 3-6 minutes 30-60 minutes 1-2 hours 2-4 hours What is the half-life of dexmedetomidine? 2 minutes 2 hours 20 minutes 20 hours PACU NURSE EDUCATION Which of the following are serious side effects of Precedex? (Select two) Hypertension Hypotension Bradycardia 21 Glycopyrrolate is given to treat bradycardia, in addition to aid in reversing paralytic agents, but can cross the blood-brain barrier causing delayed awakening. True False Anxiety Which neuromuscular blocking agent can be reversed with sugammadex? Succinylcholine Rocuronium Cisatracurium Mivacurium The vagal blockade that occurs with an IV dose of glycopyrrolate may last for 2-3 hours 20-30 minutes 2-3 hours 24 hours PACU NURSE EDUCATION 22 Appendix B Literature Review Matrix Reference Banik, R. K., MD, Ph.D., Honeyfield, K., BA, Qureshi, S., MD, & Research Design & Level of Evidence Level 4 Theoretical /Conceptual Framework Purpose/ Aim Population /Sample n=x Variables Instruments /Data collection Results Implications for future research Implications for future practice Retrospective case series To estimate the incidence and causes of perioperative endotracheal reintubation and determine the mortality rate of reintubation. n = 196 Age, ASA status, surgical case, OR time, BMI, emergent or elective cases. QA database at the medical center, stored in passwordprotected data files and analyzed in a spreadsheet. This was limited due to self-reporting and only in one hospital system. However, it is consistent with previous findings and common risk factors for reintubation. In practice, we need to evaluate the risks of reintubation and possibly continue intubation longer in patients with several risk factors. Level 2 Prospective Study To identify the medication errors in the perioperative settings. n=1,137 Medication orders, handoff, documentation , pharmacy communicatio n, and medication reconciliation Analysts sent out a form to the PA-PSRS database for medication errors that occurred from 1/201712/2017. The reintubation rate was 0.09% and the incidence of reintubation was the same for genders. 47% of the reintubated patients were 65 years or older, and 76% of the group were ASA status of 3 or 4. Intraabdominal procedures carried the highest risk of reintubation and cases longer than 180 minutes increased the mortality as well. 1,137 reports came back reporting actual or potential medication errors. 73%, n=830 were from the intraoperative setting, and 27%, n=307 More research is needed to figure out how to prevent communication errors attributed to medication errors. In practice, implementing a streamlined way of medication ordering and developing a hand-off report with medication dose, time, and route may help reduce errors. Reddy, S. G., MD, FASA. (2021). Incidence and Mortality Rate of Perioperative Reintubation: Case Series of 196 Patients. AANA, 89(6), 476 479. www.aana.com/aanajournalonline Cierniak, K. H., PharmD, MS, BCPS, Gaunt, M. J., PharmD, & Grissinger, M., RPh, FISMP, FASCP. (2018, December 19). Perioperative medication errors: Uncovering risk from behind the drapes [PDF]. http://patientsafety.pa.gov/ADVISORIES/Documents/2 01812_Perioperative.pdf. PACU NURSE EDUCATION Dahlberg, K., Sundqvist, A.-S., Nilsson, U., & Jaensson, M. 23 Level 3 Interview/ qualitative To identify nurses perception of competence needed to work in a PACU setting, and what characterizes an expert nurse in the PACU Determine the incidence, and commonalities, and determine if the event of reintubation in the PACU could have been avoided. n=16 In-person interviews were recorded and re-read by two authors. Individual interviews were conducted, and data were analyzed using thematic analysis. Level 3 Retrospective cohort study n= 107,845 ASA physical status 3 and 4. This is a scale used to identify the risk and health status of the patient. This can vary by the provider's interpretation of physical status. Statistical analyses were conducted using IBM SPSS 19.0.1, IBM Corp, and an Excel spreadsheet. Level 5 Single arm, unblinded, observational study Evaluate the incidence of desaturation in the PACU following deep extubation. Determine if different case factors contribute to desaturation as well. n=300 No exclusions were set in place, and comorbidities such as a history of asthma were included. Put into two groups, those that desaturated in the PACU and those that did not. Used SAS software version 9.4 for statistical analysis. Level 1 A doubleblind, randomized controlled trial To evaluate the effect of sugammadex on neostigmine and the quality of recovery n = 40 Age 65 years or older, ASA status of 2 or 3, and under general anesthesia. The Wilcoxon rank-sum test was used to compare the two groups. The Fisher (2022). Nurse competence in the post-anaesthesia care unit in Sweden: A qualitative study of the nurses perspective. BMCNursing, 21(1). https://doi.org/10.118 6/s12912-021-00792-z Haritos, G., DNAP, CRNA, Smith, C. A., DNAP, CRNA, Hass, R. E., Ph.D., CRNA, PHRN, & Becker, A., MSN, CRNA. (2019). Critical events leading to endotracheal reintubation in the postanesthesia care unit: A retrospective inquiry of contributory factors. AANA Journal, 87(1), 5963. Juang, J., Cordoba, M., Xiao, M., Ciaramella, A., Goldfarb, J., Bayter, J., & Macias, A. (2021). Post-anesthesia care unit desaturation in adult deep extubation patients. BMC Research Notes, 14(1). https://doi.org/10.1186/s13104-021-05560-5 Mraovic, B., Timko, N. J., & Choma, T. J. (2021). Comparison of recovery after sugammadex or neostigmine reversal of rocuronium in geriatric patients undergoing spine from the PACU Six subthemes and three themes were identified. The main themes were being adaptable and creating a safer care environment. During the study period of 08/201002/2017, only 89 patients required reintubation. Male patients 58.4% and abdominal procedures (32.6%) were the highest common procedures in both groups. 13/300 (4.3%) patients had an episode of desaturation (SpO2<90% for longer than 10 seconds) in PACU. History of asthma was the notable comorbidity found in the desaturation group of 46.15% vs 17.77% of patients in this study. Both groups were given the reversal 5 min after surgery completion and a TOF of More research is needed on the competence of PACU nurses. In a practice setting, it is important to continue adding education to improve the competence of their staff. More research is needed at an individual level at the hospitals. This would help identify the events of reintubation and how to prevent them within that hospital. In practice, implementing a RAP predictive risk index can help prevent the incidence of reintubation because it will identify patients at high risk. This is an extension of the research by the author who also published Incidence of Airway Complications Associated with Deep Extubation in Ambulatory Ophthalmic and Head-and-Neck Surgery in Adults. In practice, it is important to keep the findings in mind but also continue to assess the appropriateness of deep extubation based on the individual patient. This was a limited study on one type of surgical procedure and more research In practice, we know that Sugammadex can reverse rocuronium faster and may be PACU NURSE EDUCATION 24 after rocuronium in geriatric patients undergoing lumbar spine surgery. surgery: A randomized controlled trial. Croatian Medical Journal, 62(6), 606 613. https://doi.org/10.3325/cmj.2021.62.606 Robert, C., Soulier, A., Sciard, D., Dufour, G., Alberti, C., Level 2 CONSORT Level 1 Randomized control study Boizeau, P., & Beaussier, M. (2021). Cognitive status of patients judged fit for discharge from the postanaesthesia care unit after general anaesthesia: A randomized comparison between desflurane and propofol. BMC Anesthesiology, 21(1). https://doi.org/10.1186/s12871021-01287-9 Zhu, B., Sun, D., Yang, L., Sun, Z., Feng, Y., & Deng, C. (2020). The effects of neostigmine on postoperative cognitive function and inflammatory factors in elderly patients a randomized trial. BMC Geriatrics, 20(1). https://doi.org/10.1186/s12877-02001793-4 Compare the cognitive status of inpatients without preoperative cognitive impairment while being anesthetized with either Desflurane or Propofol anesthesia at the time of discharge from the PACU. Observe the effect of different neostigmine doses on cognitive function and peripheral inflammatory factor levels in elderly patients. exact test was used to compare nominal-scale variables. n=60 Length of surgery, noise in the recovery room, and timing of the end of anesthetic to first cognitive test. Digit Symbol Substitution Test (DSST), Stroop Color Word interference test, and the Visual Verbal Learning Test (VLT) n= 120 No difference in age, sex, BMI, preoperative MMSE score, ASA classification, type of surgery, and underlying conditions. SPSS 21.0 software for statistical analysis, qualitative data expressed as frequency rate, one-way analysis of variance, and nonparametric test (rank kernel test) 2 twitches. The sugammadex group had a TOF of > 0.9 22 min faster than the neostigmine group. The sugammadex group showed faster recovery in the OR but the recovery times in the PACU and first ambulation were the same in both groups. Only two patients in the Desflurane group and three patients in the Propofol group had significant cognitive changes when discharged from PACU. would be needed to show different procedure recovery times. beneficial to use in longer cases to fully reverse and decrease the incidence of incomplete reversal. More research is needed to determine if this works with more patient populations. The study was limited by patient selection. In practice, it is important to know what medications we use that may delay discharge from the PACU. This study showed there is no large delay between the two anesthetics used. Doses of 0.02 mg/kg can reverse within 10 min, 0.03 mg/kg takes 5 mins and 0.04 mg/kg can lower the recovery time in PACU without increasing their length of hospital stay. Extubation and PACU times of the More research can be done to determine the doses given in other surgeries and compare Sugammadex. In practice, it is best to reverse a patient that has been given a muscle relaxant to avoid residual muscle relaxant and reintubation. PACU NURSE EDUCATION 25 groups given 0.02 mg/kg and 0.04 mg/kg were significantly shorter than the control group. When TOF is lower than 0.9 the patients should be routinely monitored and given muscle relaxant antagonists due to the sensitivity of throat muscles and decrease the chance of residual muscle relaxation. PACU NURSE EDUCATION 26 Appendix C IOWA Model of Evidence-Based Practice Used/reprinted with permission from the University of Iowa Hospitals and Clinics, copyright 1998. For permission to use or reproduce, please contact the University of Iowa Hospitals and Clinics at 319-384-9098 PACU NURSE EDUCATION 27 Appendix D Site Agreement March 30, 2022 To Whom it May Concern: IU White Memorial Surgery Department has partnered with Marian University to assist with one of the DNP projects. The project will entail medications used during surgical procedures. It will be an educational opportunity for the IU White surgical team in regard to medications, reasons for administration, half-life, side effects, and reversals. Thank you for this opportunity. Sincerely, Leslie M Smith, BSN RN Director - Clinical Operations of Perioperative Services Indiana University Health Frankfort and White Memorial Hospitals Frankfort Office: 765.656.3635/Fax: 765.656.3118 White Memorial Office: 574.583.1741/Fax: 574-583-1721 Cell: 765.654.8864 lsmith41@iuhealth.org PACU NURSE EDUCATION 28 Appendix E SWOT Analysis Strengths Weaknesses Current need for this education Clinical site need Schedule conflicts within the group Time management SWOT ANALYSIS Opportunities Threats Better patient outcomes Shortened PACU recovery time Reduced medication interactions COVID-19 IRB Approval Staff resistance POST ANESTHESIA CARE UNIT EDUCATION 29 Appendix F IRB Approval Institutional Review Board DATE: 02-09-2023 TO: Hilda Bartel & Bradley Stelfluf, DrAP, MBA, CRNA FROM: Institutional Review Board RE: S23.113 TITLE: Providing PACU Nurse Education on Commonly Used Anesthetic Medications SUBMISSION TYPE: New Project ACTION: Determination of Conditional EXEMPT Status DECISION DATE: 02-09-2023 The Institutional Review Board at Marian University has reviewed your protocol and has determined the procedures proposed are appropriate for exemption under the federal regulations conditional upon the following modification. Please include the following language in your consent document to clarify the voluntary nature of the research participation: While completion of the training is compulsory, your research participation is completely voluntary. By consenting to participate, there are no additional requirements for you and you are giving us permission to include your data in our analysis and resulting publications or presentation. If you do not consent, your data will not be included in our analysis. If you are amenable to this modification, your protocol qualifies as exempt, 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. If you are not amenable to the modification, review of your protocol is not complete. Please contact the IRB Chair at irb@marian.edu to discuss next steps. Although researchers for exempt studies are not required to complete online CITI training for research involving human subjects, the IRB recommends that they do so, particularly as a learning exercise in the case of student researchers. Information on CITI training can be found on the IRBs website: http://www.marian.edu/academics/institutional-review-board. It is the responsibility of the PI (and, if applicable, the faculty supervisor) to inform the IRB if the procedures presented in this protocol are to be modified of if problems related to human research participants arise in connection with this project. Any procedural modifications must be evaluated by the IRB before being implemented, as some modifications may change the review status of this project. Please contact me if you are unsure whether your proposed modification requires review. Proposed modifications should be addressed in writing to the IRB. Please reference the above IRB protocol number in any communication to the IRB regarding this project. __________________________________________ Amanda C. Egan, Ph.D. Chair, Marian University Institutional Review Board POST ANESTHESIA CARE UNIT EDUCATION 30  ...

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... QUANTITATIVE TRAIN-OF-FOUR 1 Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2023 Quantitative Train-of-Four Monitoring and the Assessment of Train-of Four Count Clifton Meyer Marian University Leighton School of Nursing Chair: Sara Franco, DNP, CRNA, APRN X Project Team Members: James Skrabak, DO X James A. Skrabak,DO James A. Skrabak,DO (Apr 19, 2023 10:30 EDT) Bradley Stelflug, DrAP, MBA, CRNA X Date of Submission: 03/21/2023 DrAP, CRNA QUANTITATIVE TRAIN-OF-FOUR 2 Table of Contents Abstract ............................................................................................................................................ 3 Introduction ...................................................................................................................................... 5 Background ............................................................................................................................ 6 Problem Statement ................................................................................................................. 9 Organizational Gap Analysis of Project Site .................................................................... 10 Review of the Literature ................................................................................................................ 11 Search Methodology ............................................................................................................. 11 Qualitative vs. Quantitative Monitoring ............................................................................... 11 Decreased PACU Events ...................................................................................................... 12 Practice Change .................................................................................................................... 13 Theoretical/Conceptual Framework ............................................................................................... 13 Project Aims and Objectives .......................................................................................................... 14 Project Design and Methods ......................................................................................................... 15 Instruments ..................................................................................................................................... 16 SWOT Analysis, ................................ 16 References ...................................................................................................................................... 18 Appendix A Appendix B Appendix C Appendix D QUANTITATIVE TRAIN-OF-FOUR 3 Abstract Background: Many surgical procedures require muscle paralysis of the patient to ensure optimum operating conditions. Monitoring the level of paralysis is an important responsibility of the nurse anesthetist throughout the entire procedure. At the conclusion of the procedure, the paralysis is reversed with reversal medications, the doses of which are determined by the level of muscle response to an electronic stimulus. The most frequently used method of assessing this response is a subjective method requiring the nurse anesthetist to visualize and/or feel the muscle movement and base their reversal dose off this interpretation. This method is known as peripheral nerve stimulation (PNS). If, in fact, the strength of the results is misinterpreted, the patient may be underdosed with reversal agent and suffer residual neuromuscular blockade symptoms (RNMB) in the Post Anesthesia Care Unit (PACU). Newer technologies have evolved to provide the nurse anesthetist with a quantitative approach to assessing the return of muscle strength, clinically referred to as the Train-of-Four Ratio (TOFR). This technique removes subjectivity, provides objectivity, and has been shown to decrease RNMB symptoms in recovering patients. Purpose: The purpose of this project was to assess whether the use of subjective PNS accurately correlates with the data provided by the objective quantitative data from electromyographic neuromuscular monitoring (EMG). A second aim was to assess whether quantitative neuromuscular monitoring use aids in decreasing RNMB symptoms in PACU. Methods: This project utilized a quality improvement design. Quantitative data was collected on surgical patients undergoing muscle paralysis. Numerical data from the EMG device was then compared to the clinicians PNS rating at the time of reversal of paralysis. A second EMG reading was taken immediately after the patient was extubated to assess the TOFR value. Data QUANTITATIVE TRAIN-OF-FOUR was analyzed using descriptive statistics to assess the validity of the data as well as statistical significance. Implementation Plan/Procedure: The project took place at Putnam County Hospital. Fifteen surgical patients requiring muscle paralysis were monitored with EMG monitoring and PNS monitoring. EMG data was be hidden from the anesthesia provider during the project. Implications/Conclusion: Keywords: Quantitative neuromuscular monitoring, residual neuromuscular blockade, qualitative neuromuscular monitoring, peripheral nerve stimulator, electromyography, neuromuscular blockade reversal. 4 QUANTITATIVE TRAIN-OF-FOUR 5 Quantitative Train-of-Four Monitoring and the Assessment of Train-of-Four Count Introduction The use of neuromuscular blocking medications is a cornerstone in anesthesia practice. This class of drugs is important in the practice of securing an airway, keeping a patient motionless for specific surgeries, and in breaking life-threatening situations such as laryngospasm (Nagelhout & Elisha, 2017). Administration of these non-depolarizing neuromuscular blockers (NNMB) requires the monitoring of their effects to ensure the patient is properly paralyzed perioperatively. Furthermore, the use of this monitoring is needed to quantify the patients state of paralysis for the proper dosing of a reversal agent prior to emergence. Inaccurate monitoring and/or interpretation of the monitoring data can lead to improper dosing of the aforementioned reversal agents, thus leading to residual neuromuscular blockade symptoms (RNMB) in the recovery room (Wiatrowski et al., 2018). RNMB has been reported in anywhere from 20-60% of patients in the Post Anesthesia Care Unit (PACU). The complications of RNMB include hypoxia, hypoventilation, airway obstruction, and re-intubation (Wiatrowski et al., 2018). Conventional monitoring of neuromuscular blockade is done with train-of-four monitor known as a peripheral nerve stimulator (PNS). This method gives qualitative data to the anesthetist in the form of muscle twitches that are subjectively assessed visually and/or via touch. Based on this assessment the dose of the reversal agent is then administered. If this dose is inadequately matched to the state of NMB still in the patients circulation, RNMB will occur (Lee, 2021). Acceleromyography (AMG) and electromyography (EMG) offer a quantitative approach to monitoring the level of patient paralysis which offers objective numerical data based on the strength of the muscle twitch in response to an electrical stimulus. With this objective QUANTITATIVE TRAIN-OF-FOUR 6 data, there is no variance between providers when it comes to interpretation (Lee, 2021). The purpose of this project is to investigate if the use of quantitative monitoring is superior to conventional PNS monitoring in accurately assessing the recovery from chemical paralysis in the surgical patient. Background Commonly used NMBs in anesthesia include drugs such as rocuronium, vecuronium, cisatracurium, and succinylcholine. The first three mentioned are classified as nondepolarizing drugs in that they do not elicit the transmission of an nerve impulse down the motor neuron. They are classified as competitive antagonists such that they outcompete acetylcholine (ACh) at the receptor site and block its effect (Nagelhout & Elisha, 2017). A unique aspect of these drugs is they require a reversal agent to ensure the nicotinic receptors are open to respond to ACh thereby enabling skeletal muscles to regain function again. Important muscles affected by NMBs include the muscles of respiration; diaphragm, intercostals, internal and external obliques (Nagelhout & Elisha, 2017). Like many of the interventions performed in anesthesia, the proper use of NMBs requires the vigilant monitoring of their effect. The indication for monitoring is to be able to establish continued dosing of NMBs perioperatively, and the proper dosing of a reversal agent at the end of the procedure (Nagelhout & Elisha, 2017). Inadequate dosing during a procedure may lead to complications due to patient movement. Proper post procedure dosing of reversal agents is critical in preventing RNMB in the PACU (Nagelhout & Elisha, 2017). As mentioned in the introduction, the patient complications related to RNMB include hypoxia, muscle weakness, reintubation, and death. Despite this, Wiatrowski et. al. (2018) cited that while nearly 77% of polled anesthetists felt RNMB was an important issue, approximately 41% of the polled QUANTITATIVE TRAIN-OF-FOUR 7 providers admitted to infrequently using monitoring when administering NMBs. Furthermore, Nagelhout & Elisha (2017) found surveyed anesthetists felt their patients rarely fell victim to RNMB, less than 1% of the time in fact. However, they went on to state that objective studies suggested that RNMB may be present up to 52% of cases. These results are echoed by Alenezi, et. al. (2021) with their findings of RNMB of 26-88% in PACU patients. The most popular monitoring device for ascertaining the level of muscle return is the peripheral nerve stimulator (PNS) device, also known as a twitch monitor or nerve stimulator (Alenezi, et al., 2021). This device supplies an electrical impulse to elicit a response which the anesthetist feels, visualizes, or both. The nerve stimulator results are qualitative and open to interpretation by different providers (Wiatrowski, et al., 2018). Furthermore, while these tests are used frequently, they are not explicitly sensitive (Claudius & Viby-Mogensen, 2008). Therefore, the subjectiveness of this specific type of monitoring may lend itself to the inadequate reversal of the paralyzed patient thus leading to RNMB complications from either underdosing or overdosing of the reversal agent (Wiatrowski et al., 2018). Objective, quantifiable measurement of return of muscle function is perhaps ideal in that the TOF data can be displayed as a number or ratio. Furthermore, a quantifiable value is not open for interpretation between providers (Cladius & Viby-Mogensen, 2008). AMG monitoring provides this objectivity in that it quantifies the TOF ratio based off the strength of the muscle contraction associated with the stimulator impulse. In addition, this type of monitoring has been considered the gold standard according to Lee (2021). This device adds an accelerometer attached to the thumb in addition to the stimulator electrodes on the ulnar nerve. Once the impulse is triggered, the AMG unit converts the muscle movement data into a ratio value for the anesthetist to base dosing off of. Optimal TOF ratio of 0.9 has been documented as the patient QUANTITATIVE TRAIN-OF-FOUR 8 having recovered from the NMB and can be successfully extubated (Lee, 2021). The objectivity of the AMG monitor has led to the development of recommended reversal drug dosages based off the TOF ratios; this guides the anesthetist in administering the proper reversal dose thereby decreasing the likelihood of RNMB (Lee, 2021). Renew (2021) found that in a study done that compared the assessment of TOFC subjectively by clinicians compared to the use of EMG, clinicians overestimated the return of muscle function 64% of the time with a TOFC of 1-3 and 13% of the time with a TOFC of 0-4. EMG monitors work similarly to AMG monitors in that they offer objective quantitative data regarding the rate of recovery from neuromuscular blockade. EMG monitors have an advantage in that they do not require the free motion of the patients thumb to obtain a measurement. Many surgical cases require the tucking of the patients arms and thus restrict movement of the thumb (Renew, 2021). EMG monitors also correlate well with the data provided from AMG monitors, so the use of the EMG may be considered the gold standard in the future due to its ease of implementation (Renew, 2021). The ramifications of RNMB are many. Hunter (2017) found that 58% of patients 70-90 experienced RNMB symptoms as well as 30% of 18-50 years. In addition, the average length of stay in PACU was increased in these patients. The delay in PACU patient discharge places an increased workload on the PACU staff, increases patient and hospital costs, and delays subsequent surgical cases from starting (Wiatrowski et al., 2018). Should the patient require intubation and admission, the costs for both the patient and hospital increase rapidly. In addition, the patient is placed at an increased risk of infection, injury, and morbidity/mortality. Postoperative pulmonary complications (POPC) are typically the main complications seen with RNMB. Hunter (2017) found that respiratory events were far more frequent when the TOF ratio QUANTITATIVE TRAIN-OF-FOUR 9 was <0.7, however these complications were not seen with a TOF ratio >0.7. This indicates the benefits of objectively quantifying the muscle response with AMG/EMG. Alenesi et. al. (2021) found similar results in that 30% of patients arrived to the PACU with RNMB symptoms and TOF ratios of <0.9 compared to the quantitatively assessed group of only 4.5%. The use of either type of device comes with pros and cons related to ease of use, cost, and availability. PNS devices are typically cheaper to purchase and easier to implement in the operating room. Wiatrowski et. al. (2018) found them to be more cost effective in, initial purchase terms, compared to the AMG/EMG devices which can range from $800-$2400. Furthermore, these can be used on either the orbicularis oculi muscle on the face or the ulnar nerve. While the facial region is commonly accessible during a procedure, the arms are frequently tucked. The AMG monitor must be placed on the thumb to work properly, thus making it more difficult to attach perioperatively (Wiatrowski, et al., 2018). The EMG monitor does not require muscle movement and can be utilized even when arms are tucked (Renew, 2021). However, the benefit of quantifiable readings from the AMG and some planning to place the monitor before the patient is positioned may offset these drawbacks. Problem Statement Combining all of the above findings has led this author to pursue investigation into whether the use of EMG monitoring, compared to the standard PNS monitor, results in decreased overestimation of TOFR in the chemically paralyzed patient. This, in turn, should result in a more accurate dosing of and timing of neuromuscular blocker reversal agents. With a quantifiable approach to emergence and extubation of the patient, the incidence of RNMB symptoms of the chemically paralyzed surgical patient should therefore decrease as well. This author conducted a quality improvement (QI) project using a quantitative neuromuscular monitor QUANTITATIVE TRAIN-OF-FOUR 10 EMG and PNS monitors for the assessment of TOFR, and dosing of reversal agents administered to chemically paralyzed patients in the operating room (OR). The presence of RNMB symptoms was recorded as well as the PNS qualitative and EMG objective data that was used in arriving at the reversal doses. These results were then compiled and tested for statistical significance and presented in an effort to establish any objective benefit of one monitor type over the other in preventing/reducing RNMB in the PACU. Needs Assessment and Gap Analysis Putnam County Hospital (PCH) is a small rural critical access hospital serving the city of Greencastle, IN and the surrounding county. The surgery center has four ORs with typically two in frequent use. In addition, there are two main endoscopy suites that operate almost daily. Being that this hospital is small, budget, staff, and resources are accounted for judiciously. The anesthesia team consists of one anesthesiologist and two part-time certified nurse anesthetists (CRNAs) who alternate weeks. In direct relation to the project, the devices used for NMB monitoring consist of three PNS monitors with ball electrodes and one PNS monitor with corded electrode leads. There are currently no EMG or quantitative devices at PCH. Neostigmine is the most used reversal agent and sugammadex is available if needed, however it is typically only utilized for emergencies or patients slow to return from NMB. The use of the PNS monitor is almost exclusively placed on the orbicularis oculi muscle when assessing NMB and dosing of reversal. There is no formal intensive care unit (ICU) available should a patient experience severe RNMB symptoms and need mechanical ventilation for an extended period. Severe cases would need transferred out by ambulance or helicopter to an appropriate facility. A typical shift has enough PACU nurses staffed to recover two patients at a time. Any delay in PACU discharge QUANTITATIVE TRAIN-OF-FOUR 11 causes a delay in any following OR cases. The ability to objectively monitor NMB drugs and quantify the patients return of muscle strength could potentially benefit this location by decreasing the incidence of RNMB, averting any delay in PACU discharge, and decreasing the need for additional staff for prolonged patient recovery. Review of the Literature Literature searches were conducted using databases such as PubMed, EBSCO, Google Scholar and Up to Date. Search terms included: quantitative neuromuscular monitoring, acceleromyography, electromyography, qualitative neuromuscular monitoring, residual neuromuscular blockade, Train of four monitoring, and neuromuscular monitoring. The search resulted in approximately 450 articles initially. These were then narrowed down with exclusion criteria such as being published in the last ten years (with 3 exceptions), written in the English language, and relevant to humans and not animals. These articles were then screened based on title and the abstracts were investigated for relevance to the project. All articles used in this project were either from a credible journal, peer-reviewed, or associated with an academic center. Levels of evidence within the articles range from I-VI based of the Melnyk & Fineout-Overholt hierarchy of evidence classification (2012). Based on the inclusion criteria, 17 articles were selected for full review, with 12 articles used in the literature review matrix (Appendix A). Qualitative vs. Quantitative Monitoring Neuromuscular monitoring is achieved by assessing either the strength of a muscle twitch or the strength of a muscle nerve depolarization. In reference to qualitative and quantitative means of assessment, qualitative refers to the most common method called a peripheral nerve stimulator (PNS). This method was found to be inferior compared to either AMG or EMG QUANTITATIVE TRAIN-OF-FOUR 12 monitoring in establishing the objective level of neuromuscular recovery after paralysis (Claudius et al., 2008). Furthermore, Claudius et al. (2008) discovered this to be true across different types of neuromuscular blocking agents as well. The variation between clinical providers in their qualitative assessment of TOFC with a PNS can be drastic. This is especially true if a baseline TOFC is not assessed after induction but prior to the administration of paralysis Wiatrowski et al., 2018). Improper assessment of qualitative TOFC can lead to inadequate reversal dosing and increased RNMB symptoms in PACU (Alenezi et al., 2021). In studies done with quantitative monitoring, the evidence is such that a clear picture can be drawn to show the benefits of implementing AMG or EMG, but specifically EMG monitoring. Wiatrowski et. al. (2018) showed that quantitative monitoring with EMG showed less RNMB occurrences in PACU compared to those monitored with qualitative PNS. EMG was found to be easier to use than AMG due to the lack of muscle motion needed to obtain a measurement. In addition, EMG was found to more accurately detect near to full recovery of muscle function than AMG monitoring (Renew, 2021; Lee, 2021). Finally, the ability to objectively produce a quantifiable value to reflect the level of recovery TOFR, quantitative methods of assessment take subjectivity out of the equation (Khandkar et al., 2016). The clinically accepted value for a full recovery from NMB is TOFR 0.9 (Lee, 2021). With quantitative monitoring, there is no guesswork in establishing the level of recovery. The monitor clearly displays this value for the clinician to see. Decreased PACU Events Ramifications of improperly reversing NMB can be serious. A prospective cohort study found that 66% of the paralyzed surgical patients examined had a critical respiratory event (CRE) in PACU (Alenezi et al., 2021). A CRE is classified as inadequate pulmonary function, QUANTITATIVE TRAIN-OF-FOUR 13 airway obstruction, decreased respiratory muscle function, and aspiration (Alenezi et al., 2021). The use of PNS monitoring was associated with a higher incidence of CREs in the study as compared to quantitative TOF monitoring. Interestingly female gender and shorter duration of surgery were also factors (Alenezi et al., 2021). Wiegel et. al. (2022) expands on this topic to demonstrate that the use of quantitative monitoring implementation decreased pulmonary complications, PACU discharge times, and inpatient post-surgical stays. Practice Change The use of equipment can be perceived as a change from the norm, cumbersome, and time consuming. Thus, many practitioners will default to what is easiest and quickest (Weigel et. al., 2022). A retrospective study of practice change implementation from 2016-2020 showed that initial TOFR documentation/validation was only 1%, but by the end of the practice change in 2020 it was up to 93%. The specific implementation was the adoption of EMG monitoring within a hospital group instead of using PNS devices (Weigel et al., 2022). This practice variation can be seen across political borders as well. Danish practitioners were found more likely to use objective monitoring than their United States colleagues in a survey conducted by Thomsen et. al. (2020). With the evidence overwhelmingly pointing to the benefits of objective quantitative monitoring, there is less and less validity to push back to its use. Theoretical/Conceptual Framework The theoretical framework that guides this project is the concept of translating evidence into practice. The Iowa Model of Evidence-Based Practice to Promote Quality Care fits the theoretical framework well. It also serves as a guide to help focus the steps of the project as well as offering key points to consider when evaluating the projects progress (White & Spruce, 2015). The Iowa Model is specifically aligned with making evidence-based changes in practice QUANTITATIVE TRAIN-OF-FOUR 14 as this project aims to do. Graphically, Figure 1 shows the model displayed as a form of flow chart demonstrating a clear path between the different aspects of the change process from establishing the triggers for change to evaluating the evidence and dissemination of the results (White & Spruce, 2015). The first step of the Iowa Model is described as trigger, for this project the trigger was knowledge focused related to literature findings and philosophies of care. These findings were suggesting that the implementation of quantitative monitoring of neuromuscular blockade provides better outcomes than qualitative PNS monitoring (Alenzi et al., 2021; Claudius et al., 2008; Lee, 2021; Nagelhout & Elisha, 2017; Renew, 2021; Wiatrowski et al., 2018). Next, these findings were assessed to be of interest to Putnam County Hospital in that they currently only use PNS monitoring of their patients. The anesthesia department strives to deliver the best care and was interested in purchasing new neuromuscular monitoring equipment, so this data was of interest to them. A team was formed that consists of a DNP Chair, Clinical Site Member (Head of Putnam Anesthesiology), and an additional member to aid in reviewing the project. The project then continued into the research and literature review phase which helped establish the related research to determine whether evidence exists to institute a change (White & Spruce, 2015). Should the data present as beneficial, the project moves into the pilot phase of changing the practice. Essentially a plan is developed to trial the change and evaluate its implementation. These findings are then evaluated, and a decision is made to adopt this change or move away from it. Implementation is not simply the final step, as any new practice requires constant evaluation over time to ensure it is current best practice (White & Spruce, 2015). Project Aims and Objectives QUANTITATIVE TRAIN-OF-FOUR 15 The purpose of this project is to improve the monitoring capabilities of chemically paralyzed surgical patients at Putnam County Hospital. Research has shown that quantitative means of monitoring neuromuscular blockade are linked to improved patient recovery in PACU and more accurate extubation criteria compared to PNS monitoring. Project Aim: To examine whether quantitative EMG TOFC monitoring leads to a more accurate assessment of neuromuscular blockade in surgical patients compared to qualitative PNS monitoring. The objectives of this project are to: 1. Determine whether anesthesia provider qualitative assessment of TOFC is over/under-estimated compared to quantitative EMG measurement. 2. Utilize the quantitative and qualitative data and correlate this with extubation times. 3. Examine whether TOFR is 0.9 at arrival to PACU. 4. Assess whether quantitative EMG monitoring reduces RNMB symptoms in PACU. Project Design and Methods The project was conducted in the OR at Putnam County Hospital with a convenience sample of surgical patients requiring muscle paralysis for the procedure. The actual sample size was 15 patients. Gender, age, and surgery type were not listed as factors of selection. The overall aim of the project was to improve the quality of care by utilizing quantitative neuromuscular monitoring. Each patient had an EMG monitor device placed on them for the procedure. The placement was done before the patient was given any paralytic drugs and a baseline TOFR was assessed. The baseline measurement ensured the monitor was placed properly and that the QUANTITATIVE TRAIN-OF-FOUR 16 collected data was accurate. The monitor was placed out of view of the anesthesia provider, and the anesthetic was performed as normal. When the time came for assessment of muscle function prior to reversal, an EMG measurement was taken at the same time as the clinician utilized the PNS device. Both values were recorded, and the patient was reversed. The dose of reversal drugs was also recorded. A second reading was taken immediately after extubation of the patient as well. This value served as the PACU TOFR value and assessed how appropriately the reversal drugs were dosed according to the PNS feedback. Both the pre-reversal and post extubation TOFR numbers were correlated to the subjective PNS value for evaluation of over/underestimation. The time between reversal dosing and extubation was also recorded. Assessment for and occurrence of RNMB symptoms was recorded as well as any additional doses of reversal that may be given. It should be noted that the measurement of the EMG value does not affect the care of the patient as the value is not determining any change in therapy during the case. Instruments Data to be collected was limited to total number of patients tested, duration of surgical case, amount of paralytic agent given, PNS value, EMG value at reversal and post extubation, occurrence of RNMB symptoms in PACU, and time to extubation after reversal. For this study, identifiable patient demographic data is not necessary. The PNS monitor is used on every patient undergoing muscle relaxation despite their gender, this is also the case for EMG monitoring. This is also true for the type of surgery being performed. An attempt to correlate surgical procedure or gender/age to RNMB symptoms is beyond the scope of this project. Descriptive analysis was used to examine the data for statistical significance as there were two types of measurements taken on the same subject each surgical case. QUANTITATIVE TRAIN-OF-FOUR 17 SWOT Analysis A strengths, weakness, opportunities, threats analysis (SWOT analysis) was performed (Figure 2) for the project to aid in uncovering any further items that may need to be addressed before moving forward. The analysis revealed overall strengths in that the project has buy-in from the hosting hospital, the Director of Anesthesia, and the CRNA staff, as well as the PACU staff. One brand of equipment has been secured for use which will enable the project to move forward. Weaknesses uncovered were that the author is no longer in clinicals at this site and will require schedule manipulation to be present to obtain data. Furthermore, one aspect of the data is deemed subjective in that it requires an opinion from the anesthesia provider as to what they feel they are seeing with the PNS monitor. Opportunities in favor of the project are that the practice of using quantitative monitoring is increasing in ORs (Lee, 2021). In addition, Putnam County Hospital prides itself on offering a positive clinical experience for students and is open to improving their practice as such. Specific threats to the project include the exacerbation of the COVID-19 virus in the United States which has prevented some students from attending clinicals. Second, with decreased surgical cases in relation to the pandemic, any potential decrease in the anesthesia budget could prevent the purchase of quantitative equipment should the practice be adopted. Results Patient Sample and Baseline Data The study sample consisted of 15 (n) surgical subjects requiring chemical muscle relaxation for the procedure. The sample was divided into 6 females (40%) and 9 males (60%). The patient demographic were not required for data gathering purposes, they are only shown to demonstrate the distribution within the sample. All 15 (100%) subjects arrived in the OR and had QUANTITATIVE TRAIN-OF-FOUR 18 their TwitchView monitor electrode placed before induction of anesthesia. A baseline measurement was taken immediately after the administration of an induction agent before any paralytic administration. This method was not required to gain accurate measurements according to the Blink Device product representative. However, this practice ensured data gathering was done under the same conditions for all patients and practitioners. The mean baseline TOFR was 100.8%. The purpose of the baseline is to ensure proper electrode contact and verify the monitor is functioning properly. The normal range for baseline TOFR is between 97-104% as per the manufacturer (Blink Device Company, 2022). 100% of the sample population fell within this range, verifying proper electrode placement and monitor function. Table 1.1 Baseline TOFR 105 104 103 102 TOFR 101 100 99 98 97 96 95 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Patient Selection of Paralytic Agent at Induction The particular paralytic agent used upon induction varied between Succinylcholine and Rocuronium. The scope of this study was not to interfere/alter patient care or practitioner QUANTITATIVE TRAIN-OF-FOUR 19 practice. Therefore, the paralytic agent on induction was chosen according to the patient presentation/situation. Succinylcholine was utilized in 40% of the patients and Rocuronium in 60%. Maintenance of Paralysis The maintenance of the paralysis phase of the surgeries was controlled with Rocuronium in 100% of the patients. Total dosage required during the cases varied depending on length of procedure, patient metabolism, and provider practices. The mean total dose for the population was 47.3mg with a max of 70mg and a minimum of 35mg. Once rocuronium was administered, the patient was continuously monitored through the entire case with a data point generated every 10 seconds. The continuum of paralysis consists of TOFR as the lowest level followed by TOFC (Train of Four Count), then ending with the PTC (Post Tetanic Count). A TOFR is measured until the paralytic dose occupies enough receptors to drop into the TOFC range. Essentially, the TOFR is unable to be measured if the fourth twitch in the TOFC is abolished. This happens at 75-80% paralysis. If the dose is enough to achieve 100% paralysis, the patients fall into the PTC stage (Nagelhout & Elisha, 2017). 93% (14) of the sample population fell into the PTC range during the cases and were maintained there. One patient was maintained with a TOFC for the entire procedure. QUANTITATIVE TRAIN-OF-FOUR 20 Table 1.1 Total Rocuronium dose 80 70 Milligrams 60 50 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Patient Reversal of Paralysis Reversal of paralysis was accomplished with either neostigmine and glycopyrrolate or sugammadex. The agent of which was chosen by the practitioner based on clinical signs or personal preference. Of the sample, 4 patients were given sugammadex for reversal (26.7%). One of these administrations was to a patient after having had received initial reversal with neostigmine and glycopyrrolate. Counting initial reversal dosing, 80% (12) of the patient received neostigmine and glycopyrrolate for reversal. The mean neostigmine dose at reversal was 4.08mg with a maximum of 5mg and a low of 2.5mg. An attempt to find a correlation between total rocuronium dose and the dose of neostigmine was made, however data analysis showed there was an extremely weak to no positive correlation between the two. QUANTITATIVE TRAIN-OF-FOUR 21 Table 1.3 Correlation between total rocuronium dose and neostigmine dose Total Roc dose Neostigmine dose Total Roc Neostigmine dose dose 1 0.067969 1 Assessment of Paralysis Level at Reversal At the time of reversal, values were recorded from the providers assessment of TOFC using the PNS and from the TwitchView monitor. The monitor value was hidden from the providers view as to not alter care delivery in any way. The mean PNS value at reversal was 2.93 twitches. The maximum was 4 twitches, and the low was 1 twitch. Data from the TwitchView monitor showed a mean TOFR of 23% with a high of 48% and a low of 8%. An attempt to find a correlation between the values of the two measurement types yielded a moderate to weak positive correlation at best. See Tables 1.4 and 1.5 for results. Table 1.4 Correlation between TOFR % and PNS values at reversal TOFR at reversal TOFR at reversal PNS value at reversal PNS value at reversal 1 0.394627 1 QUANTITATIVE TRAIN-OF-FOUR 22 Table 1.5 TOFR vs PNS at Reversal 50 45 40 35 30 25 20 15 10 5 0 1 2 3 4 5 6 7 TOFR reversal 8 9 10 11 12 13 14 15 PNS at reversal Following the reversal dose, another data point was captured at the time of extubation. The provider was asked to check PNS twitches before removing the endotracheal tube. At this point, a TOFR value was recorded as well to ensure both values were recorded at the same point in time. All 15 patients (100%) achieved 4 twitches at this time, however the TOFR values varied widely. The mean TOFR at extubation was 75.5% with the highest being 100% and the lowest being 37%. The TOFR measurements showed that 60% (9) of the patients were extubated with a TOFR < 90%. Data gathered from years of study with TOFRs show that a TOFR of less than 0.9 (90%) is considered not fully reversed from paralysis and places the patient at risk for RNMB symptoms in PACU. Furthermore, of the 6 patients achieving a TOFR > 0.9, 3 of these were reversed with sugammadex. A single patient required a subsequent dose of sugammadex after receiving reversal with neostigmine and glycopyrrolate. See Table 1.6. QUANTITATIVE TRAIN-OF-FOUR 23 Table 1.6 TOFR Value at Extubation > 0.9 < 0.9 Time: Reversal to Extubation An additional data point gathered in the study involved measuring the time from the administration of the reversal agent to extubation of the patient. The mean time to extubation was 11.8 minutes. This value accounts for the entire sample (15) and does not account for the type of reversal drug used. The longest time to extubation was 25 minutes and this patient was initially given neostigmine and glycopyrrolate. They then required a dose of sugammadex to become fully reversed and extubated. The shortest time was 5 minutes, this patient was given sugammadex. An attempt to find a correlation between the TOFR at reversal and time to extubation was made. A weak negative correlation was found suggesting that with an increase in TOFR at reversal, a shorter time to extubation can be expected. QUANTITATIVE TRAIN-OF-FOUR Table 1.7 Correlation between TOFR at reversal and extubation time (all patients) Time to extubation Time to extubation TOFR at reversal TOFR at reversal 1 -0.23708 1 When the same data is adjusted to remove the subject who received sugammadex for reversal a stronger negative correlation is show. This finding shows that when utilizing neostigmine and glycopyrrolate, having a higher TOFR at reversal tends to lead to shorter extubation times. Data displayed in Tables 1.8 and 1.9. Table 1.8 Correlation between TOFR at reversal and extubation time (neo/glycol patients) Time to extubation Time to extubation TOFR at reversal Table 1.9 TOFR at reversal 1 -0.48277 1 24 QUANTITATIVE TRAIN-OF-FOUR 25 TOFR and Time to Extubation 60 50 40 30 20 10 0 1 2 3 4 5 6 7 Time to extubatio 8 9 10 11 12 13 14 15 TOFR at reversal Using the same correlation method to assess whether there was a relationship between the PNS values and time to extubation, it was found that there was a very weak negative correlation. This suggests that the data provided to the anesthesia provider from the PNS is perhaps less reliable than that of the quantitative TwitchView monitor. One would expect there to be a negative correlation based off the practice that a higher PNS twitch count indicates less paralysis. See Tables 2.0 and 2.1 for results. Table 2.0 PNS at reversal PNS at reversal Time to extubation Time to extubation 1 -0.14979 1 QUANTITATIVE TRAIN-OF-FOUR 26 Table 2.1 PNS Value and Time to Extubation 30 25 20 15 10 5 0 1 2 3 4 5 6 7 PNS at reversal 8 9 10 11 12 13 14 15 Time to extubation A correlation between the PNS value at extubation and the TOFR was difficult to make as every patient had a PNS count of 4 twitches. When comparing this to the TOFRs at extubation, it is worth noting that 60% of the patients were extubated with a TOFR < 0.9 indicating inadequate reversal. However, when using the PNS data alone, a subjective TOFR could be assessed at 0.9 respectively. The value itself is qualitative as the fourth twitch is assessed either by feel or visual observation when compared to the first. Post Operative Residual Neuromuscular Blockade All patients were assessed for RNMB symptoms on arrival to PACU. Of the sample, none showed signs of RNMB in PACU, however one patient required sugammadex after initial reversal with neostigmine in the OR. Since this was recognized in the OR it could not technically QUANTITATIVE TRAIN-OF-FOUR 27 be labeled as RNMB. It is worth noting that had this not been caught in the OR, having one patient classified as having RNMB would equate to 6% of the patient population sampled. Sugammadex This study was done to assess the differences in quantitative and qualitative neuromuscular monitoring. The drugs used for paralytic reversal did not affect the TOFR measurements pre-reversal. Sugammadex did have an effect on the time to extubation after reversal and the TOFR at extubation, however. Of the 3 patients who received sugammadex as their initial and sole reversal agent, 100% of them reached a TOFR at extubation. Furthermore, 100% of them were extubated in less than 9 minutes. Discussion In this quality improvement project, current practices for assessing the return of muscle function after neuromuscular blockade were investigated. A comparison between the most widely utilized practice of qualitative PNS monitoring and the somewhat newer practice of quantitative TOFR monitor was made. The PNS form of monitoring is qualitative in that it relies on a practitioner to feel or visually assess the patients muscle twitch 100% of the providers performing anesthesia in during the study performed PNS measurements on the patients orbicularis oculi muscle when assessing TOF. While this location is easily accessible during most surgeries, it is not the most reliable when it comes to assessing a patients return of respiratory muscle function. This location is more reliable when assessing the level of paralysis at the vocal cords before intubation (Nagelhout & Elisha, 2017). The TwitchView monitor electrode is placed at the ulnar nerve location which better evaluates the return of respiratory muscle function after paralysis. The PNS monitor has no form of quality control or baseline verification other than to elicit a TOF count before administering paralytic and qualitatively QUANTITATIVE TRAIN-OF-FOUR 28 assessing the responses. The intensity of the twitches must then be remembered by the provider and compared to the twitches at reversal. The TwitchView monitor runs an electrode verification test when initiating monitoring. This ensures subsequent measurements are reliable. This could account for the wide range of TOFR values at the administration of reversal when compared to the linear values from the PNS. The TOFR is also a ratio and not a count of 1-4, this factors in as well. Current practice of reversing a patient from paralysis is based upon the TOFC from the PNS monitor. Most providers consider 2 twitches as a sign that the patient can be reversed effectively with neostigmine and glycopyrrolate. The findings in this study show that even with a TOFC of 4 before reversal, the TOFR can be as low as 8%. While the twitch intensity should increase after reversal, relying on qualitative assessment may not accurately portray the actual TOFR. This can be seen in the evidence when comparing the TOFC to the TOFR at extubation. All 15 patients (100%) had a TOFC of 4 at extubation according to the PNS data, what was not able to be recorded was the TOFR from this. The providers were able to verbalize what they felt was a TOFR of 0.9, however there was no way to be certain qualitatively. When the TOFR data from the TwitchView monitor was compared to this, the numbers showed that this method is widely inaccurate. The mean TOFR at extubation was 0.75 or 75%. According to the literature, extubation should not be attempted until a TOFR of 0.9 or greater is achieved (Nagelhout & Elisha, 2017). The lowest TOFR at extubation was 0.37, and the highest with reversal by neostigmine was 100%. When looked at quantitatively, the level of paralytic reversal varies greatly. These findings also suggest that a significant number of patients are arriving to the PACU inadequately reversed from paralysis. This was verified in the study. QUANTITATIVE TRAIN-OF-FOUR 29 When assessing the overall proportion of patients extubated with a TOFR > 0.9, it was found that 60% of the sample were inadequately reversed upon extubation. This was not shown to be highly correlated with the dose of neostigmine given either. The correlation between TOFR at extubation and neostigmine dosing was moderately negative. This seems counterintuitive in that a larger dose of neostigmine should lead to a greater TOFR at extubation. Time to extubation and neostigmine dose were weakly positively correlated, which again is potentially unexpected as a higher dose of neostigmine would suggest a faster reversal and shorter extubation time therefore exhibiting a negative correlation. These findings may show that simply giving a larger dose of neostigmine may not lead to a more complete and rapid reversal of paralysis. Sugammadex was used for reversal on 3 patients as the initial agent and one patient as a secondary agent. A dose of sugammadex costs approximately $82. This is a dose of 200mg which was the dose given to each patient in the study. A vial of neostigmine 1mg/ml (10ml) costs approximately $28. Glycopyrrolate costs approximately $7.50 for a 0.2mg/ml vial (1ml). When looking at these numbers, the total cost for the sugammadex was $328. This was for 4 doses of the drug as well. The total cost for 12 doses of neostigmine was $336 and glycopyrrolate $305 respectively. Add these together and the total dollar amount of drug to reverse 12 patients was $641. Reversing 12 patient with sugammadex could cost as much as $948. What these numbers do not show is how these initial costs translate to PACU costs. Using the Gundersen Health System (2023) example of PACU and OR costs, an initial PACU charge of $1823 is charged to each patient for the first hour. Any additional minutes stayed after that are charged at a rate of $30/min. If 60% of the patients in this study arrived to PACU with a TOFR < 0.9, an assumption could be made that they ended up staying longer than that initial hour and QUANTITATIVE TRAIN-OF-FOUR 30 incurred undue costs. This was data was not gathered in this study, but it is worth mentioning. A second correlation could also be made that in a hospital such as Putnam County Hospital (PCH), having the majority of patients arriving to the PACU inadequately reversed could lead to decreased OR turnovers and delays of cases. The TwitchView monitoring system costs approximately $2,500 with each electrode priced at $25. Depending on actual PACU operating costs and reimbursement policies, an extended PACU stay of 30 minutes for one patient could cost the hospital at least $300. Preventing just 10 patients from extended PACU stays from RNMB would end up paying for the monitor and a 10 pack of electrodes. Hospitals such as PCH operate with a limited number of staff. Often, the OR staff consists of dual role nurses who help in the OR and in PACU. Should a patient have an increased length of stay in PACU, they require constant nurse monitoring. This can divert resources away from the OR staff and delay subsequent cases from starting. Furthermore, if a second patient is coming to PACU while the initial patient is still recovering, the delays could be even further. This situation can be made worse should the patient require mechanical ventilation support. Ensuring the patients are fully reversed with a TOFR > 0.9 with quantitative monitoring can help alleviate this situation with accurate objective data. A more focused study on the PACU recovery times would be warranted to validate this data. While there were no overt RNMB symptoms recorded on arrival to PACU, there was one patient requiring additional reversal due to inadequate initial reversal with neostigmine. This was caught in the OR before arriving to PACU. However, this does not mean that of the 60% of patients arriving to PACU with a TOFR < 0.9 are all fairing completely well. Desaturations may be attributed to RNMB as can increased oxygen requirements or the use of an oral airway in PACU. The only way to associate these instances with RNMB symptoms is to check the TOFR in PACU. QUANTITATIVE TRAIN-OF-FOUR 31 Strengths and Limitations Strengths of this study included the use of a well-established quantitative TOFR monitoring system and support from the Blink Device Company. The monitor, all the electrodes, and a simulation device for practice was provided for this study. Live, real-time training and support was also provided when needed. Provider support for the study was also high in that there was no pushback to using the monitor or gathering data. Objectivity within the study was maintained in that the providers never saw the monitor display during the cases. Provider care delivery was not altered in any way to detract from the data or endanger the patient. Limitations in the study included a small sample size as well as a limited loan time on the monitor. Other data such as inhalation concentrations/durations during the cases were not recorded. Narcotic administration was not considered as well. Patient demographics and comorbidities were not considered for this study and may or may not have had an effect on the outcomes. Accurate PACU costs for the care of RNMB symptoms were not obtained as these vary widely. With better data in this area, a more concrete cost/benefit ratio could be made on the financial benefits of quantitative monitoring. Future Project Recommendations Time and logistics played a factor in this project. In order to get a larger sample size, dedicated time away from clinical cases may need to be granted especially if the sponsoring site is different than the current student clinical site. Performing the study at a center with a higher frequency of cases requiring paralysis would increase the sample size and decrease the loan time on the monitor as well. Recording any respiratory events in PACU as well as PACU to discharge time would help correlate the RNMB data better. Conclusion QUANTITATIVE TRAIN-OF-FOUR 32 Post operative residual neuromuscular blockade is a real and present issue. With data showing at least 60% of patient arriving in PACU inadequately reversed, there is no argument to be made when it comes to assessing the level of paralysis reversal. Current majority practice of using the PNS monitor leads to inaccurate subjective data that varies widely. Changing practice to implementing an objective monitoring system to quantitatively assess the TOFR is key to helping reduce inadequate reversal of paralysis in surgical patients. While the study lacked concrete evidence of RNMB symptoms in any of the patients in PACU, it showed that subjective PNS monitoring is ineffective. It also showed that it is only a matter of time that an adverse event should happen in the PACU related to RNMB based of the proportion of patients inadequately reversed arriving to recovery. This study also showed that there was little to no correlation in reversal dosing and higher TOFR values when using neostigmine and glycopyrrolate. A second subsequent finding was that sugammadex is superior to neostigmine in its ability to provide rapid adequate reversal of paralysis of all the patients who received it. All of the patients receiving sugammadex had a TOFR> 0.9 at extubation. Overall, a larger sample size and longer duration of the study is warranted to thoroughly prove the preliminary findings of this project. QUANTITATIVE TRAIN-OF-FOUR 33 References Alenezi, F. K., Alnababtah, K., Alqahtani, M. M., Olayan, L., & Alharbi, M. (2021). The association between residual neuromuscular blockade (rnmb) and critical respiratory events: A prospective cohort study. Perioperative Medicine, 10(1). Retrieved October 1, 2021, from https://doi.org/10.1186/s13741-021-00183-7 Claudius, C., Viby-Mogensen, J., Warner, D., & Warner, M. (2008). Acceleromyography for use in scientific and clinical practice. Anesthesiology, 108(6), 11171140. https://doi.org/10.1097/aln.0b013e318173f62f Fuchs-Buder, T., Nemes, R., & Schmartz, D. (2016). Residual neuromuscular blockade. Current Opinion in Anaesthesiology, 29(6), 662667. https://doi.org/10.1097/aco.0000000000000395 Hunter, J. (2017). Reversal of residual neuromuscular block: Complications associated with perioperative management of muscle relaxation. British Journal of Anaesthesia, 119, i53i62. Retrieved October 1, 2021, from https://doi.org/10.1093/bja/aex318 Khandkar, C., Liang, S., Phillips, S., Lee, C. Y., & Stewart, P. A. (2016). Comparison of kinemyography and electromyography during spontaneous recovery from nondepolarising neuromuscular blockade. Anaesthesia and Intensive Care, 44(6), 745751. https://doi.org/10.1177/0310057x1604400618 Lee, W. (2021). The latest trend in neuromuscular monitoring: Return of the electromyography. Anesthesia and Pain Medicine, 16(2), 133137. Retrieved October 2, 2021, from https://doi.org/10.17085/apm.21014 QUANTITATIVE TRAIN-OF-FOUR 34 Money, K., Lee, Y., & Elliott, A. (2019). Sugammadex compared with neostigmine/glycopyrrolate: An analysis of total pacu time, responsiveness, and potential for economic impact. INNOVATIONS in pharmacy, 10(3), 1. https://doi.org/10.24926/iip.v10i3.1798 Murphy, G. S. (2018). Neuromuscular monitoring in the perioperative period. Anesthesia & Analgesia, 126(2), 464468. https://doi.org/10.1213/ane.0000000000002387 Murphy, G. S., Szokol, J. W., Avram, M. J., Greenberg, S. B., Shear, T. D., Vender, J. S., Parikh, K. N., Patel, S. S., & Patel, A. (2016b). Residual neuromuscular block in the elderly patients. Survey of Anesthesiology, 60(3), 109. https://doi.org/10.1097/sa.0000000000000223 Nagelhout, J. J., & Elisha, S. (2017). Nurse anesthesia (6th ed.). Saunders. Nemes, R., Lengyel, S., Nagy, G., Hampton, D. R., Gray, M., Renew, J., Tassonyi, E., Flesdi, B., & Brull, S. J. (2021). Ipsilateral and simultaneous comparison of responses from acceleromyography- and electromyography-based neuromuscular monitors. Anesthesiology, 135(4), 597611. https://doi.org/10.1097/aln.0000000000003896 Rezaiguia-Delclaux, S., Laverdure, F., Genty, T., Imbert, A., Pilorge, C., Amaru, P., Sarfati, C., & Stphan, F. (2020). Neuromuscular blockade monitoring in acute respiratory distress syndrome: Randomized controlled trial of clinical assessment alone or with peripheral nerve stimulation. Anesthesia & Analgesia, 132(4), 10511059. https://doi.org/10.1213/ane.0000000000005174 Rodney, G., Raju, P. C., & Ball, D. R. (2015). Not just monitoring; a strategy for managing neuromuscular blockade. Anaesthesia, 70(10), 11051109. https://doi.org/10.1111/anae.13219 QUANTITATIVE TRAIN-OF-FOUR 35 Thomsen, J. D., Marty, A. P., Wakatsuki, S., Macario, A., Tanaka, P., Gtke, M. R., & stergaard, D. (2020). Barriers and aids to routine neuromuscular monitoring and consistent reversal practicea qualitative study. Acta Anaesthesiologica Scandinavica, 64(8), 10891099. https://doi.org/10.1111/aas.13606 Weigel, W. A., & Thilen, S. R. (2021b). Neuromuscular blockade monitoring and reversal. Advances in Anesthesia, 39, 169188. https://doi.org/10.1016/j.aan.2021.07.010 Weigel, W. A., Williams, B. L., Hanson, N. A., Blackmore, C., Johnson, R. L., Nissen, G. M., James, A. B., & Strodtbeck, W. M. (2022). Quantitative neuromuscular monitoring in clinical practice: A professional practice change initiative. Anesthesiology. https://doi.org/10.1097/aln.0000000000004174 Wiatrowski, R., Martini, L., Flanagan, B., Freeman, K., & Sloan, N. (2018). AANA Journal Course - neuromuscular blockade: evidence-based recommendations to improve patient outcomes. AANA Journal, 86(2), 157167. Retrieved August 31, 2021, from chromeextension://efaidnbmnnnibpcajpcglclefindmkaj/viewer.html?pdfurl=https%3A%2F%2Fw ww.aana.com%2Fdocs%2Fdefault-source%2Faana-journal-web-documents-1%2Faanajournal-course-residual-neuromuscular-blockade-evidence-based-recommendations-toimprove-patient-outcomes-april-2018.pdf%3Fsfvrsn%3Dfe505fb1_6&clen=433813 QUANTITATIVE TRAIN-OF-FOUR 36 Appendix A Citation Alenezi, F. K., Alnababtah, K., Alqahtani, M. M., Olayan, L., & Alharbi, M. (2021). The association between residual neuromuscular blockade (rnmb) and critical respiratory events: A prospective cohort study. Perioperative Medicine, 10(1). Claudius, C., VibyMogensen, J., Warner, D., & Warner, M. (2008). Acceleromyography for use in scientific and clinical practice. Anesthesiology, 108(6), 11171140. Research Design & Level of Evidence Prospective Cohort Study Population / Sample size n=x Major Variables Instruments / Data collection Results Surgical patients over 18 years old Level 2 n=30 Demographics, perioperative data, and Critical Respiratory Events in PACU. TOFR in PACU after extubation in OR Mann-Whitney U tests, chisquare tests, and independentsample T tests. TOFR data gathered with TOF-Scan acceleromyography device on patients who arrived in PACU after being reversed and extubated in OR. 86% of patients were paralyzed with rocuronium, only 76% of these were reversed with neostigmine. 53% of these patients experienced RNMB (TOF<0.9). 