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... Career Curriculum & Badging Using Canvas FYS & HWB Careers Course in Curriculum Ongoing/Senior Seminar (finish all courses w/ a B or higher) Get Started M1 & M2: Learn about The Exchange & CORE, attend an appointment or office hours Complete Assessments M3: Complete 1 personality and 1 career assessment with a reflection in Canvas Assess Your Skills: M4: Learn about employability and transferable skills, as well as NACE competencies Research Careers & Employers M5: Conduct career & employer research with a reflection and complete an informational interview Get Your Documents in Order M6: Get resume approved, create a cover and thank you letter, as well as a reference page Prep for an Interview M7: Prepare for interviews-virtual and in person, and complete a mock interview Set Yourself Apart M8 & M9: Create a robust LinkedIn account, take a professional headshot, and learn about workplace and dining etiquette Plan for Post Grad Success M10: Learn about different post graduation paths, personal finance, and other adulting topics. Complete the First Destination Survey and conduct exit interview with The Exchange Get Connected & Gain Experience Attend career related events, join organizations, complete service and get connected to the working world. Participate in mission trips, study abroad, internships, gain leadership experience, and more!  ...

... An Undergraduate Teaching Assistant Programs Impact on the Faculty Teaching Experience: A Phenomenological Approach 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 Mona T. Kheiry, Ed.D. May 2024 ii Copyright by Mona Kheiry All Rights Reserved May 2024 iii Fred S. Klipsch Educators College Marian University Indianapolis, Indiana APPROVAL OF THE CAPSTONE PROJECT This capstone project, An Undergraduate Teaching Assistant Programs Impact on the Faculty Teaching Experience: A Phenomenological Approach, 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. Date: iv Table of Contents Tables and Figures ........................................................................................................................... vii Abstract .......................................................................................................................................... viii Introduction ......................................................................................................................................1 Background Information ........................................................................................................................... 2 Prediagnostic Work ................................................................................................................................... 3 Problem Statement & Significance ........................................................................................................... 5 Purpose Statement ................................................................................................................................... 6 Literature Review ..............................................................................................................................8 Employer and Educators Wants and Needs............................................................................................. 8 The Changing Student Body .................................................................................................................... 10 Faculty Stress and Workload................................................................................................................... 13 Ideas for Faculty Supporting Underprepared Students .......................................................................... 16 Undergraduate Teaching Assistant (UTA) Programs .............................................................................. 18 Intervention .................................................................................................................................... 22 Methodology ................................................................................................................................... 25 Setting ..................................................................................................................................................... 25 Area of Focus .......................................................................................................................................... 26 Participants ............................................................................................................................................. 26 Courses................................................................................................................................................ 27 Faculty ................................................................................................................................................. 28 Undergraduate Teaching Assistants ................................................................................................... 30 Researcher Role ...................................................................................................................................... 32 Procedure................................................................................................................................................ 33 Inviting Faculty Participants ................................................................................................................ 34 Expectations of Faculty ....................................................................................................................... 35 Inviting Students to Apply to the UTA Program.................................................................................. 36 Compensation for UTAs ...................................................................................................................... 36 UTA Responsibilities............................................................................................................................ 37 Undergraduate Teaching Assistant Training ....................................................................................... 38 Instrumentation ...................................................................................................................................... 40 Data Collection ........................................................................................................................................ 41 v Classroom Observations ..................................................................................................................... 41 Interviews............................................................................................................................................ 43 Validity and Reliability............................................................................................................................. 43 Data Analysis ........................................................................................................................................... 44 Connections to Theoretical Framework.................................................................................................. 46 Confidentiality ......................................................................................................................................... 48 Results............................................................................................................................................. 49 Introduction ............................................................................................................................................ 49 Painting a Picture - Classroom Observation Findings ......................................................................... 49 Painting a Picture Descriptions from Participants ........................................................................... 52 Themes and Subthemes.......................................................................................................................... 55 Conclusion ........................................................................................................................................... 76 Discussion........................................................................................................................................ 77 Interpretation of Findings ....................................................................................................................... 77 Theme 1: Extra Layer of Support ........................................................................................................ 78 Theme 2: Enhanced Teaching Experience .......................................................................................... 84 Theme 3: UTA Bridged a Gap .............................................................................................................. 90 Theme 4: Professional Growth Through Self-Reflection .................................................................... 93 Revised Conceptual Assumptions ....................................................................................................... 94 Limitations .............................................................................................................................................. 96 Recommendations for Future Research ................................................................................................. 97 Implications and Recommendations ...................................................................................................... 98 Challenges to Consider ......................................................................................................................... 100 Conclusion ............................................................................................................................................. 102 References..................................................................................................................................... 104 Appendix A .................................................................................................................................... 