66% of patients had a CRE in PACU. Systematic Review 55 articles were studied evaluating acceleromyography and its clinical application for NMB monitoring Comparisons of acceleromyography to electromyography in assessing neuromuscular blockade levels. Location of monitor lead placement. Assessment of RNMB symptoms. Data in this review focused on time to T1 recovery with AMG vs EMG. Lag times, onset time, and max block differences when assessing with AMG vs EMG. Randomization assessing the frequency of RNMB symptoms in PACU related to the use of AMG/EMG perioperatively AMG and EMG were both found to be useful in decreasing PRNMB symptoms as compared to traditional PNS assessment which is highly subjective. These methods were also checked against different agents with similar results. Clinical criteria for administering reversal agents was not as reliable as using quantifiable monitors such as AMG/EMG. Evidence Level 1 QUANTITATIVE TRAIN-OF-FOUR Rezaiguia-Delclaux, S. , Laverdure, F. , Genty, T. , Imbert, A. , Pilorge, C. , Amaru, P. , Sarfati, C. & Stphan, F. (2021). Neuromuscular Blockade Monitoring in Acute Respiratory Distress Syndrome: Randomized Controlled Trial of Clinical Assessment Alone or With Peripheral Nerve Stimulation. Anesthesia & Analgesia, 132 (4), 10511059. Randomized Control Trial 37 Level 1 ARDS patients in Intensive Care Units n=77 Comparing TOF monitoring to clinical monitoring of ARDS patients on atracurium for continuous paralysis. Would dosages be different. Patient demographics, body measurements and McCabe scores were collected on admission. SOFA (sequential organ failure assessment) was used as well. Daily atracurium dose was collected. ICU mortality was assessed with Pearsons X2 test with the Monte Carlo method. Statistical analysis was done with R software. The clinical + TOF group was found to have higher overall atracurium doses as well as higher daily atracurium doses. Mortality was higher in the C+TOF group but days on ventilator were averaged within one day. Lee, W. (2021). The latest trend in neuromuscular monitoring: Return of the electromyography. Anesthesia and Pain Medicine, 16(2), 133137 Review of the literature Multiple studies evaluated. Level 4 n=229 Comparison of AMG vs EMG neuromuscular monitoring Review of multiple studies evaluating the variation of TOF ration/count between EMG and AMG devices as well as the variation in clinical difficulties of use AMG monitoring was found to have a higher rate of perceived error and difficulty of implementation. EMG was found to be less dependent on patient arm position and was able to produce accurate results even if muscle movement was restricted. Khandkar, C., Liang, S., Phillips, S., Lee, C. Y., & Stewart, P. A. (2016). Comparison of kinemyography and electromyography during spontaneous recovery from non-depolarising neuromuscular blockade. Anaesthesia and Randomized Control Trial Surgical patients requiring paralysis Level 1 n=23 Comparison of precision of KMG and EMG on TOF ratio Software R statistical computing software, BlandAltman analysis for repeated measurements. KMG/EMG monitors were placed and ran repeated measurements which were compared for precision/repeatability. Both KMG and EMG proved to reliably report TOFR. KMG was more precise overall, however it overestimated the TOFR by 0.08 as compared to EMG in the TOFR range of 0.80-0.90. EMG proved to me more reliable in preventing RNMB. QUANTITATIVE TRAIN-OF-FOUR 38 Intensive Care, 44(6), 745751. Renew, J. (2021) Monitoring neuromuscular blockade. Up to Date. Retrieved January 23, 2022 Thomsen, J. D., Marty, A. P., Wakatsuki, S., Macario, A., Tanaka, P., Gtke, M. R., & stergaard, D. (2020). Barriers and aids to routine neuromuscular monitoring and consistent reversal practicea qualitative study. Acta Anaesthesiologica Scandinavica, 64(8), 10891099. Wiatrowski, R., Martini, L., Flanagan, B., Freeman, K., & Sloan, N. (2018). AANA Journal Course neuromuscular Review of literature, evidence based clinical guideline Level 4 Focus group interviews, qualitative study n=40 Level 4 Qualitative vs quantitative TOF monitoring differences and benefits Review of literature and practices from multiple studies. EMG is recommended as superior to AMG monitoring due to more reliability, ease of use, and positive indication of recovery. Use of NMB monitoring and reversal, barriers and aids to routine monitoring, and NMB monitoring after succinylcholine. Collection of data was done with a 14-question survey. The results were then tallied for interpretation Danish practitioners were more likely to use objective monitoring whereas US practitioners used subjective monitoring. Collection of data relating to RNMB symptoms such as hypoxia, dyspnea, reintubation, etc. Quantifying the level of neuromuscular blocker reversal compared to qualitative observation. Study groups evaluated with quantitative methods of neuromuscular monitoring such as AMG/EMG showed less RNMB symptoms than those monitored qualitatively. TOFR was also more accurately conveyed with quantitative monitoring vs provider visual/tactile assessment. Danish and United States practitioners and their differences. Review of literature, evidence based clinical guideline Level 4 Multiple studies reviewed from 12 subjects to 640 subjects Subjective qualitative PNS monitoring compared to objective quantitative methods. Practitioner variation. QUANTITATIVE TRAIN-OF-FOUR blockade: evidencebased recommendations to improve patient outcomes. AANA Journal, 86(2), 157 167. Weigel, W. A., Williams, B. L., Hanson, N. A., Blackmore, C., Johnson, R. L., Nissen, G. M., James, A. B., & Strodtbeck, W. M. (2022). Quantitative neuromuscular monitoring in clinical practice: A professional practice change initiative. Anesthesiology. Nemes, R., Lengyel, S., Nagy, G., Hampton, D. R., Gray, M., Renew, J. R., Tassonyi, E., Flesdi, B., & Brull, S. J. (2021). Ipsilateral and Simultaneous Comparison of Responses from Acceleromyography- and 39 Retrospective study Review of anesthesia records Level 3 n=2807 Establishment of documented TOFR greater than or equal to 0.9. Equipment trials, educational videos, quantitative monitoring, and a professional practice metric were all instituted to establish a practice change. T-test and chi-square tests before and after interventions. StataMP 16 was used for statistical analysis. P values were two-tailed Quasiexperimental study/RCT Convenience sample of consented/enrolled patients Level 2 n=50 AMG and EMG monitors were linked to simultaneously measure contraction and action potentials at the adductor pollicis. Comparisons of the accuracy, repeatability, and agreement of the AMG vs EMG monitors were assessed. The study was aimed to determine which monitor was the most reliable and at what point in recovery the data was most accurate. Bland-Altman analysis was used on normalized data. ANOVA calculations were done for repeatability Over time (2016-2020) the rate of documented TOFRs of 0.9 or better improved from 1% to 93%. Postimplementation PACU stays were shorter, fewer postop pulmonary complications, and inpatients were discharged sooner as well. AMG was able to detect early recovery sooner than EMG, but was less sensitive to complete recovery. EMG was also more reliable and showed to be a better indicator of recovery for extubation, QUANTITATIVE TRAIN-OF-FOUR 40 Electromyography-based Neuromuscular Monitors. Anesthesiology, 135(4), 597611. Rodney, G., Raju, P. C., & Ball, D. R. (2015). Not just monitoring; a strategy for managing neuromuscular blockade. Anaesthesia, 70(10), 11051109. Weigel, W. A., & Thilen, S. R. (2021). Neuromuscular blockade monitoring and reversal. Advances in Anesthesia, 39, 169 188. Editorial/Expert opinion based on scientific evidence Level 4 Editorial/Expert opinion based on scientific evidence Postoperative and perioperative patient data from multiple studies was analyzed for RNMB symptoms Monitoring neuromuscular blockade with traditional PNS monitors compared to quantitative devices. Variances in provider practice. Data was collected based on a TOFR > 0.9 being considered fully reversed from paralysis. Quantitative monitoring confirmed the TOFR after clinicians used qualitative measures for reversal. Convenience sample of PACU patients Comparison of AMG and EMG monitoring and best clinical practice for their use Data was used from multiple studies to measure the occurrence of RNMB symptoms on arrival to PACU when quantitative monitoring was used n=72 Level 4 There was found to be a high correlation with RNMB after surgery, potentially as high as 41%. It was also found that a majority of polled providers feel that RNMB is very uncommon, highlighting a potential knowledge deficit on the subject. Fewer patients arrive to PACU with RNMB symptoms when monitored with quantitative equipment compared to traditional PNS monitoring. Normalized and nonnormalized values show a drastic reduction in RNMB symptoms in PACU patients when quantitative monitoring is used. QUANTITATIVE TRAIN-OF-FOUR Appendix B Figure1. 41 QUANTITATIVE TRAIN-OF-FOUR 42 Appendix C Microsoft Office. (2021). Simple Gantt Chart. https://templates.office.com/en-us/simple-gantt-chart-tm16400962 Quantitative Train-of-Four Monitoring and the Assessment of Train-of-Four Count Marian University Project Start: Mon, 8/23/2021 1 Aug 23, 2021 Display Week: Aug 30, 2021 23 24 25 26 27 28 29 30 31 Sep 6, 2021 Sep 13, 2021 Sep 20, 2021 Sep 27, 2021 Oct 4, 2021 Oct 11, 2021 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 W T F S S M T W T F S S M T W T F S ASSIGNED TASK TO PROGRESS START END Project Planning and Data Gathering Establishing a topic 100% 8/23/21 8/26/21 Formulate a Needs Assessment Name 100% 8/26/21 8/28/21 Establish a PICOT 100% 8/28/21 9/1/21 Gather research and Establish Project Team 100% 9/4/21 9/11/21 Obtain Team Committee Form 100% 9/12/21 9/14/21 Synthesizing the Research Proposal Draft 1 100% 10/1/21 11/25/21 Proposal Draft 2 100% 11/15/21 1/27/22 Indirect Hours Log 100% 12/6/21 12/9/21 12/6/21 2/15/22 1/24/22 1/31/22 Proposal Draft 3 Informal Project Presentation Project Approval Final DNP Proposal Committee Team Approval Project Site Agreement Letter 1/31/22 2/7/22 2/8/22 2/14/22 2/13/22 2/21/22 Submit to IRB 2/22/22 2/26/22 Final Paper Conversion 2/28/22 3/4/22 IRB Decision 3/28/22 4/5/22 Data Collection 3/29/22 4/11/22 Analyzing the Data 4/11/22 4/18/22 Final Full Draft 4/18/22 4/25/22 Indirect Hours Log 4/25/22 5/2/22 Data Collection Insert new rows ABOVE this one M T W T F S S M T F S S M T W T F S S M T W T F S S M T W T S M T W T F S S QUANTITATIVE TRAIN-OF-FOUR 43 Appendix D Figure 2. STRENGTHS WEAKNESSES Established Need site interest Head of Anesthesia as team member Site able to aid in obtaining equipment Many studies published on topic/related topics Data relatively easy to gather more than one vendor for equipment Testing process Not current clinical site Some subjective data OPPORTUNITIES THREATS This COVID-19 practice is becoming more established elsewhere Equipment becoming more popular/available Potential recommendations for quantitative monitoring Clinical site desires to be example for others/students preventing student access to hospital budget decrease could prevent equipment purchase Anesthesiologist may choose to leave position in future Not obtaining IRB approval A Word Templates Online. (2021). 20+ Creative SWOT analysis templates (Word, Excel, PPT, EPS). https://www.wordtemplatesonline.net/swot-analysis-template/ Final Draft DNP Project signed2 Final Audit Report Created: 2023-04-19 By: Cliff Meyer (cmeyer1857@gmail.com) Status: Signed Transaction ID: CBJCHBCAABAA5uI1FNrHNDHFmnn__MrHHXocEbKM2x5Y 2023-04-19 "Final Draft DNP Project signed2" History Document created by Cliff Meyer (cmeyer1857@gmail.com) 2023-04-19 - 1:14:28 AM GMT- IP address: 208.103.31.166 Document emailed to jskrabak@pchosp.org for signature 2023-04-19 - 1:17:47 AM GMT Email viewed by jskrabak@pchosp.org 2023-04-19 - 2:28:53 PM GMT- IP address: 208.103.13.238 Signer jskrabak@pchosp.org entered name at signing as James A. Skrabak,DO 2023-04-19 - 2:30:05 PM GMT- IP address: 208.103.13.238 Document e-signed by James A. Skrabak,DO (jskrabak@pchosp.org) Signature Date: 2023-04-19 - 2:30:07 PM GMT - Time Source: server- IP address: 208.103.13.238 Agreement completed. 2023-04-19 - 2:30:07 PM GMT Names and email addresses are entered into the Acrobat Sign service by Acrobat Sign users and are unverified unless otherwise noted.  ...

... The Impact of External Factors on the Lived Experience of Teacher Residents ___________________________________________________ A Capstone Project Presented to The Faculty of the Fred S. Klipsch Educators College Marian University ___________________________________________________ In Partial Fulfillment of the Requirements for the Degree Doctor of Education in Organizational Leadership ___________________________________________________ By Karen Wright, Ed.D. May 2023  Copyrighted by Karen Wright All Rights Reserved Abstract Teacher residency programs were designed to fill the space of teacher shortages, by placing highly trained novice teachers into school buildings to complete a yearlong assignment. The impact of teacher residencies is dependent on their ability to decrease teacher shortages, meet the needs of partner schools while increasing the supply of highquality K-12 educators (Berry et al., 2008). This study used a mixed methodology to investigate the lived experiences of teacher residents and the impact of external factors such as mental health challenges, mentor teachers, and stakeholder expectations when determining program effectiveness. This action research paper shares the lived experience of seven teacher residents as they engaged in their first semester of the residency experience at an Indiana liberal arts university. Data was collected and analyzed via interviews and the Maslach Burnout Inventory in order to understand the threshold of burnout, impact of the interventions designed, and improve the lived experience of residents while decreasing the likelihood of burnout. Keywords: clinical faculty, mentor teacher, residency program, teacher residents Fred S. Klipsch Educators College Marian University Indianapolis, Indiana APPROVAL OF THE CAPSTONE PROJECT This capstone project, The Impact of External Factors on the Lived Experience of Teacher Residents, has been approved by the Graduate Faculty of the Fred S. Klipsch Educators College in partial fulfillment of the requirements for the degree of Doctor of Education. Dedication I dedicate this capstone to my maternal grandmother, Ernestine Williams. Because of the woman you were, I am able to stand with confidence, walk with purpose, speak in moderation, and seek to model a life lived according to Gods will. iv Acknowledgement I would first like to acknowledge my mother and father, Pauline and Robert Turner for being a constant source of love and support. To my father for being the first man who truly loved me, and my mother for being fearless in her role of teaching me how to be and why I am an amazing strong black woman. Secondly, I must acknowledge my husband Charles Wright, II for being my greatest cheerleader, best friend, and safe space. Without you, this would have been unsurmountable. I also acknowledge my beautiful daughters, Jaila and Hannah for bringing new meaning to my life, laughter in the home, and pride as I watch you develop into intelligent, strong, and compassionate women. I hope that you are as proud of me, as I am of you. Finally, Id like to acknowledge my committee members, Dr. LaTonya Turner, Dr. Jeffery Kaufman, and Dr. Jeffrey Hannah, for walking beside me through this journey and being the timely push when needed. Thank you for the time you spent helping me make the mark. v TABLE OF CONTENTS Page DEDICATION ...iv ACKNOWLEDGEMENTS ....v LIST OF TABLES ....vii LIST OF FIGURES .viii CHAPTERS I. STUDY DESCRIPTION ....1 II. LITERATURE REVIEW.......9 III. METHODOLOGY....20 IV. INTERVENTION DEVELOPMENT...28 V. INTERVENTION PROPOSAL31 VI. INTERVENTION EVALUATION...38 VII. IMPLICATIONS AND REFLECTION64 VIII. EXECUTIVE SUMMARY...68 REFERENCES .....72 APPENDICES ..80 LIST OF TABLES TABLE Page 1. Residency Program Courseload Options .35 2. Intervention Summary ..37 3. External Factors and Narrative Themes....39 4. Participant Profiles.....42 5. MBI Scale Score 0-6......57 6. MBI Percentile Score Key.....60 vii LIST OF FIGURES FIGURE Page 1. Resident School Placement Types.41 2. Resident Placement Roles .42 3. MBI-ES Emotional Exhaustion Percentile Scores ....58 4. MBI-ES Depersonalization Percentile Scores ..59 5. MBI-ES Personal Accomplishment Percentile Scores .59 6. Number of Residents Reporting Burnout Beginning vs. End of Semester61 viii 1 STUDY DESCRIPTION Introduction Teacher shortage and low retention related issues are impacting educational systems across the nation (Center for Educator Recruitment, Retention & Advancement, 2021). A need to equip prospective educators with the tools to endure the storm, accompanied with the need to provide educators with the strategies and sensitivities to meet the academic and social emotional needs of students, could be seen as a growing focus for university educator preparation programs and school partners. Teacher retention is a national challenge. Schools are seeing staffing shortages due to educators leaving the profession, a decline in the number of applicants, and challenges in retaining licensed educators (Garcia & Weiss, 2020). Although veteran teachers make up a great deal of the educator workforce in the United States, the largest percentage of educators leaving the profession are novice teachers (Seelig & McCabe, 2021). More than 44% of teachers leave the profession within the first five years (Ingersoll et al., 2018). As school districts experienced increased teacher shortages, substitute pools diminishing, and an on-going sense of anxiety amongst school personnel on both the district and local levels, the search as to how to adequately prepare, promote, and support new cohorts of educators led to a deeper look into how to sustain urban teacher residencies (Berry et al., 2008). The innovative design of urban teacher residencies centers around the best practices in recruitment, program participant selection, preparation, placement, and induction. The sound of the alarm to develop the classroom response teams, the first responders, and on 2 the ground academic tactical teams, forced a closer look at the teacher residency experience at an Indiana liberal arts university. This research took place in Indianapolis, Indiana at a faith-based institution that seeks to take on the charge of training educators diverse in field experiences and equipped with the knowledge and practices to make a difference. Graduates from the educator preparation program completed a minimum of 200 to 300 field hours with a variety of school settings and populations. The school partner portfolio included Catholic schools, public school corporations, and public charter schools. Education candidates served in urban, suburban, and high need areas. The program was built on the cornerstone of Franciscan values, which foster the recognition of the dignity of every individual, a commitment to peace and justice, and understanding of the need and responsibility to work towards reconciliation and stewardship. In 2020, after a year of program development with key school districts and the National Institute for Excellence in Teaching (NIET), the Marian Promise was executed. The promise centered around four critical objectives: 1.) Build coherence between systems and structures for support for new teachers at the university, school, and district levels. 2.) Recruit and select high-quality residency candidates and mentor teachers of diverse backgrounds to strengthen the pipeline of effective teachers, including those with a concentration in STEM, in partnering high-need LEAs. 3.) Build the capacity of resident teachers and mentor teachers during the residency period to support the development of effective educators in high-need schools, and 4.) Build the capacity of new teachers and 3 mentor teachers during a two-year long induction period to support instructional excellence, retention, and student achievement in high-need schools (PR/Award # U336S190002 from the Department of Education). There were three teacher residents in the academic program year 2020-2021 working with a mentor teacher, enrolled in graduate courses to secure their masters degree, living off a stipend, and fully engaged in their assigned school community for an academic calendar year. These residents agreed to a one-year commitment as a teacher resident at a designated partner school. There were sixteen teacher residents in academic program year 2021-2022, and twenty-two teacher residents for academic program year 2022-2023. In the review and preliminary analysis of anecdotal data, there appeared to be a relationship between the lived experiences of each individual resident and their assessment of the program effectiveness and their willingness to remain in the field of education. To continue to grow and improve the residency program, time was invested in better understanding the lived experiences of the residents. Residents shared their struggles with mental health access, the importance of the mentor role in creating a climate in which they felt supported and respected, and the additional stress of attempting to meet the expectations of building administrators while holding firmly to what the resident believed was expected. The interest in program growth and improvement became the catalyst to engaging in a process of program reflection and by extension, the focus of this study. 4 Problem Statement Retention rates during the early years of teaching are decreasing, meanwhile teacher retirement rates are increasing (Center for Educator Recruitment, Retention & Advancement, 2021). In some California districts the effort to address low teacher retention and the teacher shortage resulted in attempting to meet the staffing needs with substitutes and teachers who have not completed a teacher preparation program (Hirschboeck et al., 2022). Therefore, the challenge was to provide aspiring educators with a teacher residency experience that prepares and develops residents to be effective in the classroom and remain in education upon residency completion. This required a deeper analysis of the resident experience and program design in meeting this goal. When implemented well, residencies can produce positive outcomes that support the training of better prepared educators, increase of teacher retention, and establishment of a teacher pipeline (Hirschboeck et al., 2022). During the 2021-2022 academic calendar year, concerns began to surface in the form of program feedback, emails, meeting dialogue, and teacher resident responses, indicating a possible misalignment of the program design for the resident experience and the reported lived experience of the resident. As a result of the data, concerns voiced, and short stories shared, it became evident that a deeper dive into the resident experience was needed. Through analysis of the data and pre-diagnostic work, common themes were able to be identified in program surveys, emails, resident discussions, and forums. One common theme was that the lived experience of the residents was stressed due to the expectations of the building administrators and district personnel. This brought into 5 question whether the issue was related to the performance of the teacher resident or the unrealistic or undisclosed expectations on the teacher residents abilities. Challenges in aligning program roles and expectations of the educator preparation program with the expectations of the partnering schools or districts could affect the experience of the residents. In some cases, the residents were seen as employees positioned to learn from the experiences and expertise provided by the mentor teacher. In other cases, the resident was seen as a teacher assistant and unfortunately utilized to fill in scheduling gaps or unexpected building staffing needs. Finally, teacher residents were received, just as the program expected and hoped, as novice teachers, positioned in their buildings to grow professionally, and be a positive addition to the building climate and culture, while utilizing effective teaching strategies to meet the needs of the students. Varied stakeholder interpretations produced varied teacher resident lived experiences. The ability to build positive relationships with mentor teachers was a second theme that surfaced in the diagnostic work. The mentor theme surfaced in two forms. The first was the challenge or success in building a positive relationship with the assigned mentor teacher. The second was the level of accessibility and support available and given by the mentor teacher. The perceived quality of the mentor relationship and the level of accessibility of the mentor, in some cases determined the positive or negative evaluation of the resident experience. It became clear in the conversations and feedback given that the mentor played a critical role in not only how residents experienced the residency, but also how they evaluated their own personal and professional abilities. This interpretation of 6 their ability also dictated how they showed up in the classroom and their willingness to take initiative, think outside of the box, and make mistakes. The third theme was the challenge in accessing mental health supports. Multiple residents shared the unexpected emotional toll they experienced based on the stressors of the job in meeting both the academic and social emotional needs of their students. In some cases, residents shared that before the residency they were able to access mental health support services through the university, but this was no longer available to them because they were in their school placements during the mental health support hours. This highlighted yet another external factor that could directly impact the resident experience and the perspective on continuing in education. Teacher residency is more than a commitment to a yearlong placement. It can also be an opportunity to develop as an educator and build a professional network, while meeting the staffing and student needs of a school or district. The idea of being able to simply build positive student-teacher relationships does not equate to effective teaching (Gillen, 2021). The journey is much more complex. For teacher residents to see or reach the professional status that they so earnestly seek and hope to accomplish, the experience should align with the established expectations. Although this may create a general focus, it does not consider the individual struggles, successes, or experiences of the residents impacted by the role of the mentor teacher, mental health challenges, professional stressors, and external influences. To understand the experience, this research study sought to gain an understanding of the unique role external factors play for individual residents. Not only was there 7 motivation to explore these areas, but there was also a benefit in diving deeper into understanding the prevalence, spaces for proactive programming, and trends. This presented two research questions for discovery: 1.) How do the external factors associated with a teacher residency impact the lived experience of the teacher resident? and 2.) What interventions can be utilized to enhance the lived experience of the teacher resident to increase the likelihood of teacher retention and program satisfaction? The purpose of this mixed methods, action research study was to understand and use the lived experiences of teacher residents in the residency program to identify key interventions to try and enhance their experiences. These enhancements were believed to be able to lead to an increase in the likelihood of teacher retention and program satisfaction. Understanding the resident experience could assist in improving residency programs to not only better support teacher residents, but also create an awareness of key external factors that impact the day-to-day engagement of teacher residents with students, colleagues, faculty, and their graduate coursework. Through interviews teacher residents were given an opportunity to share their experiences and give voice to their challenges and successes. Utilizing the qualitative research strategy provided data that could be employed to transform the residency program and ignite discussions surrounding the impact of external factors on teacher residents and the connection to teacher retention and program effectiveness in educator preparation programs nation-wide. Exploring the resident experience and the impact on teacher retention was important to understand the issues that hinder recruitment, educator development, 8 and retention, leading to the designing of policies and programming that address the issues presented (DAmico et al., 2022). Analyzing teacher residency through the lived experience of the resident to increase teacher retention and overall program satisfaction could benefit both the resident and established school partners. According to Hirschboeck et al. (2022), effectively implemented residency programs can facilitate positive outcomes for school partner Local Education Agencies by supplying well-trained educators and creating a ready hire teacher pipeline. Considering the current teacher shortage and decreased teacher retention rates, teacher residency programs have not only grown in popularity, but are seen as an effective strategy in both recruiting and retaining educators in rural and urban areas (Guha et al., 2017). 9 LITERATURE REVIEW The lived experience of residents was critical in assessing the effectiveness of any teacher residency program. Researchers have looked at the lived experience from the investigative lens of program effectiveness, lessons learned, development of teacher identity, and first year challenges. Through this research the goal was to discover the impact of the lived experience in relation to program development and improvement. By researching this phenomenon, the goal was to gain information that can be used to proactively address external factors that are having internal consequences. To begin this discovery, research was collected on the lived experience and the impact of the external factors associated with the experience. An understanding of this phenomenon could be beneficial in creating a collaborative narrative that supports the teacher residents versus shattering their self-perceptions and adversely affecting the ability to retain the preservice educators in both the classroom and field. Impact of Residency Programming & Resident Experiences The exploration of teacher resident experiences and teacher retention is not a recent investigation (Gillham et al., 2016), but one that is necessary when exploring program effectiveness and success. Omission of how the teacher resident experiences the program, could yield favorable program results, but fail to paint an accurate picture of the overall success of the program. As an example, the Ohio Resident Educator Program was found to be successful in preparing educators, yet the participants in the program did not 10 consider their participation in the program to promote retention, which was one of the program goals (Gillham et al., 2016). The data collected showed that the teacher residents saw the experience as another layer of stress. This information provided a lens in which to examine the program, which could have been missed had the lived experiences of the participants been excluded. Based on this research one could conclude that program effectiveness cannot be limited to program results but must also include the experiences of the participants when obtaining said results. Meeting the goal of the program design or obtaining the expected technical result in and of itself does not equate program effectiveness. California districts struggled to fill teacher vacancies due to an increase of retirements and resignations (Carver-Thomas et al., 2022) leading to the implementation of a residency program in which districts were able to successfully fill vacancies, but were unable to impact teacher retention, without additional adaptive program measures. The trend of increased vacancies and a limited supply of educators created a need to conduct a study on alternative staffing. Through the study it was confirmed that the utilization of teacher residency programs proved to be a viable way to reduce the impact of the staffing shortage (Carver-Thomas et al., 2022). The study included seventeen districts, eight of which were identified as the largest in the state. The programs consisted of a one-year residency, with a mentor teacher and financial stipend. In other situations, the California residency program required teacher residents receive an additional two years of mentoring and a stipend with tuition assistance in exchange for teaching in a high need subject and location for 3-4 years upon their residency completion (Carver-Thomas et al., 2022). Understanding the need to not 11 only provide teacher residents but also retain them, California also focused their attention on how to enhance the experience of residents to promote retention. California added additional staff to support teachers and teaching conditions in order to promote retention. The addition of counselors, smaller class sizes, and hiring of full-time distance learning staff, all played a role in increasing retention rates (Carver-Thomas et al., 2022). California acknowledged that providing a teacher residency program was not enough to ensure retention and recognized that by partnering the program with other benefits that enhanced the lived experience of the residents, there was an increase in the likelihood of retention. Additional research was completed by West Ed and the California Commission on Teaching Credentialing to review the California Teacher Residency Grant Program and determine if the experiences of residents differed based on their subgroup (Hirschboeck et al., 2022). Although the collected survey data of residents, mentors, program leads, and partnership team members resulted in positive findings on the working relationship between mentors, the experienced challenges affected the overall experience of the resident. Many of the residents experienced financial challenges and over half were unable to pay their monthly bills. Through the administration of a spring 2021 resident survey, in which 75 percent of African Americans reported challenges in paying school expenses and more than 90 percent reported challenges in paying bills, it was determined that the resident experience posed a threat to the overall program ability to increase residents of color due to the disproportionate impact (Hirschboeck et al., 12 2022). The program design restricted the program effectiveness, due to the impact on the resident experience. Across the nation, various educator preparation programs are attempting to address the staffing shortages in K-12 education settings (Prepared to Teach, 2022). Multiple programs were highlighted in Alaska, California, Colorado, New Jersey, New Mexico, New York, South Carolina, Virginia, and Washington. Although there are some commonalities among program design, there are also some contrasts in the duration of the residency, the target licensing, days of co-teaching per week, and stipend amount. With each program, there was also a note of changes made or new focal points designed to improve the experience of the resident. Below are some of the program elements addressed: Adjusting course content and assignments to meet the needs of the resident. Financial support and tuition assistance to mitigate the financial burden on the resident. Opportunities to substitute in their assigned district or partner school to offset the financial burden on the resident. Developing mutually beneficial relationships with a clear understanding of the program goals and expectations to better support the resident. The findings suggest that program design, and implementation, regarding how they impact or benefit the resident, can be important considerations in evaluating the programs ability to affect resident retention and overall program effectiveness in meeting the identified goals. 13 Impact of Mentor Teachers on the Residency Experience The lived experience of a teacher resident includes the impact of the role of the mentor teacher. The mentor teacher plays an essential role in both the development of the teacher residents educator identity and instructional practices. Although mentor teachers are based in the assigned classroom of the teacher resident and/or school building, mentoring can be delivered in multiple formats outside of the classroom. Expert or skilled mentoring by university faculty and/or peer mentoring by a cohort member also going through the residency program assist in creating a student environment conducive to learning, facilitating a positive school climate, and the engagement of residents in their school system (Leon, 2014). Beyond the assignment of university faculty, resident mentors can also be building instructional coaches, lead teachers, and those deemed highly effective by building administrators and/or district human resources personnel. Skilled mentors create an environment that promotes the development of a positive teacher identity, thereby increasing the probability of retention (Walkington, 2005). Having a positive teacher identity facilitates a positive perception of professional effectiveness and membership. Identity development of new teachers is directly impacted by individuals involved in the teacher preparation program, such as mentor teachers, fellow colleagues, students and their families, as well as the overall school community (Gatti, 2019; Izadinia, 2015; Johnston 2016; McIntyre & Hobson, 2016). Novice educators with a keen sense of teacher identity not only tend to engage in more reflective practices (Ruohotie-Lyhty & Moate, 2016; Yuan & Mak, 2018), but also support higher retention rates, commitment to professional development, and overall teacher 14 effectiveness (Adnot, Dee, Katz, & Wyckoff, 2017; Izadinia, 2015, McIntyre & Hobson, 2016; Noonan, 2018). Strong teacher identity allows the resident to affirm that teaching is in fact a profession in which they can be successful. Skilled mentors are also critical in the building of self-confidence and instructional competence (Saffold, 2006). In understanding the resident experience, voice must be given to the role and impact of the mentor teacher in this area of building personal confidence and professional effectiveness. Mentor teachers are key stakeholders in the teacher residency program design, and therefore can impact how residents view themselves as educators. The co-teaching/mentor model was determined to create a safe learning space in which the teacher resident experiences a gradual release and increase of teaching responsibilities (Chu, 2020). Under this mentor model, a sense of legitimacy was experienced when the teacher resident and mentor teacher were presented as equal (Chu, 2020). The danger in this model resided in the ineffective implementation in which the resident feels inferior or inconsequential to the mentor teacher. Creating a balanced space with individuals with unbalanced experiences can be tricky. Chu (2020) recognized the third space nestled between real life experiences in the classroom, continued learning through the university curriculum, and the teacher residents ability to operate as a professional in the classroom. This third space or sweet spot can be difficult for a mentor teacher to obtain with a resident, thereby resulting in unintended stress for both parties. Resignations of novice teachers in many cases can be attributed to challenging classroom experiences that affect their moral compass and classroom effectiveness (Odell 15 & Huling, 1998). In a North Dakota based program, the lived experience of residents was used to gather information on program impact (Gourneau, 2014). Five key areas of struggle were identified: classroom management/time management, working with parents and families, differentiating instruction, students with difficult behaviors, and assessment of student learning. Although each of the six residents shared the same challenges, they also shared the reality of considering leaving the profession had it not been for the support of the mentor teacher, a key academic stakeholder. All six resident teachers stated numerous times that without the mentoring support of this program they would have contemplated leaving this profession like so many others (Gourneau, 2014, p. 301). This study supported the critical role the mentor teacher plays in counteracting the stressors or challenges experienced in the residency placement. The depth of the relationship experienced by residents and mentors is developed over the yearlong placement and centered on the cornerstone of trust and respect (Berry et al., 2008). The successful development of the relationship and collaborative aspect can produce high-quality educators in high need schools and school districts, yet it does not come without tensions. In analyzing the lived experiences of mentor teachers in the countrys first urban teacher residency program, mentor teachers shared not only the benefits and successes of being a mentor teacher, but also the tensions that developed when hosting a teacher resident (Gardiner, 2011). Some of the tensions presented focused on the responsibility of mentoring and included the draining task of always balancing their needs and the needs of the students, along with the sense of being overwhelmed by always having someone with you to model for and engage in the practice. Other tensions 16 focused on the students and the ability to establish authentic relationships and sharing their students instructional time. As a teacher resident, experiencing these tensions may be difficult to process and if processed in a negative light not only can affect the lived experience of the resident, but also their mental health. Impact of Mental Health on the Residency Experience The correlation between human service workers and stress in the workplace has been a phenomenon studied for over 40 years (Cherniss, 1980), yet studies related to stress and the workplace for first year educators is a recent area of research focus. To better understand the relationship between an educators workplace, stress, and burnout, Fimian and Blanton (1987) investigated the professional demands of educators and the pervasiveness or presence of depression. Utilizing the Teacher Stress Inventory and Maslach Burnout Inventory, an analysis was conducted on the influence of identity challenges, lack of control, unmet needs, and minimal administrative and peer support on educator stress and burnout. The research sample included 413 pre-professionals and first year special education educators. The inventories were self-administered and measured the level of anxiety and depression, and the findings reported approximately half of the educators scoring beyond the threshold for depression. Understanding this tendency and natural mental health response to the responsibilities, expectations, and challenges experienced as a first-year teacher required an intentional exploration of the impact on the lived experience of residents who are engaging in their first year of teaching as a resident. 17 Although the research does not specifically address teacher residents, the role of pre-professionals and first year teachers is remarkably similar. Both groups are being placed in a school building to deliver instruction, engage in the building community, develop professional relationships, and meet the socio-emotional needs of students. Work related stress can infiltrate our personal lives causing our mental health to suffer (Francisco et al., 2022). Understanding the significance the workplace plays in the resident experience and mental health is crucial. Acknowledging that professional and workplace demands have a direct correlation to teacher mental health (Borrelli et al., 2014), creates a responsibility to understand how residents are experiencing their workplaces and furthermore assess whether the resources are available to residents to address seasons of mental health instability. Workplace burnout can result in a feeling of depression or stress related to anxiety and various workplace factors (McLean et al., 2020). The workplace not only refers to the location in which the resident serves, but also the conditions. Acknowledging that the variations in resident experiences in school leadership, personnel, supports, culture and climate, and workplace conditions may be too great of a challenge to address in one study, the focus becomes how to create program adjustments that positively impact the lived resident experience. Therefore, the more logical approach was to address the accessibility and programmatic opportunities to provide mental health support to the resident. In a longitudinal study with 255 newly assigned female educators, Schonfeld (1991), discovered that educators in the more challenging schools had an increase in depressive symptoms linked to the working conditions. The impact of the working 18 conditions began shortly after the school year launched. This suggested that to be proactive in minimizing a negative impact on a residents mental health, resources, strategies, and or check-ins must be established either before or immediately after the commencement of the school year. Understanding when teacher residents begin to feel challenges related to the workplace or working conditions in their residency, will increase the program efficiency in supporting residents in this delicate space. Classroom student adversity, material resources, and school climate are three features experienced by all beginning teachers that likely have implications for their mental health and career optimism (McLean et al., 2020, p.3). The long-term impact of not addressing or planning mental health supports could have a direct consequence on the residents ability to finish the residency, engage with students, families, mentor teachers, and co-workers, and enter the teaching profession with adequate experience and confidence. Past research has highlighted the importance of teachers personal perception of their work environment including students, peers, and building administrators (Beltman et al., 2011), and the influence on their willingness and commitment to remain as educators (Darling, 2003; Warner-Griffin, Cunningham, & Noel, 2018). Poor mental health in educators is significantly correlated to workplace demands and minimal support (Borrelli et al., 2014). Understanding how the resident environment may impact their mental health, can help to understand their experience, and develop the necessary proactive interventions (McLean et al., 2020). A 2020 research study conducted by McLean et al., investigated numerous factors that could impact an educators mental health and their perception about the profession by utilizing the Jobs Demands-Resources model, an instrument comparing the impact of 19 job demands and job resources. The study explored first year teachers self-reported symptoms of depression and anxiety and how they may be affected by classroom demands and resources. A total of 265 seniors were recruited to participate in this longitudinal study from a university teacher preparation program in the Southwestern United States with majors in early childhood, elementary, and special education. Through the study data was collected that was consistent with the Job Demands-Resources model. Job demands surfaced as a predictor of teacher outcomes, while school climate, as a resource, exhibited potential as a protective factor. In broad summary the findings demonstrated that experiences typically endured by beginning educators are likely to impact educator outcomes (Eccles & Roeser, 2010). 20 METHODOLOGY The research design was mixed methods using narrative action research and the collection and analysis of survey data. Utilizing mixed methods increased the ability to gain information on multiple aspects of the research (Maxwell, 2013), the lived experience of residents and the external factors that impact them. The narrative inquiry explored the lived experiences of teacher residents through individual stories (Creswell & Poth, 2018). As a benefit, action research targets specific events or phenomena (in this case the lived experiences of teacher residents), in professional or organizational spaces to discover solutions to improve the organization or program (Bloomberg & Volpe, 2019). According to Bloomberg and Volpe (2019), Action research studies have direct relevance to improving practice and advocating for change (p.55). Action research has been used as a tool to explore solutions or answers to program or organization challenges with a systemic process based in data and data analysis. Most importantly, action research engages the program or organizational stakeholders in the problem-solving process, facilitating changes that benefit both parties (Bloomberg & Volpe, 2019). In this research study the use of narrative action research provided critical qualitative data in the authentic lived experience of seven residents, arming the program and key stakeholders with information that can be used to enhance the lived experiences of residents and address possible program deficiencies or opportunities for growth. 21 Quantitative research was conducted via survey distribution and data analysis. To collect quantitative data, participants received two surveys. Participants received the Maslach Burnout Inventory Educator Survey, (see Appendix A) and a demographic based survey (see Appendix B). The collection of quantitative data provided a space in which to gather measurable data on the authentic lived experience of the resident. Interviews Semi-structured interviews and group interviews were conducted. Neutral interview locations and virtual programs were vetted to provide an atmosphere conducive to protecting the confidentiality of the participants and the process. The vetting process included ensuring the meeting location were neutrally accessible. All interviews were facilitated virtually. During the interviews, access was restricted to invited participants, the confidentiality expectation was shared before any discussion took place, and the WebEx meeting room was locked once the interviews began. Both group discussions and 1:1 interviews were video recorded, providing both a visual and audio data sample. Participants received information concerning the study both via email and flyer. Interviews and forum participation dates were established utilizing Calendly, a scheduling tool which allows a level of confidentiality and wide range of day and time choices. Recruitment emails regarding the research study and participant needs were distributed the fourth week of August. All interviews and forums were held in December before the residents went on winter break based on their schools calendar. Resident interview questions were intentionally designed to eliminate bias and leading, while creating a clearance for participants to dive into their experiences, 22 thoughts, and processing of their residency exposure as an individual. All questions were open-ended and allowed the participant to share his or her experience without content parameters. Interviews ranged from 35 to 60 minutes. The resident group interview was limited to groups of three to five to ensure both time and space for the voices and thoughts of each participant. The same target questions (see Appendix C) were utilized for both the individual and group interviews, due to the social nature of the group setting, participants played a role in the direction of the conversation in relation to the residency program. The focus group, or group interview, was approximately 60 minutes in length. Each session was recorded via WebEx, providing both a visual and audio recording. Audio recordings were transcribed to begin the data analysis process. Participant names were replaced with pseudonyms. Pseudonyms were assigned once the final confirmation of consent had been received and before the recording began. During the group interview all participants who consented and agreed to utilize the pseudonyms given for themselves and the participants, were permitted to continue in the study. Pseudonyms were distributed in personal emails sent directly to the verified email address of the participant. This research was conducted with a two-point focus. The first focus was to collect data on the individual and unique experiences of the residents. Each resident has an individual story and experiences the residency through their own individual lens. This data was collected using individual interviews and demographic surveys. Qualitative research was beneficial when investigating the unique differences between a participants 23 experience and expectations. The insight provided through resident narratives can be used to shape the current residency program and serve as a comparable analysis to the strengths and challenges of others. Individual interviews took place the third week of November 2022 to the first week of December 2022. The second focus or objective was to collect data in relation to the overall experience of the residents as a group. Data was collected via a group interview. This allowed residents to share their experiences throughout all critical points of programming and offer a perspective that may not be tapped into otherwise. The use of the group interview provided an overall program perspective, using the individual contributions of the group interview members. Calendly was also used to schedule group interviews. Group interviews took place the second week of December 2022. Qualitative research verifications regarding participant sampling and methodology were conducted. Questions (see Appendix C) in both interview formats were open-ended, thereby avoiding leading questions and giving participants the role of supplying data. All collected data provided through individual and group interviews was analyzed and coded using MAXQDA software and followed the established interview protocol (see Appendix D) using the guidance provided by Jacob and Furgerson (2015). Based on the guidance, the interview protocol included the development and utilization of an opening and closing interview script along with researcher prompts ensuring the verbal collection of confirmed consent in addition to written consent. Interviews were recorded and transcribed. 24 Surveys Quantitative data was collected through the administration of a survey. Research participants received the Maslach Burnout Inventory- Educators Survey (MBI-ES), created by Christina Maslach, Susan E. Jackson, and Richard Schwab. The survey addresses three scales, emotional exhaustion, depersonalization, and personal accomplishment (Maslach et al., 1996). Surveys were administered remotely using Mind Gardens Transform systems, at the beginning of the first residency semester, and again at the end of the first residency semester. The beginning of the first residency semester round of surveys were remotely distributed via Mind Garden on September 1, 2022 and all responses were received by September 12, 2022. The end of the first residency semester round of surveys were remotely distributed via Mind Garden on December 13, 2022 and all responses were received by January 17, 2023. Additional demographic survey data was collected in reference to gender, graduate programming options, school placement, ethnicity, and placement site familiarity. Demographic survey data was collected via Google Form and distributed September 1, 2022 and all responses received by September 6, 2022. Participant Selection Teacher residents in the 2022-2023 academic year were selected to participate in the research study for the fall semester. Stakeholder sampling was used to obtain feedback from participants who were involved in the full execution of the residency program (Palys, 2008). Prospective participants, members of the 2022-2023 resident cohort, received initial information concerning the resident research study both via email 25 and flyer in August 2022. A second email was then distributed three days after the initial notification inviting interested parties to attend an informational, to provide an opportunity for prospective participant questions as well as research clarifications. During the informational session, the purpose and methodology of the research was shared, and copies of the consent form (see Appendix E) were also reviewed and distributed to all interested parties via an email attachment. Once individuals expressed interest in participating in the research, a digital version of the consent form was sent to their personal emails for digital signatures. Consent forms were stored digitally in a password locked folder and hard copies were stored in a locked file cabinet, restricted to researcher access only. The participant volunteer window was a total of eight days and closed on August 31, 2022. Upon the window closing seven residents agreed and consented to participate in the research study. The participant pool represented residents from both elementary and secondary content areas as well as multiple partner school programming (public, public charters, private Catholic). Participants were given the following choices of participation: Audio and visually recorded 45-to-60-minute individual interview and/or 60-to75-minute group interview. Required: Maslach Burnout Inventory Educator Survey Required: Demographic Survey. Twenty-two residents were enrolled in the 2022-2023 academic year, seven of those residents consented to being a part of the research project. 26 Limitations Joseph Maxwell (2013), identified two common threats to the validity of any research study, researcher bias and the impact of the researcher on the participants within the study. In order to address both researcher bias and the impact of the role of the researcher, the goal was to not become indifferent or eliminate the influence in totality, but instead, the goal was to conduct the study with integrity and acknowledge and understand the impact of the researchers role, and use it for productivity (Maxwell, 2013). In this study, I was both the researcher and organizational stakeholder. My role as program director placed me in a position of authority over the program residents, which could influence resident participation and survey response. As the program director I had a personal investment on the success of the program and narrative of program effectiveness for our residents and community partners. To address the impact of my role on research validity, the MBI-ES was emailed to participants through a third party and all data collected through the same third party, allowing participants an additional level of confidentiality. Invitations to participate in the study were distributed via email accompanied with the consent form to eliminate the stress and influence that may be presented in an in-person contact. In addition, once participants consented, they were invited to an informational session in which they had the opportunity to ask any additional questions in order to establish a safe participation space. The lines of the researcher and participants can be blurred with any methodology due to the process being collaborative, yet using questioning and inquiry, changes can be 27 made in program practices and assessed for impact (Stringer, 2014). To minimize the blurring of these lines and maintain the validity of the research process, data verifications were utilized. When conducting qualitative research, verification of the study refers to the strategies and processes utilized during the research to ensure reliability and validity (Morse et al., 2002). The first verification centered on the selection of the methodology. The selection of narrative action research aligned with the research goal of gaining understanding of the individual lived experiences of the residents while collecting data that would facilitate program improvements. The second verification took place in the form of participant sampling. According to Morse et al. (2002), the sampling should be limited to participants who are best positioned to have knowledge of the topic being studied. Participants were limited to teacher residents in the current research year. Bias can be explained as the failure to account for prejudiced questions or practices in a study (Pannucci & Wilkins, 2010). Biases may surface through participant sampling or testing. In this study, participant sampling was restricted to residents enrolled during the 2022-2023 academic year. Restricting the sampling participants to those who are best positioned to have knowledge of the topic being studied, was a strategy to address possible research bias through sampling (Morse et al., 2002). Research notification and invitations to participate were sent to all currently enrolled residents, and all consenting participant data was collected and analyzed. Utilizing all data counteracts the practice of solely analyzing data believed to support a desired finding. In addition, survey and interview questions were vetted by a qualitative published researcher to eliminate potential bias in question formatting. 28 INTERVENTION DEVELOPMENT Program interventions were designed based on the data from pre-diagnostic surveys and interviews. To gain a level of insight into the beliefs and perceptions of key program stakeholders, an informal survey was distributed. Through the informal survey, pre-diagnostic data was received from seventy-four participants. The surveys consisted of nine questions. Four questions gathered demographic data, while the remaining five questions targeted data related to understanding the expectations that each stakeholder held for teacher residents. The five targeted questions were as follows: 1. In your opinion what is the purpose/goal of resident/intern teaching? 2. What is the expectation of a resident/intern teacher? 3. What has been your experience working with resident/intern teachers? 4. In your opinion what experiences would be beneficial for residents/interns during their placement. 5. What supports do resident/intern teachers need and where can/should that come from? Data was received from 29 Klipsch Educator College students currently not participating in the residency program but enrolled in the teacher education prep college, seven Klipsch Educator faculty members, 13 current residents, three clinical interns, six district level administrators, eight building administrators, and eight mentor teachers. For the purpose of developing interventions, the focus was on data provided by the teacher 29 residents, district level administrators, and building administrators. The participant data scope was limited to individuals who were directly connected to the residency program. Although Klipsch Educator College students could select the residency program in the future, they were not currently connected to the program, its stakeholders, or the graduate coursework. Clinical interns were excluded from the data analysis due to their limited knowledge of the intricacies of the residency program, as they have selected to secure their educator license through traditional programming. The following themes were noted among resident teachers when describing the purpose of the teacher residency: an opportunity to learn, an opportunity to gain experience, and an opportunity to be exposed to real life situations. In analyzing resident teacher responses as to the expectations of a teacher resident the following themes surfaced: growth, an opportunity to practice skills learned, receive help and guidance, and engage in a gradual release and increase of responsibilities facilitated with the support and collaboration with the assigned mentor teacher. The responses to both the purpose and expectations of the residency program centered around the idea of professional growth, learning, and development. Residents expected to have a learning experience, one in which they are given the space to develop their professional portfolio of best practices and strategies. The next focus was responses given by district level administrators. The same two focus areas were analyzed: purpose and expectations of teacher residents. District level administrator responses in relation to the purpose of the teacher residency, produced the following themes: transition into a professional role, create a teacher pipeline, have 30 exceptional educators, and demonstrate the best instructional practices. The expectations identified by the building administrators did not focus on the provision of an opportunity for residents to develop professionally, but instead a focus on what they should already know and how they can benefit the partner schools and districts in the local community. The purpose and expectation according to district level administrators centered around service deliverables. District level administrators expected residents and the residency program to provide highly qualified candidates who will meet their current and future staffing needs. Finally, building level administrator data was analyzed and common themes identified. Again, the focus targeted the purpose and expectations of teacher residents. Interestingly, the responses to the purpose and expectations of teacher residents were similar across both focus areas. The themes were similar for both questions. Themes included the residency purpose and expectation as being one in which residents engaged in their first year of teaching, gained professional experience, and preparation. Building level administrators saw the purpose and expectation of the residency program to be centered around career development and preparation. Building level administrators expected the teacher residents to engage in a learning and development process, with the support of the mentor teacher. As a result of the literature review, resident feedback, and survey analysis, three key elements were identified that impact both the resident experience and the perception of the overall residency program. The three areas were program expectations, mental health, and communication. 31 INTERVENTION PROPOSAL Program Expectations The first proposed intervention touchpoint was the development and facilitation of mandatory summer training. Mandatory summer training was required for teacher residents, building level administrators, and mentor teachers. The training was made accessible to district level personnel, but not mandated. Although district level personnel were not mandated to participate in the summer training, the training was made available to them and used as a resource when program inquiries arose. To make the residency training accessible to all parties and respectful to the summer traveling schedules of educators, building administrators, and district personnel, the training was delivered via an online/virtual platform. The use of a prerecorded online training allowed for all stakeholders to access the information based on their availability, reference information presented, and direct any points of needed clarification to the program director and residency team with a level of anonymity. The second proposed intervention touchpoint centered around the creation of onboarding resources. These resources provided critical information to each resident before beginning their placement. Onboarding resources included the identification of their mentor teacher, key building contacts, required placement training dates, how to access the building, where to park, assigned program faculty, etc. (see Appendix F). Resources were also provided on questions to ask and things to look for once they began 32 their residency placement (see Appendix G). Understanding the building processes and how they supported the residency program and expectations was another opportunity to align the expectations to the residency program and outcome goals. The onboarding resources were designed to ensure that residents were aware of critical information and placement expectations as they planned and prepared for the transition over the summer, as well as critical information to gather once the school year had begun at their placement site. The third proposed intervention touchpoint under the umbrella of program expectations was the program check-ins. Program check-ins or status checks were conducted bi-monthly with mentor teachers and residents, with a semester status check taking place every semester with building and district personnel. During the scheduled check-ins, key stakeholders including the resident, mentor teacher, clinical faculty, program director, and district personnel (as needed) met either virtually or in-person as dictated by the schedules and availability of involved parties. During this time discussions were conducted focused on shared challenges, successes, needed supports, and program and role clarifications. This intervention was designed to address the lived experiences of our key stakeholders in relation to the expectations of the program. Engaging in these on-going discussions created a proactive measure to address any challenges or adjustments that may need to be made to maintain alignment and meet the needs of our partners and residents. Utilizing end of semester debriefs to make program adjustments allowed for accommodations and clarifications to be established at the end of 33 the fall semester and implemented in the spring, as well as at the end of the spring semester in preparation for implementation in the fall. Mental Health Interventions Mental health needs took center stage as data continued to show the need for mental health support among educators and college students. This growing need is not only a societal challenge but also a program challenge. During the pre-diagnostic work, multiple residents via email, written narrative, resident forum, and resident meetings discussed the need to access mental health services during their residency experience. The increased stress due to attempting to balance a full graduate coursework load, full time residency placement, and the challenges that arose in the classroom setting, created for some, a mental breaking point in which mental health supports were needed, yet not accessible. Mental health counseling services were provided during traditional business hours, which made it inaccessible for nontraditional students who were at their residency placements during those hours. Teacher residents shared the unexpected weight of internalizing the needs and trauma of their students. This weight was accompanied by a feeling of powerlessness in controlling their own emotions related to the trauma. Although it was not feasible for the program to provide mental health services, it was feasible to incorporate some mental wellness interventions that supported our residents, thereby hopefully improving the residency experience. As part of the mental wellness intervention, residents had access to monthly services, meetings, or activities. Each month services were made accessible to residents by a licensed therapist and/or yoga instructor with a focus on mindfulness strategies. The 34 designated licensed therapist provided small group sessions targeting strategies on how to process and respond to student trauma, how to process ones personal emotions when responding to both student and personal trauma, and self-care practices that foster mental wellness. The yoga instructor was contracted to provide yoga and mindfulness classes that demonstrated strategies and techniques that could be used in the classroom and home. All session and activity attendance was optional, allowing residents the freedom to choose which services they felt best met their mental health needs. Through these interventions residents were able to access mental health supports that promoted mental wellness. The balancing of a full-time accelerated graduate course load also presented an additional stressor for new residents. Residents entered placements at the end of their summer break with little transition time and began graduate coursework around the same time they began their residency placement and role as a resident teacher. All these events played a role in the heightened stress and adverse mental wellness status of our residents. Therefore, the final proposed intervention under the category of mental health was an adjustment of the graduate course load and schedule. Table 1 below illustrates the proposed and available schedules for new residents in the fall of 2022. 35 Table 1 Residency Program Course Load Options Semester Option A Option B Option C n/a 9 Graduate Credits n/a Fall 2022 13 Graduate Credits 7 Graduate Credits 7 Graduate Credits Spring 2023 11 Graduate Credits 8 Graduate Credits 8 Graduate Credits n/a n/a 9 Graduate Credits Summer 2022 Summer 2023 The adjustment of the graduate course load allowed residents to reduce the course load during the residency year by selecting the scheduling option that best fit their needs. No longer a one size fits all approach, students had the following options: Option A allowed students to not take any summer courses but resulted in higher course loads during the residency year. This option allowed students to graduate in May, at the conclusion of their residency year. Option B allowed students to take remote summer courses before their residency began in the fall, resulting in lighter course loads during the residency year. This option also allowed students to graduate in May, at the conclusion of their residency year. Option C allowed students to take remote summer courses, the summer after the completion of their residency year, resulting in lighter course loads during the 36 residency year. This option moved the graduation target date from May to late August, at the conclusion of the residency year. A minimum of five residents had to select the program option, for the option to be made available for the academic residency year. Program Communication Interventions The final intervention targeted both timely and quality communications. Although in previous interventions, discussions/meetings are established with mentor teachers and district and building administrators, it was also critical that effective communication was shared with the residents. During the diagnostic phase, residents shared feeling uncertain and unsure as to exactly what would happen next after being informed of their residency placement. The interventions in this case were two-fold. The first included a program orientation before residents left campus for their summer break. The orientation addressed the program structure, next steps, signing of their program agreement, and contact information for their assigned Clinical Faculty and Program Director. Incorporating the orientation at the end of the semester minimized the stress that comes with the unknown and provided a contact to answer questions as they arose versus residents building anxieties related to unanswered questions over the summer break. Secondly, residents were provided resources that gave information related to their placement, assigned mentor, building contacts and access procedures to allow for a smooth transition before summer classes began and were directed to complete virtual introductions with their mentor. 37 Each program adaptation/intervention (see Table 2) was designed to meet the needs of our residents and improve the program effectiveness. The data collected was utilized in evaluating the intervention impact on improving the lived residency experience and overall residency program. Table 2 Intervention Summary Intervention Category Program Expectations Mental Health Support Mandatory summer training for program stakeholders. Implementation of onboarding process. Program status check-ins. Monthly mental wellness meetings, activities, and/or resources. Program Communication Choice of graduate course load options. Residency Program Orientation. Key contact information distributed. 38 INTERVENTION EVALUATION Evaluation of the intervention impact was completed using the transcribed data collected through resident interviews and surveys. All transcriptions of interviews were uploaded into MAXQDA, a qualitative analysis software. The goal of the data analysis was to identify external factors and assess the impact of the interventions on the lived experiences of the residents. Upon uploading the data into MAXQDA, coding and thematic analysis were conducted providing both information on the reported external factors as well as narratives that could be analyzed to determine program intervention effectiveness. Table 3 provides data on the external factors reported by the research participants as well as the common themes discovered through a three-step coding process. Thematic analysis was also conducted by identifying the themes in the participants narrative (Riessman, 2008). This analysis provided a framework to compare the pre-diagnostic themes with the collected data and determine if the themes remained the same after the interventions were put into place, or if new themes were presented among the 2022-2023 resident research participants. 39 Table 3 External Factors & Narrative Themes Parent Codes Experience (33) Retention (9) Program Suggestions (23) Biggest Challenges (11) Successful (6) Sub Codes Theme Frequency n/a Residents summarize their experiences in their partner school placements. Finances, family, friendships, health, outside employment, academics Shared suggestions on how to improve the program. Shared challenges that impacted the experience. Identification of program elements that contributed to resident success. Initial expectations, graduate course load, resident check-ins, orientation, information, mentor teacher, clinical faculty, building administration Identification of elements or missing program components. 33 External Factors (15) Internal Factors (6) n/a n/a n/a Expectations (39) Grad Work (16) Communication (39) Lack of Support (15) Positive Support (47) Program Gaps (9) n/a Emotions Total 30 23 11 6 156 9 Mental Wellness (32) Pride/Confidence (19) Stress (25) 76 344 The MBI-ES data was collected via the third-party resource, Mind Garden. Mind Garden (2022), remotely distributed the survey to consenting participants, collected data and formulated individual reports. Each MBI-ES Individual Report included data 40 regarding the MBI results, scale scores, and percentile scores compared to general population norms. Participants Based on information received from the demographic survey, the participants included six females and one male. Three of the participants were placed in a public charter school, two in a catholic school, and the remaining two participants were placed in a public school district (see Figure 1). Six of the participants were placed in elementary schools and the other placed in a middle school placement. Four of the participants had some level of familiarity with their placement site via clinical placements throughout their education preparation program or as a volunteer. In addition to general demographic and placement data, the survey also captured the graduate programming option, due to the graduate programming option being expanded as one of the interventions under mental health. Five of the participants selected the Option B graduate programming in which remote summer classes were offered before the residency began in the fall, creating lighter course loads during the residency year with a May graduation. Two participants selected the Option C graduate programming in which remote summer classes were taken after the residency year completion, with lighter course loads during the residency year, and a late August graduation. 41 Figure 1 Resident School Placement Types n= 2 n=3 n=2 Participants were given various roles (see Figure 2) based on the placement site. The roles included traditional resident or teacher of record. The traditional resident was assigned to a classroom with a full-time master teacher vetted by the program. The teacher of record was assigned a master teacher but assigned as the classroom teacher for their assigned room. There is an additional layer for participants who are traditional residents or teacher of records through the Teacher Quality Partnership (TQP) grant. Participants in TQP partner schools have committed to an additional three years of service in the district or placement school upon the completion of the residency. Table 4 provides the profile of the research participants in connection to some components of the demographic data collected. 42 Figure 2 Resident Placement Roles n= 1 n= 1 n= 2 n=3 8=9 = Table 4 Participant Profiles Resident Gender Pseudonym Grade Level School Type Clara Corey Marcia Female Male Female Elementary Elementary Elementary Melissa Female Jasmine Sabrina Sharon Female Male Male Middle School P-12 Elementary Elementary Public Catholic Public Charter Public Charter Catholic Public Catholic Individual Group Interview InterDate view Date 11/28/22 12/7/22 12/13/22 11/29/22 12/13/22 11/23/22 11/21/22 11/22/22 12/15/22 12/13/22 43 Findings Data was collected and analyzed from individual and group interviews as well as a beginning and end of the semester distribution of the MBI-ES. The data collected from the MBI-ES survey provided an additional lens to the level of burnout experienced by the participants at the beginning and end of the data collection window. Burnout data related to mental wellness such as emotional exhaustion, workplace depersonalization, and feelings of personal accomplishment. Interviews were utilized to get a personal recall of lived experiences of the residents and the impact of the interventions put into place with the hope of both improving the lived experience and likelihood of retention. Through the narrative of the participants of their overall lived experience, and the ability to code via the transcriptions of their recounts, external factors were identified, and charted. In this section, the process begun in analyzing the shared experiences to determine whether or not the interventions proposed and implemented had an impact on the lived experience. By reviewing the data through an intervention lens, intervention impact was assessed. The proposed interventions centered around program expectations, mental health, and communication. Program Expectations One consistent theme throughout both the pre-diagnostic and action research data was one of expectations. As presented in previous sections, the challenge with expectations was creating a space in which the expectations were aligned and there is a unified understanding as to how the program was designed and implemented in real time. In order to address the misalignment of expectations, summer training was instituted, 44 frequent check-ins with residents and other key stakeholders were conducted, and there was the development of an onboarding process. The goal with the facilitation of the intervention strategies was that residents would not only share their understanding of the program expectations, but they also would have witnessed or experienced moments in which it was evident that our school partners also understood. Residents expressed a level of appreciation for the resident check-ins and onboarding. Corey noted, I feel like with my involvement with Marian and the communication that weve had, its been positive with our meetings that weve had recapping what is going to be happening, as well as its important for us to just sit and be able to see the other residents and share experiences for a short bit, our feelings. I really enjoy the how are you feeling time frame that we have at the beginning of the meetings. Thats something that I really look forward to. Not only did the residents identify a positive impact on their lived experience from the resident check-ins and meetings during their residency, but there was also an acknowledgement of the impact in preparation for the residency. Sabrina shared, I felt definitely a lot more support, for sure, but it was just kind of nice with the clarified expectations. Jasmine also shared, Communication has been great as well as the administration at the school that Im at. Theyre always so welcoming, so open to helping me and giving me 45 feedback, especially with behavior management, as to what is the right step I should be taking. Based on the resident feedback, building administrators understood the level of investment and time needed to support the residents as they developed their craft. Building administrators not only made themselves visible, but also engaged directly in the coaching and development. The role of the resident was understood and their role in supporting them was accepted. This is highlighted in Claras statement that, There are times that theyve coached me on different things. Like, I know my principal once spoke to me about talking to a parent and how I should phrase things, and even the Dean of Discipline did the same for me, right before I went to talk to a parent. Those moments were really helpful. Although it appeared based on the residents experiences that the interventions proved successful, the removal of one layer of expectation misalignment revealed another. Residents shared their appreciation for the information, recaps, and support being provided at the school, but they also shared their confusion, bewilderment, and self-doubt based on their personal expectations of what the teaching and classroom component would entail. Sharon, when asked whether or not she, during the residency experience, had thought teaching was no longer for her, replied, It was just when I was frustrated and upset, that teaching wasnt like in the shows, or perfect children ready to learn. But yeah, that had been the only time. But for the most part I know that this is still what I want to do. 46 Classroom management and student aggressive behaviors played a significant role in the transition from challenge to confidence, and the shattering of the idea that teaching would be easy. Many of the residents shared that they overestimated their ability to address student behaviors. Clara shared, Theres definitely areas where I feel like I thought I had it all together, like, classroom management is a great one, and then actually being in the classroom is a very different situation. Marcia, a teacher of record resident, at a public charter school, reported, My biggest thing that I was not prepared for was the behaviors that I experienced in my classroom. And from just constant screaming to hitting to running out of the room, I mean, its just kind of run the gamut of behaviors. Melissa, a middle school traditional resident, at a public charter school experienced a similar reaction and stated that, I think just, like, the students saying offensive things to teachers, disrespectful, like, a lot of cursing and stuff like that, that I wasnt comfortable with. Clara also shared, I feel like walking into the year, I felt like I was going to have a lot more in control than I did, which isnt a bad thing. Definitely a lot of learning opportunities and learning moments. And I feel like Ive been pushed in ways I wasnt necessarily expecting to, but thats okay. Each residents lived experience and the clash between perception and reality brought about a level of stress fostered by self-doubt and shock. 47 Residents experienced the same level of doubt and shock when lesson planning to a curriculum and overall building programming. Although the residents had been trained in general lesson planning in their educator preparation program, they were running into difficulty when trying to incorporate the building curriculum into their lesson planning knowledge base. It brought about a new challenge and area of self-doubt and stress. Mental Health Mental wellness interventions were the second program focus. Due to the requirements of the residency placement, residents had limited access to the mental health services provided through the university. The office was only open during regular business hours and residents were in their placement classrooms during that time. The mental health intervention included both the provision of monthly mental wellness activities and the adjustment of the graduate courseload, giving the residents the option to spread out what was originally a two-semester program, to a three-semester experience. The resident interviews illuminated multiple mental health triggers that directly impacted their lived experience. The challenges ranged from academics, familial responsibilities, intense levels of self-doubt, stress, and inefficiency of stress coping strategies. These all played a role on how residents internalized the residency experience. Residents were provided access to a licensed therapist and yoga classes in order to promote, encourage, and support mental wellness. Although the resources were offered, only one of the seven research participants took advantage of them. In speaking with Jasmine multiple stressors were revealed, 48 So like Ive been in stressful situations, but this has definitely been like times ten in that sense. So, its made it very challenging, especially since I felt like at first I wasnt mentally in any form of way or shape prepared for it..I was questioning if I wanted to be in the program at the beginning of this semester. Reason being, one, I was not in a good mental state. There is just a lot going on mentally. I am on academic probation. I got a C in the summer. It was not a good summer. The summer was rough. Like, extremely rough on top of not being mentally okay. I do not know how I got through. I really do not. Jasmine also played a large financial role for her family and the commitment to the residency program meant that not only could she not contribute at the same level financially, but she also could not contribute the same amount of time. The positive is that Jasmine was self-aware of her needs and limits. Jasmine also shared the following, I will say thank you for the one guest speaker that you brought in. Thats actually where Im getting my help, because it was quite the realization that selfcare is important. Jasmines willingness to make the time to attend the sessions also indicated her commitment to make the time to better herself. Although the remaining participant residents did not attend the sessions, it was not an indicator that they were not struggling with their own challenges to mental wellness, which was a direct impact on their experience. Marcia disclosed, 49 Ive had lots of ups and downs all over the place. Definitely a roller coaster of emotions and experiences. Starting the year was a little rough. When I agreed to go to the school, it was we were going to have three weeks of planning that was going to allow us to have our lesson plans prepped for the first two weeks and have our classrooms ready and then, some, of course, professional development as well. And thats not really what happened. Clara stated, I originally picked up a part time job, and I immediately quit it when teaching started for that reason, recognizing that I still need boundaries, especially if Im going to keep my physical health in check as well as mental. Feelings of self-doubt also permeated throughout the interviews. Residents questioned their capacity to do the work once confronted with the realities of what the true work entailed. Residents struggled with marrying their perception of the work to the actuality of the work. This caused some heightened levels of stress in the beginning of their residency experience. Corey shared, There are moments where I'm like, I dont know if I could teach this. I dont know if I am a good teacher. Jasmine, stated ..walking in, I was like, I dont know what to do. Which I didnt, I just had to figure out that I didnt know what I needed to do. But in those senses, its thrown challenges at me that I was not expecting or prepared, which once again made it very, very, challenging. 50 Marcia shared, So I did not start the year as prepared as I was hoping to. So that definitely impacted that experience and just getting started with the yearIm like this is not what I remember elementary school being like, and this is not anything like what Ive experienced at a clinical and anything like that. So it was like, is this what Im supposed to be doing. Do I know what Im doing? This line of self-questioning appeared to be the norm for all of the participating residents. Acknowledging that only 1 of the 7 research participants took advantage of the mental wellness supports, it was important to understand how the residents were in fact coping with the levels of stress. Corey shared the following strategy, One was forming like your support group with other residents at that school building and just express how that day went and just be supportive with one another and give, offer feedback, to ways that we can improve a situation as well as just give moral support to one another. Sabrina shared, Dont know that I necessarily have a good answer to this, but I think in the moment, theres really just no option that I have found that works for me to process in the moment.you kind of just have to shove it down. Ill deal with it later. For those in the moment things I definitely, on multiple occasions, have felt like Im just kind of going along during the week and like, okay, I just need to get back to the weekend and Ill put my life back together. 51 Marcia, added, I think my biggest in the moment coping is just taking deep breaths, and I try to model that for my students, especially with it being kindergarten, saying, okay, Im really frustrated right now. Im going to take a couple of deep breaths.. One may conclude, that although these can be identified as personal coping strategies for the moment, the need for a more long-term and reflective approach may be necessary to bring about a proactive versus reactive solution. Yet, the challenge is not providing the resources but coaxing the residents to take advantage of the resources provided. In reference to the graduate work, new challenges and mindsets were shared. Residents did not share any concerns about the number of credit hours that they were having to take at once, but instead the narrative as to how graduate coursework was affecting their lived experience was much more personal. Residents shared that they struggled with the balance of assignments and timelines, which could lead to some tense moments, late nights, and event schedule adjustments to meet the established deadlines. Residents were forthcoming in acknowledging that the failure to meet deadlines was not due to a lack of information, but instead their level of intentionality in accessing the information. Clara disclosed, Were trained by the point when were seniors to figure out where to put our energy and where not to when it comes to academics. And so Im sure there was a lot of information within the module that was really helpful, but theres a tendency to skim through it or to push it off to the last minute. 52 Marcia, communicated that, I think that the biggest difficulty has been kind of keeping up with the assignments and knowing whats coming up. Because I know theres been some assignments that have just, like, snuck up on me, and Im like, oh, look, this is due. Im just trying to survive the next day or the next week so those kind of further ahead assignments can sneak up on you. In addition, Sharon disclosed, I have definitely still struggled at times though, to stay on top of certain assignments and things, just planning ahead. Although the management of the grad work expectations impacted the experience, it also was considered a highlight and complement. Residents were able to experience the content at a deeper level than they had before because they were implementing the strategies in real time with the students assigned to their classroom. Clara stated, I really like the courses that weve been taking. Again, so the courses that weve taken, in addition to being in our residency, I feel like have done a really good job of meeting our needs that were also seeing within the classroom. Like, theyve been supporting kind of what were seeing anyway. Program Communications The program communication intervention focused on the on-going support from key stakeholders and their overall accessibility to residents as they maneuvered through this very unique experience. As part of the intervention all key stakeholders participated in a residency program orientation, and contact information was distributed as soon as it 53 was available so that residents, master teachers, and clinical faculty could begin some critical conversations before the placement officially began with key support stakeholders. The quality and accessibility of support was yet another impact factor for residents and their lived experience. Key support stakeholders were mentor teachers, clinical faculty, and building administrators. Sabrina shared, I have gotten along with my mentor teacher exceptionally well, so I think thats been a huge blessing. Along with it, I feel like Im learning a lot, and overall, just a very positive experience, for sure. She also mentioned, The support from my school as a whole has been really helpful. I feel like my school has worked with a lot of Marian students before, so I feel like that has contributed to how they work alongside us and how they know how to check in with us. I feel like thats been really beneficial too. And then just Marian faculty being in there weekly, I feel like is helpful. Just being able to have those conversations check-in and see where were at. Melissa commented, For sure, my master teacher, shes helped me through a lot, as well as the director and clinical faculty. I feel like Ive been able to contact you guys if I have anything. Residents confirmed in their interviews that both the support of their mentor teacher and building level staff played a role in how they experienced their residency. Based on the participant responses the lived experience of the resident was impacted not 54 only by the mentor teacher whom they received direct daily and weekly contact and support, but also by the building level staff whom they interacted with and in some cases received directives from throughout their residency. The impact of clinical faculty and their level of support, counseling, and guidance was also identified as a resource that affected the lived experience. When asked what the biggest contributor to her success was, Marcia responded, Its definitely my clinical faculty. Being a teacher of record, I dont get immediate and constant feedback from my mentor teacher, which is something that I kind of looking back, go, oh, I really should have gone a different way with this program. Clinical Faculty members were assigned to each resident over the summer to be the liaison between the partner school and university, conduct weekly observations, and provide feedback and coaching. The quality of support from clinical faculty was an external factor impacting the lived experience of the residents. Jasmine, who was in a very unique position of having someone who was fluent in speaking Spanish as well as trained in teaching in Spanish, shared the impact of having a clinical faculty member who truly knew her craft, Its been very beneficial, like having my clinical faculty going in and observing the few couple of classrooms that she has observed, and my recordings, and giving me different feedback on all of that and managing those different grade levels. Because for a couple of years, I didnt have someone that could like, oh, 55 say, youre doing good on this and this and this. I didnt really get much feedback on my Spanish content teaching area. The consistent accessibility of clinical faculty, support provided, and their ability to provide professional guidance in the specific content areas created a safe space for residents to seek guidance and unload their stressors throughout the experience. Marcia, mentioned, I think probably the biggest positive impact is the structures and support structures that have been put in place. And I think that the communication kind of from our clinical faculty thats there every day or every week and then from that to the director of the program is really good, so that everyones kind of clued in. The level of flexibility of support rounded out the support themes from the residents. Clara shared, Yeah, something that I really appreciated was my clinical facultys flexibility with us. I know theres a fine line between expectations and flexibility, but I think he was really good at recognizing that each school has their own schedules and their own needs and their own expectations within the schools. In addition, Corey shared the frequency in which he was able to meet with clinical faculty outside of work hours to help talk about classroom management. This provided him an opportunity to engage with a thought partner, eliminating the feeling of having to figure it out on his own. Corey stated, 56 She would always just whenever we needed to talk, she would invite us to Starbucks and get a cup of coffee and just talked it out. In these spaces and times, the clinical faculty were able to ease the fear of the unknown and make it a natural occurrence, free of shame or self-doubt, for not knowing the answers. Although Corey experienced some challenges in his original placement, he was able to acknowledge and identify the key contributors to his success in his current placement. Corey acknowledged that in his first placement the lack of building and administrative support, was a large piece to the need and decision to change his placement, but he expressed how pleased he was in his new placement and the level of support in the following statement, Her door would always be open and she was right in the central location where the printer is, the teachers lounge is, the bathroom is, so you would never miss her. She was very nice and positive with me and the other Marian student teacher. And whenever she would observe a lesson, she would write down whether it be an email or in a note about what shes noticed and saw, all the positive things and then some of the things that shed be looking for in the next observation or anything that we could help improve with. As a result of the change, Corey took on a teacher of record position and in his new placement, his confidence increased. 57 MBI-ES Group Findings The Maslach Burnout Inventory Educators Survey (MBI-ES) is designed to assess burnout based on the frequency in which one feels emotional exhaustion, depersonalization, and personal accomplishment. Based on the MBI-ES individual reports, burnout is measured in three forms; a depletion of emotional energy and indicator of distress due to emotionally taxing work (emotional exhaustion), a loss of enthusiasm or disconnect leading to an impersonal reaction to ones students (depersonalization), and a loss of confidence or feelings of adequacy and success in ones work with students (personal accomplishment). Each participant completed the survey at the beginning of the semester and then again at the conclusion of their first residency semester. An individual report was provided based on participant responses, providing three data points. Results were provided via an MBI Scale Score 0-6 (see Table 5), MBI Percentile Scores based on scale scores and compared to a general population of 4,000 educators, and the responses provided in the survey for each category, emotional exhaustion, depersonalization, and personal accomplishment. Table 5 MBI Scale Score 0-6 0 Never 1 A few times a year of less 2 Once a month or less 3 A few times a month 4 Once a week 5 A few times a week 6 Every day 58 Based on the data collected from the MBI Scale Scores, five of the participants experienced a decrease in emotional exhaustion from the beginning of the semester to the end of the semester (see Figure 3). Three of the participants experienced a decrease in feelings of depersonalization while one stayed the same (see Figure 4). Five of the participants experienced an increase in feelings of personal accomplishment with one staying the same (see Figure 5). Figure 3 MBI-ES Emotional Exhaustion Percentile Scores Beginning & End of Semester Emotional Exhaustion MBI Percentile Scores 99 100 90 80 70 60 50 40 30 20 10 0 99 98 93 79 76 68 64 58 41 35 32 Clara 85 26 Corey Jasmine Marcia Beginning of Semester Melissa Sabrina End of Semester Sharon 59 Figure 4 MB I-ES Depersonalization Percentile Scores Beginning & End of Semester Depersonalization MBI Percentile Scores 74 80 69 74 69 70 60 50 37 40 31 31 30 13 16 20 26 26 16 16 16 10 0 Clara Corey Jasmine Marcia Beginning of Semester Melissa Sabrina Sharon End of Semester Figure 5 MBI-ES Personal Accomplishment Percentile Scores Beginning & End of Semester Personal Accomplishment 100 90 80 70 60 50 40 30 20 10 0 95 93 92 85 85 79 79 76 68 64 41 25 16 0 Clara Corey Jasmine Marcia Beginning of Semester Melissa Sabrina End of Semester Sharon 60 The MBI Percentile score allowed the data to be considered in relation to a general population of 4,000 educators. The percentile score key (see Table 6) is based on the percentage of individuals who rated themselves as having less frequency of that scale topic and with a focus on needing to take action to reduce burnout. Table 6 MBI Percentile Scores Key Percentile Score Action Needed Emotional Exhaustion 90 or above Reduce Burnout Depersonalization 90 or above Reduce Burnout Personal Accomplishment 10 or lower Reduce Burnout Based on the data collected in the beginning of the semester, three of the participants needed to reduce burnout based on their responses related to emotional exhaustion and one of the participants needed to reduce burnout based on their responses in the area of personal accomplishment (see Figure 6). There was not a need to reduce burnout in the area of depersonalization at the beginning or end of the semester. At the end of the semester only one of the participants still showed a need to reduce burnout based on their responses in emotional exhaustion. Both depersonalization and personal accomplishment did not indicate a need to reduce burnout. 61 Figure 6 Number of Residents Reporting Burnout Beginning vs. Ending of Semester Burnout Beginning vs. Ending of Semester 0 Personal Accomplishment 1 0 0 Depersonalization 1 Emotional Exhaustion 3 0 0.5 1 End of Semester 1.5 2 2.5 3 3.5 Beginning of Semester Based on the overall group data averages, there were seven questions that moved one full level of frequency, representing a decrease in frequency of emotional exhaustion and increase of personal accomplishment from the beginning of the semester to the end of the semester. The questions are listed below: Emotional Exhaustion I feel frustrated by my job. I feel burned out by my work. I feel used up at the end of the workday. I feel emotionally drained from my work. 62 Personal Accomplishment I feel Im positively influencing other peoples lives through my work. I can easily create a relaxed atmosphere with my students. I have accomplished many worthwhile things in this job. Depersonalization showed an increase in frequency, representing a -0.1 for the question, I dont really care what happens to some students and -0.4 for the question, Ive become more callous toward people since I took this job. The movement in these areas still represents an average that is less than one, therefore based on the scale score a move from never to a few times a year. MBI-ES Individual Findings Although having the group data allowed for programming changes, the goal was to also dig into the individual experiences of the residents. As such the individual MBIES data was reviewed to identify trends and data messaging. The first analysis centered around the MBI Scale Scores. Corey, Jasmine, and Sharon all demonstrated a decrease in frequency for emotional exhaustion and depersonalization with an increase in personal accomplishment from the beginning of the semester to the end of the semester. This suggested that over time, they experienced a decrease in burn-out and increase in their confidence on the impact they were able to make in their classrooms. In contrast, Clara and Marcia demonstrated an increase in depersonalization from the beginning of the year, increasing the likelihood of burnout, yet an increase in a feeling of personal accomplishment and a decrease in the frequency for emotional 63 exhaustion. This data also suggested a decrease in burn-out over time, but a loss of sensitivity and connection with the students. It appeared through the data, that for Clara and Marcia the heightened sense of burnout in the beginning of the year impacted at some level how they saw their students. Based on the interviews this could be a result of the disillusionment and challenges with student behaviors experienced early in the placement. Melissa experienced an increase in frequency in questions related to emotional exhaustion, yet a decrease in depersonalization and increase in personal accomplishment. Melissas data suggested that although the lived experience was emotionally taxing, she was able to lessen her need to address burnout and identify within her experience success as an educator and increased connection to her students. Finally, Sabrina experienced an increase in frequency for both emotional exhaustion and depersonalization, with no change recorded in the area of personal accomplishment. It is important to note that Sabrinas rating is a 5.5 in the area of personal accomplishment representing the scale code that there is a sense of personal accomplishment a few times a week. Sabrinas data represented the outlier in that she appeared to be the one resident who grew in two areas towards increased burnout by the end of the semester. Based on Sabrinas MBI-ES percentile scores, although there was a growth towards burnout, it didnt appear to taint her ability to recognize her success as an educator and positive impact on students. The question becomes at what level of personal sacrifice is this occurring. 64 IMPLICATIONS & REFLECTION This study set out to answer two questions, 1. How do the external factors associated with a teacher residency impact the lived experiences of the teacher resident? and 2. What interventions can be utilized to enhance the lived experience of the teacher residents to increase the likelihood of teacher retention and program satisfaction? As a result of this research it has been discovered that the internal and external factors that impact the lived experience of the resident is the fear of the unknown, a distortion of the perceived role and experience of the classroom teacher, an initial questioning of ability in the beginning of the residency, and the level of support and information provided while in the program and transitioning to the new role. In addition, in some cases the familial role also was a factor of impact. Each resident shared a season of self-doubt, shock, and level of bewilderment as they entered their classrooms expecting to calm the seas of the education landscape, and yet this was not the case. At least not initially. And this breakdown between expectation perception and reality created the perfect storm for a heightened stress level. Both the qualitative and quantitative data reflected a transition, a form of movement, that is fueled by time, development, and maturation. The proposed interventions were designed to address three target areas: the impact of program expectations through an intentional onboarding process, routine 65 resident check-ins, and timely information sharing, mental health access, and communication and support. Based on the data collected through the interviews and the beginning and end of semester administration of the MBI-ES, residents consistently expressed the appreciation for the information provided, resident check-ins, and meetings. Although the mental wellness services were made accessible to residents, only one of the research participants took advantage of the resources. Due to the small sample size, one cannot conclude that the mental wellness services had an impact on the lived experience of the residents. Although access to the services was limited, there was an overall decrease of workplace burnout from the beginning of the semester to the end of the semester among the residents. Finally, the communication interventions, which included the residency orientation, the early assignment of Clinical Faculty, and the ability to connect to their mentor teachers, seemed to positively impact the experience for residents. By providing these support systems residents were able to establish and maintain strong pipelines of communication and support, which in fact appeared beneficial and in some cases made the difference from a resident contemplating exiting the program, to engaging in a reflective process, resulting in a collaborative design of next steps and an increased sense of confidence. The level of accessibility to both the mentor teacher and Clinical Faculty provided a constant safety net when their feelings of self-doubt or disillusionment began to surface. 66 Acknowledging that the alignment of program expectations, mental health resources, and communication and support all do have the ability to impact the lived experience of residents, I also assert that based on the qualitative and quantitative data, the most powerful intervention was time and maturation. As presented in the data, the beginning of the year brought an intense level of stress and self-doubt, yet with time and the opportunity to acclimate themselves into their role, residents were able to see their self-worth, replacing the beginning of the year self-doubt. Secondly, with time residents were also able to accept and process the difference in their perceptions of teaching with the reality of teaching. Therefore, it is important in moving this research further, and in discovering ways to positively impact the lived experience of teacher residents, as well as increasing the likelihood of retention into the educator profession, teacher residency programs should acknowledge the natural progression of growth. In addition to providing clear program expectations, mental wellness activities, and strong communication and support systems, residency programs should acknowledge that growth and development takes time. Resident development should be recognized and considered as a natural progression, similar to that described by Ellen Moir (1990). Ellen Moir described the first-year teacher cycle, acknowledging the highs and lows of the transition to the role of an educator. The phases included anticipation, survival, disillusionment, rejuvenation, reflection, and back to anticipation. There is a need to normalize the first-year teacher process. Based on their recalling of the experience, it appeared that the residents went through a process of professional 67 maturation that moved the needle from the experience being challenging to rewarding as they began to learn more about themselves and their capabilities. Sharon, a traditional resident, at a P-6 catholic school stated, I think the first month or two, just definitely its hard at first, but Ive just grown so much, and I feel like I even saw that within the first month. And so I think that its been nice. It is normal to enter the profession full of excitement and wonder, and then begin to experience a phase of survival after realizing that teaching may not be all that was expected in some cases and more than expected in others. There is a responsibility that through communications one creates a balanced perception of both the highs and lows of the education landscape and provide residential candidates with a balanced lens, lessening some of the overall shock of the role. It is important that educator preparation programs, residency programs, universities and colleges be intentional on exposing aspiring teachers to clinical experiences that highlight research based best practices as well as common challenges. 68 EXECUTIVE SUMMARY The purpose of this mixed method action research study was to understand and use the lived experiences of teacher residents in the residency program, to identify key interventions that will enhance the experience of teacher residents, resulting in an increase in the likelihood of teacher retention and program satisfaction. To begin this process pre-diagnostic work was completed with the current residents and key stakeholders. Based on survey data, resident interviews, and analysis of routine correspondence, common trends were able to be identified. These trends created the foundation on which the intervention plan was built. Using the preliminary data, three target areas were identified and interventions developed. Program expectations, mental health support, and communication were consistent themes throughout the data sets. Because of the breadth of each of these categories, it was necessary to identify the work. This required an adaptive approach to what some may see as a technical challenge. Northouse (2018) suggests that to engage in adaptive leadership one must first step back to analyze the complexities of a given circumstance to obtain a clearer picture of the system and present interpersonal dynamics among the stakeholders. Based on the findings a determination was made as to if the challenge is adaptive or technical. The work was not to create band-aid solutions or interventions that addressed the experiences at an elevated level, but instead to dig deeper 69 into understanding what systems, stakeholders, and emotions impacted the perceptions of the resident experience, making the challenge to develop interventions adaptive. The varied interpretations among key stakeholders had a direct impact on the experiences of the residents because it had a direct impact on the level of expectations placed on the resident. When contemplating how to intervene in this area, consideration was given to what the needs of program stakeholders were for the program to be a benefit for them. The mentor teacher needed a working relationship, respect of the resident, reassurance that the assigned classroom students will learn, and that this experience does not negatively affect their work life balance or job performance. The building administrator needed for the resident to not be a building liability, the resident to prove to be a viable option for future employment in their building, and the assignment to not add to their work life balance. The district level personnel desired for the resident and residency program to be a worthwhile investment of resources and time to the district. The resident needed to be placed in a safe space where they felt welcomed and respected, supported in growing both personally and professionally, able to make mistakes, and encouraged to establish work life balance. Attempting to create an intervention to meet each need at all times is not possible but providing the why behind the program design and importance of each role through training, on-boarding, and consistent check-ins, addressed the fears behind the unknown. Mental health access was the second intervention focus, and in similar fashion the intervention plan had to be realistic, address the need, and be based on an understanding of the key stakeholders and factions. Campus mental health services were not accessible 70 beyond business hours. Understanding the numerous moving parts of budgets, programming, human capital, and necessary paperwork, it was unrealistic to believe the extension of those hours or services would be granted in time for the 2022-2023 academic year. In addition, the residents did not request an increase in hours, they discussed a need for mental health support. Summarizing the mental health support into office hours is a technical solution, understanding the need to vent, have an outlet, and provide guidance on mental wellness strategies is adaptive. In doing the diagnostic work, it was apparent that the focus was not solely on the increase of hours, but also the need to share the experience, a need to unwind, and a way to process the trauma. The residents needed a safe space to process the new experiences and feelings. The final trend this research addressed is communication. Routinely when one thinks of communication, we think of the sharing of information. A simple exchange of ideas and or feelings. In diving deeper in order to develop an appropriate intervention, the goal was not to create a new email, memo, or informational. The resident need was greater than this. Although communication was the broad category, the real need was to relieve the anxieties sparked by the requirement to engage in unfamiliar territory. Building placements, building administrators, mentor teachers, students, families, and graduate work, presented a new set of experiences and responsibilities. Residents needed timely communication as a proactive not reactive measure. Residents needed to understand what was coming next to relieve the anxieties related to residency, being placed in a new school, and being under the direction of someone in many cases they have never met. Through timely communications, residents were equipped with the 71 necessary information that would support a smooth transition into their placement building and development of the resident/mentor relationship. Developing an effective intervention plan required an increased level of intentionality. With a commitment to create reasonable adaptive solutions to adaptive challenges, strategies were established. Technical solutions would have been a temporary fix and at such a critical time in education, a temporary fix is not an acceptable solution for such long-term consequences. 72 References Beltman, S., Mansfield, C., & Price, A. (2011). Thriving not just surviving: A review of research on teacher resilience. Educational Research Review, 6(3), 185207. https://doi.org/10.1016/j.edurev.2011.09.001 Berry, B., Montgomery, D., Curtis, R., Hernandez, M., Wurtzel, J., & Snyder, J. (2008). Creating and Sustaining Urban Teacher Residencies: A New Way to Recruit, Prepare, and Retain Effective Teachers in High-Needs Districts. https://files.eric.ed.gov/fulltext/ED512419.pdf Bloomberg, L. D., & Volpe, M. (2019). Completing Your Qualitative Dissertation: A Road Map from Beginning to End. Sage. Bogdan, R. C., & Biklen, S. K. (2003). Qualitative Research of Education: An Introductive to Theories and Methods (4th ed.). Boston: Allyn and Bacon. Borrelli, I., Benevene, P., Fiorilli, C., DAmelio, F., & Pozzi, G. (2014). Working conditions and mental health in teachers: a preliminary study. Occupational Medicine, 64(7), 530532. https://doi.org/10.1093/occmed/kqu108 Carver-Thomas, D., Burns, D., Leung, M., & Ondrasek, N. (2022). Teacher Shortages During the Pandemic How California Districts Are Responding. https://learningpolicyinstitute.org/sites/default/files/productfiles/Teacher_Shortages_During_Pandemic_REPORT.pdf Center for Educator Recruitment, Retention, & Advancement. (2021, November). SOUTH CAROLINA ANNUAL EDUCATOR SUPPLY & DEMAND REPORT. 73 https://www.cerra.org/uploads/1/7/6/8/17684955/202122_supply_demand_report__1_.pdf Cherniss, C. (1980). Staff Burnout: Job Stress in the Human Services. In Google Books. SAGE Publications. https://books.google.com/books/about/Staff_burnout.html?id=XVZqAAAAMAAJ Chu, Y. (2020). Preservice teachers learning to teach and developing teacher identity in a teacher residency. Teaching Education, vol. 32(3), 269285. https://doi.org/10.1080/10476210.2020.1724934. Creswell, J. W., & Poth, C. N. (2018). Qualitative Inquiry and Research Design: Choosing Among Five Approaches (4th ed.). SAGE Publications, Inc. DAmico, L. K., West, H. S., Baker, M. A., Roy, G., Curcio, R., Harbour, K. E., Thompson, S. L., Guest, J., Compton-Lilly, C., & Adgerson, A. (2022). Using Improvement Science to Implement and Evaluate a Teacher Residency Program in Rural School Districts. Theory & Practice in Rural Education, 12(1), 83104. https://doi.org/10.3776/tpre.2022.v12n1p83-104 Darling-Hammond, L. (2003). Keeping Good Teachers: Why It Matters, What Leaders Can Do. ASCD. Retrieved July 1, 2022, from https://www.ascd.org/el/articles/keeping-good-teachers-why-it-matters-whatleaders-can-do Eccles, J. S., & Roeser, R. W. (2010). An ecological view of schools and development. In J. L. Meece, & J. S. Eccles (Eds.), Handbook of research on schools, schooling, and human development (pp. 6e21). New York: Routledge 74 Fimian, M. J., & Blanton, L. P. (1987). Stress, Burnout, and Role Problems Among Teacher Trainees and First-Year Teachers. Journal of Occupational Behaviour, 8(2), 157165. https://www.jstor.org/stable/3000368?casa_token=z85NNn0RCFcAAAAA%3A1 nFyu0iNgfTXH7s7vRf72dLuMOoxXWsnwG1QDIxuiB6rv3QxlbPU_gIXILZOel wqnx17ZulExvQGKgBEPnl1zvkJ304JbnCgDTH3U1VV163pP0VVGyo&seq=1 #metadata_info_tab_contents Francisco, J., Cruz, J., Cruz, K., Resurreccion, L., Lopez, L., Torculas, A., Gumpal, M., Guillermo, N., & Tus, J. (2022). The Job Burnout And Its Impact on the Employees Performance Amidst the COVID-19 Pandemic. Psychology and Education: A Multidisciplinary Journal, 2(1), 156157. https://doi.org/10.5281/zenodo.6569851 Garca, E., & Weiss, E. (2020). Examining the factors that play a role in the teacher shortage crisis Key findings from EPIs Perfect Storm in the Teacher Labor Market series Report . https://files.eric.ed.gov/fulltext/ED611183.pdf Gardiner, W. (2011). Mentoring in an Urban Teacher Residency: Mentors Perceptions of Yearlong Placements. The New Educator, 7(2), 153171. https://www.academia.edu/10443412/Mentoring_in_an_Urban_Teacher_Residen cy_Mentors_Perceptions_of_Yearlong_Placements Gillham, John C.; Evans, Lesley Anne; Williams, Nicole V. (2016). The preparation of new teachers for the profession; Ohios Resident Educator Program. Leadership and Research in Education, vol. 3(1), 4-15. Gillen, J. (2021). Learning to connect: Relationships, race, and teacher 75 education. Radical Teacher, 119, 85-87. https://doi.org/10.5195/rt.2021.902 Gourneau, B. (2014). Challenges in the first year of teaching: Lessons learned in an elementary education resident teacher program. Contemporary Issues in Education Research, vol. 7(4), 299-318. Guha, R., Hyler, M. E., & Darling-Hammond, L. (2017). The Teacher Residency: A Practical Path to Recruitment and Retention. American Educator, 41(1), 31. https://eric.ed.gov/?id=EJ1137804 Hirschboeck, K., White, M., Brannegan, A., & Reade, F. (2022). Teacher Residency Programs in California: Financial Sustainability Challenges and Opportunities. Retrieved February 27, 2022, from https://www.wested.org/wpcontent/uploads/2022/01/Teacher-Residency-Programs-in-California_Brief.pdf Ingersoll, R., Merrill, E., Stuckey, D., & Collins, G. (2018). Seven Trends: The Transformation of the Teaching Force -Updated. In CPRE Research Reports. https://repository.upenn.edu/cgi/viewcontent.cgi?article=1109&context=cpre_rese archreports Jacob, S., & Furgerson, S. (2015). The Qualitative Report The Qualitative Report Writing Interview Protocols and Conducting Interviews: Tips for Writing Interview Protocols and Conducting Interviews: Tips for Students New to the Field of Qualitative Research Students New to the Field of Qualitative Research. https://nsuworks.nova.edu/cgi/viewcontent.cgi?article=1718&context=tqr Leon, M. (2014). DISTRIBUTED MENTORING 101 DISTRIBUTED MENTORING: PREPARING PRESERVICE RESIDENT TEACHERS FOR HIGH NEEDS URBAN HIGH SCHOOLS. https://files.eric.ed.gov/fulltext/EJ1044196.pdf 76 Maslach, Christina & Jackson, Susan & Schwab, Richard. (1996). Maslach Burnout Inventory -- Educators Survey (ES). Maxwell, J.A. (2013). Qualitative research design: An interactive approach (3rd ed.). Sage Publications. McLean, L., Abry, T., Taylor, M., & Gaias, L. (2020). The influence of adverse classroom and school experiences on first year teachers mental health and career optimism. Teaching and Teacher Education, 87, 102956. https://doi.org/10.1016/j.tate.2019.102956 Mind Garden. (2022). https://www.mindgarden.com Moir, E. (1990). Phases of first-year teaching. Aliefisd.net. Retrieved February 9, 2023, from https://www.aliefisd.net/cms/lib/TX01917308/Centricity/Domain/140/P hases%20of%20First%20Year%20Teachers%20Text.pdf Morse, J. M., Barrett, M., Mayan, M., Olson, K., & Spiers, J. (2002). Verification Strategies for Establishing Reliability and Validity in Qualitative Research. International Journal of Qualitative Methods, 1(2), 1322. https://doi.org/10.1177/160940690200100202 Northouse, P. G. (2018). Leadership: Theory and Practice (8th ed.). SAGE Publications, Inc. Odell, S., & Huling, L. (1998). Conceptualizing Quality Mentoring. https://assets.pearsonschool.com/asset_mgr/legacy/200727/1998_12Odell_392_1. pdf 77 Palys, T. (2008). Purposive sampling. In L. M. Given (Ed.) The Sage Encyclopedia of Qualitative Research Methods. (Vol.2). Sage: Los Angeles, pp. 697-8 Pannucci, C. J., & Wilkins, E. G. (2010). Identifying and Avoiding Bias in Research. Plastic and Reconstructive Surgery, 126(2), 619625. https://doi.org/10.1097/prs.0b013e3181de24bc Riessman, C. K. (2008). Narrative methods for the human sciences. Sage Publications. Saffold, F. (2006). Retaining Urban Teachers: The Impact of Mentoring. Retrieved December 5, 2021, from https://files.eric.ed.gov/fulltext/EJ943160.pdf Schonfeld, I. S. (1991). A Longitudinal Study of Occupational Stress in First-Year Teachers. In ERIC. https://eric.ed.gov/?id=ED335334 Seelig, J. L., & McCabe, K. M. (2021). Why teachers stay: Shaping a new narrative on rural teacher retention. Journal of Research in Rural Education, 37(8), 116. https://jrre.psu.edu/sites/default/files/2022-01/37-8.pdf Stringer, E.T. (2014). Action research (4th ed.). Thousand Oaks, CA: Sage. Prepared To Teach (2022). Teacher Preparation Programs and Teacher Candidates Supporting Staffing Needs During COVID-19 -Program Highlights. https://educate.bankstreet.edu/cgi/viewcontent.cgi?article=1036&context=pt Walkington, J. (2005, March). Becoming a teacher: Encouraging development of teacher identity through reflective practice. ResearchGate; Taylor & Francis (Routledge). https://www.researchgate.net/publication/228371609_Becoming_a_teacher_Enco uraging_development_of_teacher_identity_through_reflective_practice 78 Warner-Griffin, C., Cunningham, B. C., & Noel, A. (2018). Public school teacher autonomy, satisfaction, job security and commitment: 1999-2000 and 2011-12. Stats in Brief: U.S. Department of Education, National Center for Education Statistics. Weiss, R. S. (1995). Learning from strangers : the art and method of qualitative interview studies. Free Press. 79 Appendix A Permission for Karen Wright to reproduce 1 copy within three years of September 1, 2022 For Publications: We understand situations exist where you may want sample test questions for various fair use situations such as academic, scientific or commentary purposes. No items from this instrument may be included in any publication without the prior express written permission from Mind Garden, Inc. Please understand that disclosing more than we have authorized will compromise the integrity and value of the test. For Dissertation and Thesis Appendices: You may not include an entire instrument in your thesis or dissertation, however you may use the three sample items specified by Mind Garden. Academic committees understand the requirements of copyright and are satisfied with sample items for appendices and tables. For customers needing permission to reproduce the three sample items in a thesis or dissertation, the following page includes the permission letter and reference information needed to satisfy the requirements of an academic committee. Online Use of Mind Garden Instruments: Online administration and scoring of the Maslach Burnout Inventory is available from Mind Garden, (https://www.mindgarden.com/117-maslach-burnout-inventory). Mind Garden provides services to add items and demographics to the Maslach Burnout Inventory. Reports are available for the Maslach Burnout Inventory. If your research uses an online survey platform other than the Mind Garden Transform survey system, you will need to meet Mind Gardens requirements by following the procedure described at mindgarden.com/mind-garden-forms/58-remote-online-useapplication.html. 80 All Other Special Reproductions: For any other special purposes requiring permissions for reproduction of this instrument, please contact info@mindgarden.com 81 www.mindgarden.com To Whom It May Concern, The above-named person has made a license purchase from Mind Garden, Inc. and has permission to administer the following copyrighted instrument up to that quantity purchased: Maslach Burnout Inventory forms: Human Services Survey, Human Services Survey for Medical Personnel, Educators Survey, General Survey, or General Survey for Students. The three sample items only from this instrument as specified below may be included in your thesis or dissertation. Any other use must receive prior written permission from Mind Garden. The entire instrument form may not be included or reproduced at any time in any other published material. Please understand that disclosing more than we have authorized will compromise the integrity and value of the test. Citation of the instrument must include the applicable copyright statement listed below. Sample Items: MBI - Human Services Survey - MBI-HSS: I feel emotionally drained from my work. I have accomplished many worthwhile things in this job. I dont really care what happens to some recipients. Copyright 1981 Christina Maslach & Susan E. Jackson. All rights reserved in all media. Published by Mind Garden, Inc., www.mindgarden.com MBI - Human Services Survey for Medical Personnel - MBI-HSS (MP): I feel emotionally drained from my work. I have accomplished many worthwhile things in this job. I dont really care what happens to some patients. 82 Copyright 1981, 2016 by Christina Maslach & Susan E. Jackson. All rights reserved in all media. Published by Mind Garden, Inc., www.mindgarden.com MBI - Educators Survey - MBI-ES: I feel emotionally drained from my work. I have accomplished many worthwhile things in this job. I dont really care what happens to some students. Copyright 1986 Christina Maslach, Susan E. Jackson & Richard L. Schwab. All rights reserved in all media. Published by Mind Garden, Inc., www.mindgarden.com MBI - General Survey - MBI-GS: I feel emotionally drained from my work. In my opinion, I am good at my job. I doubt the significance of my work. Copyright 1996 Wilmar B. Schaufeli, Michael P. Leiter, Christina Maslach & Susan E. Jackson. All rights reserved in all media. Published by Mind Garden, Inc., www.mindgarden.com MBI - General Survey for Students - MBI-GS (S): I feel emotionally drained by my studies. In my opinion, I am a good student. I doubt the significance of my studies. Copyright 1996, 2016 Wilmar B. Schaufeli, Michael P. Leiter, Christina Maslach & Susan E. Jackson. All rights reserved in all media. Published by Mind Garden, Inc., www.mindgarden.com Sincerely, Robert Most Mind Garden, Inc. www.mindgarden.com 83 Appendix B Demographic Survey Questions 1. How would you best describe yourself. Asian or Pacific Islander Black or African American Hispanic or Latino Native American or Alaskan Native White or Caucasian Multiracial or Biracial A race/ethnicity not listed 2. Gender Male Female Non-binary Prefer to self-describe Prefer not to say 3. Degree Sought Masters of Arts in Teaching Masters in Special Education 4. Please select the choice that best describes your placement site. Catholic School Public Charter School Public School District 5. Please select the choice that best describes the student population at your placement site. Elementary Middle School High School 6. Have you been assigned to your placement site prior to your residency? Yes No 84 7. Which graduate programming option did you select for your residency experience? Option A No summer classes before the residency begins in the fall. Higher course loads during the residency year. May graduation. Option B Remote summer classes before the residency begins in the fall. Lighter course loads during the residency year. May graduation. Option C Remote summer classes after the residency year completion. Lighter course loads during the residency year. Late August graduation. 8. How have you agreed to participate in the research study on the lived experiences of residents? Please select all that apply. Individual Interview Group Interview Maslach Burnout Inventory Educator Survey 85 Appendix C Interview Questions Research Questions 1. Tell me about your residency experience? 2. How did your experience compare to your expectations before coming into the residency program? 3. What supports if any did you feel were beneficial during your residency experience? 4. How would you describe communication between stakeholders in the program, such as the resident, mentor teacher, clinical faculty, building administrator, program director, etc.? 5. At anytime during your residency experience, did you question your decision to be an educator? If so, what was happening for you that led to this uncertainty? 6. Were there any outside factors that impacted your residency experience? 7. Were there any internal factors that impacted your residency experience? 8. What suggestions can you give based on your experiences that would help improve or enhance the program? 9. Is there anything else you would like for me to know about your experience in the program? 86 Appendix D Interview Protocol Interviewee: __________________________________________ Assigned Pseudonym ___________________________________ Interviewer:___________________________________________ Written Consent Collected: ____________ Yes ____________ No Introductory Protocol First let me thank you for consenting to be a part of this interview and study. The purpose of this study is to explore the experience of teacher residents, with a focus on improving both the experience and the program. This interview will be approximately 45 to 75 minutes in length. This session will be recorded to protect your identity. Pseudonyms will be sent to you via email, once all consented parties have been confirmed. If at this time you feel you would no longer like to participate in this process, please let me know now and you may leave the call/room without judgment. Introduction Now that I have confirmed consent, let's begin. In your email, momentarily you will receive your pseudonym. I will use this pseudonym throughout our interview as another layer of confidentiality and anonymity protection. Any questions? Lets begin. 87 Research Questions 1. Tell me about your residency experience? 2. How did your experience compare to your expectations before coming into the residency program? 3. What supports if any did you feel were beneficial during your residency experience? 4. How would you describe communication between stakeholders in the program, such as the resident, mentor teacher, clinical faculty, building administrator, program director, etc.? 5. At anytime during your residency experience, did you question your decision to be an educator? If so, what was happening for you that led to this uncertainty? 6. Were there any outside factors that impacted your residency experience? 7. Were there any internal factors that impacted your residency experience? 8. What suggestions can you give based on your experiences that would help improve or enhance the program? 9. Is there anything else you would like for me to know about your experience in the program? Closing Protocol Thank you for your time, comments, and feedback. I appreciate your willingness to be a part of this research project. 88 Appendix E Consent Form INFORMED CONSENT STATEMENT FOR RESEARCH You are being asked to participate in a research study. Scientists do research to answer important questions that might help change or improve the way we do things in the future. This consent form will give you information about the study to help you decide whether you want to participate. Please read this form, and ask any questions you have, before agreeing to be in the study. All research is voluntary. You can choose not to take part in this study. If you decide to participate, you can change your mind later and leave the study at any time. You will not be penalized or lose any benefits if you decide not to participate or choose to leave the study later. The purpose of this study is to explore the experiences of teacher residents at Marian University with a focus on improving both the experience and program. As a current Marian teacher resident and member of the second full cohort you offer a unique perspective of the programs strengths, challenges, and overall impact on a resident and residency experience. The study is being conducted by Karen Wright, current Director of Residencies and Clinical Experiences in partnership with Marian University Klipsch Educators College. If you agree to be in the study, you may elect to participate in one or all of the following: Participate in a recorded and videoed virtual 45 to 60 minute individual or 60-75 minute group interview. Maslach Burnout Inventory Educator Survey All participants will complete the demographic survey. Before agreeing to participate, please consider the risks and potential benefits of taking part in this study. During the interview you may experience some levels of discomfort due to not being exposed to the questions before being required to answer them. To address this risk, participants will be given substantial wait time to answer questions and will be able to request a break from the interview at any given time. Participants will also be given the choice as to where they would like to have the interview conducted to provide them access in a space that feels most comfortable to you. The virtual platform allows for this level of flexibility. 89 You will not be paid for participating in this study. There is no cost to participate in the study. We will protect your information and make every effort to keep your personal information confidential, but we cannot guarantee absolute confidentiality. No information which could identify you will be shared in publications about this study. Researcher will have sole access to video and audio recordings. Audio and visual recordings will be deleted once the research is completed and all data collected and analyzed. Your personal information may be shared outside the research study if required by law. We also may need to share your research records with other groups for quality assurance or data analysis. These groups include the Marian University Institutional Review Board or its designees, and state or federal agencies who may need to access the research records (as allowed by law). Information collected in this study may be used for other research studies or shared with other researchers for future research. If this happens, information that could identify you, such as your name and other identifiers, will be removed before any information or specimens are shared. Since identifying information will be removed, we will not ask for your additional consent. If you have questions about the study or encounter a problem with the research, contact the researcher, Karen Wright, 317-955-6144 or 317-762-6229, krwright2@marian.edu. For questions about your rights as a research participant, to discuss problems, complaints, or concerns about a research study, or to obtain information or to offer input, please contact the Marian University Institutional Review Board office at IRB@marian.edu. If you decide to participate in this study, you can change your mind and decide to leave the study at any time in the future. If you decide to withdraw, please contact the researcher via the aforementioned phone numbers 317-955-6144 or 317-762-6229 and leave a message or text. You may also email the researcher at krwright2@marian.edu. PARTICIPANTS CONSENT In consideration of all of the above, I agree to participate in the following areas of this research study: Online demographic survey. Maslach Burnout Inventory Educator Survey (beginning/end semester) Resident group interview - 60 to 75-minute audio and video recorded. or Individual resident interview 45 60-minute audio and video recorded. _____(Initial) _____(Initial) _____(Initial) _____(Initial) 90 I will be given a copy of this informed consent document to keep for my records. Participants Printed Name: ________________________________ Participants Signature: ________________________________________ Date: _____________ Printed Name of Person Obtaining Consent: _____________________________ Signature of Person Obtaining Consent: __________________________ Date: ___________ 91 Appendix F Resident Information Sheet Resident: Resident Email: Bldg. Placement: Grade Level: Mentor Teacher: Grade Level: Contact Info: On Boarding Information Summer Professional Development Dates: Key Contact Person: Building Access: Parking: Background Check Info: Summer Building Access: Clinical Faculty Name Email Phone # 92 Appendix G Onboarding Checklist  ...