124 Appendix B .................................................................................................................................... 125 Appendix C .................................................................................................................................... 126 Appendix D .................................................................................................................................... 127 Appendix E .................................................................................................................................... 130 Appendix F .................................................................................................................................... 134 Appendix G .................................................................................................................................... 137 Appendix H .................................................................................................................................... 140 vi Appendix I ..................................................................................................................................... 142 Appendix J ..................................................................................................................................... 144 Appendix K .................................................................................................................................... 145 Appendix L..................................................................................................................................... 146 Appendix M ................................................................................................................................... 147 vii Tables and Figures Table 1: Benefits and Challenges of Teaching Assistants ........................................................................... 19 Table 2: Course Demographics ................................................................................................................... 27 Table 3: Faculty Demographics ................................................................................................................... 28 Table 4: Student Demographics .................................................................................................................. 31 Table 5: Observation Schedule ................................................................................................................... 42 Table 6: Interview Details ........................................................................................................................... 43 Table 7: UTA Responsibilities ...................................................................................................................... 53 Table 8: Themes, Subthemes, and Faculty ................................................................................................. 56 Table 9: List of Themes and Subthemes ..................................................................................................... 76 Figure 1: Faculty-Student Dependency Cycle ............................................................................................. 22 Figure 2: Faculty-UTA-Student Capacity-Building Tripartite ....................................................................... 23 Figure 3: Hermeneutic Circle ...................................................................................................................... 24 viii Abstract Several job demands impact faculty engagement (Finkelstein, 1996; Peterson, 2004; West, 2012), which has implications for the success of higher education institutions and the student experience (Delmas & Childs, 2021; Cole et al., 2012; Hakanen et al., 2006; Harter et al., 2002; Marken, 2021; Shahid, 2019). The purpose of this qualitative study is to illuminate the lived experience of higher education faculty as they engage in a job resource of an Undergraduate Teaching Assistant (UTA) program. The focus of the study is the faculty perspective as they interact with their UTAs and the impact on faculty as UTAs support students of varying levels of preparedness. The data from the study indicates faculty had an overall positive experience with the program with four main themes emerging, including UTAs being an extra layer of support for faculty, UTAs creating an enhanced teaching experience for faculty, UTAs bridging a gap between faculty and students, and interactions with UTAs contributing to faculty professional growth. This research provides an enhanced understanding of how a UTA program impacts the faculty teaching and learning experience and receive teaching support in their classrooms. Administrators, student support centers, and faculty support centers can have a better understanding of the faculty experience when receiving classroom support, and how this impacts faculty inside and outside of the classroom. Keywords: higher education, faculty engagement, teaching support, undergraduate teaching assistants, underprepared students 1 Introduction Shortly after the height of the COVID-19 pandemic, several articles were published by popular and reputable higher education news sources discussing faculty disengagement (McClure & Fryar, 2022; McClure, 2022; McClure, 2021; Noonoo, 2020; Warner, 2021). While the articles all have slightly different angles as to the reasons for and symptoms of faculty dissatisfaction, they have a similar, basic message faculty are feeling devalued, which is negatively impacting faculty morale (McClure & Fryar, 2022; McClure, 2022; McClure, 2021; Noonoo, 2020; Warner, 2021) and low morale is impacting faculty behavior (McClure & Fryar, 2022; McClure, 2022; McClure, 2021). In addition, faculty are lacking the resources they need to do their jobs. McClure and Fryar (2022) perhaps put it best in their article The Great Faculty Disengagement, People need to feel safe, valued, and confident that they have the resources needed to do their jobs. And while those needs have always existed, the pandemic has brought new light to the extent to which our employers have failed to deliver. In many ways, institutions have neglected to create conditions for people to flourish (McClure & Fryar, 2022). The articles mirror what the researcher witnesses in her role at her institution. As Director of the Center for Teaching and Learning (CTL) of a higher education institution, the researcher interacts with faculty daily to support them with a myriad of pedagogical issues. Her interactions provide anecdotal evidence that faculty are feeling stressed, devalued, and disengaged. One faculty member shared: We are so stretched and pulled I feel like Play-Doh. We need more space, we need more faculty, and we need more resources. It feels toxic and that pulls out the joy. How can we do more with less? Do more with less were trying to teach students and being asked to do more with less. It makes it very difficult (Anonymous, personal communication, 2022). In addition, faculty are feeling ill-equipped to manage challenges they are encountering when teaching students. Over the last decade, there has been increased diversity within the college student body in the United States, encompassing socioeconomic status, increased enrollment in international 2 students, racial and ethnic backgrounds, and disability status (Brown & DiGaldo, 2011; Cleveland-Innes, 2020; Espinosa et al., 2019; Ortiz & Waterman, 2016; Smith, 2007). One of the results of the shifting student body is some students entering college at lower levels of preparedness, requiring faculty to increase remedial education in their courses (Brothen & Wambach, 2012; Saxon & Morante, 2014). Faculty feel inexperienced and unsupported in working with the shifting student population, causing feelings of frustration and powerlessness: Were growing and expanding, but not providing students and teachers with the training and support needed neurodiversity, ESL students, and students who read at a 4th-grade level in college. Theres no input and resources. We are expanding without the infrastructure to support it (Anonymous, personal communication, 2022). Students needing extra assistance are indicated as taking a considerable amount of time, contributing to stress levels of faculty (Quick, 2013). This study investigates how best to support higher education faculty with these challenges. Background Information Working at a Center for Teaching and Learning (CTL) in a small, private, faith-based, higher education institution in Indiana, the researchers role is to directly support faculty with their teaching and scholarship. The CTL assists faculty in several ways, including professional development for teaching strategies, curriculum design, classroom management, inclusive practices, and effective use of instructional technology within their curricula. While the CTL assists all faculty, regardless of full-time or part-time status, the majority of interactions are with full-time faculty. There are close to 200 full-time faculty at the university with a student-teacher ratio of 14 to 1 (National Center for Education Statistics [NSSE], n.d.). The university faculty handbook indicates faculty are to teach 24 credit hours in a 9-month period, which equates to 4 classes a semester. Enrollment has grown by more than 200% since 2001 and is currently around 4,000. The presidents State of the University meetings emphasize growth as a top priority of the institution, intending to increase enrollment to 8,000 by 2030. Faculty perception at the 3 university is that entering students appear to have wider gaps in levels of academic preparedness, which has implications for what faculty teach, the flow of the curricula, student-faculty interactions, and the teaching methods faculty use (Perin & Holschuh, 2019). The researchers daily interactions with faculty gave her anecdotal evidence that faculty were overextended and needed additional support. However, it was unclear to the researcher what support was needed and how this may or may not be related to the dissatisfaction discussed in the articles. The researcher conducted prediagnostic work to better understand the situation and how best to approach it. What phenomenon are faculty experiencing? How does the phenomenon impact them personally and professionally? How