... TYPE Methods 23 January 2023 10.3389/fpubh.2023.1015969 PUBLISHED DOI OPEN ACCESS EDITED BY Sanjay Kumar, Armed Forces Medical College, Pune, India Early detection of SARS-CoV-2 variants through dynamic co-mutation network surveillance REVIEWED BY Sukrit Srivastava, Mangalayatan University, India Natasa Krsto Rancic, University of Ni, Serbia Qiang Huang1 , Huining Qiu2 , Paul W. Bible3 , Yong Huang4 , Fangfang Zheng5 , Jing Gu1 , Jian Sun6*, Yuantao Hao7* and Yu Liu1* *CORRESPONDENCE 2 1 Jian Sun sjian@mail.sysu.edu.cn Yuantao Hao haoyt@bjmu.edu.cn Yu Liu liuy683@mail.sysu.edu.cn Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, China, Guangdong Articial Intelligence Machine Vision Engineering Technology Research Center, Guangzhou, China, 3 College of Arts and Sciences, Marian University, Indianapolis, IN, United States, 4 Institute of Public Health, Guangzhou Medical University & Guangzhou Center for Disease Control and Prevention, Guangzhou, China, 5 School of Traditional Chinese Medicine Healthcare, Guangdong Food and Drug Vocational College, Guangzhou, China, 6 Department of Clinical Research, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China, 7 Peking University Center for Public Health and Epidemic Preparedness & Response, Beijing, China SPECIALTY SECTION This article was submitted to Infectious Diseases: Epidemiology and Prevention, a section of the journal Frontiers in Public Health 10 August 2022 02 January 2023 PUBLISHED 23 January 2023 RECEIVED ACCEPTED CITATION Huang Q, Qiu H, Bible PW, Huang Y, Zheng F, Gu J, Sun J, Hao Y and Liu Y (2023) Early detection of SARS-CoV-2 variants through dynamic co-mutation network surveillance. Front. Public Health 11:1015969. doi: 10.3389/fpubh.2023.1015969 COPYRIGHT 2023 Huang, Qiu, Bible, Huang, Zheng, Gu, Sun, Hao and Liu. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. Background: Precise public health and clinical interventions for the COVID-19 pandemic has spurred a global rush on SARS-CoV-2 variant tracking, but current approaches to variant tracking are challenged by the ood of viral genome sequences leading to a loss of timeliness, accuracy, and reliability. Here, we devised a new co-mutation network framework, aiming to tackle these difficulties in variant surveillance. Methods: To avoid simultaneous input and modeling of the whole large-scale data, we dynamically investigate the nucleotide covarying pattern of weekly sequences. The community detection algorithm is applied to a co-occurring genomic alteration network constructed from mutation corpora of weekly collected data. Co-mutation communities are identied, extracted, and characterized as variant markers. They contribute to the creation and weekly updates of a community-based variant dictionary tree representing SARS-CoV-2 evolution, where highly similar ones between weeks have been merged to represent the same variants. Emerging communities imply the presence of novel viral variants or new branches of existing variants. This process was benchmarked with worldwide GISAID data and validated using national level data from six COVID-19 hotspot countries. Results: A total of 235 co-mutation communities were identied after a 120 weeks investigation of worldwide sequence data, from March 2020 to mid-June 2022. The dictionary tree progressively developed from these communities perfectly recorded the time course of SARS-CoV-2 branching, coinciding with GISAID clades. The time-varying prevalence of these communities in the viral population showed a good match with the emergence and circulation of the variants they represented. All these benchmark results not only exhibited the methodology features but also demonstrated high efficiency in detection of the pandemic variants. When it was applied to regional variant surveillance, our method displayed signicantly earlier identication of feature communities of major WHO-named SARS-CoV-2 variants in contrast with Pangolins monitoring. Conclusion: An efficient genomic surveillance framework built from weekly co-mutation networks and a dynamic community-based variant dictionary tree enables early detection and continuous investigation of SARS-CoV-2 variants overcoming genomic data ood, aiding in the response to the COVID-19 pandemic. KEYWORDS SARS-CoV-2, co-mutation, surveillance, network, community detection Frontiers in Public Health 01 frontiersin.org Huang et al. 10.3389/fpubh.2023.1015969 Introduction sampling week. Since the earliest sampling time in this study was 1 March 2020, the 1st week was defined as from 1 to 7 March 2020. And the last week of the study period was designated from 12 to 18 June 2022, i.e., the 120th week. The evolution of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) presents ongoing risks and threats to natural and vaccine-induced immunity and the effectiveness of diagnostics and therapeutics (13). With the rapidly increasing volume of SARS-CoV-2 genomes, leveraging this wealth of data for variant surveillance quickly becomes intractable due to a daunting computational hurdle of using gold-standard phylogenetic approaches (4). Routine analysis of the expanding scale of sequence data helps the authorities to detect and monitor variant viruses for further characterization and assessment of risk but developing efficient methods is still a core need in this field. A growing body of evidence shows that multiple mutations arising simultaneously in one genome, referred as co-mutation, can be a reliable predictor for viral variant monitoring (59). A collection and combination of co-mutation communities resulted from genomic data accumulated over time helps to capture the evolution and transmission patterns of SARS-CoV-2 (7). Nevertheless, the efficacy of periodic surveillance of co-mutation-based SARS-CoV-2 phylogeny using only updated data for a more computational feasible but globally correspondent evolutionary profile is still an outstanding issue to be addressed. In this study, we developed a co-mutation network surveillance framework to dynamically scout the nucleotide co-occurring pattern of sequences retrieved weekly. The homogeneous co-mutations in the network were found to agglomerate into groups of co-mutation communities characterized as variant markers. These variant markers contribute to weekly updates of a dictionary tree representing community-based SARS-CoV-2 evolution. Emerging communities indicate the presence of new viral variants or new branches of existing variants. We demonstrate this process and interpretation through dynamic creation of global evolution history of major SARS-CoV2 variants and validate its variant surveillance efficiency by tracking multiple variants circulating in some of the major contributors that provide SARS-CoV-2 genomes in Global Initiative on Sharing Avian Influenza Data (GISAID) (10). Co-mutation network surveillance SARS-CoV-2 variant surveillance are performed periodically. We repeatedly executed weekly detection protocols for real-time tracking of circulating co-mutation network using our method (Figures 1A C). These co-mutation networks across weeks were integrated to form a dynamic dictionary for variant monitoring and early warning (Figure 1D). The following subsections detail the complete workflow. Before network creation, mutations with an allele frequency at the weekly level 1% were eliminated since such mutations are considered unfixed in a viral population (11) leading to poor computation effectiveness in co-mutation community detection (7). Step 1. Weekly co-mutation community network Step 1.1. The affinity model for identication of paired co-mutations We model a mutations tendency to be present or absent in a genome where another mutation is already present (Figure 1A). Suppose that, at each genome, independently of all others, mutation j is present with probability pj+|i+ if mutation i is present but with probability pj+|i if mutation i is absent. Their tendency to co-occur can be defined as the degree of difference of the two probabilities using a log odds ratio (12). ij = log( (1) When paired mutations co-occur more often, the log odds ratio is expected to be positive (Supplementary Figure 1A). Or, conversely, their log odds ratio becomes negative (Supplementary Figure 1B). A more or less equal value of pj+|i+ and pj+|i turns ij to be close to zero, suggesting mutation js presence or absence is independent to mutation i (Supplementary Figure 1C). Then, identification of comutation pairs becomes a series of hypothesis testing problems with H0 : ij = 0 (Figure 1A). Our analysis considered only co-mutations with positive co-occurrence. It has been shown that the binary co-occurrence X follows the extended hypergeometric distribution with a general form of, Materials and methods Data source A total of 11,529,602 SARS-CoV-2 genomes were retrieved from GISAID on 25 June 2022. The low coverage sequences (genomes with >5% Ns) were first excluded and only complete genomes (genome length >29,000 base pairs) sampled from humans with explicit collection dates were included. Genomes with duplicated GISAID sequence names were further detected and eliminated, resulting in a dataset of 10,249,122 (88.9%) records. Due to sparse or delayed sequence submission during early epidemic and at the end of data retrieval, we exclusively involved genomes sampled between 1 March 2020 and 18 June 2022 in our study. Then a bioinformatic pipeline, as reported by our previous study (9), was applied to the remaining 10,246,539 (88.9%) sequences to extract and annotate all single nucleotide polymorphisms (SNPs) and insertions/deletions (INDELs) for each genome. In consequence, 519,230,825 mutational events from these sequences were exported and labeled with the Frontiers in Public Health pj+|i pj+|i+ / ). 1 pj+|i+ 1 pj+|i mi P X=k = k
! ! ! ! mj N mi ij k X mi N mi ij s e / e (2) mj k s mj s s=0
for max mi + mj N, 0 k min(mi , mj ) and the same co-mutation distribution arises if their roles are switched (12). Obviously, this distribution (i.e., Eq. 2) depends only on mi , mj , N and ij , but not on pj+|i+ or pj+|i , indicating insensitive to their respective prevalence. The ij can be estimated by maximizing Eq. 2 with X = observed amount of co-occurrence of mutation i and j substituted for k and the maximum likelihood estimate ij is termed to be an affinity metric of co-occurrence (12). Then the P-values can 02 frontiersin.org Huang et al. 10.3389/fpubh.2023.1015969 FIGURE 1 The schema of dynamic SARS-CoV-2 co-mutation network surveillance. (A) The affinity-model-based identication of co-mutation pairs. (B) An illustration of weekly co-mutation network, where nodes and edges with the same colors represent the gathering homogeneous co-mutations, referred to as co-mutation communities. (C) The arborescence indicating SARS-CoV-2 evolution through modeling the hierarchical containment of partition of viral population based on the detected communities presence or not, where nodes correspond to communities with the same colors as in (B). (D) Weekly updates of a dictionary tree representing community-based SARS-CoV-2 evolution, which is a union of two trees. One is the co-mutation community tree detected at the current week, where historically circulating communities were colored in yellow but emerging communities in cyan. Another is last weeks dictionary tree whose nodes are colored in gray. The union results in an update of the dictionary tree where nodes and edges included in at least one tree are preserved and colored by their circulating features. Step 1.2. Co-mutation network and co-mutation communities be calculated as the exact probabilities of co-occurrence greater than or less than what is observed. The computation of false discovery rate across all P-values provides correction for multiple hypothesis testing and the cutoff for identification of paired co-mutations is set at 0.001. Frontiers in Public Health Each pair of co-mutations will result in a connection or an edge leading to an adjacency matrix which defines the co-mutation w network. Let Aw = (Aw ij ) be the adjacency matrix where Aij = 1 if 03 frontiersin.org Huang et al. 10.3389/fpubh.2023.1015969 mutation i and j form a co-mutation pair at week w, or else Aw ij = 0. Specifically, Aw = 0 if i = j. So, it defines an undirected network ij (Figure 1B), denoted by Gw = (Vw , Ew ), where Vw is a set of nodes corresponding to all mutations involved at week w and Ew is a set of edges each linking a co-mutation pair. The affinity model indiscriminately identifies homogeneous and heterogeneous co-mutation pairs (Supplementary Figures 1D, E), which are respectively abbreviated as HoCPs and HeCPs. A HoCP is a pair of co-occurring mutations with equal or close mutation frequencies, while a HeCP is the opposite. A lot of indexes can be used to measure the homogeneity of paired co-mutations. For simplicity, we inherited the rate of the co-mutation (RCM) from Qin et al. (7) to determine a HoCP. |Mi Mj | RCMij = p |M i | |Mj | It ranges from 0 to1 with a value of 1 representing that all elements in a child set are included in its parent set. That is to say, cx cy if and only if most of the elements in cx are elements in cy where |cx | < |cy |. To model evolution histories of SARS-CoV-2 similar to a phylogenetic tree, we constrained edges in Rw to those resulting from direct containing relationships. For example, if the concatenated containing relationship cx cy cz is found, only cx cy and cy cz but not cx cz will be included, resulting in cz cy cx in the arborescence. Once the containing relationships between groups have been established, the arborescence can be created and visualized by R igraph. Step 2. Dynamic creation of a co-mutation community dictionary tree (3) A phylogenetic tree contains smaller trees descending within its branches. A containing tree descends and branches, while within its branches a contained tree itself descends and branches. Instead of a simple pileup in a dictionary, we simulated the phylogenetic tree to leverage the hierarchical containment structure of genome groups present with the co-mutation communities to progressively build the arborescence to capture the evolution patterns of SARS-CoV-2. Specifically, we called it a dictionary tree.  where Mt = Genomes with mutation t (t = i or j) and | | denotes the total number of elements in the set. This is equivalent to the Ochiai efficient (13), which ranges from 0 to 1. The larger it is, the more homogeneous the two mutations co-occur in the same viral population. Due to the sequencing errors, a relaxed RCM 0.9 instead of 1.0 was empirically used as a cutoff to determine a HoCP (Supplementary Figures 2A, B). The HoCPs identified form an aggregated community structure with groups of strongly linked nodes (Figure 1B). We excluded nonHoCP nodes and applied the Girvan-Newman partition algorithm (14) to discover these HoCP groups, named with co-mutation communities hereafter, which was executed by R igraph (15) package. Different from co-mutation modules defined by shared co-mutations (7), the community detection method may get finer division for these HoCPs (Supplementary Figures 3A, B). Step 2.1. Initial dictionary tree The initial dictionary was composed of all the co-mutation communities detected at 1st week, where phylogenetic relationships were determined by their hierarchical containment in the arborescence (Supplementary Figure 5). And the arborescence structure of these communities is consistent with Qin et al. (7) using historically accumulative genomes as of 16 March 2021. Step 1.3. Weekly co-mutation community tree The co-mutation communities exhibit hierarchical organization in weekly co-mutation network (Figure 1B). This hierarchy can be captured by division of the viral genomes and their hierarchical containment according to the detected communities presence or not (7). We built an arborescence, a directed rooted tree, to depict their concatenated containment between these divisions and then used its topological ordering to find the hierarchical relationship (Figure 1C). In detail, the arborescence, denoted by Tw = (Cw , Rw , r), incorporates nodes Cw corresponding to genome groups present and labeled with the detected co-mutation communities at week w, joint by directed edges Rw representing the identified containing relationships with the direction going from parent to child and rooted by a complete group r ( Cw ) including all genomes besides those with absence of any co-mutation community. Different from the exact containing relationship, some of the genomes in a child set may not be included in its parent set due to sequencing errors or algorithm limitation in genotype or mutation calling. To that end, we defined a containing relationship cx cy (cx , cy Cw ) through their Simpson index beyond a cutoff determined by evaluation of historical communities (Supplementary Figure 4). The Simpson similarity is calculated as, Simcx cy = Frontiers in Public Health |cx cy | min(|cx | , cy ) . Step 2.2. Creation of weekly dictionary tree Since 2nd week, the dictionary trees will be built through a union of two trees: last weeks dictionary tree and current weeks co-mutation community tree (Figure 1D). Before union, similar comutation communities on these two trees should be first merged. Step 2.2.1. Merging current weeks co-mutation communities into dictionary Co-mutation communities identified at the current week may have been included in the dictionary. While some are fresh communities composed of completely new mutations that have not been detected before, or some have common but not identical mutations in last weeks dictionary. They can be a compression of, an extension of, or even partially overlap with well-established communities in the old dictionary (Supplementary Table 1). These communities were adjusted based on the principle that preserved the historical dictionary structure as much as possible where the Jaccard index was used to measure similarity of paired communities. In detail, the updating rules are: (i) a new community will be substituted by its most similar one in the dictionary if community compression occurs; (ii) a new community with an extension of at least two mutations will be progressively split into two: one corresponding to its most similar communities in the dictionary and another one for its extension; (iii) a new community will be replaced by its most similar one in (4) 04 frontiersin.org Huang et al. 10.3389/fpubh.2023.1015969 the dictionary with a Jaccard similarity 0.5 (16) if partial overlap happens, or else it will be kept. All community adjustment has been listed in Supplementary Table 2. (Supplementary Table 3). These communities, illustrated by feature communities of WHO-named Alpha (B.1.1.7), Beta (B.1.351), Gamma (P.1), Delta (B.1.617.2) and Omicron (B.1.1.529) variants, demonstrated very sensitive detection in variants emergence and concurrent growth, peaking, and decline in their epidemic, indicating strong surveillance potential (Supplementary Table 4, Supplementary Figures 9, 10). The filtration of mutations with low occurrence rate (1%) provided more accurate and reliable capture of viral variants signal with a prevalence level of about 1% (Figure 2). Step 2.2.2. Re-creation of current weeks co-mutation community tree We re-built the co-mutation community tree at the current week using communities after adjustment according to the flowchart described in step 1.3. Before that, communities, that are identified as intermediate nodes in last weeks dictionary tree and leading to those communities present at the current week, will be appended (Supplementary Figure 6). Step 2.2.3. Union of last weeks dictionary tree and current weeks community tree We executed the union of two trees using union function in R igraph. All communities (nodes) and their hierarchical relationships (edges) included in at least one tree will be preserved as part of the new dictionary tree (Figure 1D). Completely new communities which may suggest emergence of new branches are highlighted in color. Hierarchical containment between co-mutation communities reveals the phylogenetic relationships The affinity model was applied to each weekly data set to detect paired co-mutations. These weekly co-mutations contributed to the formulation of a co-mutation network where HoCPs gathered into groups of densely interconnected communities (see Materials and methods section). Interestingly, the co-mutation network displayed a community clustering structure (Figures 3AE left), exemplified by the gathering of co-mutation communities into groups such that communities within groups are closer to each other. The gathered communities seemed to be connected to higher-level communities at the network center. By partitioning the viral population according to the communities presence or not and their containing relationships, we dynamically established the hierarchical containment of the variants at different stages of the pandemic. This structure captures the hierarchical organization of these communities. These relationships were visualized using an arborescence to depict their hierarchy. This computational framework provided accurate insights on weekly epidemic communities and their branching relationships highlighting circulating SARS-CoV-2 variants (Figures 3AE right and Supplementary Table 2). It also showed sensitive and accurate detection capability in emerging communities indicating novel evolutionary branches (Supplementary Figures 11AE). Workow benchmark and validation Our dynamic surveillance framework using co-mutation network was benchmarked through monitoring major SARS-CoV-2 variants and their branches at global level. National level data from primary contributors, including South Africa, India, Brazil, Philippines, United Kingdom (UK) and United States of America (USA), were leveraged to further validate the surveillance efficiency. Considering huge fluctuation in sample size in different countries and collection weeks, distinct mutation filtration rules were utilized before genomic surveillance. Specifically, when total genomes collected across the 120 weeks were <200,000, we only kept mutations that had occurred in 10% or more of genomes with occurrences >10 in at least one sampling week. Otherwise, the same parameters were used as global surveillance. In addition, variant surveillance at national level will focus on early detection and prevalence monitoring of co-mutation communities indicating novel or rapidly circulating variants or their branches. Worldwide dictionary tree of co-mutation communities provides global proles of SARS-CoV-2 variants Results Co-mutation communities capture the emergence, circulation, and extinction of SARS-CoV-2 variants Based on the above facts, we periodically created dictionary trees to continuously accumulate and store weekly detected comutation communities and their evolutionary relationships (see Materials and methods section). As of mid-June 2022, a dictionary tree comprised of 235 co-mutation communities has been built to imprint the whole evolutionary history of SARS-CoV-2 virus (Supplementary Table 5). This dictionary tree was progressively developed over 120 weeks and represented the time course of SARS-CoV-2 branching, coinciding with GISAID clades (Figure 4). Curiously, the community including the co-mutation pair of A28877T and G28878C independently appeared in different branches of Gamma (P.1) and Omicron (B.1.1.529 branches of BA.1 and BA.2), suggesting possible recombination events of these viral descendants (Supplementary Table 5). A total of 10,246,539 SARS-CoV-2 sequences sampled between 1 March 2020 and 18 June 2022 were included in this study. These viral sequences have been distributed over 120 sampling weeks and experienced an exponential growth over time, from thousands to hundreds of thousands a week (Supplementary Figure 7). We identified 166,893 nucleotide mutations with a total of 519,230,825 mutational events from this data, but only 1,208 (0.7%) reached a frequency of > 1% in at least 1 week (Supplementary Figures 8A, B), indicating a high chance of unstable mutations, or even sequencing error. The counting statistics in co-mutation discovery (see Materials and methods section) from such a giant data set showed that the comutation communities highly condensed viral variation information Frontiers in Public Health 05 frontiersin.org Huang et al. 10.3389/fpubh.2023.1015969 FIGURE 2 Temporal dynamics of major WHO-named SARS-CoV-2 variants identied by co-mutation communities using worldwide data. All mutations included were priorly ltered with a frequency of >1%. The scatter plots showed the prevalence changes over time of community-based variant surveillance. The circles were sized by the median of RCMs of aggregated co-mutation pairs at each sampling week. In the background, the prevalent trajectories of the variants were shown using histograms in pink. Dynamic co-mutation network surveillance provides early detection of SARS-CoV-2 variants data from South Africa, India, Brazil, Philippines, UK and USA (Supplementary Table 7), which exhibited significantly earlier detection of key co-mutation communities referring to major WHO-named SARS-CoV-2 variants (Figure 5B and Supplementary Table 6). Our efficient computational framework performed SARS-CoV-2 variant surveillance through weekly tracking of the circulating co-mutation network. When novel co-mutation communities arise, our method is expected to provide timely detection at a low prevalence, identify their phylogenetic branches of emerging variants, and aid in early warning and response. We found no significant superiority for our method in detected time at global level surveillance in contrast with Pangolins monitoring (Figure 5A and Supplementary Table 6), which may result from signal flooding due to massive data. However, it demonstrated a strong advance at national level monitoring, illustrated using Frontiers in Public Health Discussion We developed a co-mutation network surveillance framework for dynamical nucleotide co-occurrence pattern investigation of weekly sequences and leveraged this framework to deliver an evolution and transmission monitoring of SARS-CoV-2 (Figure 1). This strategy required nothing more than weekly genomic data, enabling us to execute monitoring with only a laptop but to offer 06 frontiersin.org Huang et al. 10.3389/fpubh.2023.1015969 union of weekly co-mutation communities. This method avoids the huge computational burden caused by the use of cumulative data (7). Second, the affinity model (12) was introduced for statistical discovery of weekly co-mutation pairs (either HoCPs or HeCPs), further contributing to the creation of a weekly comutation network. The network conglomerated HoCPs forming groups of co-mutation communities while HeCPs aided in generating community clusters that unveil novel branching patterns. This approach identifies emerging communities and their branching relationships with the latest circulating ones, indicating novel variants and their evolutionary relationships. This strategy contrasts most of previous researches that focuses on discovery of individual communities (9, 16). Several recent efforts seek to compensate for the sensitivity and accuracy of emerging variants using phylogenetic tree to improve real-time variant surveillance. Most of these studies focus on trend survey of viral mutations (3, 17, 18) or their phenetic clustering (11, 19) but not real variant monitoring. Time-series clustering of frequency trajectories of mutations has been found to be an efficient tool in variant discovery and prediction (9, 16). Challenges arise in interpreting these results due to discrepancies in cluster features of the same variants that hinder comparisons of horizontal (betweencountry) or longitudinal (across-time) monitoring results. Our current work provides merging rules of co-mutation communities to overcome this problem. The phylogenetic-tree-based methods such as Pangolin (20), Nextstrain (21), and GISAID (22) have been consistently proposed for SARS-CoV-2 variant detection and their evolution surveillance. But several challenges have been acknowledged. First, their computational complexity and statistical uncertainty in the phylogenetic construction reduce the monitoring efficiency (7). Second, their subtyping fineness either results in excess burden on variant surveillance (e.g., Pangolin with >2,000 lineages, so far) or delayed detection and communication of dangerous variants (e.g., Nextstrain with 31 clades and GISAID with 11 clades) (9). Our method gives moderate resolution of 235 variants (Supplementary Table 5) and achieves realtime variant discovery through the identification of novel co-mutation communities. There are limits to this study. The current work provides near real-time detection of novel co-mutation communities indicating emergence of novel variants at a low prevalence but not a true appearance of previously unobserved variants. Thus, the global dictionary tree accumulated from weekly co-mutation communities recorded the major branches reaching the prevalence threshold (>1%), and could not be thought as a substitute of GISAIDs global phylogeny of SARS-CoV-2. In addition, multiple consistency indexes have been introduced in our surveillance framework and their thresholds for similarity measurement are all empirical. We believe it is a trade-off between detectability and discriminability in variant monitoring. The efficacy of the empirical thresholds was verified throughout the study. FIGURE 3 Weekly co-mutation network and co-mutation community tree for viral variant surveillance. Worldwide sequences at rst detected week of major WHO-named SARS-CoV-2 variants were included for network creation [(AE) left] and arborescence generation [(AE) right]. Nodes (i.e., co-mutation communities) located at close branches of the arborescence were shown with the same or similar colors. Appended nodes (see Material and methods section) were shown in white. The same colors were designated to nodes and edges that made up the communities in the co-mutation network. Emerging communities indicating novel viral variants were highlighted with red boxes. efficient surveillance of major viral variants and their branches (Figure 4). Confidence in the monitoring of spreading variants came through retrospectively evaluating multiple variants of the pandemic (Figures 2, 3) and verifying its timeliness, accuracy and reliability in detection through comparing it with Pangolin nomenclature at global and national level data sets. Our approach provided several weeks earlier warning using national level data (Figure 5), highlighting its powerful potential in variant surveillance and public health response. This work is a profound advancement over previous studies. First, it provides periodic co-mutation network surveillance using weekly genomic data but produces global evolutionary history through the Frontiers in Public Health Conclusion In this study, a simple, explainable, and accurate approach was presented for SARS-CoV-2 variants surveillance, enabling an early detection and continuous investigation of viral variants 07 frontiersin.org Huang et al. 10.3389/fpubh.2023.1015969 FIGURE 4 Worldwide dictionary tree comprised of co-mutation communities detected as of mid-June 2022. In total, 235 co-mutation communities were collected and piled up for arborescence creation. The branching process displayed high consistency with GISAID clades (S, V, O, G, GR, GH, GV, GK, GRY and GRA) through a comparison of weekly genome grouping using these communities or GISAID designation, which details have been listed in Supplementary Table 2. FIGURE 5 Capture of the emergence of WHO-named SARS-CoV-2 variants. (A) The heatmap of worldwide prevalence calculated from variants feature co-mutation communities. Their rst detected weeks were marked with different symbols depending on detection frameworks. (B) The heatmap of national-level prevalence of the same communities using data from country rst detected. These countries include South Africa, India, Brazil, Philippines, UK or USA. Frontiers in Public Health 08 frontiersin.org Huang et al. 10.3389/fpubh.2023.1015969 Acknowledgments overcoming genomic data flood and aiding in the response to the COVID-19 pandemic. We would like to thank Mr. Shuming Zhu for his precious IT support. Data availability statement Conict of interest Publicly available datasets were analyzed in this study. This data can be found at: https://www.gisaid.org/. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Author contributions YL, YHa, and JS conceived, designed, and supervised the project. YHu and FZ collected the data. QH, HQ, and YL performed computations, analyzed the results, and drafted the manuscript. PB and JS were instrumental in reviewing and editing the manuscript. JG, JS, and YHa provided critical revision for important intellectual content. All authors contributed to the article and approved the submitted version. Publishers note All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. Funding Supplementary material This work was supported by the Guangdong Basic and Applied Basic Research Foundation (2021A1515011591 to YL) and the Guangdong Medical Science and Technology Research Foundation (A2021104 to YL). YHa gratefully acknowledges the support of K. C. Wong Education Foundation. The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh.2023. 1015969/full#supplementary-material References 13. Kalgotra P, Sharda R, Luse A. Which similarity measure to use in network analysis: Impact of sample size on phi correlation coefficient and Ochiai index. Int J Inform Manage. (2020) 55:102229. doi: 10.1016/j.ijinfomgt.2020.1 02229 1. Adlhoch C, Gomes HC. Sustainability of surveillance systems for SARS-CoV-2. Lancet Infect Dis. (2022) 22:9145. doi: 10.1016/S1473-3099(22)00174-8 2. Oude Munnink BB, Worp N, Nieuwenhuijse DF, Sikkema RS, Haagmans B, Fouchier RAM, et al. 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... CLINICAL AND LABORATORY OBSERVATIONS Downloaded from http://journals.lww.com/jpho-online by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hC ywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 03/28/2023 Side Effects With a Focus on Lymphadenopathy Following COVID-19 Vaccination in Pediatric and AYA Oncology Patients Jennifer A. Belsky, DO, MS,* Whitney R. Carroll, MS2, Guang Xu, PhD, and Seethal A. Jacob, MD, MS* Summary: The Coronavirus Disease 2019 (COVID-19) pandemic led to the swift development of multiple vaccinations. Vaccine side effects were well-documented in the healthy adult cohort and included fever and lymphadenopathy, however, side effects in the pediatric immunocompromised population have not been reported. This retrospective study investigated vaccine-eligible children and adolescent young adult oncology patients 12 to 35 years old. We found uncommon, mild, and self-limiting side effects among pediatric cancer patients and survivors. This data will help guide pediatric and AYA oncologists in providing anticipatory guidance and serve as a guide to managing lymphadenopathy as a potential confounder of malignancy. Key Words: pediatric oncology, supportive care, COVID-19, vaccination (J Pediatr Hematol Oncol 2023;45:8890) BACKGROUND The Coronavirus Disease 2019 (COVID-19) pandemic saw rapid availability of multiple vaccines approved for use in adults and children 12 years old or older.1 Of importance, in healthy adults, data from all 3 available vaccines (PzerBioNTech, Moderna, and Johnson & Johnson (J&J) demonstrated concern for lymphadenopathy (0.4-8.4%) and fever (4.7%), which have been attributed to locally activated antigens migrating to draining lymph nodes.24 Similar rates have been reported in children 12 years and older.4 Adenopathy was reported as an unsolicited event in 1.1% of patients receiving the Moderna vaccine. Axillary swelling or tenderness was listed separately and occurred in up to 16.0% of patients 18 to 64 years of age and up to 8.4% of patients over 65 years of age (vs. 4.3% and 2.5% in the corresponding placebo groups, respectively). Patients receiving the Pzer-BioNTech vaccine had a self-reported rate of adenopathy of 0.3%. Clinically, axillary swelling or Received for publication December 14, 2021; accepted December 13, 2022. From the *Department of Pediatrics, Indiana University School of Medicine; Division of Pediatric Hematology Oncology, Riley Hospital for Children; Division of Pediatrics, Indiana University College of Medicine; and Marian University College of Osteopathic Medicine, Indianapolis, IN. Research reported in this publication was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under Award Number K23HL143162. The content is solely the responsibility of the authors and does not necessarily represent the ofcial views of the National Institutes of Health. The authors declare no conict of interest. Reprints: Jennifer A. Belsky, DO, Division of Pediatric Hematology Oncology, Riley Hospital for Children, 705 Riley Hospital Drive, Indianapolis, IN 46202 (e-mail: jbelsky@iu.edu). Copyright 2023 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/MPH.0000000000002621 adenopathy manifested within 2 to 4 days after either dose and lasted on average 1 to 2 days (Moderna) and 10 days (Pzer-BioNTech). Among all study vaccine recipients in the Pzer-BioNTech group, 4.7% of patients 18 to 55 years old experienced a fever 38C. In addition, myocarditis and pericarditis have been observed.4,5 With the overwhelmingly positive protective effects of the vaccine, there are some unintended side effects and hesitancies in the general population, as well as the immunocompromised patient population. It remains unclear what proportion of oncology patients will experience a vaccine side effect, including adenopathy on imaging, whether the rate of adenopathy will vary between different doses and unique vaccines, the size, number, laterality, and morphology of affected lymph nodes, or how long nodes will remain abnormal in an appearance on various imaging modalities. Findings may be present for a longer period on higher sensitivity imaging such as 18FDG PET (PET), in which inammatory activity may be detected even in nonenlarged nodes. In addition, febrile neutropenia is a serious complication for patients on therapy that has the potential for hospitalizations, intravenous antibiotic administration, and burden for patients and hospitals. To best counsel families on expectations surrounding the vaccine, data regarding the risk of side effects must be available. Considering these preliminary ndings, it is unknown if children and adolescents and young adults (AYA) with cancer and altered immune function will have similar side effects. This retrospective study aimed to explore and describe the side effects of the COVID-19 vaccine in the pediatric and AYA oncology population. MATERIALS AND METHODS Study Design and Patient Selection We performed a retrospective chart review of oncology patients at Riley Hospital for Children and Indiana University Health who received at least 1 dose of the COVID-19 vaccine from March 2021 to August 2021 with an active or previous oncology diagnosis, treated on a pediatric oncology protocol. All patients cared for at these 2 sites who met the following were included: (1) 12 years of age or older to 35 years or younger of age, (2) received any COVID-19 vaccination (Moderna, Pzer, or J&J), and (3) had an active or previous oncology diagnosis. At the time of this manuscript, only the Pzer vaccine was available for children older than 12 years of age. Patients who received a COVID-19 vaccine outside the state of Indiana were exempt. Data was collected and reviewed from the initial COVID-19 vaccination date through 8- weeks following each vaccination, including prior COVID-19 testing. This 88 | www.jpho-online.com J Pediatr Hematol Oncol  Volume 45, Number 2, March 2023 Copyright r 2023 Wolters Kluwer Health, Inc. All rights reserved. J Pediatr Hematol Oncol  Volume 45, Number 2, March 2023 study was exempted from the institutional review board at Indiana University. Procedures and Statistical Design Downloaded from http://journals.lww.com/jpho-online by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hC ywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 03/28/2023 We obtained demographics, clinical symptoms, laboratory and imaging results, hospitalizations, and outcomes data from each patients electronic medical record. Clinical outcomes were followed up to 8 weeks after the last COVID vaccine was given. Our institutions COVID-19 vaccination guidelines followed recommendations outlined by the Centers for Disease Control, which recommended vaccination for all immunocompromised patients.5 Vaccination records for this study were obtained through the Children and Hoosier Immunization Registry Program (CHIRP), Indianas online vaccination database, and conrmed with the electronic medical record. Patients without a conrmed immunization history were excluded. The means, medians, SDs, and condence intervals of quantitative demographic variables, such as patient ages, were analyzed using GraphPad Prism (v9.2.0). Categorical data such as race, gender, diagnosis, therapies, vaccine status, and side effects were counted, and the proportions of those were calculated and presented in percentage. Observations We identied 122 unique patients who received a COVID-19 vaccination over the study period (Table 1). More than half of the patients were male (n = 86, 55.7%) with a median age of 18 years (range: 12-30 y). All 3 vaccine options were administered (Pzer n = 102, Moderna n = 17, J&J n = 3), and 98.4% (n = 120) of patients completed the primary vaccination series. Among these patients, 34.4% (n = 42) were actively receiving chemotherapy or within 9 months of receiving intensive chemotherapy. Of patients receiving leukemia therapy, the majority were in maintenance therapy (n = 7, 87.5%). Of the 122 patients who received the vaccine, 3 unique patients (2.5%) had a reported reaction. Of patients who had a reaction, all patients were white, male, had no prior COVID infection, and received the Pzer vaccine. Side effects were reported <24 hours of receiving the vaccine and resolved without intervention in <48 hours. No patients were hospitalized for fever and neutropenia or additional COVID-19 vaccine-related symptoms. We identied 47 (38.5%) patients who underwent imaging as part of their routine treatment or surveillance, including CT (n = 16), magnetic resonance imaging (n = 14), ultrasound (2), and radiograph (15), with only 1 patient found to have incidental lymphadenopathy (Fig. 1). Of the 2 patients with lymphadenopathy, Patient 1, who self-reported ipsilateral axillary lymphadenopathy, was 9 months postcompletion of anaplastic large cell lymphoma chemotherapy and presented 6 weeks after receiving the second Pzer vaccine. CT with contrast was concerning for a 5.03.0 cm axillary lymph node ipsilateral to vaccine administration. The suspicious lymph node was biopsied, and pathology was consistent with relapsed anaplastic large cell lymphoma. Patient 2, with lymphadenopathy found incidentally on routine CT with contrast imaging as part of treatment surveillance, was 3 months postchemotherapy for Hodgkin lymphoma. Imaging characteristics included a new right axillary lymph node measuring 1 cm with enlarged sub-centimeter bilateral axillary lymph nodes and a small 1 mm right upper lobe lung nodule (Fig. 1A). Follow-up 18FDG PET/CT scan 4 weeks later showed improvement of lymphadenopathy COVID-19 Vaccination in Children With Cancer TABLE 1. Patient Characteristics and Side Effects Following COVID-19 Vaccine Administration Cancer Cohort Characteristic N (%) Unique patients Male Sex Median age in years (range) Race/Ethnicity White Asian Black Pacic islander Hispanic/Latino Non-Hispanic/Latino Type of Cancer Solid tumor Leukemia Central nervous system Lymphoma Reported side effects within 8 wk Numbness Fever Chills Myalgia Headache Lymphadenopathy Routine surveillance imaging Incidental lymphadenopathy 122 68 (55.7) 18 (12-30) 112 5 4 1 10 112 (91.8) (4.1) (3.3) (0.8) (8.2) (91.8) 33 25 25 22 (27.0) (20.1) (20.1) (18.0) 2 1 1 1 1 1 47 1 (1.6) (0.82) (0.82) (0.82) (0.82) (0.82) (38.5) (0.82) with Deauville 2 score, consistent with prior scarred lymph nodes at the end of therapy (Fig. 1B), and complete resolution of his previously identied lung nodule. CONCLUSIONS The results of this cohort study suggest the majority of pediatric and AYA oncology patients 12 years of age or older had few side effects following COVID-19 vaccination. Those who did, reected what has been reported in the general adult population, with a lower incidence of reported and imaging-conrmed lymphadenopathy. Children with cancer are prone to severe COVID-19 infections,6 and oncologists hesitant to recommend the COVID-19 vaccination to patients both on and off therapy should be aware of the expected post-vaccine course to appropriately guide patients and families.7,8 Our retrospective review identied rare, mild, and self-limiting side effects without evidence of increased fever and neutropenia complications following the COVID-19 vaccine. As febrile neutropenia remains a serious complication for patients on therapy that leads to hospitalization, intravenous antibiotic administration, and burden for patients and hospitals, it is a reassuring nding in this cohort. In addition, we did not detect a higher incidence of symptomatic lymphadenopathy, which may provide reassurance to families struggling with vaccine hesitancy. Vaccine clinical trials are currently underway for children younger than 5 years old, with little published data surrounding side effects in the eligible pediatric oncology population. A limitation of this study is its retrospective nature, with a small sample size. In addition, this paper focuses on short-term clinical responses, while future research must address the immunologic response level in pediatric oncology patients. Future studies must focus on larger, prospective studies investigating side effects and incidental lymphadenopathy to better guide Copyright 2023 Wolters Kluwer Health, Inc. All rights reserved. www.jpho-online.com Copyright r 2023 Wolters Kluwer Health, Inc. All rights reserved. | 89 J Pediatr Hematol Oncol Belsky et al  Volume 45, Number 2, March 2023 Downloaded from http://journals.lww.com/jpho-online by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hC ywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 03/28/2023 FIGURE 1. Lymphadenopathy imaging findings post-COVID-19 vaccination. 1A, Initial CT Chest with Intravenous Contrast 36 hours post-COVID-19 vaccination. New right axillary lymph node measuring 1 cm. Additionally enlarged sub-centimeter right and left axillary lymph nodes. New tiny 1 mm right upper lobe lung nodule. 1B, Follow-up 18FDG PET/CT scan 4 weeks post-COVID-19 vaccination. Mildly FDG avid bilateral axially lymph nodes, likely reactive. No FDG pulmonary nodule was identified. Overall Deauville score 2. clinicians in counseling regarding COVID-19 vaccination in children and AYAs with cancer. 5. REFERENCES 1. Krammer F. SARS-CoV-2 vaccines in development. Nature. 2020;586:516527. 2. Mehta N, Sales RM, Babagbemi K, et al. Unilateral axillary Adenopathy in the setting of COVID-19 vaccine. Clin Imaging. 2021;75:1215. 3. Tu W, Gierada DS, Joe BN. COVID-19 vaccination-related lymphadenopathy: What to be aware of. Radiol Imaging Cancer. 2021;3:e210038. 4. Local Reactions, Systemic Reactions, Adverse Events, and Serious Adverse Events: Pfizer-BioNTech COVID-19 Vaccine. 6. 7. 8. Accessed December 12, 2021. 2021. https://www.cdc.gov/ vaccines/covid-19/info-by-product/pfizer/reactogenicity.html COVID-19 Vaccines are Effective. 2021. Accessed December 25, 2021, https://www.cdc.gov/coronavirus/2019-ncov/vaccines/ effectiveness/index.html Belsky JA, Tullius BP, Lamb MG, et al. COVID-19 in immunocompromised patients: a systematic review of cancer, hematopoietic cell and solid organ transplant patients. J Infect. 2021;82:329338. Biswas N, Mustapha T, Khubchandani J, et al. The Nature and extent of COVID-19 vaccination hesitancy in healthcare workers. J Community Health. 2021;46:12441251. Wolfson S, Kim E, Plaunova A, et al. Axillary adenopathy after COVID-19 vaccine: no reason to delay screening mammogram. Reig Radiology. 2022;303:297299. 90 | www.jpho-online.com Copyright 2023 Wolters Kluwer Health, Inc. All rights reserved. Copyright r 2023 Wolters Kluwer Health, Inc. All rights reserved.  ...