can a department like ours help? Prior to formal research, the researcher set forth to gain answers to these questions through prediagnostic work consisting of a survey and interview questions. Prediagnostic Work Heifetz & Linsky (2017) emphasize the critical importance of diagnosing a situation prior to implementing an intervention when practicing adaptive leadership. This prediagnostic work allows individuals to better understand the work, including challenges, dynamics, and complexities involved in a situation (Heifetz & Linsky, 2017). Root causes of problems can be identified, enabling individuals to address issues at the core rather than simply treating symptoms. This understanding helps facilitate an effective intervention tailored to the specific needs of the situation. An informal survey and informal interviews provided anecdotal data that allowed the researcher to explore the direction of the research. The prediagnostic survey was completed in the spring of 2022. The portion of the survey pertinent to this study included two qualitative questions: What can the CTL do to better support faculty overall and what specific offerings or support would faculty like to see? Three themes emerged from the survey, including a high workload, dissatisfaction with requirements from administration, and feeling 4 unsupported in helping certain student populations. Faculty indicated feeling too overextended to participate in CTL services or offerings. Due to their responsibilities and schedule, professional development was a luxury they couldnt afford. In addition, some faculty expressed dissatisfaction and frustration with professional development expectations from university administration, such as requiring faculty to complete training modules. Finally, faculty indicated they felt frustration toward the challenges of teaching the growing diversity of the student body and needed support in this area. Lack of experience in teaching certain populations, such as multilingual students, neurodiverse students, or students of varying academic preparedness, made it challenging for faculty to provide students with the support they needed to be successful. Interviews were conducted to further explore the faculty experience and to better understand what interventions could be implemented that would be supportive, impactful, and less of a drain on their workload. These confidential interviews were conducted by the researcher in the fall of 2022 with ten faculty from different disciplines, different tenure status, and a range in years of experience. A few questions targeting demographic information were included in addition to eight main questions (see Appendix A). Themes emerged from this process that mirrored data from the survey. Almost every faculty member mentioned that their workload is exhausting and draining. Some revealed that the level to which they were stretched with job tasks was so great it felt toxic, pulling the joy out of their work. They indicated a feeling of drowning and a desperate need for balance. Many of the faculty indicated it was necessary for them to teach an overload or that the number of students in their courses had increased. Another area that almost every faculty member mentioned was the mental and emotional demands of working with students from varying backgrounds and levels of academic preparedness. Students being dependent on faculty to assist them with basic academic skills was specifically mentioned. While the faculty clearly found teaching to be meaningful and energizing, they 5 found it challenging to try to teach students with varying academic starting points in terms of knowledge within the content area and knowledge and skills for how to be a successful college student. The prediagnostic data helped frame the problem. The survey and interviews revealed that faculty felt frustration when teaching certain populations of their students; however, faculty indicated not having extra time to engage in the CTL services that might be a support, such as professional development workshops and consultations. Administration requiring faculty to engage in CTL services is unlikely to feel motivating and supportive to faculty, who already feel overextended, overwhelmed, and frustrated. While offering voluntary professional development might help, the burden faculty feel from their workload seems to be a barrier to this potential idea. Feeling overextended and frustrated, faculty appeared to be protecting their time and energy by disengaging from extras, including professional development. Problem Statement & Significance A high workload, exhaustion, and feeling unsupported are antecedents of burnout and job disengagement (Afrahi et al., 2022; Aslam et al., 2018; Han et al., 2020; Sabagh et al., 2018). Ignoring signs of disengagement risks a negative impact on faculty, including their well-being, morale, burnout, and a decrease in their retention (Shahid, 2019; Hakanen et al., 2006; Cole et al., 2012; Harter et al., 2002). Moreover, faculty engagement has several implications for student success, institutional effectiveness, and employee productivity. Employee engagement is positively related to job attitudes (Hakanen et al., 2006), job performance (Bakker & Bal, 2010), health and wellness outcomes (Cole et al., 2012), organization profitability, and productivity (Harter et al., 2002). Moreover, faculty engagement is linked to an improved student experience (Marken, 2021) and student retention (Delmas & Childs, 2021). The research found that increased faculty engagement through strategically timed, encouraging emails had a positive, significant effect on student performance in the courses (Carrell & Kurlaender, 6 2020). Additionally, faculty who are burned out provide lower-quality instruction (Klusmann et al., 2008; Pyhlt et al., 2021). This investigation explores a classroom intervention that implements a job resource designed to support higher education faculty with their teaching. According to the Job-Demands-Resources model (Baker & Demoutri, 2007) a job resource refers to parts of a job that support individuals in achieving work goals, reducing job demands (and the resulting costs), and stimulating growth, learning, and development. A job resource also promotes overall well-being. A job demand is an aspect of a job that requires sustained physical or mental effort at a cost to the individual, such as time pressure, emotional demands, or physical exertion (Baker & Demoutri, 2007). Implementing an intervention that is considered a job resource has a two-fold effect of reducing burnout and increasing engagement, whereas eliminating a job demand only reduces burnout (Shaufeli, 2017). By investing in faculty with a job resource so they feel supported and connected within the institutional community, we can build capacity within our faculty which has implications that extend to our students and the overall health of the university. Purpose Statement Given the prediagnostic work and guidance of the literature, the purpose of this phenomenological qualitative study is to illustrate the lived experience of higher education faculty as they engage in an implemented job resource of an Undergraduate Teaching Assistant program. If implemented effectively, the researcher believes undergraduate teaching assistants embedded into the classroom can be a source of faculty support, potentially easing workload and stress. This research provides an enhanced understanding of the faculty teaching and learning experience, particularly experiences related to students of varying levels of academic preparedness and how faculty experience teaching support in their classrooms. Administrators, student support centers, and faculty support 7 centers can have a better understanding of the faculty experience when receiving classroom support and how this impacts faculty inside and outside of the classroom. The following research questions are addressed with an emphasis on the lived experience of participants, which is the core of phenomenological research. Phenomenology is a qualitative research approach that explores the essence of human lived experiences, which are the subjective perspectives of individuals as they encounter a phenomenon. By deeply understanding the lived experience of individuals, researchers gain insight into the meanings, emotions, perceptions, and interpretations that individuals encounter, helping to better understand the phenomenon (Heidegger, 2005). The research questions were guided by the prediagnostic work and the review of the literature. 1. How do faculty experience stress and workload when engaging in an Undergraduate Teaching Assistant program? 2. How does an Undergraduate Teaching Assistant program impact the lived experience of faculty with their job, as a whole? 3. How does an Undergraduate Teaching Assistant program impact the lived experience of faculty in the classroom as it relates to teaching students of varying academic preparedness? This capstone project contains five main sections, including a literature review, a description of the implemented intervention of an Undergraduate Teaching Assistant program, a methodology section describing the research methods, and a results section, including a discussion of the implications of research findings. The literature review steps through five areas to better understand the context of the challenge and what ideas already exist. These areas include employers and educators wants and needs, the changing student body, faculty stress and workload, ideas for faculty supporting underprepared students, and benefits and challenges of undergraduate teaching assistant programs. 