... Surgical and Radiologic Anatomy (2023) 45:297302 https://doi.org/10.1007/s00276-023-03085-z ANATOMIC VARIATIONS Extracranial hypoglossal neurofibroma with a variant ansa cervicalis: a case report Chandler Dykstra1 Emma Dwenger1 Elizabeth Parent1 Sumathilatha SakthiVelavan1 Received: 25 July 2022 / Accepted: 12 January 2023 / Published online: 1 February 2023 The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature 2023 Abstract Purpose This case report aims to explore a rare combination of findings in a cadaver donor: variant ansa cervicalis, vagus (CN X) and hypoglossal (CN XII) nerve fusion, and extracranial hypoglossal neurofibroma. Background The type of ansa cervicalis variation presented in this report has been documented in less than 1% of described cases. The CN X-CN XII fusion has been reported in one prior study. Additionally, hypoglossal neurofibromas are benign neoplasms of the peripheral nerve sheath. There are only two known cases of extracranial hypoglossal neurofibroma described in the literature. Case report The study investigated a swelling of the right CN XII in a 90-year-old female cadaver donor. Detailed dissection, examination of the region, and histopathological analysis of the mass followed. The entire course of CN XII and other cranial nerves were examined to exclude concurrent pathology. A fusiform enlargement of the right CN XII was observed in the submandibular region, measuring ~ 1.27 1.27 cm. The superior portion of the right CN XII was fused to the right CN X, exiting the jugular foramen. The superior root of ansa cervicalis, normally a branch of CN XII, was found to arise from CN X on the right side. The left CN XII and CN X were unremarkable. Histopathological examination revealed benign neurofibroma. Conclusion The anatomical variation and rare location of the tumor necessitate further investigation to better understand pathogenesis, clinical correlation, and surgical implications. This study furthers knowledge of this condition and contributes to the currently limited body of research. Keywords Extracranial neurofibroma Neurofibroma Ansa cervicalis Anatomical variation Introduction The ansa cervicalis, located superficial to the carotid sheath within the carotid triangle of the neck, is a nerve loop arising from cervical nerve roots C1, C2, and C3 [3]. This loop connects the superior root (C1) with the inferior descending root (C2, C3) of cervical spinal nerves and innervates the infrahyoid muscles, which primarily function to preserve phonation and deglutition [3, 5]. Typically, the superior root of the ansa cervicalis is derived from C1 nerve fibers branching off the hypoglossal nerve [5]. Variation in composition and course of the ansa cervicalis is more commonly seen among inferior roots [5]. However, this case report describes * Sumathilatha SakthiVelavan ssakthivelavan@marian.edu 1 Marian University College of Osteopathic Medicine, 3200 Cold Spring Rd, Indianapolis, IN 46222, USA a unique combination of findings in which the hypoglossal and vagus nerves are fused upon exiting the jugular foramen, thereby giving rise to a rare variation of the ansa cervicalis in which the superior root of the ansa branches solely off the vagus nerve. While the vagus nerve and hypoglossal nerve typically exit the skull separately via the jugular foramen and hypoglossal canal, respectively, only one other case has been identified whereupon the vagus nerve and the hypoglossal nerve are fused with the ansa cervicalis arising from the vagus nerve [9, 11]. Furthermore, this type of ansa cervicalis variation often referred to as a type IV vagal ansa under the Jelev classification system, has been estimated to occur in less than 1% of reported cases [3]. Although usually asymptomatic, awareness of possible anatomic variation of the ansa cervicalis becomes especially important during surgery of the head and neck, particularly for surgeons who perform laryngeal reinnervations [3, 9, 11]. 13 Vol.:(0123456789) 298 Additionally, this case report presents an extracranial hypoglossal neurofibroma. Hypoglossal neurofibromas are rare, slow-growing, benign neoplasms of the peripheral nerve sheath consisting of Schwann cells, perineurial cells, and fibroblasts [7]. Most neurofibromas occur sporadically, with 10% of cases associated with Neurofibromatosis type 1 (NF-1), an autosomal dominant disorder [1, 7]. Literature suggests that only 5% of neurogenic tumors in the neck arise from the hypoglossal nerve, with most of these being Schwannomas [1, 7]. Further, it has been found that hypoglossal tumors are more frequently intracranial, with extracranial extension occurring in 30% of cases [1, 7]. The combination of these statistics makes this case exceedingly rare, as only two cases have been documented as purely extracranial hypoglossal neurofibroma in the literature [2, 7]. The purpose of this report is to explore the rare combination of ansa cervicalis variation, vagus-hypoglossal nerve fusion, and extracranial hypoglossal neurofibroma. This case highlights the importance of documenting and understanding the relationship of ansa cervicalis variants with surrounding anatomical structures, especially in the context of maximizing surgical outcomes. Case report A 90-year-old female donor was examined during routine dissection in a medical school anatomy laboratory. The donors cause of death was Alzheimers disease. Initially, a swelling of the right hypoglossal nerve was noticed while dissecting the carotid triangle. Detailed dissection and thorough examination of the region followed to further investigate this finding. The entire course of hypoglossal nerves and other cranial nerves were examined bilaterally, both intracranially and extracranially, to exclude concurrent pathology. Photographs of the mass and the entire course of the right hypoglossal nerve were taken. The dimensions of the tumor were measured using digital calipers. After documentation, researchers carefully removed the mass for biopsy and sent the specimen to a pathology laboratory for analysis. A histopathological examination of the tumor was performed using hematoxylin and eosin staining techniques. Photographs of microscopic images were taken, and a pathologist was consulted. A fusiform enlargement of the right hypoglossal nerve was observed in the submandibular region. It measured approximately 1.27 1.27 cm (Fig. 1a). Concurrently, researchers found the superior portion of the right hypoglossal nerve fused to the right vagus nerve (Fig. 1b). The right hypoglossal nerve, which usually leaves the skull through the hypoglossal canal, was found fused at its exit to the right vagus nerve that emerged from the jugular foramen. Additionally, the superior root of the ansa cervicalis, normally a branch of the hypoglossal nerve, 13 Surgical and Radiologic Anatomy (2023) 45:297302 Fig. 1a Right carotid triangle showing the tumor and its relations. b Right carotid triangle showing the variant ansa cervicalis and its relations. 1. Hypoglossal nerve, 2. Vagus nerve, 3. Accessory nerve, 4. Common carotid artery, 5. External carotid artery, 6. Sternocleidomastoid, 7. Superior belly of omohyoid, 8. Posterior belly of digastric, 9. Superior thyroid artery, 10. Common trunk of lingual and facial arteries, 12. Occipital artery, 13. Internal carotid artery, 14. Superior root of Ansa Cervicalis, Open arrow: Fused Hypoglossal and Vagus nerves, Closed arrow: Neurofibroma Fig. 2Hematoxylin and Eosin staining reveals localized (sporadic) neurofibroma with neoplastic Schwann cells (1), abundant collagen fibers (2), scattered fibroblast (3), and venules (4) was found to arise from the vagus nerve on the right side. Meanwhile, the left hypoglossal and vagus nerves appeared unremarkable. No other tumors were noted, nor was any other anatomical variation present along other cranial nerves on either side. Histopathological examination and special staining revealed the tumor to be a benign neurofibroma (Fig. 2). Surgical and Radiologic Anatomy (2023) 45:297302 Discussion Ansa cervicalis The ansa cervicalis is a neural loop with two roots located in the neck that innervates the infrahyoid muscles. This neural loop consists of a superior root from cervical spinal nerve C1 and an inferior root comprised of nerve fibers from the ventral rami of C2-C3 [5]. In typical ansa cervicalis formation, the fibers arising from cervical spinal nerve C1 course along the hypoglossal nerve and then descend from the hypoglossal nerve as the superior root of the ansa cervicalis [5]. Several variations of both the formation and course of the ansa cervicalis have been reported and categorized [9]. The variations in the formation of the ansa cervicalis are grouped into five broad categories by Jelevs Classification (Fig. 3). In Type I, there is no superior root formation of the ansa cervicalis. Type II is typical ansa cervicalis formation with the ansa cervicalis branching off the hypoglossal nerve. Type III variation consists of C1 fibers branching off both the hypoglossal and vagus nerves. This variation is termed vagohypoglossal superior root and previous case reports described both nerves as being of uniformed thickness [5, 8]. In Type IV variation, the superior root of the ansa cervicalis branches solely off the vagus nerve. Type V variation has C1 fibers Fig. 3Common scheme of the proposed classification of the ansa cervicalis in human [3]. (Reprinted by permission from John Wiley and Sons, Clinical Anatomy, Some unusual types of formation of the 299 going through both the hypoglossal and vagus nerves but no ansa formation. All of these types, except for Type II, occur in less than 1% of the population [3]. In a typical anatomic presentation, the vagus nerve and hypoglossal nerve exit the skull separately via the jugular foramen and the hypoglossal canal, respectively [11]. However, in this case, the right hypoglossal and vagus nerves were fused immediately after their exit from the hypoglossal and jugular foramina, respectively. The hypoglossal and vagus nerves have an approximately 1.5 cm fused portion, and the superior root of the ansa cervicalis branched solely off the vagus nerve 3 cm from the point of its separation. According to Jelevs classification of known variation in the formation of the ansa cervicalis, this would most closely relate to a Type IV variation. The classic Type IV variation occurs in less than 1% of the population and is described as the superior root of the ansa cervicalis branching solely off the cervical part of the vagus nerve [3, 15]. This case presentation is not a true type IV since the C1 fibers ran along the fused vagal-hypoglossal trunk before the superior root emerged as a vagal ansa [9]. There have been several documented cases of vagal contribution to the superior branch of the ansa cervicalis [3, 5, 8, 15]; however, there has only been one additional case reported of fusion of the hypoglossal and vagus nerves with the ansa cervicalis branching solely off the vagus nerve [11]. While variations of the superior root of the ansa cervicalis are rare, anatomic variations of the inferior root are much more common due ansa cervicalis in humans and proposal of a new morphological classification. Jelev L, 2013) 13 300 to various cervical root contributions that are possible [6, 15]. Bilateral inferior root variations have been documented, whereas there have been no documented cases of bilateral superior root variations [6]. Embryological perspective The hypoglossal nerve passes through the hypoglossal foramen and emerges out of the skull anterior to the occipital condyle, just anteromedial to the jugular foramen. Embryological evolution has shown that the hypoglossal canal is formed by the fusion of the intervertebral foramina of the area vertebralis of the occipital region [4]. In adults, the canal is separated from the jugular opening by the jugular tubercle, which is highly variable in shape and size [14]. In this case, it was likely that the tubercle was narrow, and the external opening of the hypoglossal canal was in close proximity to the jugular opening. The hypoglossal nerve is a purely somatic motor nerve formed from the union of several pre-cervical nerves that innervate the occipital myotomes, which develop into the tongue muscles [12]. C1-3 nerves are ventral rami and supply the supra and infrahyoid muscles that developed from the cervical somites. Hence, the hypoglossal nerve is in close proximity to the upper cervical nerves, which is the likely reason for the C1 root coursing along the hypoglossal nerve for a short distance before separating as ansa hypoglossi or the superior root of ansa cervicalis. Besides the motor fibers, communication between the cervical and hypoglossal nerves carries afferent fibers from the meninges [5]. The vagus nerve is a mixed nerve with extensive sensory and motor functional components [12]. In an embryo, several communications exist between the nodose ganglion of the vagus and the hypoglossal nerve [12]. In adults, communications between the vagus nerve and the hypoglossal nerve containing an intermixture of afferent and efferent fibers of the tongue have been shown [12]. Besides these fibers, the functional components of the vagus nerve are distinct from the hypoglossal nerve [12]. The extensive communication at the nodose ganglion and proximity of the two nerves likely caused the fusion of the vagus and hypoglossal trunk in this case. An extension of C1 fibers into the vagus nerve results in a vago-cervical complex [14]. Since the vagus and hypoglossal nerves were fused, the C1 fibers most likely formed a vago-cervical complex and traveled along the fused hypoglossal-vagus trunk before entering the hypoglossal nerve (to supply geniohyoid and thyrohyoid) while some fibers continued in the vagus nerve before separating as the superior root of ansa cervicalis (to supply the infrahyoid muscles). It was likely that the vagus nerve, hypoglossal nerve, and C1 fibers had pseudo communications with no fiber exchange but were attached by connective tissue fibers only. 13 Surgical and Radiologic Anatomy (2023) 45:297302 Ansa cervicalis implications Typical innervation of the sternohyoid, sternothyroid, and superior belly of the omohyoid occurs through the superior root of the ansa cervicalis branching off the hypoglossal nerve [5, 9]. However, this case displays unusual participation of the vagus nerve in the innervation of these muscles by the superior root branching off the vagus nerve [9]. Due to this arrangement, paralysis of the infrahyoid muscles may occur following a lesion of the vagus nerve anywhere in the neck proximal to the branching point of the vagal ansa [5, 16]. This variation in the anatomy of the ansa cervicalis could be of considerable clinical significance to surgeons, as the infrahyoid muscles have important roles in deglutination and phonation, so any abnormality in innervation could cause confusion [3, 9, 11]. This is particularly important for surgeons who perform reinnervations of laryngeal and facial muscles, as the ansa cervicalis is the prime choice due to its proximity to the recurrent laryngeal nerve and its involvement in phonation [3, 9, 11]. Surgeons prefer to use the ansa cervicalis, instead of the hypoglossal nerve, to reanimate the face following facial nerve palsy to eliminate potential future complications with phonation and deglutition from hypoglossal nerve deterioration [9]. Although there has been debate over which branch of the ansa cervicalis should be used in these procedures, the use of the superior root has been reported to improve surgical outcomes [5]. The point of separation of the vagus from the hypoglossal may be confused for the superior root coming off the hypoglossal, and the vagus may be inadvertently used as the nerve graft; this may result in severe complications [16]. Knowledge of ansa cervicalis anatomic variations could help to prevent iatrogenic vagus nerve injuries during harvesting procedures [16]. Hypoglossal neurofibroma Peripheral nerve sheath tumors (PNSTs) are a subset of neuroepithelial tumors affecting the cells comprising the myelinated nerve covering. Most PNSTs are benign in nature and are classified as neurofibromas or Schwannomas [1]. Literature suggests that only 5% of the neurogenic tumors in the neck arise from the hypoglossal nerve [7]. Hypoglossal neurofibromas are rare, slow-growing, benign neoplasms of the peripheral nerve sheath consisting of Schwann cells, perineurial cells, collagen fibers, and fibroblasts that are relatively circumscribed but unencapsulated [1]. Schwannomas differ from neurofibromas in that they consist only of Schwann cells and are fully encapsulated [10]. PNST's of the hypoglossal nerve are classified into the following three subtypes: intracranial (Type A), intracranial-extracranial (Type B), and extracranial (Type C) [10], with the vast majority occurring intracranially Surgical and Radiologic Anatomy (2023) 45:297302 [1]. It is estimated that around 30% of hypoglossal tumors extend extracranially. However, purely extracranial hypoglossal neurofibroma is exceedingly rare and has only been reported in two cases. [1, 2]. Most of these neurofibromas occur sporadically, with 10% of cases associated with Neurofibromatosis type 1 (NF-1) [1, 7]. NF-1, an autosomal dominant disorder caused by a somatic mutation in the NF-1 gene, affects roughly 1 in 2500 births and is characterized by diffuse neurofibromas, caf-au-lait spots, and optic disturbances [7]. Neurofibromas in the cervical region most frequently occur in the cervical plexus, brachial plexus, and vagus nerve [1]. Of the few reported cases of hypoglossal neurofibromas, there are only two case reports of hypoglossal neurofibromas occurring in the cervical region [1, 2]. One of these cases indicated that the patient had NF-1 [7]. Due to donor privacy regulations and ethical concerns, researchers were not able to conduct genetic testing to officially exclude neurofibromatosis as a diagnosis; however, no additional tumors nor any other visible signs of disease (caf-au-lait spots, Lisch nodules, etc.) were noted during dissection. Hypoglossal neurofibroma implications Although neurofibromas are often benign and asymptomatic, they can present with dysphagia, dysphonia, tongue wasting on the affected side and other symptoms depending on the size, location, and vascularity of the tumor [10, 11, 13]. While MRI is the preferred diagnostic modality for PNSTs, surgeons often utilize additional forms of imaging, such as high-resolution MR neurography, to anatomically map the tumor and adjacent nervous and vascular structures to assist with preoperative planning [10, 13]. Fine needle aspiration and biopsies can also be performed to distinguish among PNSTs, but the former only has a 60% likelihood of providing an accurate interpretation of results, while the latter is not recommended due to excessive bleeding and scarring around the tumor [13]. Resection of a hypoglossal neurofibroma carries a risk of neural dysfunction, as neurofibromas usually involve fascicles of the original nerve that are indistinguishable from surrounding nerve tissue, thereby making complete resections difficult without sacrificing portions of the parent nerve [7]. Despite this, microsurgical resections are still the preferred method of treatment because neurofibromas are relatively radio and chemo-resistant [7, 10, 13]. Due to the high rate of morbidity associated with complete microsurgical resections, subtotal and near-total resections are sometimes offered as an alternative approach [13]. However, recent advancements in microsurgical techniques have significantly decreased postoperative complications and reported mortality rates to as low as 1% [13]. 301 Conclusion The anatomical variations of ansa cervicalis, coexistent vagus-hypoglossal nerve fusion, and rare location of the extracranial hypoglossal tumor represent an exceptionally unique case presentation. Despite known cadaveric research limitations, this study documents and furthers the knowledge of these coexistent findings and contributes to the currently limited body of related clinical and anatomical research. Although donor privacy regulations prevented researchers from excluding neurofibromatosis as a differential diagnosis, researchers are confident this condition did not clinically contribute, considering no other tumors were found during thorough dissection. Additionally, the clinical implications of a variant ansa cervicalis should be considered, particularly among otolaryngology surgeons. Knowledge of ansa cervicalis anatomical variations and localization of structures is vital for maximizing otolaryngological surgical outcomes. In a clinical setting, a combination of patient history, genetic testing, the radiographic and histopathological examination could be utilized for diagnostics and various surgical interventions. This case may benefit from future research to better understand the pathogenesis and clinical significance of the findings. Acknowledgements The authors sincerely thank those who donated their bodies to science so that anatomical research could be performed. Results from such research can potentially increase mankind's overall knowledge that can then improve patient care. Therefore, these donors and their families deserve our highest gratitude. The authors also thank Dr. Elizbeth Delery Ph.D. for the assistance with histopathology images and Dr. Robert Blair M.D. for pathology consultation. Author contributions CD, ED, EP, and SS-V: contributed to the study conception and design. Material preparation was done by CD and ED. All authors wrote the main manuscript text. CD: prepared Figs. 1 and 2. All authors reviewed the manuscript. Funding The authors did not receive support from any organization for the submitted work. Data availability This declaration is not applicable. Declarations Conflict of interest The authors have no competing interests to declare that are relevant to the content of this article. Ethical approval Since the research was on a cadaver, the Marian University Institutional Review Board cleared and indicated that the study did not need a review or approval (IRB#B22.101). References 1. Curioni OA, De Souza RP, Mercante AM, De Jesus AC, Pavelegeni A, Dedivitis RA, Rapoport A (2015) Extracranial neurogenic 13 302 2. 3. 4. 5. 6. 7. 8. 9. 10. Surgical and Radiologic Anatomy (2023) 45:297302 tumors of the head and neck. Braz J Otorhinolaryngol 81:604 609. https://doi.org/10.1016/j.bjorl.2015.08.012 Friedman L, Eisenberg AA (1935) Neurofibroma of the hypoglossal nerve. Ann Surg 101:834838. https://doi.org/10.1097/00000 658-193503000-00003 Jelev L (2013) Some unusual types of formation of the ansa cervicalis in humans and proposal of a new morphological classification. Clin Anat 26(8):961965. https://doi.org/10.1002/ca.22265 Karasu A, Cansever T, Batay F, Sabanci PA, Al-Mefty O (2009) The microsurgical anatomy of the hypoglossal canal. Surg Radiol Anat 31:363367. https://doi.org/10.1007/s00276-008-0455-x Kikuta S, Jenkins S, Kusukawa J, Iwanaga J, Loukas M, Tubbs RS (2019) Ansa cervicalis: a comprehensive review of its anatomy, variations, pathology, and surgical applications. Anat Cell Biol 52:221225. https://doi.org/10.5115/acb.19.041 Kumar N, Patil J, Mohandas R, Sirasanagandla NS, Guru A (2014) Rare case of double looped ansa cervicalis associated with its deep position in the carotid triangle of the neck. Ann Med Health Sci Res 4:2931. https://doi.org/10.4103/2141-9248.131705 Lum SG, Baki MM, Yunus MR (2021) A rare case of cervical hypoglossal nerve neurofibromas in a patient with type 1 neurofibromatosis. Braz J Otorhinolaryngol 88:812816. https://doi.org/ 10.1016/j.bjorl.2021.01.006 Nayak SB, Shetty P, Reghunathan D, Aithal AP, Kumar N (2017) Descendens vagohypoglossi: rare variant of the superior root of ansa cervicalis. Br J Oral Maxillofac Surg 55:834835. https:// doi.org/10.1016/j.bjoms.2017.06.007 Noorozian M, Bayat M, Abdollahifar M, Azimi H, Noori-Zaden A, Rad AA, Nejhad SF, Salimi M, Mohammadi R, Amini A, Abbaszadeh H (2015) A case report: rare communication of ansa cervicalis. Anat Sci 12:14 Ram H, Agrawal SP, Husain N, Chakrabarti S (2015) Hypoglossal schwannoma of parapharyngeal space: an unusual case 13 11. 12. 13. 14. 15. 16. report. J Maxillofac Oral Surg 14:7376. https://doi.org/10.1007/ s12663-011-0308-8 Ranjana Verma SD (2005) Unusual organization of the ansa cervicalis: a case report. Braz J morphol Sci 22:175177 Schoenwolf G, Bleyl S, Brauer P, Francis-West P (2021) Larsens human embryology. Elsevier, Philadelphia Suri A, Bansal S, Sharma BS, Mahapatra AK, Kale SS, Chandra PS, Singh M, Kumar R, Sharma MS (2014) Management of hypoglossal schwannomas: single institutional experience of 14 cases. J Neurol Surg B Skull Base 75:159164. https://d oi.o rg/1 0. 1055/s-0033-1356924 Suslu HT, Gayretli O, Coskun O, Bozbuga M, Serifoglu L, Gurses IA (2014) Anatomical and morphometrical evaluation of the jugular tubercle. Br J Neurosurg 28:503506. https://doi.org/10.3109/ 02688697.2014.889656 Vollala VR, Bhat S, Manjunatha Nayak S, Raghunathan D, Samuel V, Rodrigues V, Mathew JG (2005) A rare origin of upper root of ansa cervicalis from vagus nerve: a case report. Neuroanatomy 4:89 Zhu A, Mohan S, Richmon JD, Jowett N (2020) An anatomic variant of the ansa cervicalis precluding its use as a donor nerve. Ann Otol Rhinol Laryngol 129:7881. https://doi.org/10.1177/ 0003489419875975 Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.  ...

... TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 1 Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2023 Does an Online Educational Workshop for Certified Registered Nurse Anesthetists Reduce the Perceived Clinical Barriers and Promote Willingness to Change Practice to the Use of Spinal Anesthesia for Patients Undergoing Total Hip Arthroplasty? Harjyot Sensi Marian University Leighton School of Nursing Chair: Dr. Sara Franco 3/10/2023 _________________________ (Signature) (Date) Project Team Members: Dr. Nicholas Alexander Jones 3/10/2023 _________________________ (Signature) (Date) Date of Submission: March 12, 2023 TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE Table of Contents Abstract................................................................................................................................3 Introduction .........................................................................................................................4 Background ....................................................................................................................5 Problem Statement .......................................................................................................11 Organizational Gap Analysis of Project Site ............................................................11 Review of the Literature ....................................................................................................12 Theoretical Framework/Evidence Based Practice Model/Conceptual Model...................19 Goals/Objectives/Expected Outcomes ..............................................................................20 Project Design/Methods 21 Project Site and Population ..........................................................................................21 Measurement Instrument(s) ........................................................................................22 Data Collection Procedure ..........................................................................................22 Ethical Considerations/Protection of Human Subjects ...23 Data Analysis and Results.24 Conclusion ........................................................................................................................27 References ..........................................................................................................................28 Appendices Appendix A ..................................................................................................................32 Appendix B ..................................................................................................................33 Appendix C ..................................................................................................................34 Appendix D ..................................................................................................................35 Appendix E ..................................................................................................................40 2 TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 3 Abstract Total Hip Arthroplasty (THA) is a commonly performed procedure in the operating room and often the patient population undergoing this procedure are elderly with multiple comorbidities. Despite new research on spinal anesthesia (SA) many hospital facilities continue to utilize general anesthesia (GA). One of the most important adverse outcomes noted with GA is the activation of the neuroendocrine stress response. The neuroendocrine stress response is responsible for increased mortality and morbidity and is activated through pain under general anesthesia. The utilization of spinal anesthesia prevents the activation of the neuroendocrine stress response as pain signals are blocked along the ascending nerve fibers. The purpose of this DNP project was to educate certified registered nurse anesthetist (CRNAs) at an acute care hospital in an urban city in the Midwest via an online educational workshop and identify the perceived barriers that prevent CRNAs from utilizing SA technique in practice for THA patients. This was measured through an online power point presentation module along with a pre-and post-survey. The surveys were designed by using Likert-based questions focusing on the impact of SA and GA on patients presenting for THA, barriers to the use of SA, and their confidence in use of SA in this patient population after participating in the power-point presentation. The results of the survey showed a statistical significance in their confidence in the use of SA of p < .05, demonstrating the impact of the educational module in the post-survey results. Some limitations notable in this study were small study sample, lack of compliance and incentive for participating in this project, technical issues, and lack of in-person training. Keywords: general anesthesia, spinal anesthesia, neuraxial anesthesia, regional anesthesia, total hip arthroplasty, total hip replacements, post anesthesia recovery unit, hemodynamic complications, comorbidities, CRNAs, barriers, and facilitators. TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 4 Does An Online Educational Workshop for Certified Registered Nurse Anesthetists Reduce the Perceived Clinical Barriers to the Use of Spinal Anesthesia for Patients Undergoing Total Hip Arthroplasty? Total Hip Arthroplasty is one of the most common procedures done to replace all of the hip joint to reestablish joint function and mobility, with more than 400,000 THAs being conducted yearly in the United States (Campbell clinic, 2019). The overall incidence of joint replacements in the United States is monumental, with over 1 million total hip and total knee replacements conducted yearly (Maradit Kremers et al., 2015). The average age of these patients is 65 years and they often accompany multiple comorbidities (Nagelhout & Elisha, 2018). Maradit Kremers et al. (2015) notes a higher prevalence of total joint pathologies and chronic diseases such as strokes and myocardial infarctions. Traditionally, GA has been the most common technique for providing anesthesia. Yet as new anesthesia techniques evolve, practitioners continue to utilize GA in their practice, despite a growing body of evidence that support the superior outcomes of SA in THA (Basques et al., 2015). SA offers the benefits of reduced length of hospital stay, decreased transfusion requirements, decreased postoperative nausea and vomiting (PONV), decreased risk of deep venous thrombosis (DVT), hemodynamic stability, and decreased health care costs (Pu & Sun, 2019). Basques et al. (2015) report adverse effects noted with the use of GA, such as an increase in surgical time and postoperative recovery, transfusion requirements, ventilatory dependence, cardiac events, and readmission rates. The unfavorable effects of GA range from mild consequences to long lasting postoperative disabilities that includes cardiovascular, respiratory, and acute renal failure (Harris & Chung, 2013). SA on the other hand provides anesthesia providers the ability of quick administration of an anesthetic agent, with ease (Calderon-Ochoa et al., 2019). However, this requires consistency TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 5 in practicing the techniques of administering SA and continuous educational training for providers (Calderon-Ochoa et al., 2019). Adequate training and continuous education can increase provider comfort and offer healthier outcomes in patients even those with considerable amount of comorbidities (Matsen Ko & Chen, 2015). The purpose of this DNP project was to educate certified registered nurse anesthetist (CRNAs) at an acute care hospital in an urban city in the Midwest via an online educational workshop and identify the perceived barriers that prevent CRNAs from utilizing SA technique in practice for THA patients, and assess the participants willingness to change practice after participating in an online educational module. Background THAs can be performed under GA or through SA to provide relaxation to the large group of muscles separated during the procedure (Nagelhout & Elisha, 2018). Spinal or Neuraxial anesthesia is defined by localization of the nerves of the peripheral nervous system with a local anesthetic to reduce pain modulation during the course of a surgical procedure (Nagelhout & Elisha, 2018). Despite the noted benefits of SA, 60.9% of THAs are being performed under GA, and 39.1% are conducted under SA (Matsen Ko & Chen, 2015). A growing number of studies reveal the use of SA being limited to high volume large specialty centers (Parvizi & Rasouli, 2015). Regardless of the numerous benefits of SA, specific barriers such as patient refusal, patient anxiety, provider unfamiliarity and discomfort, fear of litigation, surgeon preference, hospital policy, and hospital culture can pose a significant challenge to utilizing this technique. According to Duale et al. (2015) the most common barrier identified by providers is risks and time consumption associated with performing SA. Calderon-Ochoa et al. (2019) emphasize the safety of SA; however, errors in administration of this technique can lead to pain at the puncture TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 6 site, post-dural puncture headache (PDPH), and compromise in heart rate due to a higher level of block. Comorbidities The goal of THA is to provide pain relief to promote mobility and a restored quality of life. The majority of the patients presenting for a THA often suffer from multiple comorbidities such as cardiopulmonary, renal, and cerebrovascular diseases, and approximately 50% are obese (Nagelhout & Elisha, 2018). The most common cause of disability experienced by patients undergoing THA is some form of degenerative joint disease stemming from arthritic inflammatory changes associated with aging and disease pathologies (Nagelhout & Elisha, 2018). Common risk factors for the development of osteoarthritis are age, obesity, gender, and trauma (Haebich et al., 2020). Obesity gives rise to the increasing number of joint arthroplasty surgeries and simultaneously increasing morbidity and mortality due to comorbidities that exist with obesity (Haebich et al., 2020). Obesity is strongly linked with cardiovascular disease, diabetes, strokes, cancer, kidney failure, and osteoarthritis, which most commonly affects the joints of the hip, knee, foot, and hand (Nagelhout & Elisha, 2018). A meta-analysis conducted by Pozzobon et al. (2018) supports the link between increasing body mass index and a sedentary lifestyle with osteoarthritis. The management of hip joint replacements does not end at surgery and requires clinicians to implement appropriate techniques during surgery that considers the recovery aspect as well. Patients undergo several months of physical therapy and frequent follow-ups for imaging and routine checkups (Maradit Kremers et al., 2015). Therefore, utilizing an anesthetic technique that decreases postoperative complications and revisions is even more critical to prevent further hindrances in recovery (Maradit Kremers et al., 2015). TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 7 Spinal versus General Anesthesia There has been extensive recent research which has further distinguished the benefits of SA compared to GA in the intra and postoperative settings of THA patients. For example, Parvizi & Rasouli (2015) analyzed a study establishing reduced 90-day mortality, reduced 30day mortality, and reduced postoperative complications using the SA technique. The likelihood of decreased morbidity and mortality associated with the neuraxial approach is due to the minimized risks of fatal cardiac events, onset of circulatory clots and reduced risks of significant blood loss (Parvizi & Rasouli, 2015). Although more frequently used, GA is associated with increased surgical site infections (SSI) and intraoperative hemodynamic instability which can pose significant harm to the patient (Parvizi & Rasouli, 2015). Furthermore, GA often leads to impaired cognitive function and delirium in the elderly population, along with higher use of opioid requirements post-operatively (Parvizi & Rasouli, 2015). Patients who received SA have found to have decreased opioid requirements, postoperative pain, and an overall appropriate cognitive function profile (Parvizi & Rasouli, 2015). Overall, it is established that GA has an increased ability to cause in hospital unfavorable outcomes. Nagelhout & Elisha (2018) noted patients undergoing THA who receive GA have an overall increased risk of death, respiratory failure, and intensive care admissions. Spinal Anesthesia The primary purpose of SA as stated by Nagelhout & Elisha (2018) is to prevent the transmission of pain signals from the surgical site to the spinal cord and higher centers in the brain, known as the somatosensory areas of the cortex and amygdala, where pain signals are perceived. SA utilizes local anesthetic with or without opioids, which is deposited into the TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 8 subarachnoid space outside of the spinal cord into the CSF, anesthetizing the spinal cords nerve roots to block transmission of pain signals along a nerve fiber and suppressing ascending pain signals. Pain can be a significant source of morbidity and mortality due to the activation of the stress response and its effect on multiple organ systems. Sympathetic nervous system activation (SNS) ensues from surgical pain and stress that causes the release of catecholamines, cortisol, and hormones that have compensatory and potentially adverse effects on heart rate, peripheral, systemic vascular resistance, increased blood pressure, which increase myocardial demand and oxygen consumption. The use of SA prevents the physiological stress response to surgery and pain and provides superior surgical analgesia. Additional documented benefits of the SA technique are decreased postoperative ileus and improved cardiopulmonary profiles in high risk patients. This significant intraoperative profile is substantial due to the fact that a large majority of THA patients have underlying cardiac pathology and are incapable of tolerating the adverse effects caused by surgical pain. SA allows the patients to remain awake for the procedure and avoiding the possible ill effects of an endotracheal tube such as dental damage, aspiration, vocal cord damage, nerve injury, and ventilatory dependence (Nagelhout & Elisha, 2018). Possible Complications of Spinal Anesthesia Nagelhout & Elisha (2018) discussed potential side effects of SA such as significant hypotension and bradycardia. Once the local anesthetic is deposited in the subarachnoid space, it can spread towards nerve fibers of the autonomic nervous system (ANS). The ANS controls the sympathetic nerve fibers of the heart, known as the cardiac accelerators that can become anesthetized by the local anesthetic, leading to substantial drops in blood pressure due to unabated vasodilation. Additionally, bradycardia can occur as the vagal fibers in the heart are affected which cause slowing of the hearts conduction frequency which further compromises TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 9 blood pressure. This phenomenon of bradycardia and hypotension can be combated by administering adequate crystalloids and colloid solutions to provide ample preload to the heart prior to the administration of SA. An alternative approach to preventing hypotension and bradycardia is through the use of 5HT3 antagonist, Ondansetron, prior to administrating spinal anesthesia. Other modalities such as pelvic tilting and administering ephedrine, a mixed alpha and beta-agonist, and phenylephrine, a pure alpha-agonist, are effective in treating bradycardia and hypotension. Postoperative nausea and vomiting (PONV) is an accompanying side effect on spinal anesthesia; however, it is less common (Nagelhout & Elisha, 2018). Another possible complication of spinal anesthesia is PDPH that occurs due to a decrease in the cerebrospinal fluid in the subarachnoid space due to a leak through the dura mater (Nagelhout & Elisha, 2018). Several causes that attribute to this occurrence are large cutting needles, female gender, age, and cerebrovasodilation (Nagelhout & Elisha, 2018). Nagelhout & Elisha (2018) also notes a 70% increase in PDPH with the use of a 16-guge Toughy needle (cutting needle bevel) and recommends only a non-cutting needle (blunt tip) be utilized. The risk of PDPH can be minimized or avoided by using an appropriate needle, and vasodilation can be combated through the administration of vasoconstrictor drugs such as caffeine and theophylline. Nagelhout & Elisha (2018) also emphasize an important point that not all headaches after SA is caused by the anesthetic technique itself, rather there are diverse causes such as anxiety, lack of sleep, dehydration prior to surgery, hypoglycemia, and simply due to the lack of caffeine intake the morning of surgery. TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 10 Possible Complications of General Anesthesia The goal of GA is to alter neuronal activity, thereby providing immobility, amnesia, and a state of unconsciousness (Nagelhout & Elisha, 2018). The most common receptors targeted to achieve this goal are enhancing GABA and antagonizing NMDA receptors either through IV or inhaled agents (Nagelhout & Elisha, 2018). GA in patients with pre-existing comorbidities can be significantly compromised due to surgical stimulation and subsequent SNS activation (Nagelhout & Elisha, 2018). For example, the SNS stimulation can activate the coagulation pathway, increasing the likelihood of a thromboembolic event (Harris & Chung, 2013). Other considerations can be highlighted by the fact that a multitude of anesthetic drugs which are utilized to promote unconsciousness can cause a decrease in systemic vascular resistance leading to hypotension (Nagelhout & Elisha, 2018). Studies reveal the risk of myocardial infarction in elective non-cardiac surgery is up to 5% with GA (Harris & Chung, 2013). Heart failure can occur in up to 6% of patients with pre-existing cardiovascular disease (Harris & Chung, 2013). The utilization of mechanical ventilation during GA can cause numerous respiratory complications such as aspiration, atelectasis, bronchospasm, laryngospasm, and worsening of pre-existing lung pathologies. About 70% of patients experience atelectasis, the most common cause of postoperative hypoxemia. Unidentified atelectasis can increase risks for the development of acute lung injury and pneumonia (Harris & Chung, 2013). PONV can occur in 20% to 30% of patients and 70% to 80% in patients who are high risk (Harris & Chung, 2013). Other complications commonly occur with GA are sore throat, dental impairment, postoperative cognitive decline, and possible drug-related anaphylaxis (Harris & Chung, 2013). TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 11 Summary The selection of an anesthetic for any patient is multifactorial, encompassing the patient's age, gender, comorbidities, operative times, type of surgery, blood loss associated with the procedure, cost of the kind of anesthetic, and the surgeon and patient preference. A wide range of ill effects from GA should alert an anesthesia provider to seek other methods of anesthesia that are proven to be superior in patients presenting for a THA (Parvizi & Rasouli, 2015). Problem Statement The consequential effects that accompany the use of GA in patients undergoing THA are well understood by anesthesia providers. GA significantly impacts patient recovery and overall rehabilitation, post-surgery. Anesthesia providers may not always have full control of which anesthetic type to utilize, but full reasons for the underutilization of SA are still unclear. The goal was to deliver a power-point educational presentation to CRNAs in an urban hospital in the Midwest and help identify current barriers as to the underutilization of SA. Needs Assessment & Gap Analysis Current literature suggests that THA cases are expected to rise by four million by 2030. A leading cause of degenerative joint disease is obesity (Nagelhout & Elisha, 2018). As per the World Health Organization, approximately 13% of adults across the nation are classified as obese, with an expected rise in the rate of obesity in the future (Haebich et al., 2020). Evidence supports patients undergoing THA are high-risk patients due to their multiple comorbidities and the use of GA has shown to produce adverse outcomes in THA candidates. Due to the higher obesity rates in our nation, it is necessary to implement an anesthetic technique that decreases morbidity and mortality and promotes improved patient outcomes throughout the peri-operative period. TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 12 The project site for this DNP project currently employs GA and peripheral nerve block (PNB) as its choice of anesthesia for patients requiring THA. There is no current set protocol that limits the project site to GA and PNB; however, there is no set protocol in place that recommends SA for patients undergoing THA. Various anesthesia providers have varying degrees of opinions for the utilization of SA. A myriad of evidence supports the use of SA to prevent the adverse outcomes associated with GA in this patient population. Further research was conducted to identify existing barriers that limit CRNAs from employing SA as their chosen mode of providing anesthesia to patients undergoing THA to improve morbidity and mortality. Literature Review Methods A comprehensive review was conducted for articles published in the last ten years comparing SA and GA. Additionally, articles were reviewed which assessed barriers to the utilization of SA. Two databases were searched in January 2022 using Google Scholar and PubMed. Boolean phrases used AND and OR that utilized the keywords general anesthesia, spinal anesthesia, neuraxial anesthesia, regional anesthesia, total hip arthroplasty, total hip replacements, post anesthesia recovery unit, hemodynamic complications, comorbidities, CRNAs, barriers, and facilitators. The inclusion criteria for articles included a patient population undergoing THA, published in English, hip and knee arthroplasties studies, studies involving regional or neuraxial anesthesia, human participants only, and patients older than age 18. Exclusion criteria for articles were those younger than 18 years of age, not written in the English language, published over ten years ago, and animal research studies. As a result, 1,122 articles were identified, and 735 articles were eliminated due to the exclusion criteria listed above. After TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 13 735 articles were eliminated, 387 articles were assessed for eligibility, and 375 articles were excluded, with only 12 articles meeting the inclusion criteria. General Anesthesia versus Spinal Anesthesia In a randomized control trial conducted by Zhang et al. (2021) the effects of GA was examined on 110 patients from January 2019 to December 2020. The observation group was given SA and the control group was given GA. The primary outcome measured were the excellent anesthesia rate allocating the anesthesia effect into three grades: excellent, good, and poor. The secondary outcomes measured were blood pressure, heart rate, postoperative complications, length of hospitalization, and time in the recovery room. Data was evaluated using SPSS 22.0 software and a value of P<0.05 was noted to be significant. SA was noted with excellent anesthesia rate superior to GA. In regards to hemodynamic, values for blood pressure and heart rate were considerably lower in the observational group (P<0.05). SA provided a stable hemodynamic profile in the observation group. The overall length of hospital stay and recovery period were significantly shorter for the observation group (P<0.5). The safety and superiority of SA was confirmed through this study due to the local effects of SA versus the systemic effects created by GA that produces a profound effect on the patients overall hemodynamic status (Zhang et al., 2021). In a retrospective study conducted by Memtsoudis et al. (2014) the authors aimed to estimate the consequences of anesthesia type on postoperative outcomes. The study measured the following variables: cardiopulmonary complications, length of hospital stay (LOS), and ICU admissions and the impact of general anesthesia on these variables. The interest of this cohort study stems from a growing body of research that is continuously evaluating the impact of anesthetic agents on intraoperative outcomes. Data was obtained from 494 hospitals in the United States and 872, 416 charts were reviewed. About 60% of the patients in the study were TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 14 noted to have received GA. Some of the comorbidities noted in the study sample were, obesity, sleep apnea, and cardiopulmonary disease. The Deyo index was employed to denote the comorbidity burden which was defined by the value of 0.74 (1.06). The Deyo index was 1.77 (1.15) in patients with cardiopulmonary complications who were administered GA. The ICU admission rates were higher in groups of patients who received general anesthesia with cardiopulmonary disease and were of advanced age. When comparing SA and GA using confidence intervals (CI) in relation to pulmonary (0.7-0.94), cardiac (0.88-1.06), and combined complications (0.83-0.95), the outcomes were noted not significant (P<0.0001). Although when comparing SA and GA, SA was linked with a 