8 Literature Review The review of literature starts by better understanding what employers and educators want and need from graduating students, which can help frame an appropriate intervention. It then moves to the realities of the teaching landscape of faculty, reviewing changes in the student body that faculty find challenging, as well as the workload and subsequent stress faculty encounter in their jobs. Understanding this context supports an adaptive approach and helps to mitigate less effective, technical ideas that do not consider all factors. The literature review ends with ideas for faculty supporting students with varying levels of academic preparedness. Employer and Educators Wants and Needs The core of faculty jobs at the university in this study is to teach students to be prepared to pursue professional goals. The university promises its students will be exceptionally well prepared for a good life and professional pursuits through academic programs that guide students in achieving excellence and an engaged approach to learning on campus and beyond. It is expected that students achieve these outcomes from multiple avenues, however, faculty bear a significant responsibility. Given these expectations of faculty, a better understanding of what outcomes employers and educators want and need from graduating students can frame an appropriate intervention. The literature reveals that employers and educators want graduates who can take on challenges and persevere (Hart Research Associates, 2013; Finley & McConnell, 2022). Alsop et al. (2006) define empowerment as the process of enhancing an individuals or groups capacity to make purposive choices and to transform those choices into desired actions and outcomes. They go on to discuss the impact of interventions on empowerment. It is hypothesized that interventions to improve agency and enhance opportunity structures can increase peoples capacity to make effective choices and that this can bring about other development outcomes (Alsop et al., 2006). This explanation aligns with what 9 employers are looking for in their employees. Hart Research Associates (2013) conducted a study to better understand employer priorities and what they think college students need to succeed in the workplace. The study revealed the following: Nearly all those surveyed (93%) agree, a candidates demonstrated capacity to think critically, communicate clearly, and solve complex problems is more important than their undergraduate major. More than nine in ten of those surveyed say it is important that those they hire demonstrate ethical judgment and integrity; intercultural skills; and the capacity for continued new learning. More than three in four employers say they want colleges to place more emphasis on helping students develop five key learning outcomes, including: critical thinking, complex problemsolving, written and oral communication, and applied knowledge in real-world settings (Hart Research Associates, 2013). In addition, the American Association of Colleges and Universities (AAC&U) conducted a national survey of higher education professionals (Finley & McConnell, 2022). As well as including questions on what common institutional learning outcomes shape student success, they also asked what mindsets, aptitudes, and dispositions were essential for success and closing the equity gap. The top four items indicated as being most important for higher education to develop in students included curiosity and capacity for lifelong learning, persistence, agency/ability to take initiative, and resilience. Administrators and educators felt these mindsets, aptitudes, and dispositions were just as important as other, more explicit student learning outcomes (Finley & McConnell, 2022). Harsh and Mallory (2013) specifically discuss the elements that build learning capacity and increase the performance of at-risk students. They posit that building capacity for successful students is best realized by focusing efforts on four areas, including: 10 Cultivating learning by going to deeper levels of learning, organizing learning clearly with all important information included, and focusing on the meta-skills needed to be successful with a single skill. Intentionally incorporating cognitive strategies that serve as a learning chain to build full understanding along a successive learning path. Supporting students to develop resilience and self-efficacy to build their personal success factors. Cultivating student success through scholarship, service, and the growth of leadership skills (Harsh & Mallory, 2013). These outcomes for students are important, outlining the skills, habits, attitudes, and values needed to build capacity in students so they can be successful in college classrooms and beyond. However, the implication is that faculty are responsible for teaching our students these capacitybuilding habits. Is it realistic for faculty to be taking on these multilayered outcomes given the current context in which they teach? The researcher continued the review of the literature to better understand the challenges of teaching students of varying academic preparedness that faculty discussed in the prediagnostic work, which may help outline a more holistic approach to supporting both students and faculty. The Changing Student Body The current higher education student body in the United States is the most culturally and socioeconomically diverse than ever before (Habley, 2012; Snyder et al., 2019; Tienda, 2013), with increasing diversity in college enrollment rates since 2000 for those between 18-24 years old (Hussar et al., 2020). This wide range of diversity includes ethnicity, race, international students, socioeconomic status, level of academic preparedness, and disability status (Brown & DiGaldo, 2011; Cleveland-Innes, 11 2020; Espinosa et al., 2019; Ortiz & Waterman, 2016; Smith, 2007). At the university in question, admission test scores are no longer required, which faculty perceive as leading to a wider array of academic preparedness for those entering. Students are considered underprepared if they perform below college standards in math, reading comprehension, and/or writing skills (Hughes, Gibbons, & Mynatt, 2013), and are often required to take remedial coursework (Provasknik & Planty, 2008). Underprepared students and increases in remedial education are continuing (Brothen & Wambach, 2012; Saxon & Morante, 2014) with one study indicating that 60% of those entering community colleges are required to take remedial education (Smith Jaggars & Hodara, 2013). Faculty feedback received from the interviews the researcher conducted indicated concerns over the basic reading and writing levels of students with one faculty member stating that some students are reading at a 4th-grade level. Other concerns surrounding preparedness included a lack of basic knowledge in the content area, deficient study skills, student lack of understanding of how they best learn, and a shortage in habits that increase their chances of learning and retaining information, such as note-taking and active listening strategies. Other student challenges included students with high anxiety, working with absent student-athletes, teaching students whose first language is not English, and supporting student accommodations for those with disabilities. Some of the faculty indicated feelings of powerlessness in helping with some of these challenges. While some faculty indicated in the prediagnostic work that student changes in academic preparedness are due to less stringent university entrance requirements, the research surrounding this is unclear. The literature investigating test-optional admission practices is limited and complex. While studies do find an increase in applications after adopting test-optional policies (Maguire, 2018; Lofaro, 2021; Matheny, 2022), literature shows that there is small to no impact on racial, ethnic, and socioeconomic status on the student body (Bennett, 2022; Rubin & Gonzlez Canch, 2019; Saboe & Terrizzi, 2019; Matheny, 2022). Moreover, the literature shows that graduation rates and GPAs are 12 similar to those who submit scores (Lofaro, 2021; Matheny, 2022; Osaki, 2022), implying that any changes in the student body do not negatively impact student success. There is an assumption that graduation rates and GPAs indicate student preparedness. Matheny (2022) states, Although there may be small differences in these outcomes for submitters and non-submitters, test-optional policies do not result in admitting students who are substantially less prepared, as some have feared. However, the literature does not consider modifications higher education institutions implement in student support services or changes in faculty teaching practices to ensure student success. This is a gap in the literature and inconsistent with the findings in the prediagnostic work for this study. Faculty indicated that the student population appears less prepared now than in years past, requiring them to teach remedial content in their courses to help students succeed. In one study, Sachar et al. (2019) wanted to better understand what underprepared students experienced as well as the faculty interactions and perceptions of these students. While faculty had a mix of positive and negative perceptions, one theme was frustration with students lack of preparedness and feelings of helplessness when working with them. Faculty indicated the top teaching strategy in working with these students is individual support. Another study by Quick (2013) analyzed faculty perceptions and preparedness in working with academically vulnerable (underprepared) students. Faculty self-reported data indicated that 80% felt they played a vital role in meeting the educational needs of the academically vulnerable, but that 82% felt the responsibility to assist these students should fall on student learning centers. This indicated that faculty seemed to want to help, but perhaps felt there were barriers to adequately help or felt assisting students with remedial education was simply not their job. In terms of preparedness to teach this population, 44% of faculty indicated they had no formal training or only on-the-job experience. The study suggested that half of respondents felt they could benefit from further professional development in instructional strategies to support academically vulnerable students (Quick, 2013). In addition, 48% of faculty from disciplines other than teacher education indicated that making accommodations for these 13 students decreased their teaching effectiveness; the top frustration in teaching students with reading and writing difficulties was having a lack of time (Quick, 2013). Faculty frustrations could also be due to the perception that assisting students with remedial work is not their job and lowering their job status. Status is defined as the ranking of ones position in an organization surrounding dimensions of power, prestige, and esteem (Nelson & Quick, 2007). When employees feel they