11% decrease in complications overall. Therefore, an overall decrease in cardiac and respiratory complications was associated with SA especially in the elder population. SA was concluded as the choice of anesthetic for those who are of advanced age with comorbidities (Memtsoudis et al., 2014). A retrospective study undertaken by Haughom et al. (2015) notes an increase in the number of transfusions and blood loss associated with the procedure. Due to the head of the femur at the hip joint being very vascular and the inability to use a tourniquet to minimize blood loss, blood transfusions are a possible requirement especially in the elderly population. Haughom et al. (2015) studied the role of SA and GA in minimizing blood loss and transfusion requirements. Historically, SA has been associated with decreased estimated blood loss during orthopedic surgeries. Their study evaluated 28,857 patients undergoing THAs, and 11,317 of these patients received SA and 17,540 patients received GA. SA compared to GA proved to require lower number of blood transfusions (14.23% vs 17.51%). Operative times were shorter for those patients who received SA (88.94 vs 100.97 minutes). The study compared spinal versus general in regards to examining other complications such as pneumonia (0.23% vs 0.36%; P= 0.046), ventilator dependency greater than 48hours (0.04% vs. 0.12%; P= 0.045), stroke TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 15 occurrences (0.07% vs 0.19%; P= 0.01), infection rates (0.22% vs 0.34%; P= 0.066), and death (0.12% vs 0.21%; P= 0.089). SA proved to decrease the risk of blood transfusion by 18% when compared to GA. Studies as such are crucial to understanding the impact of blood loss during surgery and offer evidence based research to guide practice to decrease mortality and morbidity associated with blood transfusions (Haughom et al., 2015). A similar retrospective chart review study conducted by Kelly et al. (2021) demonstrated lower estimated blood loss of 328.3ml with SA vs 393ml with GA. Six percent of patients were discharged the same day with SA and 0.8% with GA. Administration of intrathecal fentanyl along with the local anesthetic in the subarachnoid space was noted to decrease pain scores in the post-anesthesia care unit (PACU); whereas, those who received GA had higher pain scores requiring increased doses of narcotics in the PACU (Kelly et al., (2021). Perlas et al. (2016) conducted a retrospective cohort study of 10,868 patients who underwent THA and total knee arthroplasty (TKA), and among those patients 8,553 patients received SA. The study confirmed a total reduction in the number of death within 30 days of elective THA and 58% risk reduction in total. Similar to other studies in this literature review, SA decreased the amount of blood loss during surgery, prompted shorter operating room time, and shorter LOS (Perlas et al., 2016). Basques et al. (2015) conducted a retrospective study comparing GA and SA for total hip arthroplasty. The goal of this study was to note the LOS, readmission following elective THA, and adverse events. The proposition of this study was that there would be significance in the data from patients who underwent GA. In this study 20,936 patients underwent elective THA and 12, 752 patients (60.9%) received GA and 8,184 patients (39.1%) received SA. Interestingly, patients who received GA were relatively healthy, younger, with decreased comorbidity burden, and had higher BMIs in comparison to those who received SA. Patients in the GA cohort were TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 16 1.31 times more likely to have an adverse event, 5.81 times more likely to require ventilator support, 2.17 times likely to have an unplanned intubation, 2.51 time likely to have a stroke, 5.04 times likely to have cardiac arrest, and 1.34 times likely to require blood transfusion (Basquest et al., 2015). Impact of Spinal Anesthesia As previously noted, exaggerated SNS responses can have serious effects on high risk patients throughout the peri-operative period. Das et al. (2015) evaluates the effects of SA and GA on hemodynamics through neuroendocrine stress response elicited during laparoscopic surgery. Some of the variables measured were heart rate (HR), mean arterial pressure (MAP), serum cortisol, oxygen saturation (Spo2), and end-tidal carbon dioxide (EtCO2). Patients were divided into two groups of 15, and group A received general anesthesia and group B received SA. To measure cortisol levels, venous blood samples were collected prior to the initiation of anesthesia and 30 minutes after the creation of a pneumoperitoneum for the visualization of contents within the abdominal cavity. Continuous intraoperative vital sign monitoring would demonstrate any changes in HR, MAP, SPo2, EtCO2, and electrocardiogram changes. Statistical Package for Social Sciences (SPSS) was utilized to analyze data obtained from the two groups. HR was noted to decrease in both groups, but more so in group B than A. Group B was also noted with a lower but healthy MAP in comparison to group A. Cortisol levels were found to be higher before and after the creation of a pneumoperitoneum in group A and a decrease noted for group B. There were no occurrences in SPo2 and EtCO2 in either group. In patients who received GA, hypertension and tachycardia (increased HR) were prominent, which are general neuroendocrine stress responses often elicited from surgical stress. These effects were not present in group B due to the vasodilation and sympathetic blockade of the vagal fibers in the heart. The authors of this study agree that SA attenuates the stress response associated with TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 17 surgery, as distinguished by the decrease in cortisol levels and MAP. They also note a decrease in pulmonary complications since patients do not have to be intubated or extubated under SA and are able to ambulate sooner (Das et al., 2015). Iwasaki et al. (2015) illustrates the ill effects of the surgical stress response as hyperglycemia from excess cortisol, immunosuppressive effects, catecholamine release form the adrenal medulla spilling norepinephrine responsible for tachycardia and hypertension, fat and protein catabolism, and inflammatory changes throughout the body. An overview of reports note patients receiving SA did not demonstrate many of the known stress responses to surgical stimuli; whereas, GA has shown to exaggerate many of the surgical stress responses (Iwasaki et al., 2015). Barriers to spinal anesthesia use The field of healthcare is ever evolving and advances in knowledge and technology are shaping the field of medicine. Diseases pathologies and patient profiles in the modern world can often be quiet complex requiring continuous development of ones knowledge in education and research. In a retrospective review conducted by Williams et al. (2015) 49 articles were analyzed to understand barriers to organizational advancement towards improved knowledge and practice. The five barriers discovered by the authors of this article were, workload, non-supportive staff/management, shortage of resources, lack of authority to implement change, and workplace culture. As per the authors, it is imperative to eliminate even one of these barriers prior to proceeding forth with changes in patient care (Williams et al., 2015). There are increasing number of hip replacement surgeries taking place daily and are often taking place in ambulatory settings to expedite discharge from hospitals. SA and GA both have characteristics to offer to expedite the discharge process. According to Capdevila et al. (2020), GA offers a faster onset and offset of anesthesia; whereas, SA is linked to less postoperative TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 18 complications, early discharge, and overall 90% rate of success. Through this observational study the authors were able study 592 patients undergoing orthopedic, urogenital, varicose vein stripping, and gastroenterological procedures. Fifty nine percent of patients received SA and 73% of patients received GA. The aim was to identify factors that impact choosing which anesthetic type to be used for the designated surgery. The results were based on responses from a presurgery self-reported questionnaire (surgery, surgeon, patients medical status, and choice of anesthesia), and a questionnaire administered seven days after surgery to collect data on patients pain and overall satisfaction. The authors of this study discovered that patients fears, level of anxiety, and stress significantly impact the providers decision in choosing a type of anesthetic (Capdevila et al., (2020). A cross-sectional ancillary study conducted by Duale et al. (2015), explored barriers faced by anesthesia provider in regards to conducting regional anesthesia for patients presenting for thoracotomy or thoracoscopy. A 9-item questionnaire was disseminated and responses from 84 anesthesiologist was statistically analyzed using XLStat. The questionnaire in specific analyzed barriers to the use of epidural block (EDB) and continuous paravertebral block (PVB) for thoracic procedures. The results displayed technical barriers as the most common reason mentioned by the participants. Technical barriers include the risk of placing an epidural or paravertebral block, time consumption, and financial cost. The next common reasons listed were nursing barriers followed by reluctance of colleagues (surgeons and nurse managers) (Duale et al., 2015). Multivariable Analysis Podmore et al., 2019 aimed to identify gaps in research on patient outcomes based on their comorbidities at the time of surgery. Their findings did reveal increased LOS and mortality in those identified with overall 11 comorbidities. Ultimately surgeries have to be conducted on TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 19 sick patients to provide them pain relief and functional joint abilities; however, health care providers need to understand the complexity of these patients with increased number of comorbidities and design a plan to mitigate physical and mental postoperative challenges (Podmore et al., 2019). Articles in this literature review agree upon SA providing superior outcomes to GA through various studies on varying patient types (Warren et al., 2020; Tirumala et al., 202; Wilson et al., 2020). SA offers desirable patient outcomes and produces less intraoperative adverse events. These articles validate the importance of choosing and tailoring anesthetic agents to offset potential complications and delay in recovery. Despite validating the desirable effects of SA, it continues to remain an underutilized technique due to fear, confidence level in skill, hospital culture, and fears expressed by patients. Theoretical Framework The theoretical framework or model used to guide this project is the Change Theory of Nursing constructed by Kurt Lewin (Nursing Theory, 2020). The Change Theory is appropriate to help guide this quality improvement project because it fosters change in professional practice in a world of healthcare that is constantly evolving. It is a three-stage model of change defined as the unfreezing-change-refreeze model, emphasizing old knowledge and habits being replaced by new knowledge and improved practices (Nursing Theory, 2020). The first stage is unfreezing, which emphasizes the importance of abandoning old practices and cultural attachment to practices and beliefs that conforms individuals to a set of ideas and groups. As a result, individuals or groups will have to re-direct themselves in the opposite direction of their current beliefs. The second stage is change or movement in one's beliefs and practices towards a practice more consistent with the present. Lastly, the refreezing stage emphasizes locking in the shift in behaviors and ideas as the new standard of practice TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 20 (Nursing Theory, 2020). For a model depiction of The Change Theory, please see Appendix A. Collaboration of The Change Theory and The Quality Improvement Project Step 1: Unfreezing The CRNAs have commonly adopted the practice at this critical care hospital in Indiana to use general anesthesia for all patients undergoing THA. Therefore, the online educational workshop will provoke some introspection among the CRNAs regarding their past views and practices and learn to let go. Step 2: Change Through the online educational workshop, the CRNAs will be educated on the patient population requiring THAs, the consequences of general anesthesia in this patient population, and the benefits of spinal anesthesia. The aim is to promote change in practice, based on evidence-based findings. Step 3: Refreeze In this stage, the idea is to ensure that new knowledge and practices are retained as the new standard by which anesthesia is provided to ensure the best clinical outcomes. Project Aims and Objectives This quality improvement project aimed to provide a power-point educational presentation to disseminate knowledge and literature supporting the benefits of SA and to identify current clinical barriers to its use. The goal of the power-point academic presentation was to inform the CRNAs of the varying degree of comorbidities among patients requiring THA and how GA adversely affects the health outcomes in these patients. The modules will also educate the participants on the perceived barriers discovered through evidence-based literature that was conducted by the PI. Before the online learning module, the CRNAs completed a presurvey questionnaire to evaluate the participant's current knowledge of using SA for THA and TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 21 identify perceived barriers. The post-survey questionnaire will assess the participant's willingness to change practice and utilize SA after participating in the online educational module. Project Design / Population and Setting This DNP project utilized a quasi-experiential design surveying CRNAs practicing in an acute care urban hospital in the Midwest and evaluated current trends in practice. It assessed barriers to the utilization of SA for THA. A sample of CRNAs actively practicing and with relevant experience performing anesthesia for THA surgeries was used. The project took place through online sources and email. CRNAs in this facility were chosen for this study due to the high volume of orthopedic cases being conducted under GA. Participants in the survey were invited to join a power-point educational presentation which consisted of a pre-and-post study. The academic module was created using power-point, a course system for online teaching and learning. The surveys were made available through Qualtrics. The Primary Investigator (PI) sent an email link to the clinical nurse specialist at this hospital for the power-point presentation and the surveys. The clinical nurse specialist sent out the weblinks provided by the PI to the CRNAs, along with the consent and the purpose of this study. The participants were given one month to complete the module and the pre-and post-survey at their own pace. The recruitment period for this project took place between July 2022 and August 2022. The data was analyzed using Microsoft Excel. Data collection/Measurement To measure the CRNAs knowledge of SA for THA and identify perceived barriers, a 9item demographic questionnaire and a 14-item questionnaire survey devised using a 5-point Likert scale were developed by the PI (Appendix D). These questionnaires collected nonidentifiable data relating to demographics, experience, knowledge about GA, SA, their TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 22 effects on THA patients, and perceived barriers to using SA. After participating in the educational workshop, a 14-item post-survey was then utilized to assess their willingness to change practice. The PI developed the surveys and validated them by the members of this DNP project. Data Collection Procedure Intervention The project with the educational module and surveys were sent to 23 CRNAs, and six CRNAs participated in this project. The clinical nurse specialist sent weekly email reminders to promote compliance. This data collection process began with the CRNAs reading an informed consent available in the pre-survey through Qualtrics. Once consent was obtained, the participants generated a random number through a link that would serve as their identification for the project. They would also use that number to participate in the post-survey. Once the presurvey was completed, the CRNAs then participated in the power-point presentation, which provided insight into anesthetic techniques and their impact on patients undergoing THA. The pre-survey aimed to measure clinical barriers, provider knowledge, and confidence and skill level in SA. The pre-survey also attained information regarding participants' demographics, gender, age, educational background, and years in clinical practice. Post-Intervention After the power-point presentation, participants then participated in a post-educational survey. Once data collection was completed, results from Qualtrics were obtained, and data analysis was conducted using Microsoft Excel. The data was analyzed through paired t-tests. Significance was reviewed utilizing a P value of < .05. TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 23 Ethical Consideration Approval for this DNP project was granted by Marians Institutional Review Board (IRB) and the IRB committee of the hospital before the commencement of the project. Participation in this study was voluntary, and participants were free to join the study or opt-out at any point. The participants of this study could not be identified through any of the data collected, and the participants were made aware of their anonymity. The participants were informed about the purpose of this study and why they were chosen to participate in it. All collected data will be stored in a password-protected computer in the PIs home and deleted upon completing this project. Minimal harm to the participants was presented in this project as it did not involve sensitive questions or social, psychological, physical, or legal liability. Informed consent, along with the purpose of this study, was presented on the first page before the pre-survey. There was no patient or patient-related health information used to conduct this project. Data Analysis and Results The 9-Item questionnaire revealed 50% (3) female and 50% (3) male participants. 83.33% of participants were in the age group of 25-35, and 16.67% were in the age group of 3645. Of the six participants, 72.22% had a DNAP degree, and 27.78% had either a master's or DNP degree. All six participants had between one-five years of experience in providing anesthesia care. Pre-Survey Analysis The pre-survey results focused on evaluating the participant's baseline understanding of the impact of GA and SA, the pros and cons of each anesthetic modality on patients with multiple comorbidities, and baseline understanding of patient-related factors, work culture, and surgeon preferences impacting the anesthesia providers decision in choosing between GA and TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 24 SA. 66.67% of participants said they agree with wanting to know more about the impact of GA and SA and 11.11% strongly agreed. 77.78% of participants expressed being knowledgeable about the pros and cons of GA and SA and the effects of each anesthetic type on patients with multiple comorbidities. 33.33% of participants agree that SA is safer for comorbid patients presenting for THA, 22.22% strongly agreed that SA is safer, whereas 44.44% of participants expressed neither. 44.44% of participants agree on being hesitant to perform SA due to OR production pressure. 33.33% agreed, and 11.11% strongly agreed to patient fears impacting their decision to perform a SA. 55.56% agree, and 33.33% strongly agree on utilizing SA if the surgeons did not have any preferences. 55.56% of participants agreed, and 11.11% strongly agreed in feeling confident in managing patients under SA and adverse events. Lastly, 44.44% strongly agree and consent that their work culture impacts their decision to choose SA for their patients undergoing THA. The goal of the post-education survey was to analyze the transition in knowledge, confidence, and the participant's willingness to change to practice after participating in the educational module. 83.33% of participants strongly agreed, and 16.67% agreed that an online academic module increased their knowledge of SA vs GA and its impact on patients with comorbidities. 83.33% also strongly agreed that after partaking in the online educational module, their understanding of the pros and cons of GA on patients undergoing THA with multiple comorbidities has increased. 66.67% agreed, and 33.33% of participants strongly agree that they are confident in managing patients under SA and adverse events; this is a 22.22% increase in confidence level from the pre-educational survey. Some areas of statistical significance were seen in the paired t-tests after the participants received the educational workshop. In all, there were three areas of significance (p-value < .05). Questions with significant paired t-tests included: question 1. impact of GA vs SA in THA (p-value= 0.042), question 2. knowledge on the pros and cons of SA and GA and its impact on THA patients with comorbidities (p-value= 0.025), and question 3. the participants level of preparedness to care for patients undergoing THA with multiple comorbidities (p-value= 0.012). TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 25 Question 1 had statistical significance between the pre-survey scores (M= 4, SD= 0.632) and post-education scores were (M= 4.83 , SD= 0.408 ). Question 2 had statistical significance between the pre-survey scores (M= 4.16, SD= 0.408 ) and post-education scores were (M= 4.83 , SD=0.408). Question 3 had statistical significance between the pre-survey scores (M= 2, SD= 1.095 ) and post-education scores were (M= 3.833 , SD= 1.169). Many areas were noted with improvement in post-educational scores through an agreement between participants; however, with a lack of any statistical significance. One of the questions that did not show statistical significance was regarding confidence in managing patients under SA and adverse events (0.235). Two other questions that met this criterion were their confidence levels in performing SA vs GA (0.530) and participant belief that SA is safer for THA patients with multiple comorbidities (0.741). Questions regarding the patient, OR, and surgeon factors impacting the CRNAs decisions to choose an anesthetic modality did not show any statistical significance, nor any significant changes noted in scores post-educational module. This DNP project compared pre-test and post-test of participants to change practice after participating in an educational module. The average pre-test score was 51.17, the average posttest score was 59.17. This project had an increase in the participants willingness to change practice which was not statistically significant (P-value > 0.05). Figure 1 Willingness to Change Scores 60 59.17 58 56 54 52 50 51.17 48 46 Pretest Posttest TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 26 Discussion The primary purpose of this DNP project was to identify perceived clinical barriers and promote the utilization of SA for patients having THA. The study had both strengths and weaknesses that impacted the results of this study. Some strengths of this project were familiarity with the site, ease of access to modules, and surveys through email. The participants did not have to go to a class session physically; instead, the modules were accessible from anywhere through the participant's email. The project was self-paced over a month, with educational material organized to review evidence-based research and pathophysiology. Several limitations impacted the overall outcomes and results of this research project. The internal weaknesses of this project were that this was an asynchronous online learning module that lacked in-person instructions on performing spinal anesthesia. In addition, the online module could not answer questions and concerns regarding the educational material. The PI's inexperience with creating online educational modules and self-created surveys can be considered a weakness, as the validity of these tools can be questioned. Some other limitations included a small sample size, biases of participants, setting, time, limitations in the data collection process set forth by the hospital, lack of compliance and incentive for participating in this project, and technical issues. 23 CRNAs were invited to participate in this research project; however, there were only six participants since this was a voluntary research project. Larger sample size would provide precise data as well. Having participants from multiple hospital settings would provide distinct data. For future research, it is recommended to include a larger sample size, conduct research, and collect data over a more extended period with participants from multiple hospitals. TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 27 The inclusive results reveal an increased knowledge of SA and GA and their impact on THA patients, a deeper understanding of the pros and cons of each anesthetic modality, and better preparedness to care for patients with multiple comorbidities under SA. In addition, it was confirmed that many barriers to performing SA were due to patient-related factors, OR production pressures, and surgeon preferences. Conclusion THAs cases continue to be among the most common orthopedic procedures conducted in the nation successfully. They aim at restoring mobility and reducing pain associated with arthritis. However, it is more essential than ever to be cautious in the type of anesthetic chosen for patients due to the rising number of hip replacements cases stemming from hip pathologies and hip fractures and the increasing concern regarding accompanying cardiopulmonary and cerebrovascular diseases that exist among these patients. The growing age of patients, preexisting conditions, and cement prostheses are risks that promote complications. Numerous data demonstrate the impact of anesthesia on the patients overall well-being in combination with the previously mentioned factors (Perlas et al., 2016). Numerous articles support the benefits of SA in attenuating the ill effects of the surgical stress response noted in patients with a THA. By modifying our practice and providing continuous education on a regular basis, the health of the surgical patient can significantly improve, and mortality and morbidity can be reduced. This DNP project facilitated education for CRNAs on understanding the effects of SA and GA on surgical patients presenting for THA, identified barriers to the limited use of SA, and evaluated willingness to change practice. Data analysis revealed a greater depth of understanding by the CRNAs of SA and GA, the impact on this patient population, and increased confidence level in SA. Ultimately, practice change can be elicited by further continuous education. TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 28 References: Basques, B. A., Toy, J. O., Bohl, D. D., Golinvaux, N. S., & Grauer, J. N. (2015). General compared with spinal anesthesia for total hip arthroplasty. The Journal of Bone and Joint Surgery. American Volume, 97(6), 455461. https://doi.org/10.2106/JBJS.N.00662 Calderon-Ochoa, F., Mesa, A. O., Rincon, G. P., Pinton, I. Q. (2019). Effectiveness and safety of exclusive spinal anesthesia with bupivacaine versus femoral sciatic block during the postoperative period of patients having undergone knee arthroscopy: Systematic review. Colombian Journal of Anesthesiology, 47(1), 57-68. https:// doi: 10.1097/CJ9.0000000000000092 Campbell Clinic. (2019, February 15). Total joint replacement procedures continue to increase. https://www.campbellclinic.com/total-joint-replacement-procedures-continue-to-increase/ Capdevila, X., Aveline, C., Delaunay, L., Bouaziz, H., Zetlaoui, P., Choquet, O., Jouffroy, L., Herman-Demars, H., & Bonnet, F. (2020). Factors determining the choice of spinal versus general anesthesia in patients undergoing ambulatory surgery: Results of a multicenter observational study. Advances in Therapy, 37(1), 527540. https://doi.org/10.1007/s12325-019-01171-6 Centers for Disease Control and Prevention. (2021, September 27). Adult obesity maps. https://www.cdc.gov/obesity/data/prevalence-maps.html Das, W., Bhattacharya, S., Ghosh, S., Saha, S., Mallik, S., & Pal, S. (2015). Comparison between general anesthesia and spinal anesthesia in attenuation of stress response in laparoscopic cholecystectomy: A randomized prospective trial. Saudi Journal of Anaesthesia, 9(2), 184188. https://doi.org/10.4103/1658-354X.152881 Dual, C., Gayraud, G., Taheri, H., Bastien, O., & Schoeffler, P. (2015). A French nationwide survey on anesthesiologist-perceived barriers to the use of epidural and paravertebral TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 29 block in thoracic surgery. Journal of Cardiothoracic and Vascular Anesthesia, 29(4), 942949. https://doi.org/10.1053/j.jvca.2014.11.006 Haebich, S. J., Mark, P., Khan, R., Fick, D. P., Brownlie, C., & Wimhurst, J. A. (2020). The influence of obesity on hip pain, function, and satisfaction 10 years following total hip arthroplasty. The Journal of Arthroplasty, 35(3), 818823. https://doi.org/10.1016/j.arth.2019.09.046 Harris, M., & Chung, F. (2013). Complications of general anesthesia. Clinics in Plastic Surgery, 40(4), 503513. https://doi.org/10.1016/j.cps.2013.07.001 Haughom, B. D., Schairer, W. W., Nwachukwu, B. U., Hellman, M. D., & Levine, B. R. (2015). Does neuraxial anesthesia decrease transfusion rates following total hip arthroplasty?. The Journal of Arthroplasty, 30(9 Suppl), 116120. https://doi.org/10.1016/j.arth.2015.01.058 Iwasaki, M., Edmondson, M., Sakamoto, A., & Ma, D. (2015). Anesthesia, surgical stress, and "long-term" outcomes. Acta Anaesthesiologica Taiwanica : Official Journal of the Taiwan Society of Anesthesiologists, 53(3), 99104. https://doi.org/10.1016/j.aat.2015.07.002 Kelly, M. E., Turcotte, J. J., Aja, J. M., MacDonald, J. H., & King, P. J. (2021). General vs neuraxial anesthesia in direct anterior approach total hip arthroplasty: Effect on length of stay and early pain control. The Journal of Arthroplasty, 36(3), 10131017. https://doi.org/10.1016/j.arth.2020.09.050 Maradit Kremers, H., Larson, D. R., Crowson, C. S., Kremers, W. K., Washington, R. E., Steiner, C. A., Jiranek, W. A., & Berry, D. J. (2015). Prevalence of total hip and knee replacement in the United States. The Journal of Bone and Joint Surgery. American Volume, 97(17), 13861397. https://doi.org/10.2106/JBJS.N.01141 TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE Matsen Ko, L., & Chen, A. F. (2015). Spinal anesthesia: the new gold standard for total joint arthroplasty?. Annals of Translational Medicine, 3(12), 162. https://doi.org/10.3978/j.issn.2305-5839.2015.06.12 Memtsoudis, S. G., Rasul, R., Suzuki, S., Poeran, J., Danninger, T., Wu, C., Mazumdar, M., & Vougioukas, V. (2014). Does the impact of the type of anesthesia on outcomes differ by patient age and comorbidity burden?. Regional Anesthesia and Pain Medicine, 39(2), 112119. https://doi.org/10.1097/AAP.0000000000000055 Nagelhout, J., & Elisha, S. (2018). Nurse anesthesia. (6th). Elsevier. Nursing Theory. (2020). Lewins Change Theory. https://nursing-theory.org/theoriesandmodels/lewin-change-theory.php Parvizi, J., & Rasouli, M. R. (2015). General compared with neuraxial anesthesia for total hip and knee arthroplasty. Annals of Translational Medicine, 3(20), 318. https://doi.org/10.3978/j.issn.2305-5839.2015.10.36 Perlas, A., Chan, V. W., & Beattie, S. (2016). Anesthesia technique and mortality after total hip or knee arthroplasty: A retrospective, propensity score-matched cohort study. Anesthesiology, 125(4), 724731. https://doi.org/10.1097/ALN.0000000000001248 Podmore, B., Hutchings, A., Skinner, J. A., MacGregor, A. J., & van der Meulen, J. (2021). Impact of comorbidities on the safety and effectiveness of hip and knee arthroplasty surgery. The Bone & Joint Journal, 103-B(1), 5664. https://doi.org/10.1302/0301620X.103B1.BJJ-2020-0859.R1 Pozzobon, D., Ferreira, P. H., Blyth, F. M., Machado, G. C., & Ferreira, M. L. (2018). Can obesity and physical activity predict outcomes of elective knee or hip surgery due to osteoarthritis? A meta-analysis of cohort studies. BMJ Open, 8(2), e017689. 30 TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 31 https://doi.org/10.1136/bmjopen-2017-017689 Pu, X., & Sun, J. M. (2019). General anesthesia vs spinal anesthesia for patients undergoing total-hip arthroplasty: A meta-analysis. Medicine, 98(16), e14925. https://doi.org/10.1097/MD.0000000000014925 Tirumala, V., Bounajem, G., Klemt, C., Maier, S. P., Padmanabha, A., & Kwon, Y. M. (2021). Outcome of spinal versus general anesthesia in revision total hip arthroplasty: A propensity score-matched cohort analysis. The Journal of the American Academy of Orthopaedic Surgeons, 29(13), e656e666. https://doi.org/10.5435/JAAOS-D-20-00797 Warren, J., Sundaram, K., Anis, H., Kamath, A. F., Mont, M. A., Higuera, C. A., & Piuzzi, N. S. (2020). Spinal anesthesia is associated with decreased complications after total knee and hip arthroplasty. The Journal of the American Academy of Orthopaedic Surgeons, 28(5), e213e221. https://doi.org/10.5435/JAAOS-D-19-00156 Williams, B., Perillo, S., & Brown, T. (2015). What are the factors of organizational culture in health care settings that act as barriers to the implementation of evidence-based practice? A scoping review. Nurse Education Today, 35(2), e34e41. https://doi.org/10.1016/j.nedt.2014.11.012 Wilson, J. M., Farley, K. X., Bradbury, T. L., & Guild, G. N. (2020). Is spinal anesthesia safer than general anesthesia for patients undergoing revision THA? Analysis of the ACSNSQIP database. Clinical Orthopaedics and Related Research, 478(1), 8087. https://doi.org/10.1097/CORR.0000000000000887 Zhang, T., Ma, Y., Liu, L., Wang, J., Jia, X., Zhang, Y., & Dong, Y. (2021). Comparison of clinical effects of general anesthesia and intraspinal anesthesia on total hip arthroplasty. American Journal of Translational Research, 13(7), 82418246. TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE Appendix A Theoretical Framework: Kurt Lewins Change Theory Hussain, S. T., Lei, S., Akram, T., Haider, M. J., Hussain, S. H., Ali, M. (2018). Kurt Lewins change model: A critical review of the role of leadership and employee involvement in organizational change. Journal of Innovation & Knowledge, 3(3), 123-127. https://doi.org/10.1016/j.jik.2016.07.002 32 TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE Appendix B IRB Approval 33 TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE Appendix C- IRB Approval 34 TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE Appendix D 9 Item-Demographic Questionnaire Please choose your answers as it appropriately fits. 1. What gender do you identify as? a. Female b. Male c. Other d. I prefer not to answer 2. What is your age? a. < 25 b. 25-35 c. 36-45 d. 46-55 e. 56-65 f. > 66 3. What is your level of education? a. Masters b. DNP c. DNAP d. Other 4. How many years of practice as a CRNA do you have? a. <1 b. 1-5 years c. 6-10 years d. 11-15 years e. 16-20 years f. > 20 years 5. Does your facility perform total hip arthroplasties? a. Yes b. No 35 TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 36 6. How many total hip arthroplasties are performed in a month? a. < 1 b. 1-5 c. 6-10 d. 11-15 e. 16-20 f. > 20 7. Do you provide anesthesia services for patients presenting for total hip arthroplasties? a. Yes b. No 8. Does your organization commonly use spinal anesthesia for total hip arthroplasties? a. Yes b. No 9. Do CRNAs in the main operating room (OR) or ambulatory room perform epidural/spinal/caudal anesthesia commonly for any type of procedures? a. Yes b. No TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 37 On a scale of 1-5, how strongly do you agree with the following statements 1. Strongly agree I want to know more about the impact of general anesthesia vs spinal. I am knowledgeable on the pros and cons of general anesthesia and spinal anesthesia and its effect on patients with multiple comorbidities I am unsure of how to care for patients with multiple comorbidities under spinal anesthesia. I believe spinal anesthesia is safer for comorbid patients presenting for total hip arthroplasty. I am confident conducting a spinal vs general anesthetic I would be hesitant to perform a spinal anesthetic due to OR production pressures. Spinal anesthesia increases my workload in comparison to general anesthesia Patient concerns or fears impacts my decision in choosing spinal anesthesia I have enough resources and support to perform a spinal anesthetic I am confident in performing a spinal anesthetic 2. Agree 3. Neither agree or disagree; undecided 4. Disagree 5. Strongly disagree TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 38 I would feel more confident if I had more experience in managing adverse events occurring from spinal anesthesia I would utilize spinal anesthesia if the surgeons did not have any preferences My work culture impacts my decision to choose spinal anesthesia for patients undergoing total hip arthroplasty My workplace would be hesitant to amending current practice. Post Test: On a scale of 1-5, how strongly do you agree with the following statements 1. Strongly agree An online educational module increased my knowledge of spinal vs general anesthetic and its impact on patients with comorbidities An online educational module increased my knowledge on the pros and cons of general anesthesia and spinal anesthesia and its effect on patients with multiple comorbidities I am better prepared to care for patients with multiple comorbidities under spinal anesthesia. 2. Agree 3. Neither agree or disagree; undecided 4. Disagree 5. Strongly disagree TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE I believe spinal anesthesia is safer for comorbid patients presenting for total hip arthroplasty. I am confident conducting a spinal vs general anesthetic I would be hesitant to perform a spinal anesthetic due to OR production pressures. Spinal anesthesia increases my workload in comparison to general anesthesia Patient concerns or fears impacts my decision in choosing spinal anesthesia I have enough resources and support to perform a spinal anesthetic I am confident in performing a spinal anesthetic I would feel more confident if I had more experience in managing adverse events occurring from spinal anesthesia I would utilize spinal anesthesia if the surgeons did not have any preferences My work culture impacts my decision to choose spinal anesthesia for patient undergoing total hip arthroplasty My workplace would be hesitant to amending current practice. 39 TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE 40 Appendix E Literature Review Matrix Citation Basques, B. A., Toy, J. O., Bohl, D. D., Golinvaux, N. S., & Grauer, J. N. (2015). General compared with spinal anesthesia for total hip arthroplasty. The Journal of bone and joint surgery. American volume, 97(6), 455461. Research Design & Level of Evidence Retrospective cohort study, Level :3 Population / Sample size n=x Major Variables Instruments / Data collection n= 12,752 patients Operating room Charlson Comorbidity times and length Index-Instrument for of stay measuring comorbidities Adverse Events and Readmission ACS-NSQIP- for data collection Results General Anesthesia (GA) had increased operative time, +12 minutes compared to spinal anesthesia (SA). P< 0.001 GA postoperative time was an additional +5 minutes compared to SA. P< 0.001. https://doi.org/10.2106/JBJS.N.00662 Patient who underwent GA were 1.31 times likely to have an occurrence of an adverse event, 5.81 times likely to have prolonged ventilatory use, 2.17 times likely to have an unplanned, 2.51 likely to have a stroke, 5.04 times likely to have a cardiac arrest, and 1.34 times likely to require a blood transfusion The rate of readmission was noted without any significance. TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE Capdevila, X., Aveline, C., Delaunay, L., Bouaziz, H., Zetlaoui, P., Choquet, O., Jouffroy, L., HermanDemars, H., & Bonnet, F. (2020). Factors Determining the Choice of Spinal Versus General Anesthesia in Patients Undergoing Ambulatory Surgery: Results of a Multicenter Observational Study. Advances in therapy, 37(1), 527540. https://doi.org/10.1007/s12325-019-01171-6 Observational, Cohort study Level: 4 n= 592 patients 41 Postoperative recovery Factors associated with use of the anesthetic technique Comparison between spinal chloroprocaine, prilocaine, and bupivacaine Efficacy of spinal and general anesthesia Features of spinal anesthesia according to the local anesthetic agent Data collection- A preanesthetic selfadministered questionnaire and a 7day post-surgery selfadministered questionnaire. Average time between local anesthetic (LA) and onset of surgery was 20 mins and motor blockade of the lower extremity was 9 minutes. Instruments: SAS 9.1 version software, The Mann-Whitney test, Krustal-Wallis test, Student t Test and chisquared test. The use of additional pain modalities with SA was in 26% of cases, and the use of GA due to failed SA only occurred in 4.5% of patients. The attainment rate of SA was 91.6% of time. The median onset between induction of anesthesia and the onset of surgery was 15 minutes with delays due to extubation averaging 60 mins. Patients fear of the type of anesthesia was 30.2% for GA and 14% for spinal anesthesia, and stress and anxiety caused by GA was 24.6% and 14.3% for SA. TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE Das, W., Bhattacharya, S., Ghosh, S., Saha, S., Mallik, S., A Randomized trial & Pal, S. (2015). Comparison between general anesthesia Level: 2 42 n=30 patients Cortisol Group A: 15 patients BP HR and spinal anesthesia in attenuation of stress response in Group B:15 laparoscopic cholecystectomy: A randomized prospective EtCO2 trial. Saudi journal of anaesthesia, 9(2), 184188. SPO2 https://doi.org/10.4103/1658-354X.152881 Instrument: SPSS (t-test and Chi-square). Data collection: Microsoft excel sheet GROUP B Cortisol levels 30 minutes post- P=0.004 Pre pneumoperitoneum cortisol level- GA: 18.37g/dl, SA: 19.65 g/dl Postpneumoperitoneum cortisol level- GA: 21.15g/dl, SA: 13.24g/dl MAP difference b/w group A and B: P= 0.01 TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE Dual, C., Gayraud, G., Taheri, H., Bastien, O., & Cross sectional ancillary study n=84 anesthesiologist 43 Perceived barriers Schoeffler, P. (2015). A French Nationwide Survey on Anesthesiologist-Perceived Barriers to Level: 4 Activity per center the Use of Epidural and Paravertebral Block in Team size Thoracic Surgery. Journal of cardiothoracic and Activity per physician vascular anesthesia, 29(4), 942949. https://doi.org/10.1053/j.jvca.2014.11.006 Technical barriers Data Collection: 9Item electronic questionnaire, Instruments: Microsoft office, Excel 2003, Redmond WA Multivariate descriptive analysis: Epidural Block for Analagesia: F1 + F2: 47.4% of the variance. Paravertebral block for analgesia: F1+F2: 51.8% of the variance Risk Activity per center: P= 0.037 Complexity Complexity: P=0.008 Time consumption Time consumption: P= 0.028 Cost Nursing barriers Surgeons: P= 0.001 Supervision Nurse Manager: P= 0.003 Training Hospital Manager: P= 0.001 Reluctance of colleagues Cost: P= 0.085 Surgeons Nurse Manaer TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE Haughom, B. D., Schairer, W. W., Nwachukwu, B. U., Hellman, M. D., & Levine, B. R. (2015). Does Neuraxial Anesthesia Decrease Transfusion Rates Following Total Hip Arthroplasty?. The Journal of arthroplasty, 30(9 Suppl), 116120. https://doi.org/10.1016/j.arth.2015.01.058 Nonrandomized n= 28,857 observational cohort General anesthesia Level: 4 group: n= 17,540 Neuraxial Anesthesia: n=11,317 44 Operative Time Data collection: NSQIP database Length of Stay Post-operative Transfusion Complication Surgical Complication Superficial infection Deep infection Organ Space Infection Wound dehiscence Reoperation Unplanned readmission Medical complication Pneumonia Unplanned intubation DVT , PE Instruments: t-tests and Chi-squared tests. Patient group who received neuraxial anesthesia displayed shorter operative time P<0.001 and lower transfusion rates 14.23% vs 17.51% Overall complications 4.62% vs. 5.23% P= 0.019 And lower medical complication rates 2.63% vs 3.42%; P< 0.001 Pneumonia: P= 0.046 Unplanned intubation: P=0.018 Vent use > 48 hrs P= 0.045 Stroke: P=0.01 Deep Infection: P= 0.066 Death: P=0.089 TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE & King, P. J. (2021). General vs Neuraxial A retrospective chart review. Anesthesia in Direct Anterior Approach Total Hip Level : 3 Kelly, M. E., Turcotte, J. J., Aja, J. M., MacDonald, J. H., Arthroplasty: Effect on Length of Stay and Early Pain Control. The Journal of arthroplasty, 36(3), 10131017. https://doi.org/10.1016/j.arth.2020.09.050 n= 500 n= 376 Neuraxial anesthesia n= 124 General anesthesia 45 Fluid Estimated Blood loss Preoperative hematocrit Postoperative day 1 hematocrit Change in hematocrit PACU MME PACU pain PACU Nausea Same day discharge LOS Hour Readmission Data collection: Administrative database Chesapeake Regional Informational System for patient demographics Instruments: t-tests and Chi-test, SPSS 25.0 Neuraxial anesthesia patient: EBL: 328.3ml vs GA 393.1ml Patients in the NA group experienced shorter procedural time NA: 50.2 vs GA: 54 Patients in the NA group consumed less MME in PACU NA: 10.2mg vs GA: 15.6mg Length of hospital stay under GA: 32.7 hours vs GA: 38.1 hours. Approximately 61% of patients were discharged the same day in the NA group . TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE Memtsoudis, S. G., Rasul, R., Suzuki, S., Poeran, J., Retrospective Cohort Study n= 872, 416 patient records 46 Combined outcomes Cardiac complications Data collection: Administrative data from premier perspective database Deyo Index Pulmonary complications Instrument: KruskalWallis Test Danninger, T., Wu, C., Mazumdar, M., & Level : 3 Vougioukas, V. (2014). Does the impact of the type of anesthesia on outcomes differ by patient age and comorbidity burden?. Regional anesthesia Prolonged Length of stay and pain medicine, 39(2), 112119. ICU Utilization. https://doi.org/10.1097/AAP.0000000000000055 Technique and Mortality after Total Hip or Knee A Retrospective Cohort Study Arthroplasty: A Retrospective, Propensity Level: 3 Perlas, A., Chan, V. W., & Beattie, S. (2016). Anesthesia n= 10,868 n= 8,553 Spinal Anesthesia n=2,315 general anesthesia Death MI Data Collection: University Health Network Electronic Data Warehouse MACE Scorematched Cohort Study. Anesthesiology, PE 125(4), 724731. Blood transfusion https://doi.org/10.1097/ALN.0000000000001248 Patients who received general anesthesia were 0.91 time likely to experience major complications, 0.88 times likely to experience pulmonary complications, 1.02 times likely to have an ICU admission and 0.87 times likely to have an increased LOS. Instrument: MannWhitney U Test, Chisquare test, and Fisher exact test Charlson Risk score 30 day mortality= 0.19% in spinal anesthesia group and 0.8% in the general anesthesia group, risk ration= 0.42; 95% CI, 0.21 to 0.83; P=0.0045 Spinal anesthesia was noted with a shorter length of stay 5.7 vs 6.6 days. TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE Podmore, B., Hutchings, A., Skinner, J. A., MacGregor, A. J., & van der Meulen, J. (2021). Impact of An Observational study n= 640,832 patients 47 Length of hospital stay Emergency readmissions comorbidities on the safety and effectiveness of hip Level: 6 Improvement in severity of joint problems. and knee arthroplasty surgery. The bone & joint journal, 103-B(1), 5664. Data Collection: Oxford Hip or Knee Scores (OHS/OKS), healthrelated quality of life (HRQoL) Hospital Episode Statistic dataset (HES) Patients who had heart diseases have 1.2 days longer LOS and readmission rate was 1.5% and mortality 0.2% higher. In patients with heart disease, differences in improvement of OHS was -0.4 and -0.6 for OKS. https://doi.org/10.1302/0301-620X.103B1.BJJ2020-0859.R1 Williams, B., Perillo, S., & Brown, T. (2015). What are A Scoping Review: the factors of organisational culture in health care n= 49 articles Perceived barriers Workload Instrument: Charting the data, a descriptive analytical method Level 6 settings that act as barriers to the implementation of evidence-based practice? A scoping review. Other staff/management not supportive Nurse education today, 35(2), e34e41. Lack of resources https://doi.org/10.1016/j.nedt.2014.11.012 Lack of authority to change practice Workplace culture resistant to change. Data Collection: Multiple databases were conducted using Medline, EMBASE, EBM Reviews, Google Scholar, The Cochrane Library. Barriers to: Workload: 38 Other Staff/Management not supportive of research: 37 Lack of resources: 28 Lack of authority to change practice: 22 Workplace/professional culture resistant to change: 14 TOTAL HIP ARTHROPLASTY AND ANESTHETIC TECHNIQUE Padmanabha, A., & Kwon, Y. M. (2021). A Retrospective study Outcome of Spinal Versus General Anesthesia in Level: 3 Tirumala, V., Bounajem, G., Klemt, C., Maier, S. P., n= 2,656 patients 48 Indication for revison THA Data collection: Charlson comorbidity Index (CCI) Implant Revised Implant Fixation Revision Total Hip Arthroplasty: A Propensity TXA use Score-Matched Cohort Analysis. The Journal of Surgeons the American Academy of Orthopaedic American College of Surgeons-National Surgical Improvement (ACS-NSQIP) database Instrument: SPSS 25 IBM Pts undergoing GA had a significantly longer procedure time (174 versus 161, P< 0.01); higher intraoperative time (402 versus 305, P<0.01); extended length of time of surgery (odd ration 2.45) Mean Operational time Surgeons, 29(13), e656e666. https://doi.org/10.5435/JAAOS-D-20-00797 Blood loss and transfusions Post-operative complications Length of stay Zhang, T., Ma, Y., Liu, L., Wang, J., Jia, X., Zhang, Y., & Dong, Y. (2021). Comparison of clinical effects of general anesthesia and intraspinal anesthesia on total hip arthroplasty. American journal of transational research, 13(7), 82418246. A Prospective Study Level: 6 n= 110 patients Anesthesia effect Blood pressure Heart Rate Data collection: Excellent anesthesia rate Observation in the OR Excellent anesthesia rate in the control group: P<0.05 MAP and HR P< 0.05 Post-operative recovery room and total hospitalization time Instrument: SPSS 22.0 statistical analysis software Postoperative recovery time and in hospitalization time P< 0.05 DocuSign Envelope ID: 1A7FB13C-1EA6-4B79-AF4B-65AA768D45B7AF2EC514 FB23 8D5 B357-0EEC229CFD42  ...