must complete tasks that are considered lower status, this can create status inconsistency. Status inconsistency occurs when an individual perceives a discrepancy between status hierarchies that are inconsistent with one another (Bacharach et al., 1993). For example, level of education and job tasks might create a status inconsistency for higher education faculty if they have a Ph.D. and are teaching students basic reading and writing skills. Status inconsistency can lead to role stress (Bacharach et al., 1993), which is specifically mentioned in the literature surrounding faculty stress. Sabagh et al. (2018) found that one of the predictors of faculty burnout was over-qualification, which is the perception that one is overqualified for the work. While several ideas are mentioned to help support faculty in teaching underprepared students, faculty high workloads and lack of time are persistent themes in the literature, making some of the ideas mentioned seem unrealistic. The researcher continued the review of the literature to better understand faculty workload and sources of faculty stress. Faculty Stress and Workload Employers and educators want students who can persevere and readily apply cognitive and affective skills and habits to nuanced situations (Hart Research Associates, 2013; Finley & McConnell, 2022). There seems to be an expectation that institutions, through their faculty, teach students these skills. However, this expectation does not consider the high faculty workload and resulting stress. Research surrounding faculty stress has been explored since the mid-1980s with some research as early 14 as 1956. Eckert and Williams (1972) conducted research focused on how faculty view themselves and their jobs at 43 private and public colleges in Minnesota. They included a section focused on faculty satisfaction and dissatisfaction. In their research, faculty listed fewer dissatisfactions than satisfactions, which the authors felt suggested reasonably high morale with their jobs. Most frequently scored irritations or frustrations included colleagues poor attitudes and inadequate salaries. Also included are routine duties, long hours, poor facilities, excessive committee work, inter-faculty relations, and administrative red tape. They compared the data to a previous questionnaire conducted years earlier (Eckert & Stecklein, 1961) and found increases in complaints specifically with inter-faculty relations, poor facilities, long hours, and excessive committee work. Similar stressors are found in later studies. Gmelch et al. (1985) conducted a national study that included 40 public and 40 private Ph.D. granting universities selected at random. They found the top three stressors to be imposing excessively high selfexpectations, securing financial research support, and having insufficient time to keep abreast of current developments in the field. Other sources of stress included inadequate salaries, writing for publications, heavy workloads that cannot be finished in a normal workday, job demands interfering with personal activities, inadequate progress, frequent interruptions, and attending meetings (Gmelch et al., 1985). More recent literature has similarities to the older literature but suggests increasing responsibilities contributing to stress. Sabagh et al. (2018) analyzed research on faculty burnout to synthesize the studies and identify themes. They found that job demands and a lack of resources had a clear damaging effect on faculty burnout. Predictors of burnout in the workplace included high workload, role conflict, role ambiguity, over-qualification (the perception that one is overqualified for the work), pressure to increase research, high numbers of students taught, lack of performancecontingent rewards, and imbalances between teaching, research, and service. A qualitative study in the UK looked at associated stressors of academic roles at teaching-focused universities (Darabi et al., 2017). They conducted online interviews with 31 faculty and found several factors contributed to stress. 15 Factors included increasing numbers of students, heavy workloads, increasing administrative burdens, time pressure, poor management, funding cuts, and the changing nature of higher education. They specifically mentioned that the demands of the job cannot be accomplished within normal working hours (Darabi et al., 2017). In addition, the Higher Education Research Institute conducted a 2016-2017 national Undergraduate Teaching Faculty Survey which had a section focused on sources of faculty stress. The top three items faculty reported as being extensive sources of stress included self-imposed high expectations, lack of personal time, and increased work responsibilities. Moreover, 31.4% of faculty considered leaving academia, and 44.6% considered leaving their current institution for another institution (Stolzenberg et al., 2019). Since workload and lack of time were a significant demand identified through my prediagnostic work and were revealed consistently through the literature, I specifically investigated this area further. Studies have indicated that faculty workload has significantly increased over the years (Nakano et al., 2021; Rosser & Tabata, 2010; Townsend & Rosser, 2007). Nakanos et al. (2021) findings indicated that academic workload has increased significantly in ten years from 2007 to 2017, which may be attributed to a significant increase in evaluations due to accountability metrics and administrative duties attached to increasingly complex and cumbersome administrative processes. Other studies indicated that perceived workload contributed to faculty stress (Donovan, 2018; Adrian et al., 2014). A suggestion in the literature for supporting faculty with workload issues is for higher education administrators to create a quantitative workload framework or calculation to better ensure a fair balance between research, service, and teaching duties (Blodgett et al., 2018; Griffith & Altinay, 2020). While this suggestion has its merits, its not within the power of a department like ours to make this kind of contribution. Another factor in faculty workload is the amount of time faculty need to devote to students with varying levels of academic preparedness (Quick, 2013). The prediagnostic work revealed the challenges 16 faculty face when working with students of varying academic preparedness and other needs. Would an intervention specifically supporting faculty with the diverse needs of students be an appropriate job resource for faculty? To frame a possible innovation for supporting faculty in this way, it is important to understand what ideas already exist in the literature. Ideas for Faculty Supporting Underprepared Students Faculty indicated in the prediagnostic work that supporting students of varying academic preparedness was a time-consuming challenge they felt ill-prepared to manage. Ideas for how to support faculty with this challenge were investigated through the literature. While many ideas were reviewed, the researcher was looking for an innovative approach that would not overburden faculty. Faculty professional development for teaching underprepared students is an overarching common recommendation in the literature for supporting faculty in understanding and effectively teaching this population (Gabriel, 2016; Sachar et al., 2019; Quick, 2013; Shankle, 2016). In addition, its suggested that faculty provide underprepared students individual support (Sachar et al., 2019; Shankle, 2016), although a definition of individual support was not provided. What was absent in the literature regarding teaching underprepared students in higher education is differentiated instruction, which is more commonly used in K-12 schools to support students with varying abilities (Santangelo & Tomlinson, 2009). As Smale-Jacobse et al. (2019) describe it, differentiated instruction is a studentcentered method of instruction that acknowledges students different starting points. Teachers intentionally create curricula that adapt to students learning differences, executing the adaptations while carrying out instruction (Smale-Jacobse et al., 2019). While Santangelo & Tomlinson (2009) have found that the successes of differentiated instruction discovered in the P-12 environment can be realized in higher education settings, several barriers have been revealed in the literature. The top five listed barriers include teacher lack of knowledge of this type of instructional method, time constraints, 17 class size, school administration and facilities, and lack of resources (Lavania & Nor, 2020). Santangelo & Tomlinson (2009), while advocating for differentiated instruction, acknowledge the amount of time required by instructors: Effective differentiation requires a significant amount of time, effort, and dedication on the part of the instructor. In so far as the preparation for any college course can be characterized as substantial, preparing for a course that involves differentiated content, processes, and products proved even more intensive. (Santangelo & Tomlinson, 2009, p. 14) However, smaller sizes of P-12 classes do appear to help teachers more readily utilize this method. In 2007 and 2008, the Canadian Education Association conducted a study to better understand the impact of class size on student learning. The class sizes were reduced to 20 or fewer students in 90% of primary classes and 23 or fewer in all primary classes. Nearly three-quarters of the teachers reported that the reduction in class size allowed them to increase small-group work and differentiated instruction (Bascia, 2010). While the research surrounding class size and differentiated instruction is promising, several studies indicate higher education faculty have a lack of time to engage in differentiated instruction, professional development, and individualized learning (Lavania & Nor, 2020, Griffith & Altinay, 2020; Hott & Tietjen-Smith, 2018; Quick, 2013; Shankle, 2016). Lack of time and experience has made some higher education faculty turn to other methods to close the gap between underprepared students and expected course outcomes. Faculty are feeling pressured or even forced to dilute course content so underprepared students can complete their courses (Brothen & Wambech, 2012; Pitts et al., 1999). In addition, some faculty are inflating grades in order to retain students and keep students happy (Shankle, 2016). It appears some faculty are feeling frustrated and out of options when it comes to underprepared students, lowering expectations instead of building capacity within the students to achieve course goals. Other recommendations to help support faculty in teaching underprepared students in higher education included creating programs or learning communities so faculty can network and share resources (Quick, 2013; Sachar et al., 2019), 18 working closely with advising and tutoring centers (Huston, 2019; Quick, 2013), modifying pedagogy to be more engaging (Gabriel, 2016), building trust and rapport with underrepresented students (Gabriel, 2016), and establishing a peer mentoring program (Shankle, 2016). While some faculty are lowering expectations to make courses easier for students who need extra assistance (Brothen & Wambech, 2012; Pitts et al., 1999; Shankle, 2016), the literature shows the flaws of this approach, as employers and educators want students to be resilient (Hart Research Associates, 2013, Finley & McConnell, 2022). How can we use alternative approaches that empower students and build capacity rather than dependency? Moreover, is there a less time-consuming approach, providing faculty with more immediate support embedded in the classroom? Hustons (2019) article discusses innovative ways academic support can be integrated into courses. The concept intrigued the researcher, as it appeared to be an adaptive response to the situation that would help make progress in supporting faculty and potentially build capacity in students. The researcher investigated the concept to understand if integrating this type of framework into a teaching assistant program could be beneficial. Undergraduate Teaching Assistant (UTA) Programs Huston (2019), the director of academic success at Seminole State College in Florida, specifically discussed the concept of embedded tutors, a proactive strategy to partner with faculty to integrate student tutors into courses that need it most. Instead of tutors passively waiting for students to come to them, tutors work alongside the faculty to support students in various ways. Many of the tasks outlined for embedded tutors resembled teaching assistants. The researcher reviewed Undergraduate Teaching Assistant (UTA) programs and how they may or may not be an approach to supporting faculty and students. 19 Owen (2011) provided a review of the literature surrounding teaching assistants which have been utilized in various capacities since the 1960s. There are benefits and challenges of incorporating TAs in the classroom for the student learners, the student TAs, and for the faculty. The benefits and challenges cited by Owen are listed below in Table 1. Table 1: Benefits and Challenges of Teaching Assistants Teaching Assistants Learners Faculty Benefits Enhanced learning by teaching material Development of mentoring relationships Affective gains, such as enhanced self-esteem, awareness, and tolerance of others Compensation via credit or monetary Enhanced knowledge acquisition and academic skill development Learning from someone who understands their interests and motivations Relying on TA to answer questions and serve as a mediator or moderator with an instructor Challenges Possible violations of confidentiality Conflict of interest bias toward students Anxiety produced from evaluating and organizing peers Provoke anxiety and defensiveness in some students unfamiliar with the type of program May feel information received from peers is less valid Challenges traditional view of the instructor as the authority figure TAs assist with a variety of tasks, such as clerical, tech support, grading, facilitating discussion groups or lab, or creating & delivering lesson plans Gain insight from TA on classroom personalities, dynamics, and comprehension of course materials Utilize TAs as student mentors or to reinforce knowledge Time and energy are needed to supervise, monitor, and collaborate with TA TAs may need support with confidence or self-efficacy issues Faculty may feel guilt for not earning their keep Faculty reluctance from complete independence to being interdependent with a TA The information compiled by Owen appears very promising; however, she cautions faculty about the amount of time and energy that goes into a teaching assistant. Another study specifically mentioned that the investment of faculty time into the UTA program was mitigated when their office managed the organization and training of TAs. Begley et al. (2019) launched a study in which they conducted further analysis of a Service Learning UTA program. The 20 initial purpose of the program was to support faculty with the logistical aspects of service learning in their classrooms. However, what they found were rich relationships being established between the faculty and their TAs in which TAs were collaborative partners in improving the teaching and learning in their classrooms. TAs were engaged in different ways but were beneficial for the intended logistical tasks as well as serving as teaching consultants and pedagogical co-designers. Faculty found TAs helped improve the course and provided essential feedback. In addition, feedback from faculty did not include negative comments about invested time in working with TAs which the authors attributed to the extensive initial training program and subsequent weekly meetings with TAs through the ServiceLearning Office. This suggests that if the organization, management, and training of the UTA program is in a separate office, such as a Center for Teaching and Learning, perhaps this mitigates the amount of time invested by the faculty member (Begley et al., 2019). Begley et al. go on to state that since the management and instructional load of the TAs is not on the faculty, this allows them more time and space to develop the collaborative relationship with the TAs that the faculty values. Herrman and Waterhouse (2008) included a Lessons Learned section in their study about the benefits of using UTAs in a nursing program. In addition to discussing logistical scheduling conflicts, they point out the importance of discussing the confidentiality of student information to ensure UTAs are aware of this responsibility. They addressed this by adding a confidentiality statement to a course contract, as well as emphasizing it during orientation. They go on to discuss the need to ensure faculty understand the role and expectations of UTAs so they are effectively utilized. Some faculty did not benefit from their UTA as much as others due to scheduling conflicts, a perception of overburdening the UTA, the comfort level of the UTA with the materials given to them, and other challenges. Addressing these issues with faculty early on will help with the UTA programs success (Herrman & Waterhouse, 2008). Furthermore, they discuss the importance of intentionally evaluating the maturity level of UTAs. They address this by including specific scenarios in the interview process with potential UTAs. The 21 scenarios included information such as working with others, confidentiality, and helping students to help themselves. Intentionally assessing maturity was deemed important to better ensure the UTA would have the autonomy and level of responsibility needed in the role (Herrman & Waterhouse, 2008). Despite these lessons, 79% of students found the UTAs helpful in their program. In addition, the UTAs were 95.7% positive about their experience and faculty were 96.7% positive. Faculty appreciated the extra support the UTAs provided and the program was viewed as highly successful (Herrman & Waterhouse, 2008). Could an Undergraduate Teaching Assistant program be a job resource for faculty by directly integrating student support into the classroom? A UTA could support faculty in a variety of ways, including extra assistance for less prepared students. This could help faculty and higher education institutions approach students of varying academic preparedness from a capacity-building framework. The next section discusses the intervention of an Undergraduate Teaching Assistant program, including a description of the faculty-student dependency cycle, why a UTA program could be a more adaptive approach to supporting faculty, and the hermeneutic phenomenological method chosen to approach the intervention. 22 Intervention Based on the researchers prediagnostic work and review of the literature, she hypothesizes that faculty lack of time due to workload, inexperience, and lack of teaching support create feelings of frustration and powerlessness when encountering underprepared students in their courses (Quick, 2013). Feeling powerless to effectively support this population, some faculty lower expectations in varying ways, such as diluting course content and inflating grades (Brothen & Wambech, 2012; Pitts et al., 1999; Shankle, 2016). This creates a dependency cycle, locking students into perpetual underpreparedness, which continues to present challenges for faculty as the cycle persists (see Figure 1). Figure 1: Faculty-Student Dependency Cycle Underprepared students needing additional assistance Faculty lacking time, experience, and teaching support Faculty lowering expectations Faculty feelings of frustration and powerlessness This is an adaptive challenge. Unlike technical challenges that have a straightforward solution to fix the problem, adaptive challenges are more complex and require a different response (Heifetz, 1994). As Heifetz (1994) explains, we make headway with adaptive challenges by making progress with peoples values, attitudes, and habits of behavior. The literature seems to support an intervention that will bridge the gap for underprepared students, as this will also support faculty with their workload. 