... ONDANSETRON AND SPINAL ANESTHESIA 1 Ondansetron before spinal anesthesia in cesarean sections: An evidence-based educational intervention Madison Jimison Marian University Leighton School of Nursing Chair: Dr. Derrianne Monteiro __________________________________ (Signature) Project Team Members: Dr. Adrienne Merrick __________________________________ (Signature) Date of Submission: 03/13/2023 ONDANSETRON AND SPINAL ANESTHESIA Table of Contents Abstract..4 Introduction6 Background6 Problem Statement.....7 Organizational Gap Analysis of Project Site..8 Review of the Literature....8 Theoretical Framework..11 Goals/Objectives/Expected Outcomes...11 Project Design/Methods.12 Project site and population.12 Methods......13 Data collection....14 Ethical Considerations14 Data analysis and Results.......15 Discussion...17 Conclusion...18 References...19 Appendices Appendix A.....24 Appendix B.25 Appendix C.31 Appendix D 33 2 ONDANSETRON AND SPINAL ANESTHESIA Appendix E.34 Appendix F.35 3 ONDANSETRON AND SPINAL ANESTHESIA 4 Abstract Background and Review of Literature: Spinal anesthesia is the current gold standard of practice for providing care in elective cesarean sections. However, spinal anesthesia is commonly associated with untoward side effects including activating the Bezold-Jarisch reflex leading to significant hypotension and bradycardia. Current evidence-based literature shows the administration of a 5-HT3 antagonist, such as intravenous Zofran, can reduce these side effects as well as reduce the amount of vasopressors used to provide optimal patient care. Purpose: This study explored the efficacy of an educational intervention on increasing the willingness and knowledge to utilize a 5-HT3 antagonist before a spinal anesthetic in cesarean sections Methods: An email list of 25 active anesthesia providers at a large metropolitan hospital was acquired and presented the educational opportunity via email. This included a Qualtrics preeducational questionnaire, an attached educational PowerPoint, and a Qualtrics post-educational questionnaire. These helped to determine current anesthetic practices, basic knowledge of Zofran, and willingness to adopt a 5-HT3 antagonist into anesthetic practices before spinal anesthesia. Implications/Conclusion: The implementation of an educational intervention on eight anesthesia providers significantly increased education and knowledge. Alternatively, the educational intervention did not significantly increase willingness to change anesthetic practices due to the high extremely willing response rate in the pre-educational questionnaire. Keywords: ondansetron, Zofran, 5-HT3 antagonist, spinal anesthesia, subarachnoid block, cesarean sections, blood pressure, hemodynamics, hypotension ONDANSETRON AND SPINAL ANESTHESIA 5 Ondansetron before spinal anesthesia in cesarean sections: An evidence-based educational intervention Introduction Spinal anesthesia is a vital component for providing adequate and satisfactory care for cesarean sections. However, a spinal anesthetic is commonly associated with activating the Bezold-Jarisch reflex which contributes to significant hypotension and bradycardia (Tatikonda et al., 2019). This can cause untoward effects on both the mother and the baby. Recent studies have shown significant prevention of spinal-induced side effects when a 5-hydroxytryptamine 3 (5-HT3) antagonist, such as ondansetron (Zofran) is administered before the procedure. Proper formation and implementation of an educational intervention that includes the discussion of intravenous (IV) Zofran before performing a spinal anesthetic can optimally increase anesthesia providers use which can further improve patient outcomes, reduce vasopressor use, and reduce care costs. Background Spinal anesthesia first dates to 1885 when cocaine was injected into the spinous process of the lumbar area to produce loss of sensation (Marx, 1994). Since then, it has been effective in a variety of procedures and preferred for its avoidance in airway manipulation, adverse effects of certain general anesthetic drugs, improved postoperative pain, and reduced postoperative opioid requirements (Stewart et al., 2020). However, spinal anesthesia is not free from unfavorable side effects or considerations since it is associated with physiologic changes of the central nervous system, cardiovascular system, respiratory system, and gastrointestinal system (Nagelhout & Elisha, 2018). Specifically, spinal anesthesia blocks sympathetic nerve transmission that results in arterial vasodilation, decreased systemic vascular resistance, venous pooling, and reduction in ONDANSETRON AND SPINAL ANESTHESIA 6 venous return that occurs in up to 75% of cases (klebar, 2019). Furthermore, the BezoldJarisch reflex is activated with an abrupt autonomic withdrawal of sympathetic response and increased vagal tone. The combination of increased venous pooling and increased vagal tone may result in profound hypotension and bradycardia that can be challenging to rapidly treat or reverse (Nagelhout & Elisha, 2018). Hypotension prevents perfusion to critical organs in the body such as the heart and brain and is important in maintaining homeostasis. Maternal hypotension results in problematic nausea and vomiting and if severe, may result in decreased level of consciousness, aspiration of gastric contents, and cardiovascular collapse (Nagelhout & Elisha, 2018). Detrimental neonatal effects such as fetal acidosis and death may develop with uteroplacental hypoperfusion (Aksoy et al., 2021). The goal is to rapidly treat hypotension in this patient population before further complications arise. Multiple strategies have been identified for optimal treatment of spinal-induced hypotension. Researchers have focused on the prevention of spinal-induced hypotension by targeting the effects of the Bezold-Jarisch reflex. It is concluded that serotonin and 5-HT3 receptors in the heart, lung, and spine are responsible for the activation of this reflex (Aksoy et al., 2021). Several studies have shown that by administering a 5-HT3 antagonist such as intravenous ondansetron (Zofran) before spinal anesthesia, it can attenuate hypotension and inhibit peripheral vasodilation, easing the Bezold-Jarisch reflex, and increasing venous return, ultimately leading to decreased side effects and vasopressor usage (Nivatpumin & Thamvittayakul, 2016). Problem Statement ONDANSETRON AND SPINAL ANESTHESIA 7 Hypotension is a common and problematic complication that is commonly associated with spinal anesthesia. It can produce detrimental effects on both the laboring mother and her baby. Many studies have shown the benefit of administering Zofran, a 5-HT3 antagonist, before performing the procedure to reduce the incidence of hypotension and its associated issues (Nivatpumin & Thamvittayakul, 2016). However, not all health care facilities or anesthesia providers routinely administer IV Zofran before spinals in cesarean sections. This project explored the efficacy of an educational intervention on increasing the willingness and knowledge to utilize a 5-HT3 antagonist before a spinal anesthetic in cesarean sections. Needs Assessment and Gap Analysis The site for this project is a health care organization that commonly performs cesarean sections. This facility demonstrated administration of IV Zofran before spinal anesthesia is not a common practice in cesarean sections. The lack of education and knowledge of IV Zofran offers an opportunity to implement an educational intervention that will optimally improve anesthesia providers willingness to adopt IV Zofran into their routine anesthetic techniques and improve knowledge on the subject. Literature Review Methods A comprehensive literature review was performed regarding the effects of administering IV 5-HT3 antagonist before spinal anesthesia in cesarean sections. The process aimed to include articles with IV 5-HT3 antagonist, such as ondansetron, as the primary intervention and its effects on hemodynamics. A comprehensive search was performed on Pubmed and CINAHL databases using primary terms and Boolean phrases including ondansetron OR Zofran OR 5-HT3 antagonist, spinal OR spinal anesthesia OR subarachnoid block, cesarean sections OR c-section, ONDANSETRON AND SPINAL ANESTHESIA 8 blood pressure OR hemodynamics OR hypotension. Exclusion criteria was applied to ensure the results included literature from the years 2015 or newer, were able to be read in English, human trials, peer-reviewed, randomized-control trial, clinical trial, or retrospective study. The search process uncovered 60 articles that were further screened for review. Further exclusion criteria were applied that limited the articles to pregnant women, 5-HT3 antagonist as primary intervention, effects on hemodynamics, and elective cesarean sections. This returned a total of 17 articles that are included in this review. Results Of the 17 articles included in this review (see appendix D), 11 articles advocated for the use of prophylactic Zofran as it reduced spinal-induced hypotension and/or decreased the amount of vasopressors that were used to control hypotension (Aksoy et al., 2021; Chatterjee et al., 2020; El Khouly & Meligy, 2016; Karacaer et al., 2017; Nivatpumin & Thamvittayakul, 2016; OrtizGomez et al., 2017; Phipps, 2016; Qian et al., 2020; Tatikonda et al., 2019; Wang et al., 2014; Xiao et al., 2019). Several factors were measured throughout the different studies but the main variables of vital signs, vasopressor use, and adverse outcomes were consistent. Two studies (Aksoy et al., 2021; Chatterjee et al., 2020), specifically studied the effectiveness of Granisetron, a 5-HT3 antagonist like ondansetron, and its effects on hemodynamics. A combined total of 320 participants were examined and both studies advocated for the use of Granisetron, and the effectiveness of decreasing blood pressure shifts and reducing the use of vasopressors, specifically ephedrine and mephentermine. Wang et al. (2014), determined that IV Zofran before spinal anesthesia significantly decreases spinal-induced hypotension as well as improved nausea and vomiting, improved acid-base balance in the newborn, and a reduced vasopressor requirement. While the study of El Khouly & Meligy (2016), demonstrated that IV Zofran ONDANSETRON AND SPINAL ANESTHESIA 9 significantly decreased blood pressure and heart rate fluctuations while also reducing the incidence of nausea and vomiting. Multiple studies examined vasopressor requirements to maintain blood pressure after spinal anesthesia. Although hemodynamics was not significantly different for patients given IV Zofran before their spinal, many studies found that vasopressor requirements were significantly reduced (Alghanem et al., 2020; Karacaer et al., 2017; Nivatpumin & Thamvittayakul, 2016; Phipps, 2016; Qian et al., 2020; Tatikonda et al., 2019; Xiao et al., 2019). Xiao et al. (2019), found that 4 mg of IV Zofran reduced the ED50 (dose required to produce a desired pharmacologic effect in 50% of the population) of phenylephrine infusions by 26%. While Karacaer (2017), confirmed that hypotensive events and phenylephrine requirements were higher in the normal saline control group compared to the group who received 8mg of Zofran prophylactically. Furthermore, the study of Ortiz-Gomez et al. (2017), concluded 8mg of Zofran before spinal anesthesia decreases the severity of hypotension, leading to an overall reduction of hypotensive events by 50% per patient. Additional findings of a prophylactic 5-HT3 antagonist before spinal anesthesia in cesareans sections include decreased episodes of shivering, and decreased antiemetic requirements (Tatikonda et al., 2019)(Oofuvong et al., 2018). Qian et al. (2020), also demonstrated 4mg ondansetron given 15 minutes before a spinal offers no additional benefits than 4mg ondansetron given 5 minutes before a spinal. Of the 17 articles, four determined IV ondansetron offered no benefit to decrease the episodes of hypotension in cesarean sections (Marciniak et al., 2015; Neumann et al., 2020; Oofuvong et al., 2018; Terkawi et al., 2015). Terkawi et al. (2015), also found that ondansetron does not reduce nausea and vomiting, pruritis, or vasopressor consumption. Additionally, one ONDANSETRON AND SPINAL ANESTHESIA 10 study found 25mg intramuscular (IM) of ephedrine 25 minutes before spinal anesthesia contributed to the best prevention of systolic blood pressure changes when compared to 4mg of ondansetron (Ranjbar et al., 2018). Theoretical Framework The Iowa Model of Evidence-Based Practice to Promote Quality Care served as the theoretical framework for this project (see Appendix A). This model focuses on identifying clinical need and translating evidence-based research into clinical practices. When analyzing this model, it was identified that underutilization of intravenous Zofran is the clinical problem addressed. The literature review identified the well documented research behind the use of Zofran before spinal anesthesia. The model suggests that if sufficient research is available in favor of the practice change, then the introduction of practice change should be pursued. This theoretical framework is relevant to this project as it proposed an educational intervention to increase the administration of an intravenous 5-HT3 antagonist before spinal anesthesia to help reduce or prevent spinal hypotension and vasopressor use in cesarean sections as demonstrated in current literature. Project Aims and Objectives The overall goal of this project was to implement an educational intervention based on current evidence-based practices to increase the knowledge and willingness to implement IV Zofran before performing spinal anesthesia in elective cesarean sections. In turn, this will reduce a myriad of problems that are commonly associated with spinal anesthesia during cesarean sections such as bradycardia, hypotension, and fetal compromise (Aksoy et al., 2021). The education intervention included certified registered nurse anesthetists (CRNA) who commonly perform elective cesarean sections. The main objectives were to first assess the basic knowledge ONDANSETRON AND SPINAL ANESTHESIA 11 of anesthesia providers and their current practices regarding spinal anesthesia in cesarean sections. A lack of knowledge of the benefits of IV Zofran contributes to decreased administration and decreased compliance. After a baseline knowledge was established, an educational intervention was implemented, and a post-educational questionnaire expectantly improved provider knowledge and increase provider willingness to perform spinal anesthesia after a 5-HT3 antagonist. Project Design/Methods This project was best suited for an educational intervention. Educational interventions have been shown to significantly improve health care workers knowledge, skills, and understanding of key concepts when compared to other interventions (Cusack et al., 2018). Since the objective of this study was to increase the understanding and utilization of a 5-HT3 antagonist before spinal anesthesia, an educational intervention will expectantly improve this outcome. An online educational opportunity was created using evidence-based research to promote best practice guidelines. A pre-test established a baseline in Zofran (or any other 5-HT3 antagonist) utilization, knowledge on the pharmacology of these drugs, as well as any hesitations or concerns on the effectiveness of Zofran before a spinal anesthetic. A PowerPoint presentation was then used to provide education and a post-test determined the effectiveness of the educational intervention on knowledge, as well as willingness to include a 5-HT3 antagonist before a spinal anesthetic in cesarean sections. Project site and population The project was implemented online via email to anesthesia providers employed within a large, metropolitan hospital with over 320 staffed hospital beds. This inner-city hospital has the ONDANSETRON AND SPINAL ANESTHESIA 12 largest number of births per year in Indiana from the years 2014-2020, with a yearly average of about 4,000 births (Community Health Network, 2020). Anesthesia providers, including certified registered nurse anesthetists (CRNA) employed at this hospital will be invited to participate in this project. Methods This project was created with the aid of Qualtrics and PowerPoint. First, a list of all active anesthesia providers was obtained by the current chief of anesthesia at the project site. Next, a self-created pre-educational questionnaire was created. It was composed of 12 questions to determine demographics, current anesthetic practices, basic knowledge of Zofran, willingness to give a 5-HT3 antagonist before spinal anesthesia, and personal hesitations on giving a 5-HT3 antagonist before spinal anesthesia (see appendix C). Next, a PowerPoint presentation was responsible for the available education. The PowerPoint included detailed information about the use of a 5-HT3 antagonist (Zofran) in spinal anesthetics for cesarean sections, basic pharmacology of Zofran, synopsis of the review of literature explained above, and benefits of administering Zofran before a spinal. Lastly, a self-created post-educational questionnaire was included. The questionnaire focused on increased knowledge and willingness to include Zofran in future anesthetic practices. It was composed of five questions that matched the pre-educational questionnaire exactly (see appendix D). Both the pre- and post-educational questionnaire were validated via Marian faculty and CRNAs. Both the pre- and post-educational questionnaires were included in a composed email as links to the Qualtrics website. The questionnaires were by invitation only and were only allowed to be taken once per participant. The PowerPoint presentation was also included as an ONDANSETRON AND SPINAL ANESTHESIA 13 attachment. The steps were listed in numerical for easy completion. The project materials remained available for two and a half weeks and a reminder email was sent halfway through the allotted time. After closing of the project, a statistical analysis was performed to determine the effectiveness of the educational intervention and willingness to include a 5-HT3 antagonist into personal spinal anesthesia practices. A Likert Scale was used for majority of the questions asked during both surveys to establish strength of an attitude in linear fashion. The questionnaires were anonymous, and participation was voluntary. Data Collection and Analysis The data collected by the pre-and post-educational questionnaire was transferred into a Microsoft Excel spreadsheet. Confidence was analyzed using SPSS software. The Wilcoxon test was best suited to determine if willingness and awareness to changed anesthetic practices as hypothesized. Ethical Considerations Internal Review Board (IRB) approval was obtained prior to initiating this DNP project. Both the project site IRB board and Marian University IRB board approval was obtained. Minimal risk was identified for participation in this study since it does not contain vulnerable or special populations, patient information or involvement, or will pose any threat on mental or physical health of its participants. Data obtained during this project was stored on a password protected computer and was not directly shared. Furthermore, personal identifiers were not used in this project which will protect anonymity. The consent process gave the participant information about the study and what will be required of them before consent is obtained. Participants will be allowed to stop the study at any time. ONDANSETRON AND SPINAL ANESTHESIA 14 Data Analysis and Results The educational opportunity was sent to 25 anesthesia providers with eight responses, making it a 32% completion rate. The amount of anesthesia experience ranged from two years to greater than 20 years with five providers having between 5- and 20-years experience. 50% of the anesthesia providers responded they performed spinal anesthesia for elective cesarean sections almost always while 25% performs often and 25% performs sometimes. Of these responses, over 62% of providers witness the hemodynamic changes associated with spinal anesthesia sometimes while 37% witness them often. Furthermore, over 87% of the providers state they must administer vasopressor medications, such as phenylephrine or ephedrine to help correct the hemodynamic effects of spinal anesthesia often and almost always. Nausea and vomiting are another untoward side effect that is commonly associated with the dramatic drops in blood pressure during spinal anesthesia. The results showed that 100% of these anesthesia providers have witnessed some form of this during their clinical practices. Fortunately, 75% of the selected anesthesia providers were previously aware of the benefits a 5-HT3 antagonist has to offer before spinal anesthesia while 75% of participants almost always give Zofran or another 5-HT3 antagonist before performing them. 62% of responses from the pre-educational questionnaire shows participants are extremely willing to include a 5-HT3 antagonist into their anesthetic practices, while 12% state they are somewhat willing, 12% state they are neither willing or unwilling and 12% state they are extremely unwilling. This compares to the post-educational questionnaire responses of 87% are extremely willing, and 12% are extremely unwilling to adopt a 5-HT3 antagonist into their anesthetic ONDANSETRON AND SPINAL ANESTHESIA 15 practices. Utilizing the Wilcoxon test to analyze these results, a significance in the preeducational and post-education questionnaire, a significant difference was not found (p>0.05). The pre-educational also included a free text answer asking for any concerns to giving Zofran before performing a spinal anesthetic, 7 responses stated none while one response considered based on patients history. The post-educational questionnaire all contained the response of none. When comparing the knowledge questions from the pre- and post-educational questionnaire, the question of Which hemodynamic changes are the most prominent in spinal anesthesia?, had a 75% correct response rate and 25% incorrect response rate before implementing the educational PowerPoint. The same question was asked after reviewing the PowerPoint and received a 100% correct response rate. Furthermore, the question Which reflex is commonly activated during spinal anesthesia that may contribute to hypotension and bradycardia?, and What is the most common sign and symptom of hypotension during cesarean sections?, both had an 87% correct response rate on the pre-educational questionnaire and a 100% correct response rate on the post-educational questionnaire. Comparing the means of the two samples, a paired t-test was utilized and was a significant difference was found (p<0.05). ONDANSETRON AND SPINAL ANESTHESIA 16 Figure 1: Mean knowledge scores of pre-educational questionnaire and post-educational questionnaire Figure 2: Post-educational questionnaire responses on willingness Discussion The results shown highlight the impact an educational intervention has on knowledge and learning. When comparing the answers to the pre-educational knowledge questions, the posteducational knowledge questions had significantly improved. Determining the educational intervention was effective by increasing knowledge. However, since most anesthesia providers answered they were already extremely willing or somewhat willing to adopt a 5-HT3 antagonist into their anesthetic practices before the educational PowerPoint was reviewed, the posteducational results on willingness was not shown to be significant. The strengths of the study predominantly included easy accessibility. Participants were able to access the questionnaires and educational PowerPoint from anywhere of their choosing. Participation in this study was also done at the participants convenience. The directions to complete the study were organized and listed in numerical fashion to limit any confusion. The information presented was evidence-based research and relevant to the chosen group of participants. ONDANSETRON AND SPINAL ANESTHESIA 17 Limitations of this study primarily consisted of the size of the study sample. Although 25 participants were invited to participate in this study, only eight participated. This small of a sample size may not reflect accurately on the overall effectiveness the study had to offer. However, the SPSS tests chosen to represent the data was created to take small sample sizes into account. Another limitation to this study is a sample bias. Although the study was created to include both CRNAs and anesthesiologists, the group of anesthesia providers at the chosen practice site consisted of only CRNAs and were therefore the only anesthesia providers to be included in this project. Lastly, the two-week timeframe to complete the project may have been another limiting factor in the project participation. Conclusion Spinal anesthesia, the gold standard of practice for elective cesarean sections commonly produces unpleasant and troublesome side effects, including hypotension and bradycardia. This can trigger detrimental effects on both the mother and baby if left untreated or inappropriately managed. Evidence-based research has recently shown that utilizing a 5-HT3 antagonist such as Zofran, can help to attenuate these effects, decrease vasopressor consumption, and limit the nausea and vomiting caused by hypotension. The implementation of an educational intervention to increase willingness and education of a 5-HT3 antagonist before spinal anesthesia in elective cesarean sections was explored. Future studies should consider finding a project site that includes both CRNAs and anesthesiologists, as well as either increasing the allotted time to complete the project or consider an in-person intervention in hopes to increase participation. Additionally, exploration of how anesthetic practices have changed since the adoption of this educational intervention may be beneficial. ONDANSETRON AND SPINAL ANESTHESIA 18 References Aksoy, M., Dostbil, A., Aksoy, A., Ince, I., Bedir, Z., & Ozmen, O. (2021). Granisetron or ondansentron to prevent hypotension after spinal anesthesia for elective cesarean delivery: A randomized placebo-controlled trial. Journal of Clinical Anesthesia, 75, 110469. https://doi.org/10.1016/j.jclinane.2021.110469 Alghanem, S., Samarah, W., Bsisu, I., Rahman, Z., Guzu, H., & Abufares, B. (2020). The effect of ondansetron administration 20 minutes prior to spinal anaesthesia on haemodynamic status in patients undergoing elective caesarean section: A comparison between two different doses. Indian Journal of Anaesthesia, 64(11), 954. https://doi.org/10.4103/ija.ija_974_19 Chatterjee, A., Gudiwada, B., Mahanty, P., Kumar, H., Nag, D., Ganguly, P., & Shukla, R. (2020). Effectiveness of granisetron in prevention of hypotension following spinal anaesthesia in patients undergoing elective caesarean section. Cureus. https://doi.org/10.7759/cureus.12113 Community Health Network. (2020). We deliver more than you're expecting. https://www.ecommunity.com/northbabies Cusack, L., Del Mar, C. B., Chalmers, I., Gibson, E., & Hoffmann, T. C. (2018). Educational interventions to improve peoples understanding of key concepts in assessing the effects of health interventions: A systematic review. Systematic Reviews, 7(1). https://doi.org/10.1186/s13643-018-0719-4 El Khouly, N. I., & Meligy, A. M. (2016). Randomized controlled trial comparing ondansetron and placebo for the reduction of spinal anesthesia-induced hypotension during elective ONDANSETRON AND SPINAL ANESTHESIA 19 cesarean delivery in egypt. International Journal of Gynecology & Obstetrics, 135(2), 205209. https://doi.org/10.1016/j.ijgo.2016.06.012 Karacaer, F., Biricik, E., nal, ., Bykkurt, S., & nlgen, H. (2017). Does prophylactic ondansetron reduce norepinephrine consumption in patients undergoing cesarean section with spinal anesthesia? Journal of Anesthesia, 32(1), 9097. https://doi.org/10.1007/s00540-017-2436-x Marciniak, A., Owczuk, R., Wujtewicz, M., Preis, K., & Majdyo, K. (2015). The influence of intravenous ondansetron on maternal blood haemodynamics after spinal anaesthesia for caesarean section: A double-blind, placebo-controlled study. Polish Gynaecology, 86(6), 461467. https://doi.org/10.17772/gp/2405 Marx, G. (1994). The first spinal anesthesia-Who deserves the laurels? Regional Anesthesia, 19(6), 429430. https://doi.org/https://oce.ovid.com/article/00002370-19941906000013/HTML Nagelhout, J., & Elisha, S. (2018). Nurse anesthesia (6th ed.). Elsevier. Neumann, C., Velten, M., Heik-Guth, C., Strizek, B., Wittmann, M., Hilbert, T., & Klaschik, S. (2020). 5-ht3 blockade does not attenuate postspinal blood pressure change in cesarean section. Medicine, 99(36), e21864. https://doi.org/10.1097/md.0000000000021864 Nivatpumin, P., & Thamvittayakul, V. (2016). Ephedrine versus ondansetron in the prevention of hypotension during cesarean delivery: A randomized, double-blind, placebo-controlled trial. International Journal of Obstetric Anesthesia, 27, 2531. https://doi.org/10.1016/j.ijoa.2016.02.003 Oofuvong, M., Kunapaisal, T., Karnjanawanichkul, O., Dilokrattanaphijit, N., & Leeratiwong, J. (2018). Minimal effective weight-based dosing of ondansetron to reduce hypotension in ONDANSETRON AND SPINAL ANESTHESIA 20 cesarean section under spinal anesthesia: A randomized controlled superiority trial. BMC Anesthesiology, 18(1). https://doi.org/10.1186/s12871-018-0568-7 Ortiz-Gmez, J., Palacio-Abizanda, F., Morillas-Ramirez, F., Fornet-Ruiz, I., Lorenzo-Jimnez, A., & Bermejo-Albares, M. (2014). The effect of intravenous ondansetron on maternal haemodynamics during elective caesarean delivery under spinal anaesthesia: A doubleblind, randomised, placebo-controlled trial. International Journal of Obstetric Anesthesia, 23(2), 138143. https://doi.org/10.1016/j.ijoa.2014.01.005 Ortiz-Gomez, J., Palacio-Abizanda, F., Morillas-Ramirez, F., Fornet-Ruiz, I., Lorenzo-Jimnez, A., & Bermejo-Albares, M. (2017). Reducing by 50% the incidence of maternal hypotension during elective caesarean delivery under spinal anesthesia: Effect of prophylactic ondansetron and/or continuous infusion of phenylephrine - a double-blind, randomized, placebo controlled trial. Saudi Journal of Anaesthesia, 11(4), 408. https://doi.org/10.4103/sja.sja_237_17 Phipps, L. (2016). Reducing hypotension in elective cesarean section patients with administration of ondansetron prior to spinal anesthesia: A retrospective chart analysis. [Doctoral dissertation]. CINAHL. Qian, J., Liu, L., Zheng, X., & Xiao, F. (2020). Does an earlier or late intravenous injection of ondansetron affect the dose of phenylephrine needed to prevent spinal-anesthesia induced hypotension in cesarean sections? Drug Design, Development and Therapy, Volume 14, 27892795. https://doi.org/10.2147/dddt.s257880 Ranjbar, M., Sheybani, S., & Jahanbin, F. (2018). Prophylactic effects of ephedrine, ondansetron and ringer on hemodynamic changes during cesarean section under spinal anesthesia a ONDANSETRON AND SPINAL ANESTHESIA 21 randomized clinical trial. Ginekologia Polska, 89(8), 454459. https://doi.org/10.5603/gp.a2018.0078 klebar, I. (2019). Spinal anaesthesia-induced hypotension in obstetrics: Prevention and therapy. Acta Clinica Croatica. https://doi.org/10.20471/acc.2019.58.s1.13 Stewart, J., Gasanova, I., & Joshi, G. P. (2020). Spinal anesthesia for ambulatory surgery: Current controversies and concerns. Current Opinion in Anaesthesiology, 33(6), 746 752. https://doi.org/10.1097/aco.0000000000000924 Tatikonda, C., Rajappa, G., Rath, P., Abbas, M., Madhapura, V., & Gopal, N. (2019). Effect of intravenous ondansetron on spinal anesthesia-induced hypotension and bradycardia: A randomized controlled double-blinded study. Anesthesia: Essays and Researches, 13(2), 340. https://doi.org/10.4103/aer.aer_22_19 Terkawi, A. S., Tiouririne, M., Mehta, S. H., Hackworth, J. M., Tsang, S., & Durieux, M. E. (2015). Ondansetron does not attenuate hemodynamic changes in patients undergoing elective cesarean delivery using subarachnoid anesthesia. Regional Anesthesia and Pain Medicine, 40(4), 344348. https://doi.org/10.1097/aap.0000000000000274 Wang, Q., Zhuo, L., Shen, M.-K., Yu, Y.-Y., Yu, J.-J., & Wang, M. (2014). Ondansetron preloading with crystalloid infusion reduces maternal hypotension during cesarean delivery. American Journal of Perinatology, 31(10), 913922. https://doi.org/10.1055/s0033-1364189 Xiao, F., Wei, C., Chang, X., Zhang, Y., Xue, L., Shen, H., Ngan Kee, W. D., & Chen, X. (2019). A prospective, randomized, double-blinded study of the effect of intravenous ondansetron on the effective dose in 50% of subjects of prophylactic phenylephrine infusions for preventing spinal anesthesiainduced hypotension during cesarean delivery. ONDANSETRON AND SPINAL ANESTHESIA Anesthesia & Analgesia, 131(2), 564569. https://doi.org/10.1213/ane.0000000000004534 22 ONDANSETRON AND SPINAL ANESTHESIA 23 Appendix A: Iowa Model of Evidence-Based Practice to Promote Quality Care Used/reprinted with permission from the University of Iowa Hospitals and Clinics, copyright 2015. For permission to use or reproduce, please contact the University of Iowa Hospitals and Clinics at 319-384-9098. ONDANSETRON AND SPINAL ANESTHESIA 24 Appendix B: Literature Review Matrix Citation Research Design & Level of Evidence Population / Sample size n=x Major Variables Instruments / Data collection Results Aksoy, M., Dostbil, A., Aksoy, A., Ince, I., Bedir, Z., & Ozmen, O. (2021). Granisetron or ondansentron to prevent hypotension after spinal anesthesia for elective cesarean delivery: A randomized placebocontrolled trial. Journal of Clinical Anesthesia, 75, 110469. Chatterjee, A., Gudiwada, B., Mahanty, P., Kumar, H., Nag, D., Ganguly, P., & Shukla, R. (2020). Effectiveness of granisetron in prevention of hypotension following spinal anaesthesia in patients undergoing elective caesarean section. Cureus. Randomized Controlled Trial, level 2 N=120 Hypotension, vasopressor requirements, nausea and vomiting, APGAR scores Mean blood pressure, VAS scores, APGAR scores 1 and 5 minutes after birth Both 3mg of granisetron and 8mg of Ondansetron before spinal anesthesia produced significantly lower ephedrine requirements compared to the placebo. Randomized controlled trial, level 2 N=200 Vital parameters including systolic, diastolic and MAP, HR, and SpO2, incidence of hypotension, APGAR scores Fall in the systolic arterial blood pressure below 100mmHg or a fall in mean arterial blood pressure of more than 20% from baseline value was taken as hypotension, vital signs, APGAR Normal saline group had 69% hypotension while granisetron group had 37% and NS group required more mephentermine. APGAR scores were comparable between the two groups. Alghanem, S., Samarah, W., Bsisu, I., Rahman, Z., Guzu, H., & Abufares, B. (2020). The effect of ondansetron administration 20 minutes prior to spinal anaesthesia on haemodynamic status in patients undergoing elective caesarean section: A comparison between Randomized controlled trial, level 2 N=152 Systolic blood pressure, diastolic blood pressure, MAP Systolic, diastolic, MAP No significant difference among blood pressure changes in all groups, however, ephedrine requirements is higher in the normal saline group. 40=8mg Zofran 40=3mg granisetron 40=normal saline 100=normal saline 100=1mg granisetron 51=4mg Zofran 51=8mg Zofran 50=Normal Saline ONDANSETRON AND SPINAL ANESTHESIA two different doses. Indian Journal of Anaesthesia, 64(11), 954. Neumann, C., Velten, M., Heik-Guth, C., Strizek, B., Wittmann, M., Hilbert, T., & Klaschik, S. (2020). 5ht3 blockade does not attenuate postspinal blood pressure change in cesarean section. Medicine, 99(36), e21864 Xiao, F., Wei, C., Chang, X., Zhang, Y., Xue, L., Shen, H., Ngan Kee, W. D., & Chen, X. (2019). A prospective, randomized, double-blinded study of the effect of intravenous ondansetron on the effective dose in 50% of subjects of prophylactic phenylephrine infusions for preventing spinal anesthesiainduced hypotension during cesarean delivery. Anesthesia & Analgesia, 131(2), 564569. Qian, J., Liu, L., Zheng, X., & Xiao, F. (2020). Does an earlier or late intravenous injection of ondansetron affect the dose of phenylephrine needed to prevent spinalanesthesia induced hypotension in cesarean sections? Drug Design, Development and Therapy, Volume 14, 27892795 Retrospective chart study, level 3 N=160 Randomized controlled trial, level 2 N=60 Randomized controlled trial, level 2 N=75 80=8mg Zofran 80=normal saline 30=Normal saline 30=4mg Zofran 25=Ondansetron given 5 min before spinal 25=Ondansetron given 15 min before spinal 25=Normal saline 25 Blood pressure, heart rate, vasopressor use, fluid intake, maternal and infantile outcomes Vital signs, vasopressor administration, crystalloid fluid, APGAR, cord blood pH, base excess 8 mg Zofran does not effectively attenuate post spinal change in maternal blood pressure during cesarean section Phenylephrine infusion rate, hypotension, hypertension, heart rate, fetal outcomes, N&V, shivering ED50 of phenylephrine infusion, vital signs, APGAR scores, arterial umbilical blood pH Intravenous ondansetron 4 mg reduced the ED50 of a prophylactic phenylephrine infusion by approximately 26% in patients undergoing cesarean delivery under combined spinal-epidural anesthesia. Blood pressure, heart rate, phenylephrine infusion rates Systolic, diastolic, MAP, heart rate, phenylephrine infusion Earlier administration of 4 mg prophylactic ondansetron contributed no benefits for lowing the dose of prophylactic phenylephrine compared to a late administration but can decrease the dose of preventing phenylephrine in patients undergoing cesarean sections. ONDANSETRON AND SPINAL ANESTHESIA Tatikonda, C., Rajappa, G., Rath, P., Abbas, M., Madhapura, V., & Gopal, N. (2019). Effect of intravenous ondansetron on spinal anesthesiainduced hypotension and bradycardia: A randomized controlled double-blinded study. Anesthesia: Essays and Researches, 13(2), 340. Ortiz-Gomez, J., PalacioAbizanda, F., MorillasRamirez, F., Fornet-Ruiz, I., Lorenzo-Jimnez, A., & Bermejo-Albares, M. (2017). Reducing by 50% the incidence of maternal hypotension during elective caesarean delivery under spinal anesthesia: Effect of prophylactic ondansetron and/or continuous infusion of phenylephrine - a double-blind, randomized, placebo controlled trial. Saudi Journal of Anaesthesia, 11(4), 408. Oofuvong, M., Kunapaisal, T., Karnjanawanichkul, O., Dilokrattanaphijit, N., & Leeratiwong, J. (2018). Minimal effective weightbased dosing of ondansetron to reduce hypotension in cesarean section under spinal anesthesia: A randomized controlled superiority trial. BMC Anesthesiology, 18(1). Randomized controlled trial, level 2 N=140 Randomized controlled trial, level 2 Randomized controlled trial, level 2 26 Blood pressure, heart rate, shivering Systolic, diastolic, MAP, shivering, ephedrine requirements, atropine requirements Prophylactic use of ondansetron before spinal anesthesia significantly reduces the requirement of ephedrine and shivering N=265 4 random groups not specified. Normal saline, 8 ondansetron , phenylephrine infusion, 8mg ondansetron and phenylephrine Blood pressure, heart rate, adverse events, vasopressor requirements, atropine Vital signs, presence of N&V and pruritis, atropine requirements, ephedrine requirements, phenylephrine requirements. A 50 g/min phenylephrine infusion reduces by 50% the incidence of maternal hypotension compared with placebo. Prophylactic ondansetron 8 mg does not reduce the incidence of maternal hypotension but diminishes its severity, reducing the number of hypotensive events per patient by 50%. N=215 Vital signs, vasopressor use, adverse events Blood pressure, heart rate, ephedrine requirements, metoclopramide requirements Ondansetron 0.05 mg/kg or 0.1 mg/kg administered before spinal anesthesia did not reduce the incidence of hypotension. Metoclopramide requirements were lower in 0.1mg/kg group compared to control. 70=4mg ondansetron 70=Normal saline 72=normal saline 71=Zofran 0.05mg/kg 72=0.1mg/kg Zofran ONDANSETRON AND SPINAL ANESTHESIA Karacaer, F., Biricik, E., nal, ., Bykkurt, S., & nlgen, H. (2017). Does prophylactic ondansetron reduce norepinephrine consumption in patients undergoing cesarean section with spinal anesthesia? Journal of Anesthesia, 32(1), 9097. Ranjbar, M., Sheybani, S., & Jahanbin, F. (2018). Prophylactic effects of ephedrine, ondansetron and ringer on hemodynamic changes during cesarean section under spinal anesthesia a randomized clinical trial. Ginekologia Polska, 89(8), 454459. El Khouly, N. I., & Meligy, A. M. (2016). Randomized controlled trial comparing ondansetron and placebo for the reduction of spinal anesthesia-induced hypotension during elective cesarean delivery in egypt. International Journal of Gynecology & Obstetrics, 135(2), 205 209. Nivatpumin, P., & Thamvittayakul, V. (2016). Ephedrine versus ondansetron in the prevention of hypotension during cesarean delivery: A randomized, doubleblind, placebo-controlled trial. International Journal Randomized controlled trial, level 2 N=108 Randomized controlled trial, level 2 N=90 Randomized controlled trial, level 2 N=100 Randomized controlled trial, level 2 N=168 54=8mg ondansetron 54=normal saline 30=4mg ondansetron 30=lactated ringer 30=25mg IM Ephedrine 50=4mg ondansetron 50=normal saline 56=10mg IV Ephedrine 56=8mg ondansetron 56=normal saline 27 Hypotensive episodes, adverse events, norepinephrine consumption Systolic, diastolic, MAP, heart rate, spO2, episodes of hypotension, norepinephrine consumption, nausea & vomiting, episodes of bradycardia 8mg Zofran 5 minutes before spinal anesthesia did not prevent spinal-induced hypotension, however, cumulative episodes of hypotension and norepinephrine consumption were significantly greater in normal saline group (p=0.009). Hypotension, bradycardia, N&V, shivering Systolic, diastolic, MAP, heart rate, incidence of bradycardia and hypotension, nausea and vomiting, shivering. IM Ephedrine 25 minutes prior to spinal anesthesia led to best prevention of systolic blood pressure changes Hypotension, bradycardia, adverse events Systolic, diastolic, MAP, N&V, Heart rate, ephedrine use, atropine use, shivering IV ondansetron significantly reduced hypotension and fluctuations in heart rate. Nausea and vomiting were also reduced. Blood pressure, N&V, APGAR, intraoperative vasopressor use Systolic, diastolic, MAP, incidence of N&V, vasopressor use, APGAR scores, No significant difference in maternal blood pressure, however, 8mg ondansetron group required less norepinephrine use than normal saline group. ONDANSETRON AND SPINAL ANESTHESIA of Obstetric Anesthesia, 27, 2531. Marciniak, A., Owczuk, R., Wujtewicz, M., Preis, K., & Majdyo, K. (2015). The influence of intravenous ondansetron on maternal blood haemodynamics after spinal anaesthesia for caesarean section: A double-blind, placebocontrolled study. Polish Gynaecology, 86(6), 461 467. Wang, Q., Zhuo, L., Shen, M.-K., Yu, Y.-Y., Yu, J.J., & Wang, M. (2014). Ondansetron preloading with crystalloid infusion reduces maternal hypotension during cesarean delivery. American Journal of Perinatology, 31(10), 913922. Terkawi, A. S., Tiouririne, M., Mehta, S. H., Hackworth, J. M., Tsang, S., & Durieux, M. E. (2015). Ondansetron does not attenuate hemodynamic changes in patients undergoing elective cesarean delivery using subarachnoid anesthesia. Regional Anesthesia and Pain Medicine, 40(4), 344348. Phipps, L. (2016). Reducing hypotension in elective cesarean section patients with administration of Randomized controlled trial, level 2 N=72 Randomized controlled trial, level 2 N=66 Randomized controlled trial, level 2 N=86 Retrospective study, level 3 N=114 28 Blood pressure, heart rate Systolic, diastolic, heart rate There was not a significant reduction in blood pressure changes. Blood pressure, heart rate, umbilical cord blood samples Systolic, MA, episodes of hypotension, incidence of nausea, umbilical venous pH, phenylephrine use Ondansetron preloading combined with crystalloid infusion significantly reduced hypotension and nausea, improved acidbase status, and reduced vasopressor use. Vital signs, N&V, pruritis, vasopressors. Systolic, diastolic, MAP, heart rate, episodes of nausea and vomiting, episodes of pruritis, phenylephrine use Ondansetron does not reduced hemodynamic changes before spinal anesthesia nor does it reduce incidence of nausea and vomiting, pruritis, or vasopressor consumption. Blood pressure, vasopressors. Systolic, diastolic, MAP, vasopressor use No significant difference with ondansetron administration, however, decreased use of vasopressor use to maintain blood pressure. 35=8mg ondansetron 34=normal saline 33=4mg ondansetron 33=normal saline 44=8mg ondansetron 42=placebo ONDANSETRON AND SPINAL ANESTHESIA ondansetron prior to spinal anesthesia: A retrospective chart analysis. [Doctoral dissertation]. CINAHL. 29 ONDANSETRON AND SPINAL ANESTHESIA 30 Appendix C: Pre-Educational Questionnaire 1. How long have you been an anesthesia provider? a. <1 year b. 1-5 years c. 5-20 years d. >20 years 2. How often do you perform spinal anesthesia for elective cesarean sections? a. Never b. Sometimes c. Often d. Almost always 3. How often do you give a 5-HT3 antagonist, such as Zofran, before your spinal anesthetic in cesarean sections? a. Never b. Sometimes c. Often d. Almost always 4. How often do you witness hemodynamic changes associated with spinal anesthesia in cesarean sections? a. Never b. Sometimes c. Often d. Always 5. Which hemodynamic changes are the most prominent in spinal anesthesia? Select TWO a. Hypertension b. Increased SNS tone c. Hypotension d. Bradycardia e. Tachycardia 6. Which reflex is commonly activated during spinal anesthesia that may contribute to hypotension and bradycardia? a. Bainbridge reflex b. Celiac reflex c. Baroreceptor reflex d. Bezold-Jarisch reflex e. Vagal response ONDANSETRON AND SPINAL ANESTHESIA 7. What is the most common sign and symptom of hypotension during cesarean sections? a. Irritability b. Pain c. Unconsciousness d. Nausea and vomiting 8. How often do you give a vasopressor, such as phenylephrine or ephedrine, after performing spinal anesthesia in a cesarean section? a. Never b. Sometimes c. Often d. Always 9. How often do you witness nausea and vomiting associated with spinal-induced hypotension? a. Never b. Sometimes c. Often d. Always 10. Are you aware of the benefits a 5-HT3 antagonist, such as Zofran, may offer before performing a spinal anesthetic in cesarean sections? a. Yes b. No 11. How willing are you to include a 5-HT3 antagonist, such as Zofran, as part of your anesthetic before spinal anesthesia in cesarean sections? (1) Extremely unwilling (2) Somewhat unwilling (3) Neither willing or unwilling (4) Somewhat willing (5) Extremely willing. a. 1 b. 2 c. 3 d. 4 e. 5 12. What is a hesitation, if any, of giving Zofran prior to performing a spinal? 31 ONDANSETRON AND SPINAL ANESTHESIA 32 Appendix D: Post-Educational Questionnaire 1. Which hemodynamic changes are the most prominent in spinal anesthesia? Select TWO a. Hypertension b. Increased SNS tone c. Hypotension d. Bradycardia e. Tachycardia 2. Which reflex is commonly activated during spinal anesthesia that may contribute to hypotension and bradycardia? a. Bainbridge reflex b. Celiac reflex c. Baroreceptor reflex d. Bezold-Jarisch reflex e. Vagal response 3. What is the most common sign and symptom of hypotension during cesarean sections? a. Irritability b. Pain c. Unconsciousness d. Nausea and vomiting 4. Are you aware of the benefits a 5-HT3 antagonist, such as Zofran, may offer before performing a spinal anesthetic in cesarean sections? a. Yes b. No 5. How willing are you to include a 5-HT3 antagonist, such as Zofran, as part of your anesthetic before spinal anesthesia in cesarean sections? (1) Extremely unwilling (2) Somewhat unwilling (3) Neither willing or unwilling (4) Somewhat willing (5) Extremely willing. a. 1 b. 2 c. 3 d. 4 e. 5 6. What is a hesitation, if any, of giving Zofran prior to performing a spinal? ONDANSETRON AND SPINAL ANESTHESIA Appendix E: Community Health Network IRB Approval Letter 33 ONDANSETRON AND SPINAL ANESTHESIA Appendix F: Marian University IRB Approval Letter 34  ...

... SUICIDE PREVENTION FOR SRNAs Date of Submission: 3/17/23 1 SUICIDE PREVENTION FOR SRNAs 2 Table of Contents Abstract....4 Introduction..5 Background..... 6 Problem Statement...8 Organizational Gap Analysis of Project Site.9 Review of the Literature.....10 Theoretical Framework..16 Goals/Objectives18 SWOT analysis.......19 Project Design/Methods.20 Project Site and Population.20 Measurement Instrument(s)...22 Data Collection......22 Ethical Considerations/Protection of Human Subjects...23 Data Analysis.23 Results....27 Discussion..35 Conclusion.37 References..38 Appendix A - Prisma..42 Appendix B - Literature matrix...43 Appendix C - Theory framework50 SUICIDE PREVENTION FOR SRNAs 3 Appendix D - Swot.51 Appendix E - Letter of site approval...52 Appendix F Measurement tools...53 Appendix G - IRB Approval letter..56 Appendix H - CITI Certificate57 SUICIDE PREVENTION FOR SRNAs 4 Correlation of Increased Stress with Depression and Suicidal Thoughts Experienced by Student Registered Nurse Anesthetists (SRNAs) Abstract This DNP projects significance is to help SRNAs self-recognize psychological and physical manifestations of negative stress, manifested as anxiety, depression, and suicidal thoughts during anesthesia training. The objective is to supply education to promote mental health awareness and resilience, overcome mental health stigma, screen SRNAs for early signs of depression and anxiety, and identify students at risk. SRNAs have displayed an increased risk for depression and suicidal thoughts due to additional stressors stemming from the program, including a lack of a paycheck. Other factors exacerbating the issue are exhaustion, despair, and substance abuse which can steer students to a mental health crisis. The population selected includes all SRNAs currently enrolled in the program (n=88). Educational information to promote wellness and tools for students to reach out for help if necessary was provided via Canvas. Qualtrics software was used to disseminate and collect data. The data consisted of 3 anonymous surveys that included the GAD-7, PHQ-9, and an additional survey of general questions based on the students perceptions of their mental health status. Students participation was voluntary and anonymous. Students received instructions on interpreting their survey results and information to follow up with counseling if needed. Utilizing qualitative statistical analysis, the GAD-7 showed 23.3% of students with severe anxiety. The PHQ-9 identified 14% with severe depression; 11% stated having thoughts of quitting, and 11.6% reported having suicidal thoughts during the anesthesia program. The parameters estimated on the regression model test confirmed that when depression, anxiety, and high levels of stress were combined significantly contributed to the outcome variable SUICIDE PREVENTION FOR SRNAs 5 of suicidality. There is an increased need to incorporate a systematic protocol to screen students for early signs of depression, anxiety, and burnout. Nurse anesthesia programs must find ways to accelerate interventional efforts to help decrease and manage distress among students and build an atmosphere that restores resilience and well-being to the students. Keywords: suicide prevention, nurse anesthesia students, depression, suicide and nurses, suicide ideation and graduate students, suicide ideation, suicide prevention program for nurses, suicide awareness. Introduction Stress is an inevitable response from our bodies to different reactions. Positive stress is the healthy way to cope with environmental stressors; negative stress or distress is the one we will want to avoid or prevent. Anesthesia training is very competitive and challenging to complete. SRNAs are described as having a substantial percentage of depression compared to non-student individuals with similar characteristics (Hoying et al., 2020). Stress has been linked to many physical manifestations, such as high blood pressure, heart disease, headaches, digestive problems, and weakened immune systems. Some psychological manifestations include irritability, sadness, anxiety, depression, and suicidal thoughts. If we integrate ways to increase awareness, screening, and referrals as interventions, suicide may be preventable. The standard should be to identify symptoms and behaviors of stress and provide the necessary tools to help students cope positively against the program's demands. The project's significance is to recognize those nurse anesthesia students who experience distress and suicidal thoughts and are at risk for depression. This project aims to provide an interactive screening risk SUICIDE PREVENTION FOR SRNAs 6 tool, evidence-based coping skills, stress-relieving activities, and educational information to promote mental health resilience and overall well-being among SRNAs. Background Researchers estimate that by the year 2030, depression will be the principal basis of illness. (Hoying et al., 2020). Currently, anxiety disorders are the most common psychological conditions in the United States, affecting 1 in 3 adults. Suicide is the second top cause of death among individuals ages 1534, with a calculated 9.3 million adults registering to have suicidal ideation last year alone (Hoying et al., 2020). The American Foundation for Suicide Prevention listed suicide as the 10th highest reason of death in the United States. Overall, 90% of all people who died were diagnosed or suffered from major depression (AFSP, 2022). Student registered nurse anesthetists (SRNAs) as well as CRNAs have reported high levels of depression and stress which can be a threat for suicide (Downs et al., 2014). Hoying et al., (2020) added that graduate students, especially nurse anesthesia students, are at unique chance for depression, anxiety, and mental health issues due to increased stress and burnout and the difficulty of their academic programs. As we know, nurse anesthesia training is inherently stressful, and SRNAs are compelled to display a heightened grade of resilience. Previous studies have revealed that high stress and anxiety can guide students to mental health crises; some factors include exhaustion, despair, substance misuse, and suicidal thoughts (Horvath & Grass, 2021). Universities may focus on having mental health and academic support services available to all students, lacking accessibility, receptiveness, and specificity for graduate students. This population of students is at an increased risk for depression and suicidal thoughts due to the added stressors from the program, work, family, children, and lack of a paycheck due to the majority of SUICIDE PREVENTION FOR SRNAs 7 SRNAs not working during the program. These external stressors, financial and social concerns increase the risk among nurse anesthesia students considerably. A study in 2014 screened a population of 34% students. Ultimately, 10 out of 13 who conversed with a therapist were not obtaining treatment, suggesting that the questionnaire recognized an elevated sample of untreated learners at-risk of committing suicide (Downs et al., 2014). A study revealed that almost 60% of health care students researched screened positive for depression, and almost 10% had suicidal thoughts in the last year (Hoying et al., 2020). Davidson et al (2018) pointed out in his study that students have access to drugs, increasing the capacity of overdose attempts coupled with school-related stress, long hours of study, absence of independence, social isolation, lateral violence, bullying, absence of positive feedback, and problems with work-life balance. A retrospective quantitative study done in 2021 obtained data from the CDC and the National Prevention Violent Death Reporting System (NPVDRS) concluded that a unique relationship between substance use and issues with mental health exists between students who completed a suicidal act versus the regular population (Choflet et al., 2021). A retrospective cohort study demonstrated the incidence of suicide among nurses compared to general population was significantly higher of 17.1 per 100,000 Vs 8.6 per 100,000. Clinicians were more likely to use antidepressants, benzodiazepines, barbiturates and opiates than regular population (Davis et al., 2021). Another study by (Chipas et al., 2012) uncovered that 47.3% (n=554) of SRNAs documented living with depression during school. 21.2% (n=245) reported suicidal thoughts. Comparing the means, they were statistically significant at the 99% confidence interval (stress vs depression: p < .05; stress vs suicidal thoughts: p < .01). The majority of the students (n=60, 6.3%) SUICIDE PREVENTION FOR SRNAs 8 reported knowing about someone who was at risk or achieved suicide during anesthesia training (Chipas et al., 2012). Problem Statement This analysis considers the prevalence of depression and suicidal thoughts in student nurse anesthesia programs. Some prominent factors include continuous exposure to a high-stress environment and the lack of students utilizing the university's current academic, spiritual, and mental health support services. Nurse anesthesia students should be screened for depression, anxiety, healthy habits, and the use of stress-relieving techniques regularly. Suppose universities screen for the risk of depression/suicidal ideation and provide educational information concerning mental health awareness. They would have current data to determine whether first-year students, second-years, or third-years SRNAs are more at risk. It is urgent to provide students with educational information to increase mental health awareness tailored to the specific needs of the nurse anesthesia students. This DNP project aims to increase awareness and identify students experiencing depression, anxiety, and suicidal thoughts. Also, to provide educational information to all SRNAs during their anesthesia training to increase awareness about how stress can profoundly affect mental health and what to do with it. The following PICOT question was formulated to guide the research in this project: By screening for risk of depression and suicidal ideation and providing educational information concerning mental health awareness can we determine whether first-years, second-years or third years are more at risk? SUICIDE PREVENTION FOR SRNAs 9 The approach utilized in this project consisted of 1) Provided educational information to increase mental health awareness and promote students' participation in stress-relieving techniques during their free time. 2) Screened students to determine depression, anxiety, and suicidal thoughts predictors. 3) Supplied students with instructions on evaluating their screening results and the steps to follow up for a referral. 