23 Simply providing faculty with professional development, while important, is a technical fix, as it does not consider faculty workload and subsequent lack of time to attend training and implement new strategies. The researcher hypothesizes that an adaptive intervention of an Undergraduate Teaching Assistant (UTA) program will be a job resource for faculty having the potential to offer meaningful support in the classroom, including mental assistance and indirect emotional relief for faculty by assisting in the classroom and supporting students. The researcher hoped that a UTA program would break the dependency cycle, providing extra teaching assistance for faculty and targeted learning assistance for students via capacity-building methods. With UTAs specifically trained to build capacity when assisting students, they can help build skills and habits students need so they are more prepared for future endeavors. A well-designed UTA program will be a job resource for faculty, creating a rich and meaningful partnership between faculty and UTAs, with both roles offering targeted support to less prepared students (see Figure 2). Figure 2: Faculty-UTA-Student Capacity-Building Tripartite Underprepared students needing additional assistance UTA Program breaks Dependency Cycle here. Faculty lacking time, experience, and teaching support Faculty lowering expectations Faculty feelings of frustration and powerlessness Phenomenology is the study of the nature and meaning of phenomena as they appear to us through experience or in our consciousness (2009, Finlay). The purpose of this investigation is to illuminate the faculty experiences while experiencing the phenomenon of a UTA program. Grbich (2012) explains phenomenology as an approach to better understanding both the hidden meanings and the 24 essence of experience. The phenomenological method was chosen to gain deeper and broader insight into the lived experience and perspectives of faculty as they participated in the intervention. Martin Heideggers (2005) philosophy of hermeneutic phenomenology was used, which focuses on the subjective experience of individuals to view the world as they see it. Unlike Edmund Husserls (18591938) original philosophy of transcendental phenomenology, hermeneutic phenomenology believes that interpretations are all we have and the hermeneutic cycle is used by the researcher for this interpretive process (see Figure 3) (Kafle, 2011). By better understanding the subjective experience of faculty as they engage in the UTA program, administrators, faculty support centers, and student support centers are better equipped with the perspectives of faculty, which informs how best to support and engage faculty as the student body shifts and changes. Figure 3: Hermeneutic Circle From What the Hell are Exemplary Hermeneutic Didactics? Placemaking by H. Ernste, 2018, Retrieved March 1, 2023, from http://ernste.ruhosting.nl/?p=627 In the next section, the methodology is discussed, including the setting of the study, involved participants, the researcher role, the procedure, instrumentation used, and data collection methods. 25 Methodology Undergraduate Teaching Assistant (UTA) programs can be successful for learners, faculty, and the UTAs in a variety of ways (Odom et al., 2014; Owen, 2011; Dickson, 2011). Given the prediagnostic work along with the success of UTA programs at other institutions, the intervention was to conduct a pilot program for UTAs organized and managed by the Center for Teaching and Learning. The phenomenological methodology is used to illuminate the teaching and learning experience of faculty within a course to which a UTA is assigned and the impact on their lived professional experience. One of the goals of the research is to better understand the facultys subjective perspectives of the program, which is why the hermeneutic branch of phenomenology is chosen. Setting The setting is a small, private, faith-based, higher education institution in Indiana with approximately 200 full-time faculty (National Center for Education Statistics [NSSE], n.d.) and 4,000 students. The organization has gone through substantial changes in terms of increased growth, acquisitions of other campuses and schools, faculty turnover, and other staffing changes. Approximately 20% of full-time faculty (42) resigned, retired, or announced an upcoming retirement during June 2023 through the spring of 2024 (FacultyDepartures2022-2023 & 2023-24, 2024). Based on the researchers prediagnostic work in the spring of 2023, which included a faculty survey and interviews, it appeared some faculty were feeling overwhelmed by their workload, were dissatisfied with university bureaucracy and requirements, and felt they needed more student support. In addition, during the fall 2023 semester when the UTA pilot program was being conducted, it was announced that both the provost and assistant provost of teaching and learning were both leaving the university. Both these positions are in leadership roles presiding over faculty. 26 Area of Focus Several delimitations have been identified for this study. The Undergraduate Teaching Assistant program was piloted in the August 2023 semester with four courses. This means four different courses with four faculty and four UTAs. The small number for the pilot was intentional, as it allowed the researcher the time, space, and budget to manage and organize this first iteration of this new program. In addition, courses with higher DFW rates were invited to participate in the program before expanding the invitation to other courses. These are courses in which a higher number of students receive a grade of D or F, and/or have higher withdrawal rates. The researcher also targeted courses with a minimum of 15 students enrolled in the course. Online courses were not included to keep the modality consistent. Also, the medical school was excluded, as the student population for the medical school is quite different from other populations due to the rigorous admission standards. In addition, the medical curricula are uniquely designed in such a way that the training needs for medical TAs are likely to be quite different. Participants Participants in this investigation are full-time, higher education faculty with the sampling a combination of convenience and purposive. Participants are selected from the higher education institution where the researcher is employed, allowing for ease of access. In addition, convenience sampling is suitable for this study since it was a small pilot program conducted within a certain amount of time. Purposive sampling is used, as the researcher selected faculty who teach courses that potentially have a higher need for extra assistance. Four courses at the university were included in the UTA pilot program, which included four full-time faculty and four undergraduate students. 27 Courses Higher-need courses were targeted for this study. Two criteria determine this higher need, including DFW rates and course size. Courses in which a higher number of students receive a grade of D or F, and/or have higher withdrawal rates may have a higher need for a UTA due to challenging content or other academic challenges. Additionally, courses that have more than 15 students may have a higher need for a UTA, as research has shown that there is a significant correlation between lower numbers of students per teacher and higher student achievement (Koc & Selic, 2015). Courses with higher numbers of students may have extra benefit from UTA assistance. Campus course data was used to determine the above criteria and the eligibility of courses for the program. The four courses in the pilot included one course each in mathematics, computer science, language, and nursing. It was also noted whether courses were required for students to take, regardless of their major, and whether there was a majority of majors or nonmajors in the course, as these demographics may impact the teaching experience for UTAs and faculty. The table below breaks down the information. Table 2: Course Demographics Course # of Students Other Sections? Required Majors/Nonmajors Course 1 13 No. Required for majors Majority majors Course 2 21 20 Required for certain majors Fulfilled language requirement Mix of majors and nonmajors Course 3 Course 4 26 Yes, one other section. Yes, two other sections. Yes, two other sections. Required for majors All majors All nonmajors The number of students listed is the number toward the end of the semester after students have withdrawn. While all UTAs mostly attended one section of the course, some UTAs opened up their time outside of class to students in other sections. Also, one UTA would attend the scheduled time for 28 both sections of a course when teaching a lesson. While the researcher tried targeting courses with a minimum of 15 students, which was based on data from previous semesters, course one had less than 15 students the entire semester. However, all other courses were well above the targeted minimum number of students, even after withdrawals. Faculty While full-time faculty were targeted for the UTA pilot program, no other criteria were considered for faculty beyond their interest in the program. The program consisted of three faculty who were recruited via an invitational email and one faculty member who was referred to the researcher because she needed assistance in her course. The email invitation contained cursory information about the UTA pilot, that the pilot was being organized and managed by the Center for Teaching and Learning, and an offer to reach out if the faculty had an interest in participating in the fall, 2023 semester. Faculty indicating interest attended an initial in-person or online meeting to further discuss the program, including specifics surrounding their role, the UTA role, the types of tasks and activities in which the UTA might engage while working in their course, and other logistical items. Faculty demographic information was obtained that may have an impact on the UTA experience, including the number of years they have taught and whether they had prior experience with a teaching assistant in one of their courses. See Table 3 for a summary of findings and faculty profiles with more detail below. To maintain confidentiality, participants have been given pseudonyms. Table 3: Faculty Demographics Faculty Years of College Teaching Hal Leah Sharon Kaylee 11 13 10 3.5 Prior Experience with Students Assisting in Class Yes Yes Yes No 29 Faculty Hal Faculty Hal had 11 years of higher education teaching experience and had graduate teaching assistants in the past. Faculty Hal decided to join the UTA pilot program because he had positive experiences with teaching assistants in the past. He felt students find teaching assistants more approachable and are sometimes more comfortable communicating with and asking their