4) Supplied tools to help foster mental health resilience, overcome mental health stigma, and increase overall well-being among SRNAs. Needs Assessment & Organizational Gap Analysis of Project Site A recognized area needs improvement at Marian University Nurse Anesthesia Graduate program specific to supporting SRNAs mental and physical well-being. Marian University does not currently provide a dedicated resource for nurse anesthesia students. The university's website outlines student support services for all undergraduate and graduate students. These services include mental, physical, academic, and spiritual health services. SRNAs are limited to accessing these benefits, considering their varied locations throughout campus and the little time-free SRNAs possess. These services are available in-person or online but often do not accommodate the hectic lifestyle of the nurse anesthesia student population. Some of these services require different bureaucracies, such as having students fill out forms and wait for appointments. All these hurdles take away the student's motivation to follow thru, leading to isolation and hopelessness. Every student received quarterly emails from student support services as a reminder to use these resources. The biggest issue is that there are no currently established guidelines from the department of student affairs to follow up with the students and their concerns. The nurse anesthesia program does not provide additional resources to explore the predominance of depression, suicidal thoughts, and healthy behaviors among SRNAs. This project plans to foster SUICIDE PREVENTION FOR SRNAs 10 SRNAs well-being by providing an interactive screening questionnaire to identify at-risk students and offer the necessary tools for referrals and knowledge to decrease suicide risk. A needs assessment can identify a gap between offered resources to help promote mental health, learning performance, and productivity and SRNAs not utilizing and benefiting from those resources leading to burnout, fatigue, increased stress, depression, and decreased academic performance. This project's goal is to help decrease this gap. Literature Review Mental health and a decline in well-being are significant problems for SRNAs. They are the subject of increased stress and anxiety levels during their doctoral program. Increased stress levels unravel a series of symptoms and dysfunctions that hinder students from developing their full potential. Unmanaged symptoms can lead to burnout, decreased motivation, depression, substance abuse, and suicidal ideation. According to Wang et al. (2021), the anesthesia specialty has scored exceptionally high compared to other medical specialties. Students suffer from sleep deprivation, high workload, school responsibilities, and lack of a salary during their anesthesia residency, making them vulnerable to burnout and depression. A literature search demonstrated that it is imperative to consistently work on prevention and screen anesthesia residents to measure their suicide risk while providing activities to help decrease stress and keep students motivated. Methods This literature search seeks research studies that identify graduate college health sciences students, SRNAs, and anesthesia residents that may be at risk of major depression and suicide. In this search, the studies selected intend to find the etiology of increased burnout, suicidal thoughts, and depression among graduate students, particularly anesthesia residents. The search does not SUICIDE PREVENTION FOR SRNAs 11 include treatment and evaluation of students who screened positive for mental health illness. Due to the limited studies, the search was extended to any article published between 2014 and 2022, peer-reviewed, written in English, expert opinions papers, and classified as primary sources studies. The search was conducted using different databases: CINAHL, PUBMED, and GOOGLE SCHOLAR. Under the CINAHL database, the search bar was used to type in Boolean phrases such as suicide prevention and nurse anesthesia students, depression and anesthesia residents, suicide and nurses, and suicide ideation and graduate students. The keywords used were SRNAs, and suicide prevention programs. Using the PUBMED database, Boolean phrases that were used: suicide prevention and nurse anesthesia students, suicide ideation and anesthesia students, depression and nurse anesthesia students, depression and anesthesia residents, suicide prevention and graduate students, and suicide and nurses. Keywords: suicide prevention program for nurses, and SRNAs. Similar articles from the previous search were also utilized. Employing GOOGLE SCHOLAR database Boolean phrases used: suicide prevention and nurse anesthesia students, suicide awareness and anesthesia residents, depression and health science graduate students. Similar articles from previous searches were used. There were 577 articles identified through database searching, and 12 articles were found through other sources, such as similar articles from previous searches. After duplicated items were removed, they were 552 articles. Records that met the primary screening were 89 articles. Fulltext articles assessed for eligibility were 21 articles. After inclusion/exclusion criteria was applied, only 12 articles met the criteria. Articles that compose the inclusion criteria were those studies that were relevant to the PICOT question and directed explicitly toward graduate health science students and anesthesia SUICIDE PREVENTION FOR SRNAs 12 residents. The exclusion criteria were defined as studies from secondary sources, literature reviews not suitable for the topic, anesthesiologists, CRNAs, and nurses. Other studies that met the exclusion criteria were studies with the intent to assess interventions for treatment, follow-ups, and evaluation of treatment to diagnose or cure a particular illness. This research search was conducted until March 2022. A PRISMA diagram of this search can be found in Appendix A. Research Samples Most of the studies in this literature review involved anesthesia residents, medical students, and graduate health students. Two studies focused on promoting awareness of depression and suicide among SRNAs (Horvarth & Grass, 2021; Melnyk et al., 2020). Few other studies involved anesthesia residents (Jaulin et al., 2021; Sun et al., 2019). Several articles involved medical students, including anesthesia students, who completed an online questionnaire (Davidson et al., 2018; Downs et al., 2014; Wang et al., 2021). Other researchers expanded their hypothesis to screen a more significant proportion of students, including health sciences undergraduates (Drum et al., 2017; Horwitz et al., 2020; Hoying et al., 2020; Rubanovich et al., 2022). Factors contributing to an increased risk of suicide behavior as a graduate student enrolled in an anesthesia program. All the studies in this review agreed that screening and counseling are the best ways to prevent suicidal behavior among students. According to Davidson et al. (2018), individuals not receiving previous treatment agreed to receive counseling and further treatment. Davidson et al. (2020) concluded that most participants who received a referral to seek treatment endorsed suicidality and benefited from preventive treatment. SUICIDE PREVENTION FOR SRNAs 13 Another study concluded that 10 out of 13 students who dialogued with a counselor mentioned receiving mental health assistance their first time, indicating the screening method identifies untreated, potentially suicidal students (Downs et al., 2014). Healthy lifestyle behaviors, such as physical and healthy dietary habits, increase motivation among students (Melnyk, 2020). Several studies recommended fostering students well-being by advancing education, counseling, social support, relaxation, physical activity, and wellness interventions to reduce burnout (Horvath & Grass, 2021). Methods to identified students at risk of suicidal behavior and to promote overall well-being of the SRNAs It is vital to adopt efficient methods to promote resiliency and mental health awareness among SRNAs. The Healer education assessment and referral program (HEAR) is an encrypted anonymous web-based program assessment to proactively recognize and direct individuals at risk of depression and suicide. It also combines a sequence of didactic exhibitions to provide teaching about suicide and depression (Davidson et al., 2018; Downs et al., 2014). Other researchers have used a variety of online assessments questionnaires commonly used by healthcare professionals, such as the Healthy lifestyle behaviors scale (HLBHS), the Patient health questionnaire (PHQ-9) (PHQ-2), the General anxiety disorder scale (GAD-7), the Perceived stress scale (PSS), the Copenhagen burnout inventory (CBI), the Harvard depression screening day, depression, anxiety, and stress scale (DASS) and the Maslach burnout inventory (MBI) (Downs et al., 2014; Jaulin et al., 2021; Horvitz et al., 2020; Hoying et al., 2020; Sun et al., 2019; Wang et al., 2021). SUICIDE PREVENTION FOR SRNAs 14 Discussion Study findings show high stress, anxiety, and burnout among SRNAs and graduate students, with females at more risk than males (Davidson et al. (2020). The recommendation is to screen students consistently throughout their anesthesia residency. A cross-sectional study concluded that 50% of the students experienced burnout during anesthesia residency, a third suffered, and one-eighth screened positive for depression (Sun et al., 2019). Education and mental health awareness need to be incentivized, and the harmful effects of long-term stress need to be emphasized. A standard variable in the literature correlates with worrying about stigma for seeking mental health screening and possibly positive outcomes and findings. It is concerning that these students with increased worry are in more danger of suicide action than general suicide risk (Rubanovich et al., 2022). The articles that utilized the HEAR program aimed to identify and reduce suicidal behaviors in high-risk students. Most importantly, the HEAR program discovered students who were suicidal and were not receiving treatment at the time; this finding was lifesaving for those students. Therefore, it is essential to implement psychological interventions and awareness for SRNAs to help facilitate lifestyle transformations, social support, and psychological guidance. Limitations in the Literature The lack of validation of the interactive survey program and the relatively low response rate were some of the limitations found in the studies. To maintain the study anonymous to keep confidentiality and restricted to one institution confined the capability to generalize the results to other universities (Davidson et al., 2018; Downs et al., 2014). Other limitations found were decreased sample sizes and response rates due to questionnaires not being mandatory. Researchers SUICIDE PREVENTION FOR SRNAs 15 also found it challenging to compare samples with the general population or even other institutions and impossible to track individuals responses over time. Few researchers opted to maintain anonymity to increase the response rate (Rubanovich et al., 2022; Sun et al., 2019). The MBI questionnaire seems to have weaknesses due to inconsistencies with the definitions of burnout. The CBI is partially consistent with the MBI but diverges for measurements of student depersonalization. Responses may be biased, indicating that students experiencing burnout might be more or less likely to respond to the survey (Jaulin et al., 2021; Wang et al., 2021). Future Research Implications Translation of evidence-based interventions to practice needs to be accelerated, emphasizing the prevention of mental health illness (Horvath & Grass, 2021; Hoying et al., 2021; Wang et al., 2021). Additional research is required to demonstrate whether the HEAR program reduces burnout and its repercussion among students. More research will be needed to track the students responses over time (Davidson et al., 2020; Sun et al., 2019). Institutions must sponsor additional research on this matter; randomized controlled trials are wanted to direct the effectiveness of interventions to stop depression and suicide among learners. There is a need to change the students physical, interpersonal, and social ecology (Drum et al., 2017; Melnyk, 2020). Future directions in this line of research are needed to include direction for marginalized groups and to develop programs that target mental health (Horvitz et al., 2020). Implications for Future Practice Most of these novel studies reveal an elevated rate of anxiety, hopelessness, and burnout among students laboring during clinicals and learning didactics on the days off from the hospital to identify potential suicidal students (Downs et al., 2014; Jaulin et al., 2021). The recommendations include providing a wellness initiative and additional strategies to reduce the SUICIDE PREVENTION FOR SRNAs 16 risk of burnout and increase the standard of the student's life. Anesthesia residents need more psychological consultation and guidance to prevent stress-related problems. (Horvath & Grass, 2021; Hoying et al., 2021; Wang et al., 2021). Even though some of the responses were low, the expectation is to increase the response rate to encourage untreated at-risk students to get help (Davidson et al., 2018). Nurse anesthesia programs must research ways to nurture students' wellbeing, decrease burnout and depression, and restore resiliency and joy (Horvath & Grass, 2021; Melnyk, 2020). Conclusion Systematic screening of learners for depression, burnout, and anxiety is desired to preserve the students mental health and well-being. The literature recommends screening SRNAs every year during their training. Despite the recommendations, a small amount of current literature shines a light on this issue. Researchers have a common suggestion for directors of anesthesia programs to improve mental health outcomes by providing attention to mental health prevention, counseling guidance, wellness culture, and social support. To sustain improvements in mental health outcomes among the student population, we must concentrate on prevention. Raising an understanding of students distress can change negative symptoms and ideas concerning emotional health. A literature matrix can be found in Appendix B. Theoretical Framework The theory of Moral Reckoning will be used as a theoretical framework to guide this project. This theory captures the process where nurses or individuals analyze and reminisce on motivation, preferences, measures, and outcomes in a particular situation. The middle-range theory of Moral Reckoning concepts includes ease, situational binds, resolution, and reflection (Smith & Liehr, 2018). SUICIDE PREVENTION FOR SRNAs 17 A diagram of this theoretical framework is found in appendix C. State of Ease A state of ease is a state of naturalness, a sense of comfort, free of agitation; ease denotes readiness and skillfulness. Nurses who experience ease are comfortable; individuals feel competent and confident (Smith & Liehr, 2018). The state of ease is the concept that describes the goal of emotional state for all students throughout their training. The use of this theory helped to assist students in achieving this emotional state and remaining in this state if possible. It also helped to examine at what stage the SRNAs felt more at ease in the program. Situational Binds Situational binds are severe and complex conflicts within individuals and others that lead to life-turning points. These conflicts lead to increased anxiety, tension, and self-questioning. (Smith & Liehr, 2018). Due to the program's rigor, SRNAs experience increased anxiety, burnout, stress, fatigue, and tension, all of which can lead to depression and suicidal thoughts. This concept helped identify students experiencing psychological symptoms and determine at what stage of the CRNA training situational binds were an issue. Resolution Resolution is a move to set things right, resolve the turmoil, and relieve the tension. It occurs when a person terminates the intolerable condition by finding a solution to the problem and deciding on a course of action. The person might make a declaration or carry out a plan (Smith & Liehr, 2018). This concept will guide students toward the resolution of a conflict. It will help validate those students that decided to follow up with a referral or those that take action to decrease stress. Reflection SUICIDE PREVENTION FOR SRNAs 18 Reflection occurs when a person, having made and acted upon a decision, reflects as they reckon past behavior and actions. Reflection raises questions about previous judgments, acts, and the essential self. It may extend over a lifetime. (Smith & Liehr, 2018). Even though the concept of reflection is difficult to measure, hopefully, students will reflect upon completing the screening questionnaire and reflecting on the educational information provided and their current emotional state. Reflection will vary per individual and will end with the individual returning to a state of ease. Project Aim & Objectives This DNP project strives to increase mental health awareness among SRNAs throughout their nurse anesthesia training. To identify SRNAs at risk or those experiencing symptoms and behaviors of increased stress, irritability, anxiety, depression, or suicidal thoughts and provide the necessary tools for referral to counseling services. Another aim is to provide students with evidence-based coping skills, a screening risk tool during anesthesia training, stress-relieving activities, and educational information to promote mental health resilience and overall well-being among SRNAs. The objectives of the project are as follows: 1- To help SRNAs self-recognize students psychological and physical manifestations of negative stress. 2- To illustrate, a PowerPoint presentation as an educational intervention available to all SRNAs promoting mental health awareness. 3- To identify SRNAs at moderate to high risk for depression and suicide. 4- To analyze the incidence of increased distress among students during their first, second, or third year of nurse anesthesia training. SUICIDE PREVENTION FOR SRNAs 19 5- To provide a screening questionnaire of open-ended questions specific to SRNAs during their training. 6- To provide the tools to guide students to interpret their questionnaire results and provide the resources for those who would want to get help. SWOT Analysis Key stakeholders in this project include: Marian University CRNA program Faculty and Director Student Services at Marian SRNAs from each cohort The benefit of this project, considered one of its biggest strengths, is that it will directly impact the CRNA program and its students if the results prove valuable to the individuals involved. Other strengths of the project include disseminating an educational presentation via canvas to all students. Since the research topic contains sensitive and private information from the students, to prevent a conflict of interest or ethical dilemmas, the students received information on how to interpret their questionnaire results and the tools to follow up with a referral for initial intervention. This project may foresee a weakness of not having enough participants because it is voluntary. Obtaining data with "at-risk" students and follow-ups may prove challenging. The participants may respond poorly to the project due to the stigma and the subject's sensibility. This project's great opportunity is that Marian University has an on-campus counseling department to serve students' needs. Another possibility is that the faculty from the CRNA program can continue screening SRNAs more frequently and encourage students to increase participation. SUICIDE PREVENTION FOR SRNAs 20 A concern that may be deemed a threat is any malfunction of the Canvas technology. The students may not want to participate in the surveys because they are busy and stressed with their current academic requirements. Another consideration will be students facing more requirements from the counseling department, making it more time-consuming for those students to receive initial help. A detailed table of the SWOT analysis is available in Appendix D. Project Design / Methods In this study, the investigator utilized a cross-sectional observational study design. This method provided an educational intervention and measured the prevalence of the participants to depression and suicide. It also helped to obtain information about the preponderance of anxiety, depression, and suicidal thoughts among SRNAs. The participants were selected based on the inclusion criteria and PICOT question set for this study. The chosen data was obtained using qualitative methods (surveys). This type of design is an excellent match for a one-time measurement of outcomes and exposures, and because of this, it was executed accurately within a short time frame with minimal cost. Project Site and Population The selected population for this study includes all SRNAs currently enrolled in the nurse anesthesia program. The setting took place at a private liberal arts university in the Midwest located in a vibrant city, offering an entry-level nurse anesthesia doctoral program. The fully accredited program offers a 36-month front-load curriculum requiring students to complete 87 credits of didactic courses. In addition to the didactic coursework, students are needed to complete a minimum of 2000 hours of clinical practice at different hospitals throughout the state and neighboring states. The program has approximately 29 students per cohort. The SRNA sample SUICIDE PREVENTION FOR SRNAs 21 comprises first-year students (n=33), second years (n=33), and third-years (n=22). The demographic data collected included age range, gender, and the current year in the program. It is pertinent to note the existing vulnerability of the participants. First-year students are enrolled in full-time didactic anesthesia doctoral coursework and sim lab simulation to prepare for entry into the clinical setting. Second-years are enrolled in part-time clinical rotations (2 days/week) plus didactic coursework along with sim lab simulation experience. Second-years initiate their doctoral research project and anesthesia reviews during their second year in preparation for the Self Evaluation Exam. Third-years students are enrolled in full-time clinical experience (4 days/week), including specialty anesthesia rotations. They are also working on finalizing their DNP project and self-review study in preparation for licensing exams. Seniors take supplemental seminar online coursework. Inclusion criteria consist of all anesthesia students enrolled in the institutions nurse anesthesia program from May 2020 until 2022. Exclusion criteria include the principal investigator (myself), CRNAs, other graduates and undergraduates from other specialties, medical students, CRNAs, and students lost in their program due to attrition or other personal reasons. Spending time at the school during the implementation phase was considered a barrier due to the constraints in clinical practice. A weekly reminder email to all participants was sent to overcome this barrier. The educative portion of the study was available to all participants thru the online canvas platform for the entire time if their institutions credentials were active. A close communication with the content expert and the participants that reached out with any technical issues accessing the course was maintained. A letter of site approval from the program director can be found in appendix E. SUICIDE PREVENTION FOR SRNAs 22 Measurement Instruments / Data Collection An informative PowerPoint promoting mental health awareness was made available to all students via canvas. Qualtrics software program was used to disseminate and collect survey data. The data were collected utilizing a one-time survey. 2-established tools were utilized to ensure the validity of the results according to findings found in the literature. Within the canvas course, I provided detailed instructions on grading and scoring interpretation of the results and the tools for follow-up if needed. Once the participants signed the informed consent, they could proceed to the survey. An external window appeared, sending the participants to an anonymous Qualtrics platform. All the data from the surveys were collected utilizing Qualtrics software. The investigator used different instruments to distribute and measure the outcomes of this DNP project. To assess for anxiety, The General Anxiety Disorder Scale (GAD-7), and to assess for depression, The Patient Health Questionnaire 9 (PHQ-9) were used (Hoying et al., 2020). Based on the literature, The PHQ-9 (Spitzer et al., 1999) is a 9-item tool that assesses depressive symptoms. Participants will rank their depressive symptoms on a 0 to 3 scale grading for the previous two weeks. The literature has found this tool to have a good sensitivity of .88 and specificity of .88, with Cronbach alphas above .87 (Hoying et al., 2020). The GAD-7 (Spitzer et al., 2006) is a 7-item tool that assesses participants' anxiety levels for the previous two weeks from 0 to 3. The literature has demonstrated good sensitivity of .89, specificity of .89, and social anxiety of .72 (Hoying et al., 2020). A third tool utilized was a survey developed by the principal investigator. This survey contained supplemental questions, including general open-ended questions, student performance, and perceptions of the program's support regarding mental health and how it affects clinical and academic performance. SUICIDE PREVENTION FOR SRNAs 23 Copies of the assessment tool can be found in the appendix F. Ethical Considerations/Protection of Human Subjects Due to the nature of this study, the confidentiality of the participants remained a priority. Marin University's Internal Review Board (IRB) approval was obtained before initiating the implementation phase of this DNP project. The surveys opened in an untraceable new window, and the results were collected anonymously. Demographically identifiable information from the participants was not collected. Clear information confirmed that the questionnaires were anonymous and voluntary. Before participants completed the survey, implied consent was needed as a pre-requisite for the experimenter to receive the results anonymously. All the data collected using Qualtrics did not include any potential identifiers of the participants, the option to anonymize data was selected. The data results were kept digitally in a password-protected private computer with only access to the primary investigator. Students received instructions and provided detailed information on how to read their scores from each survey to preserve participants' privacy. Recommendations were given for each student to follow up with either in-campus counseling, out-of-campus counseling, or other resources where they can reach out for help. IRB Determination Form Letter of Approval can be found in Appendix G. Data Analysis A method used for data collection in this cross-sectional study consisted of surveys sent to all SRNAs (N=87) currently enrolled in the nurse anesthesia program. The demographic data collected were age range and gender. To further describe the sample, we asked participants to specify their year of enrollment in the program. Supplementary general questions about students SUICIDE PREVENTION FOR SRNAs 24 perceptions and development in academic and clinical performance were included and developed by the principal investigator (H. Urbaez) for a qualitative description of the data. The investigator considered the PICO question to propose the following research questions and hypotheses: RQ1: What is the relationship between depression level and year of training for SRNAs currently enrolled in the nurse anesthesia program? H10: There is no significant difference in depression level and year of training for SRNAs currently enrolled in the nurse anesthesia program. H1a: There is a significant difference in depression level and year of training for SRNAs currently enrolled in the nurse anesthesia program. RQ2: What is the relationship between anxiety level and year of training for SRNAs currently enrolled in the nurse anesthesia program? H20: There is no significant difference in anxiety level and year of training for SRNAs currently enrolled in the nurse anesthesia program. H2a: There is a significant difference in anxiety level and year of training for SRNAs currently enrolled in the nurse anesthesia program. RQ3: What is the relationship between depression level, anxiety level, year of training, and suicidality of SRNAs currently enrolled in the nurse anesthesia program? H30: Depression level, anxiety level, and year of training do not significantly predict suicidality of SRNAs currently enrolled in the nurse anesthesia program. H3a: Depression level, anxiety level, and year of training significantly predict suicidality of SRNAs currently enrolled in the nurse anesthesia program. SUICIDE PREVENTION FOR SRNAs 25 All statistical analysis was conducted using SPSS software version 26. Before running the analysis, a data cleaning procedure was performed to ensure data quality. Listwise deletion was applied to cases with missing values. Descriptive statistics were performed to characterize the collected sample. A descriptive analysis was run to describe the continuous variables. Frequency analyses were conducted to interpret the scores on the PHQ-9 and GAD-7 using the scoring guidelines provided for these instruments. The researcher executed two one-way ANOVAs to address the first and second research questions and conducted a logistic regression analysis to address the third research question. The dependent variables in the one-way ANOVAs are depression level and anxiety level; the independent variable in both these analyses is the year of training. Furthermore, the dependent variable in the logistic regression analysis is suicidality as measured by the survey question Any thoughts of quitting during the anesthesia program?, and the predictor variables are anxiety level, depression level, and years of training. Before conducting these analyses, the investigator needed to evaluate their parametric assumptions. The assumptions of the one-way ANOVA assessed were: 1) the dependent variable is measured on a continuous scale, 2) the independent variable is measured on a categorical scale, 3) there are no significant outliers in any levels of the independent variable, 4) the data are normally distributed for each level of the independent variable, 5) there is the homogeneity of variances meaning that the variances of the dependent variable are approximately the same across the levels of the independent variable (Lund, 2021). The first assumption is deemed reasonable as both the dependent variables of anxiety level and depression level are assumed to be measured on an interval scale. The second assumption is also valid as the independent variable of years of training is categorical with the three levels of SUICIDE PREVENTION FOR SRNAs 26 first-year, junior, and senior. The third assumption was tested by calculating standardized scores for the dependent variable for each category of the independent variable. Standardized values outside the range of -3.29 to 3.29 are considered significant outliers (Tabachnick & Fidell, 2013). Hence, to consider this assumption valid, all standardized values should be less than 3.29. The fourth assumption was checked using Shapiro-Wilks test of normality. Shapiro-Wilk test evaluates the null hypothesis that the data are normally distributed. Lastly, Levenes test of equality of variances was also conducted to assess the homogeneity of variances assumption. This test examines the null hypothesis that the variances are equal across the grouping variable. The significance level for both Shapiro-Wilks and Levenes tests was determined at .05. The assumptions of the logistic regression analysis were evaluated as follows: 1) the dependent variable is dichotomous, 2) there are one or more predictor variables measured at either a categorical or continuous level, and 3) the relationship between any continuous predictor variable and the logit transformation of the outcome variable should be linear (Lund, 2021). The logistic regression model's first assumption is to be met as the outcome variable of suicidality measured using a survey item with two answer options of 'Yes' and 'No.' The second assumption is also valid as the continuous variables of anxiety level and depression level, the categorical variable of the year of training, are included in the model as the predictor variables. The third assumption of this model will be assessed using the Box-Tidwell test. This procedure includes the interaction term between each continuous variable and its natural log transformation in the logistic regression model. This assumption is assumed to be met if all interaction terms are found to be non-significant (Zeng, 2022). SUICIDE PREVENTION FOR SRNAs 27 Results The surveys were distributed utilizing different links to maintain the integrity and validity of the surveys. Out of the 87 students that received the invitation, 45 participated in this project initially, with an overall response rate of 50.7%. Most participants reported being female, 23.4% (n=27), and male 14.7% (n=17). According to their year of training, the following participated: first-year n=20, second years (juniors) n=14, and third-years (seniors) n=11. The predominant age range among participants was 26-35 n= 33, 20-25 n= 3, 36-45 n= 7, 46-55 n= 2. Descriptive Statistics The initial sample contained information from 45 students. A data screening revealed that two participants did not respond to the Generalized Anxiety Disorder (GAD) and Parent Health Questionnaire (PHQ) questions. These participants were excluded from the analysis, resulting in a sample size of 43. Table 1 displays the frequency table for the categorical characteristics of the study sample. Of the 43 participants, 46.5% were first-year, 30.2% were junior, and 23.3% were senior students. Most of the students were female (58.1%). Nearly half of the students (53.5%) were aged 20-30 years old. Based on the participants scores on the GAD, 27.9% indicated minimal anxiety, 20.9% indicated mild anxiety, 27.9% indicated moderate anxiety, and 23.3% indicated severe anxiety symptoms. In addition, using the PHQ, 25.6% were identified with minimal depression, 30.2% were identified with mild depression, 20.9% were identified with moderate depression, and 14.0% were identified with severe depression symptoms. Moreover, 95.3% indicated having signs of depression, or increased anxiety during the program, and 11% stated having thoughts of quitting during the anesthesia program. When asked whether they had ever felt the need to reach out for help during the program, 48.8% stated Yes; among these respondents, only 9.3% said that the help available on campus had met their expectations. In addition, 16.3% SUICIDE PREVENTION FOR SRNAs 28 stated that the school did well reaching out and recognizing at-risk students throughout the program. 95.3% reported that SRNAs should be periodically screened for early signs of depression and increased anxiety throughout the program. 23.3% indicated that the school did a good job fostering SRNAs mental health throughout the program. 95.3% believed that SRNAs would benefit from a protocol that promotes mental health awareness and assists students at risk, and 90.7% said that the curriculum needed to include more time off for students between semesters. Table 1 Frequency Table for Categorical Characteristics of the Sample (N = 43) Categorical Characteristic Year of Training Gender Age Anxiety Symptoms Depression Symptoms Signs of depression, or increased anxiety during the program Suicidal thoughts during the program Thoughts of quitting during the anesthesia program Frequency Percent First-years Second-years Third-years Female One 20-30 31-40 41-55 Minimal Mild Moderate Severe Minimal Mild Moderate Moderately Severe Severe No Yes No Yes No Yes 20 13 10 46.5 30.2 23.3 25 17 58.1 39.5 23 53.5 15 34.9 5 11.6 12 9 27.9 20.9 12 10 27.9 23.3 11 13 9 25.6 30.2 20.9 6 4 14.0 9.3 2 4.7 41 95.3 38 88.4 5 11.6 23 53.5 20 46.5 SUICIDE PREVENTION FOR SRNAs 29 Ever felt the need to reach out for help during the program No Yes The help available on campus meet their expectation No Yes The school does well reaching out and recognizing at- No risk students throughout the program Yes SRNAs should be periodically screened for early signs No of depression, increased anxiety Yes The school does a good job fostering SRNAs mental No health throughout the program Yes SRNAs will benefit from a protocol that promotes No mental health awareness and assists students at risk Yes No The curriculum needs to include more time off for students between semesters Yes 22 51.2 21 48.8 39 90.7 4 9.3 36 83.7 7 16.3 2 4.7 41 95.3 33 76.7 10 23.3 2 4.7 41 95.3 4 9.3 39 90.7 Table 2 displays the descriptive statistics for the continuous variables. The seven items on the GAD were used to measure anxiety level, and the nine items on the PHQ were used to measure depression level. All these items were measured on a 4-point Likert scale with scores ranging from 0 = Not at All to 3 = Nearly Every Day. The overall score for each of these variables was calculated as the sum of the scores for their respective items. Higher scores represent more severe symptoms. Anxiety scores ranged from 0 to 21 and had a mean of 9.51 (SD = 6.13). Depression scores ranged from 1 to 27 and had a mean of 9.58 (SD = 6.18). The skewness and kurtosis values suggested that the data distribution for these variables were not too skewed nor too peaked. Table 2 Descriptive Statistics for the Continuous Variables Variable Min Max Mean SD Skewness Kurtosis Anxiety Depression 0 1 21 27 9.51 9.58 6.13 6.18 0.26 0.89 -1.03 0.21 SUICIDE PREVENTION FOR SRNAs 30 Assumption Testing The researcher intended to use two one-way ANOVAs to evaluate the first and second research questions and logistic regression analysis to address the second research question. The dependent variable in the first ANOVA was depression level and in the second ANOVA was anxiety level. The independent variable in both analyses was the year of training with three levels first-year, junior, and senior. In addition, the dependent variable in the logistic regression analysis was suicidality, and the predictor variables were depression level, anxiety level, and year of training. The results of tests of assumptions for the one-way ANOVAs are detailed as follows. The first assumption to evaluate was the absence of significant outliers in the data for each independent variable level. Z-scores were calculated for depression and anxiety levels for firstyear, junior, and senior students separately (see Table 3). The values of 3.29 were used as the thresholds for identifying significant outliers. It was found that all standardized scores were between -3.29 and 3.29, suggesting that there were no significant outliers in the data. Thus, the absence of significant outliers assumption was reasonable. Table 3 Assessment of the Absence of Significant Outliers Assumption for the One-Way ANOVAs Variable Year of Training N Minimum Z-Score Maximum Z-Score Anxiety Level First-years 20 -1.10 2.15 Second-years 13 -1.72 1.62 Third years 10 -1.34 1.11 First-years 20 -1.27 3.095 Second-years 13 -1.29 1.48 Third years 10 -1.15 1.85 Depression Level SUICIDE PREVENTION FOR SRNAs 31 Another assumption of the one-way ANOVAs was the normality of data for each level of year of training. The Shapiro-Wilk test of normality was utilized for this purpose. As shown in Table 4, there were significant departures from the normality assumption of anxiety level for the first-year (SW(20) = .879, p < .05) and senior students (SW(10) = .838, p < .05). In addition, the normality assumption of depression level was violated for the first-year students (SW(20) = .860, p < .05). These results indicated that the normality assumption of both one-way ANOVAs was violated as the data were not normally distributed across all levels of the independent variable. Thus, one-way ANOVA was not appropriate analysis for addressing the first and second research questions. Given that the assumption of normal was violated, the conducting of Levenes test of equality of variances to examine the homogeneity of variances assumption was not necessary. The Kruskal-Wallis H test, as a nonparametric alternative to one-way ANOVA, was utilized to evaluate these questions. This nonparametric procedure does not make any assumptions about the data distribution and therefore is robust to departures from normality. Table 4 Results of Shapiro-Wilk Test of Normality for the One-Way ANOVAs Variable Year of Training Anxiety Level Depression Level Shapiro-Wilk Statistic df Sig. First-years .879 20 .017 Second-years .963 13 .799 Third years .838 10 .042 First-years .860 20 .008 Second-years .919 13 .246 Third years .915 10 .318 SUICIDE PREVENTION FOR SRNAs 32 After checking the assumptions of the one-way ANOVAs, the linearity assumption of the logistic regression model was also evaluated. This assumption was tested using the Box-Tidwell test by including the interaction term between each continuous variable and its natural log transformation in the logistic regression model. To consider this assumption valid, all interaction terms should be non-significant. The results of evaluating this assumption are provided in Table 5. Both interaction terms were non-significant; thus, the linearity assumption was supported. Table 5 Evaluating the Linearity Assumption of the Logistic Regression Model Variable B S.E. Wald df Sig. Anxiety 99.681 151.764 .431 1 .511 Depression -52.726 80.103 .433 1 .510 .001 2 1.000 Year of Training Year of Training: First Year -92.744 12829.890 .000 1 .994 Year of Training: 2nd-years 28.689 12157.647 .000 1 .998 Anxiety*LnAnxiety -31.978 48.675 .432 1 .511 Depression*LnDepression 18.279 27.659 .437 1 .509 Research Question 1 The first research question was developed to determine whether there was a relationship between depression level and year of training for SRNAs currently enrolled in the nurse anesthesia program. Null Hypothesis 1 shows no significant difference in depression level and year of training for SRNAs currently enrolled in the nurse anesthesia program. To test this hypothesis, a KruskalWallis H test was utilized with depression level as the dependent variable and year of training as the independent variable. This test showed no significant difference in the mean rank of depression level by year of training (H(2) = 1.706, p = .426). It can be concluded from these results that the SUICIDE PREVENTION FOR SRNAs 33 mean ranks of depression did not significantly vary between first-years (M = 19.80, N = 20), second-years (M = 25.62, N = 13), and third-years (M = 21.70, N = 10) students. Hence, these results did not provide evidence to reject Null Hypothesis 1. Research Question 2 The second research question asked whether there was a relationship between anxiety level and year of training for SRNAs currently enrolled in the nurse anesthesia program. Null Hypothesis 2 shows no significant difference in anxiety level and year of training for SRNAs currently enrolled in the nurse anesthesia program. A Kruskal-Wallis H was performed to evaluate this hypothesis. In this analysis, the anxiety level was entered as the dependent variable, and the year of training was entered as the independent variable. This test showed no significant difference in the mean rank of anxiety by year of training (H(2) = 1.754, p = .416). These results indicated the mean ranks of anxiety did not significantly differ between first-years (M = 19.80, N = 20), second-years (M = 25.69, N = 13), and third-years (M = 21.60, N = 10) students. Hence, no support was provided to reject Null Hypothesis 2. Research Question 3 The third research question asked whether there was a relationship between depression, anxiety, year of training, and suicidality of SRNAs currently enrolled in the nurse anesthesia program. Null Hypothesis 3 is that depression, anxiety, and year of training do not significantly predict the suicidality of SRNAs currently enrolled in the nurse anesthesia program. A logistic regression analysis was conducted to test this hypothesis. In this analysis, suicidality was entered as the outcome variable, and depression, anxiety, and year of training were entered as the predictor variables. Year of training was included as a categorical variable, and its reference category was senior. SUICIDE PREVENTION FOR SRNAs 34 The omnibus test results of model coefficients showed that the model provided a significantly better fit than the null model with no predictors (the intercept-only model), 2(4) = 17.646, p = .001. Negelkerke R square value of .656 and Cox & Snell R square value of .337 were calculated for this model. The Hosmer and Lemeshow test results suggested that the model fit the data well, 2(8) = 2.915, p = .940. The classification table for this model is provided in Table 6. The model correctly predicted all 38 No responses. The model also correctly predicted three (60.0%) out of the five Yes responses. Overall, the model correctly predicted 95.3% of the responses. Table 6 Classification Table for the Logistic Regression Model Predicted Suicidality Thoughts Observed No Yes Percentage Correct Suicidality No 38 0 100.0 Thoughts Yes 2 3 60.0 Overall Percentage 95.3 The parameter estimates for this regression model are reported in Table 7. Even though the model provided a good fit to the data, none of the predictor variables significantly contributed to the model (p > .05). Overall, these results suggest that the three predictor variables of anxiety level, depression level, and year of training combined significantly contribute to the model, but none of these predictor variables independently predicted the outcome variable. These results provided SUICIDE PREVENTION FOR SRNAs 35 support to reject Null Hypothesis 3, showing that depression level, anxiety level, and year of training combined significantly contributed to the outcome variable of suicidality. Table 7 Parameter Estimates for the Logistic Regression Model Variable B S.E. Wald Df Sig. Anxiety -0.388 0.269 2.079 1 .149 Depression 0.486 0.277 3.070 1 .080 1.208 2 .547 Year of Training Year of Training: First Year -20.476 7365.576 0.000 1 .998 Year of Training: Junior 2.112 1.921 1.208 1 .272 Discussion This study assessed the incidence of increased stress, anxiety and their correlation with depression and suicidal thoughts for students enrolled in a doctoral nurse anesthesia program. The qualitative analysis helped to attain a more profound knowledge of the students perceptions of their mental well-being. Second-year students and seniors are involved in direct patient care during their anesthesia practice. Studies have shown that increased stress, anxiety, and burnout are direct factors that can hinder safe anesthesia delivery, placing patients at risk. Promoting SRNAs to be at their best physical and mental well-being throughout their training is imperative. The results of this study indicated that 27.9% and 23.3% scored moderate to severe anxiety utilizing the GAD7. Additionally, 20.9% and 14% were identified with moderate to severe depression using the PHQ-9 tool. More disturbing is that 95.3 % indicated having signs of depression or increased anxiety, and 11% had thoughts of quitting the program. These results are alarming, suggesting that in this program, students encounter a low level of well-being and high levels of distress, potentially SUICIDE PREVENTION FOR SRNAs 36 affecting their mental health. Most participants implied they would benefit from periodical screening for early signs of depression and anxiety. Even though the common expectation is to abide that a high-stress career such as nurse anesthesiology is expected to be stressful, it is seen as the norm; in reality, it should not be overlooked. This studys results implore changes in the program and the incorporation of resources to give the students the essential tools to cope with increased stress and burnout. 95.3% of the participants stated that they would benefit from a protocol encouraging mental health awareness. Reinforcing a culture of support and guidance will be a vital component in SRNAs education. It is important to know that students wellness should begin with the implementation of ideas. Anesthesia programs need to start building a safe space where students can connect with classmates at another level on those so-called periodical wellness days. As we continue learning more about the consequences of distress among students, we must promote a safety culture starting today. Research questions and hypotheses that addressed the aims of the project were developed. The results of the tests showed no significant differences between depression and anxiety levels and year of training. What was demonstrated is the relationship that exists when all the variables live in combination, then there is an increased risk of suicidality. The investigator found some limitations to this study. The sample size was limited to a single academic organization. To further reduce the sample size, participation was voluntary, which further reduced the sample number. Although the response was low, the expectation is to continue expanding participation. 95.3% of the participants remarked that SRNAs should be periodically screened for early signs of depression and anxiety. Hence, further research is advised on this subject. Future SUICIDE PREVENTION FOR SRNAs 37 recommendations must be enforced in anesthesia programs to assess the progression of well-being among first-years, juniors, and seniors. It will be intriguing to conduct more research, including the entire sample size of participants for results comparison. Additional research will be needed to find ways how to track the student's responses over time. A systematic protocol needs to be created to assist those that are having suicidal thoughts and are at imminent risk of a mental crisis. There was an overwhelming reaction to increasing distress among students, and implications for future practice urge the school program director to research ways to encourage mental health awareness and screenings to promote student well-being. A wellness initiatives program, psychological consultation, and guidance tailored to the student's needs are explicitly recommended. Conclusion Increased stress can lead to a myriad of physical and psychological manifestations. Graduate students in anesthesia are exposed to physical, emotional, and financial stressors. The results of this study emphasized the heightened levels of anxiety, depression, and suicidal thoughts some students are experiencing. These results showed the need for interventions to help students deal with these stressors. Suicide can be preventable. Awareness is the key to building an inclusive culture to encourage students to learn and manage their stress positively. One student that responded positively to experiencing suicidal thoughts should be enough for anesthesia programs to shift their focus on making changes and finding ways to reach out at a personal level. Implementing wellness activities, a robust screening program, and providing students with the necessary tools to promote a healthy experience during anesthesia training should be a priority and a critical suggestion. SUICIDE PREVENTION FOR SRNAs 38 References American Foundation for Suicide Prevention. AFSP. https://www.theovernight.org/?fuseaction=cms.page&id=1034 Chipas, A., Cordrey, D., Floyd, D., Grubbs, L., Miller, S., & Tyre, B. (2012). Stress: perceptions, manifestations, and coping mechanisms of student registered nurse anesthetists. AANA journal, 80(4 Suppl), S49S55. Choflet, A., Davidson, J., Lee, K. C., Ye, G., Barnes, A., & Zisook, S. (2021). A comparative analysis of the substance use and mental health characteristics of nurses who complete suicide. Journal of clinical nursing, 30(13-14), 19631972. https://doi.org/10.1111/jocn.15749 Davis, M., Cher, B., Friese, C., 2021. Association of US nurse and physician occupation with risk of suicide. JAMA Psychiatry. 78 (6), pp 651-658. doi:10.1001/jamapsychiatry.2021.0154 Davidson, J. E., Accardi, R., Sanchez, C., Zisook, S., & Hoffman, L. A. (2020). Sustainability and Outcomes of a Suicide Prevention Program for Nurses. Worldviews on evidence-based nursing, 17(1), 2431. https://doi.org/10.1111/wvn.12418 Davidson, J. E., Zisook, S., Kirby, B., DeMichele, G., & Norcross, W. (2018). Suicide Prevention: A Healer Education and Referral Program for Nurses. The Journal of nursing administration, 48(2), 8592. https://doi.org/10.1097/NNA.0000000000000582 SUICIDE PREVENTION FOR SRNAs 39 Downs, N., Feng, W., Kirby, B., McGuire, T., Moutier, C., Norcross, W., Norman, M., Young, I., & Zisook, S. (2014). Listening to depression and suicide risk in medical students: the Healer Education Assessment and Referral (HEAR) Program. Academic psychiatry : the journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry, 38(5), 547553. https://doi.org/10.1007/s40596014-0115-x Drum, D. J., Brownson, C., Hess, E. A., Burton Denmark, A., & Talley, A. E. (2017). College Students Sense of Coherence and Connectedness as Predictors of Suicidal Thoughts and Behaviors. Archives of Suicide Research, 21(1), 169184. https://doi.org/10.1080/13811118.2016.1166088 Horvath, C., & Grass, N. (2021). Pandemic, Economic Uncertainty, and Protests: What Will Happen to Student Registered Nurse Anesthetists--Resiliency or Burnout? AANA journal, 89(5), 413418. Horwitz, A. G., McGuire, T., Busby, D. R., Eisenberg, D., Zheng, K., Pistorello, J., Albucher, R., Coryell, W., & King, C. A. (2020). Sociodemographic differences in barriers to mental health care among college students at elevated suicide risk. Journal of Affective Disorders, 271, 123130. https://doi.org/10.1016/j.jad.2020.03.115 SUICIDE PREVENTION FOR SRNAs 40 Hoying, J., Melnyk, B. M., Hutson, E., & Tan, A. (2020). Prevalence and Correlates of Depression, Anxiety, Stress, Healthy Beliefs, and Lifestyle Behaviors in First-Year Graduate Health Sciences Students. Worldviews on evidence-based nursing, 17(1), 4959. https://doi.org/10.1111/wvn.12415 Jaulin, F., Nguyen, D. P., Marty, F., Druette, L., Plaud, B., Regional coordinators of teaching in Anaesthesia and Intensive Care, Duret, C., & Fletcher, D. (2021). Perceived stress, anxiety and depressive symptoms among anaesthesia and intensive care residents: A French national survey. Anaesthesia, critical care & pain medicine, 40(3), 100830. https://doi.org/10.1016/j.accpm.2021.100830 Lund, A. (2021). The ultimate IBM SPSS Statistics guide. Retrieved from https://statistics.laerd.com/features-overview.php Melnyk, B. M. (2020). Burnout, Depression and Suicide in Nurses/Clinicians and Learners: An Urgent Call for Action to Enhance Professional Wellbeing and Healthcare Safety. Worldviews on Evidence-Based Nursing, 17(1), 25. https://doi.org/10.1111/wvn.12416 Rubanovich, C. K., Zisook, S., & Bloss, C. S. (2021). Associations Between Privacy-Related Constructs and Depression and Suicide Risk in Health Care Professionals, Trainees, and Students. Academic medicine: journal of the Association of American Medical Colleges. Smith, M. & Liehr, P. (2018). Middle range theory for nursing. Springer Publishing Company. SUICIDE PREVENTION FOR SRNAs 41 Sun, H., Warner, D. O., Macario, A., Zhou, Y., Culley, D. J., & Keegan, M. T. (2019). Repeated Cross-sectional Surveys of Burnout, Distress, and Depression among Anesthesiology Residents and First-year Graduates. Anesthesiology, 131(3), 668677. https://doi.org/10.1097/ALN.0000000000002777 Tabachnick, B. G., & Fidell, L. S. (2013). Using multivariate statistics. New York, NY: Pearson Education, Inc. Wang, J., Song, B., Shao, Y., & Zhu, J. (2021). Effect of Online Psychological Intervention on Burnout in Medical Residents From Different Majors: An Exploratory Study. Frontiers in psychology, 12, 632134. https://doi.org/10.3389/fpsyg.2021.632134 Zeng, G. (2022). A graphic and tabular variable deduction method in logistic regression. Communications in Statistics-Theory and Methods, 51(16), 5412-5427. SUICIDE PREVENTION FOR SRNAs 42 Appendix A PRISMA Diagram Records identified through database searching Additional records identified through other sources N=12 ( 577 N= Records after duplicates removed (n=552) Records screened (N= 89 ) Full-text articles assessed for eligibility (N= n =21 15 Studies included in qualitative synthesis (n = 10 ) N=15 Studies included in quantitative synthesis (meta-analysis) (n = ) N= 15 Records excluded (N = 12 ) no primary sources Ful l-text articles excluded, with reasons = 5 N=(n56 see exclusion criteri a SUICIDE PREVENTION FOR SRNAs 43 Appendix B Literature Matrix Reference Desig Purpose Population Instrument Results Implicati n / Aim Level Sample Data ons n=x Collection Future of Implication for s for Future Practice Research Evide nce Hoying, J., Melnyk, B. M., Hutson, E., & Tan, A. (2020). Prevalence and Correlates of Depression, Anxiety, Stress, Healthy Beliefs, and Lifestyle Behaviors in First-Year Graduate Health Sciences Students. Worldv iews on evidence-based nursing, 17(1), 4959. https://doi.org/10 .1111/wvn.1241 5 Descri ptive correla tional study The purpose is to analyze the preponder ance of depression , anxiety and increased stress in first-year sciencebased students & to determine predictors of depression and anxiety (Hoying et al., 2020). N= 197 first year graduate health sciences students (Hoying et al., 2020). Participants completed a personal wellness assessment survey including healthy lifestyle behaviors scale (HLBHS), patient health questionnaire 9 (PHQ-9) and general anxiety disorder scale (GAD-7) (Hoying et al., 2020). Mild depressive symptoms 84.8%, moderate 13.2%, severe 1%, moderate anxiety 7.65, severe 6.6%. Lastly, 6.6% responded positively to suicidal thoughts (Hoying et al., 2020). Translation of evidencebased intervention s to practice needs to be accelerated. We must place more emphasis on prevention to sustained improvemen ts in mental health outcomes (Hoying et al., 2020). Graduate-level learners should be screened for mental health wellness following admission into their programs, and universities should integrate CBT based interventions in their curriculum to enhance health outcomes (Hoying et al., 2020). Davidson, J. E., Zisook, S., Kirby, B., DeMichele, G., & Norcross, W. (2018). Suicide Prevention: A Healer Education and Referral Qualit y improv ement project The aim of this study is to detailed a suicide prevention program created for nurses Between 2009-2016, n=1558 medical students completed the online questionnaire Healer education, assessment, and referral program (HEAR) has 2 approaches: the 1st a series of didactic Out the individuals that completed the interactive survey program (ISP) Deficiency validating the complete ISP and low response rate. Plan to provide continuing education Although the response was low, the expectation is to grow response rate to encourage nurses not receiving SUICIDE PREVENTION FOR SRNAs Program for Nurses. The Journal of nursing administration, 4 8(2), 8592. https://doi.org/10 .1097/NNA.0000 000000000582 Jaulin, F., Nguyen, D. P., Marty, F., Druette, L., Plaud, B., Regional coordinators of teaching in Anaesthesia and Intensive Care, Duret, C., & Fletcher, D. (2021). Perceived stress, anxiety and depressive symptoms among anaesthesia and intensive care residents: A French national survey. Anaesthe sia, critical care & pain medicine, 40(3), 100830. (Davidson et al., 2018). Observ ational study To support the efforts at managing operationa l time and schedules. Enhancing detection and care of anguish anesthesia residents (Jaulin et al., 2021). 44 (Davidson et al., 2018). 2,302 French Anesthesia residents. 22.5% responded the survey (Jaulin et al., 2021). displays supplying education about depression, suicide, and function of the program. The 2nd is an encrypted, anonymous web-based screening assessment to proactively recognize and direct students in danger of developing depression (Davidson et al., 2018). containing the 9-item Patient Health Questionnair e (PHQ-9), A national online observational study used validated questionnaires (hospital anxiety and depression scale HADS), depression scales (perceived stress scale PSS), burnout (Copenhagen burnout inventory CBI) and work-related questions to assess mental health and well-being (Jaulin et al., 2021). 19.8% described symptoms of anxiety, 7.8% depressive symptoms. A high stress was identified for 55.7%, 38.9% burnout and depression (Jaulin et al., 2021). n=112 dialogued with the program counselor for formal health evaluation. N=172 nurses, 44 received counseling, 17 accepted referrals for further treatment (Davidson et al., 2018). and shifting the focus to resiliency with the hopes to draw larger audiences (Davidson et al., 2018). treatment and in a great need for help (Davidson et al., 2018). Further studies are recommend ed where a comparison with other data can be allowed. The limits of the study are linked to declarative questionnair e without an approval by clinical exam. A larger student response is needed (Jaulin et al., 2021). The study inform an elevated frequency of anxiety, depressive symptoms and burnout among students that are working and studying (Jaulin et al., 2021). SUICIDE PREVENTION FOR SRNAs 45 https://doi.org/10 .1016/j.accpm.20 21.100830 Davidson, J. E., Accardi, R., Sanchez, C., Zisook, S., & Hoffman, L. A. (2020). Sustainability and Outcomes of a Suicide Prevention Program for Nurses. Worldvie ws on evidencebased nursing, 17(1), 2431. https://doi.org/10 .1111/wvn.1241 8 PDSA model The purpose is to report the threeyear sustainabil ity and results from a program to hinder suicide among nurses (HEAR) (Davidson et al., 2020). 527 nurses In the span of 3 years. 48% high risk, 51.2% moderate risk, 9% suicide risk (Davidson et al., 2020). The HEAR program was utilized. The PDSA model of improvement was used to organize the project. The anonymous screening portion was used to identify compromised individuals at through online screening (9item patient health questionnaire PHQ-9) (Davidson et al., 2020). In the span of 3 years 53-56% of nurses reports feeling burned out. 49-60% felt emotionally drained. An average of 155-187 per year completed screening. 26-40 referrals were made per year and most individuals referred ratified suicidality (Davidson et al., 2020). Additional research is required to establish whether the HEAR program attenuates burnout and its repercussion (Davidson et al., 2020). Reproduction of the program is suggested due to the conclusion that job stressors compromise nurses. Dissemination would enhance the general health of the nurses (Davidson et al., 2020). Sun, H., Warner, D. O., Macario, A., Zhou, Y., Culley, D. J., & Keegan, M. T. (2019). Repeated Cross-sectional Surveys of Burnout, Distress, and Depression among Anesthesiology Residents and First-year Graduates. Anest hesiology, 131(3 ), 668677. https://doi.org/10 Cross section al survey study The goal of this study is to measure the popularity of burnout, anxiety, and depression in anesthesia residents and identify their associated factors Sample size of Anesthesia residents 36% 5,295 out of 14,529 invitations sent (Sun et al., 2019). Annually online surveys to students attending clinical up to a year after graduation. The Maslach burnout inventory, the physician well-being index and the Harvard depression screening day scale were used (Sun et al., 2019). Prevalence of burnout 51%, distress 32% and depression 12% (Sun et al., 2019). More research is needed to possible track individual responses over time (Sun et al., 2019). Burnout, distress, and depression are common among anesthesia residents. Perceived institutional support, workload, student debt impacts the anesthesia student wellbeing (Sun et al., 2019). SUICIDE PREVENTION FOR SRNAs .1097/ALN.0000 000000002777 46 (Sun et al., 2019). Downs, N., Feng, W., Kirby, B., McGuire, T., Moutier, C., Norcross, W., Norman, M., Young, I., & Zisook, S. (2014). Listening to depression and suicide risk in medical students: the Healer Education Assessment and Referral (HEAR) Program. Acade mic psychiatry: the journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry, 38(5) , 547553. https://doi.org/10 .1007/s40596014-0115-x Observ ational study The use of a 4-year trial of the HEAR program, to increase mental health services applicatio n and reduce suicide danger at one US medical school (Downs et al., 2014). Out of 1,008 medical students 34% (343/1,008) completed the online screening portion (Downs et al., 2014). Over four years, medical students were occupied attending inperson educational programs. An online survey, including the 9-item patient health questionnaire (PHQ-9), was used to evaluate for depression and suicidal ideation (Downs et al., 2014). 8% met the criteria for high suicidal risk; 10 out of 13 students who interviewed with a counselor were not getting mental health treatment (Downs et al., 2014). The authors recommend that future multisite analyses are required to include a comparison group, formulate a baseline, and use an anonymous identificatio n system to gauge changes in participants mental health status (Downs et al., 2014). This novel interventional program identifies at risk, potentially suicidal medical students (Downs et al., 2014). Rubanovich, C. K., Zisook, S., & Bloss, C. S. (2021). Associations Between Privacy-Related Constructs and Depression aSuicide Risk in Health Care Professionals, Trainees, and Students. Acade Observ ational study This study evaluated the relationshi p between privacyrelated constructs and selfrates depression and suicide risk N=1,224 respondents were included (Rubanovich et al., 2021). Utilizing linear and logistic regression models. An anonymous online screening with the choice to provide personal demographic was used 43% reported moderate depression; 1 in 5 reported worries about stigma for seeking mental health services (Rubanovic New researchers need to assume privacyrelated constructs may help pinpoint health care professional s and students undergoing Privacyrelated constructs correlations of mental health as a respondent who endorsed these constructs had increased probabilities of more threatening SUICIDE PREVENTION FOR SRNAs mic medicine: journal of the Association of American Medical Colleges. 47 among healthcare profession als, trainees, and students (Rubanovi ch et al., 2021). (Rubanovich et al., 2021). h et al., 2021). distress and in need of imminent mental health resources (Rubanovic h et al., 2021). depression and suicidal ideation and behaviors (Rubanovich et al., 2021). Horvath, C., & Grass, N. (2021). Pandemic, Economic Uncertainty, and Protests: What Will Happen to Student Registered Nurse Anesthetists-Resiliency or Burnout?. AANA journal, 89(5), 413418. MetaAnalys is Expert opinio n The aim is to control burnout, foster resilience, and reduce the risk of severe mental health conditions in nurse anesthesio logy programs (Horvath & Grass, 2021). Data reports of of 47% of SRNAs with depression and 21% had suicidal ideation (Horvath & Grass, 2021). Other sources A metaanalysis reviewed a 22.8% depression, 38.9% insomnia among healthcare professional s. Another systematic review found SRNAs with risk factors for burnout, heightened emotional requirement s, economic uncertainty, and social isolation (Horvath & Grass, 2021). The recommend ations consist of to provide a wellness initiative and additional strategies to decrease the risk of burnout and foster quality of life (Horvath & Grass, 2021). SRNAs have a higher chance of mental health problems such as anxiety, depression, and posttraumatic stress. Nurse Anesthesia programs must research ways to encourage students' wellbeing by reducing risks. (Horvath & Grass, 2021). Melnyk, B. M. (2020). Burnout, Depression and Suicide in Nurses/Clinician s and Learners: An Urgent Call for Action to Enhance Professional Wellbeing and Editori al article Expert opinio n To bring awareness for the alarming rise of depression and burnout among nurses, physicians None Data obtained by reviewing pertinent literature Depression ranges from 25-43% of nurses. Learners experienced high incidences of stress, burnout, and depression Organizatio ns must sponsor additional research on this issue. Randomized controlled trials are required to define the The death of a student to suicide is irreparable. We must overcome the current barriers and translate evidencedbased SUICIDE PREVENTION FOR SRNAs Healthcare Safety. Worldvie ws on EvidenceBased Nursing, 17(1), 25. https://doi.org/10 .1111/wvn.1241 6 48 , and nurses learners (Melnyk, 2020). (Melnyk, 2020). usefulness of these guidelines to dissuade depression and suicidal ideation among students (Melnyk, 2020). interventions quickly into interventions to reduce burnout, depression and revive joy (Melnyk, 2020). Wang, J., Song, B., Shao, Y., & Zhu, J. (2021). Effect of Online Psychological Intervention on Burnout in Medical Residents From Different Majors: An Exploratory Study. Frontiers in psychology, 12, 632134. https://doi.org/10 .3389/fpsyg.202 1.632134 Explor atory study This study aimed to analyze the incidence of burnout, anxiety, depression in medical residents from different majors (Wang et al., 2021). N= 210 medical residents (Wang et al., 2021). They conducted an online survey utilizing the depression, anxiety, and stress scale (DASS), the Maslach burnout inventory (MBI). SPSS 20.0 statistical software was used for data analysis (Wang et al., 2021). Anesthesia residents produced the highest level of depression, anxiety, stress, higher emotional status, lower sense of personal accomplish ment and higher depersonaliz ation (Wang et al., 2021). The authors recommend more research studies aim to anesthesia residents with the hopes to increase psychologic al consultation and guidance to prevent manage stressrelated problems (Wang et al., 2021). The online psychological intervention utilized effectively improved the psychological problems in medical residents (Wang et al., 2021). Horwitz, A. G., McGuire, T., Busby, D. R., Eisenberg, D., Zheng, K., Pistorello, J., Albucher, R., Coryell, W., & King, C. A. (2020). Sociodemograph ic differences in barriers to mental health care among Descri ptive study The purpose is to directly compare barrier classificati ons as a role of gender, race, school status, a high chance for suicide, n-3,358 college students from 4 US universities who screened positive for high suicide risk (Horwitz et al., 2020). Confidential online screening. The patient health questionnaire2 (PHQ-2) to screen for depression and the PHQ9, The alcohol use disorder identification test (AUDIT). Data analysis Depression (75%), suicidal ideation (87%), heavy alcohol (26%) (Horwitz et al., 2020). Future indications in this line of research are needed to add direction for marginalize d groups and to establish and evaluate intervention s and programs Financial concerns are more outstanding for women, minorities; privacy and stigma for men and young; cultural sensitivity for minorities (Horwitz et al., 2020). SUICIDE PREVENTION FOR SRNAs college students at elevated suicide risk. Journal of Affective Disorders, 271, 123130. https://doi.org/10 .1016/j.jad.2020. 03.115 Drum, D. J., Brownson, C., Hess, E. A., Burton Denmark, A., & Talley, A. E. (2017). College Students Sense of Coherence and Connectedness as Predictors of Suicidal Thoughts and Behaviors. Archi ves of Suicide Research, 21(1), 169184. https://doi.org/10 .1080/13811118. 2016.1166088 49 and not taking mental health treatment (Horwitz et al., 2020). Peerreview ed researc h article This structural equation modeling analysis strived to examine the associatio n between college students understan ding of coherence and connected ness and their developm ent of suicidal ideas and actions (Drum et al., 2017). using SPSS 24 (Horwitz et al., 2020). N=26,742 undergraduat e and Graduate students at 74 universities (Drum et al., 2017). To analyze a questionnaire containing 79items a model of structural equation was used. The followed variables such as vulnerability, coherence, connectedness distress and suicidality were used (Drum et al., 2017). that target mental health (Horwitz et al., 2020). Findings suggest that by adding connectedne ss and coherence to deter suicidal ideation, structural programs will raise the effectivenes s of the preventive program (Drum et al., 2017). To rescue existing conditions of health and to facilitate well-being, institutions need to create more research studies to make changes to students physical, interpersona l and social ecology (Drum et al., 2017). Heightening ecological contributions to experiences that improve selfconfidence and transform negatives into positives will enhance individuals' strength and stability (Drum et al., 2017). SUICIDE PREVENTION FOR SRNAs 50 Appendix C Theoretical Framework Figure 1. Depicts a visual presentation of the Theory of Moral Reckoning framework. (Nathaniel, A.K. 2006). SUICIDE PREVENTION FOR SRNAs Appendix D SWOT Analysis 51 SUICIDE PREVENTION FOR SRNAs 52 Appendix E Project Site Agreement Letter Leighton School of Nursing Nurse Anesthesia Program To whom it may concern, Hiranya Urbaez has permission to conduct her DNP project about analyzing the correlation and incidence of increased burnout, stress and anxiety with depression and suicidal ideation among first years, juniors and seniors during their progression through the Nurse Anesthesia training program. Thank you, Bradley Stelflug, DrAP, MBA, CRNA Director, DNP Program Nurse Anesthesia Track Assistant Professor, Leighton School of Nursing Marian University 3200 Cold Spring Road Indianapolis, IN 46222-1997 bstelflug@marian.edu 317-955-6720 (Office) 812-243-7994 (cell) SUICIDE PREVENTION FOR SRNAs 53 Appendix F Measurement Tools The GAD-7 was developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute. SUICIDE PREVENTION FOR SRNAs 54 SUICIDE PREVENTION FOR SRNAs 55 General Questions Survey Developed by the Principal Investigator 1- Have you experienced any signs of depression, increased or worsening anxiety, and/or burnout during the program? 2- Have you experienced suicidal thoughts at any time during the program? 3- Have you had any thoughts of quitting during the anesthesia program? 4- Do you ever need to reach out for help during the program? 5- Suppose you answered yes to the previous question. Did the help available on campus meet your expectations? 6- Do you feel the school does well reaching out and recognizing at-risk students throughout the program? 7- Do you agree that SRNAs should periodically be screened for early signs of depression, increased anxiety, and burnout throughout the program? 8- Do you feel the school does a good job fostering SRNAs mental health throughout the program? 9- Do you think SRNAs will benefit from a protocol that promotes mental health awareness and assists students at risk? 10- Do you believe the curriculum needs to include more time off for students between semesters? 11- Specify your year of training 12- Please Specify your gender 13- Choose an Age range: 20-25, 26-30, 31-35, 36-40, 41-45, 46-50, 51-55 20-30. 31-40. 41-55 SUICIDE PREVENTION FOR SRNAs Appendix G IRB Approval Letter 56 SUICIDE PREVENTION FOR SRNAs Appendix H CITI Training Certificate 57  ...