teaching assistant questions. He also felt that teaching assistants help students learn the material better. In addition, he felt his past experiences with teaching assistants may have helped prepare him for this experience but had doubts about having an undergraduate as a teaching assistant. Faculty Leah Faculty Leah had 13 years of higher education teaching experience and prior experience with students assisting with certain course aspects as interns. Faculty Leah decided to join the UTA pilot program because she thought it would be a good experience and had positive experiences with past offered programming through the Center for Teaching and Learning. She felt that her experience with students assisting in her class may have helped prepare her for the UTA program but was uncertain because the UTA role was quite different than the previous student assistant roles in her course. Faculty Sharon Faculty Sharon had ten years of teaching experience and had students assist in past courses, including student instructors, group tutors, graders, and a graduate teaching assistant. Student instructors differ from teaching assistants in that they do not have grading or teaching responsibilities. Faculty Sharon was excited to join the UTA pilot program so she could get extra support in the active learning environment and so the UTA could get teaching experience. Active learning and group work are emphasized in the course and Faculty Sharon finds it particularly helpful to have someone else in the classroom to help answer student questions and work with groups. She also knew she wanted her UTA 30 to assist with grading. Faculty Sharon felt her past experiences with students assisting in the classroom may have helped prepare her for the UTA program, but felt her focus was different from those past experiences. She wanted to ensure her UTA was getting an experience that helped with their growth. Faculty Kaylee Faculty Kaylee had three-and-a-half years of teaching experience and had never had a teaching assistant or students assist in other ways in the course. Professor Kaylee wanted to be a part of the UTA pilot program because she was interested in increasing peer learning. She felt having students learn from a peer and having an additional person in the class would be supportive. She also felt it would be good professional development and a learning opportunity for the UTA. Undergraduate Teaching Assistants Faculty chose their own UTA, which the researcher felt was important since faculty know their students personalities and class performance best. Faculty were asked to select students who had already taken the course in which they would be a TA. Students must have received an A or B grade in the course, had good attendance and engagement, be a junior or senior, have a GPA of 3.5 or more in the major, and a cumulative GPA of 3.0. Additional demographic information was obtained that may impact the UTA experience. All UTAs were majors in the courses in which they were assisting. In addition, all UTAs had prior tutoring experience and two UTAs also had various teaching experiences at the elementary school, middle school, or high school level. One of the UTAs was a former resident advisor, working with students in a variety of ways, including conflict resolution. Students felt these past experiences supported their UTA role. To maintain confidentiality, participants have been given pseudonyms. 31 Table 4: Student Demographics Teaching Assistant Natalie Grade Level Junior Major in TA Course Yes Yasmine Junior Yes Vaughn Junior Yes Brad Junior Yes Student Support Experience Resident Advisor Peer Tutor Peer Tutor Teaching experiences Peer Tutor Peer Tutor Teaching experiences UTA Natalie UTA Natalie had past experience as a Resident Advisor (RA) and a tutor. Her RA experience helped her with conflict resolution, communication skills, and connecting with others, all of which she felt transferred as support toward her UTA role. The tutoring experience also transferred skills to the UTA role by helping her gain practice in using different tutoring approaches and communication styles for different students. She also became proactive in asking students what they needed when tutoring. UTA Natalie also felt the UTA course associated with the program supported her in her role, specifically due to collaboration with the other UTAs, teaching a lesson, watching teaching videos, and by having another faculty member as a resource. UTA Yasmine UTA Yasmine had teaching experience at the elementary school level and started being a tutor at the same time she was a UTA. While she felt these experiences may have helped her with her UTA role, she thought the most beneficial help was to focus on the passion behind the role. Specifically, she felt passionate about student growth in the courses in which she assisted and felt proud of their progress. She was passionate about being an important resource for students and playing a role in their success. UTA Yasmine also felt the UTA course associated with the program supported her in her role, 32 specifically she felt the topics that were taught, teaching a lesson, reflecting on the UTA experience, and discussing the role with others were helpful experiences. UTA Vaughn UTA Vaughn had experience as a tutor before the program and continued tutoring while in the program. Being a peer tutor helped him gain experience in the relationship dynamics of supporting students close to his age and with increased communication skills, which he felt transferred to the UTA role. UTA Vaughn felt the UTA course associated with the program was supportive of his UTA role, particularly toward the end of the semester when he was picking up on the covered topics and could more readily apply them. He also thought it was helpful to receive immediate feedback from the UTA group on his teaching while in the course. UTA Brad UTA Brad had experience tutoring and teaching at the middle school and high school levels. He felt these past activities positively contributed toward his UTA role by giving him similar experiences from which to draw. He felt the UTA course associated with the program was supportive of his UTA role, as it reinforced topics he was familiar with and could readily apply. He felt increased confidence after teaching a lesson in class and valued the in-class discussions with other UTAs. Researcher Role The researchers role in the intervention was to organize the program, recruit faculty and UTAs, and orient and train the UTAs to prepare them to teach. The researcher observed in classrooms and conducted interviews. As the Director of the Center for Teaching and Learning, the researcher interacted with most of the full-time faculty at the institution in some capacity. These interactions often manifest as one-on-one consultations, small group work, workshops, information sessions, or supporting them via email. The researcher also collaborates and partners on campus initiatives involving faculty, which 33 results in interactions with faculty in meetings or on committees. The researchers role is typically one of support, assisting faculty with questions or goals they might have regarding their curricula, teaching, instructional technology, or scholarship. The researcher has had a moderate level of interaction with all the faculty participating in the pilot in varying ways. This may be a potential conflict of interest, as the researchers past relationships with faculty may have influenced how they responded to interview questions. In addition, the UTAs may have felt they couldnt answer honestly to the questions since the researcher organized and created the program. The researcher tried to mitigate this by encouraging faculty and UTAs to be completely honest about their experiences, emphasizing confidentiality with their answers. The researcher also let them know that their honesty was important so the program could be further improved in the future. In addition, the researcher had two colleagues partner to help conduct and gather classroom observation data. Having others involved in this portion of the research incorporates different perspectives, helping to mitigate potential researcher bias. The researcher organized the program. This means the researcher trained and communicated with the UTAs and the faculty, which is another way the researcher's role is a potential conflict of interest. The researcher believed that a UTA program could be extremely beneficial and a positive experience for the participating faculty. The researcher paid special attention to the messaging and interactions when engaging with faculty to not influence their thoughts and feelings with her own. To ensure perceptions did not make faculty feel pressured to respond in a certain way during interviews, the researcher was cognizant of the influence she had and did not share her opinions about the UTA program with faculty. Procedure The Undergraduate Teaching Assistant pilot program was conducted for 16 weeks during the fall 2023 semester. Data analysis was conducted during and at the end of the program via interviews and 34 classroom observations. To facilitate a fall start to the pilot, organization, and planning were occurring during the spring and summer before the program implementation. Several considerations were determined, such as faculty and UTA recruitment, and subsequent training to ensure participants had the resources and information they needed. Inviting Faculty Participants After reviewing course data, several courses were identified as being suitable for the UTA program, as they fit the criteria of an enrollment number of over 15 students and a history of higher DFW rates. The four courses in the pilot included one course each in mathematics, computer science, Spanish, and nursing. Three out of four faculty teaching the eligible courses for the fall, 2023 semester were identified by reaching out to department chairs. One faculty member from the nursing school was referred to the UTA program after the faculty member reached out to tutoring services for course assistance. The researchers first contact with the participating faculty was via email to gauge initial interest in having a UTA in their course. Once interest was established, a more detailed email invitation was sent about the program, including information about the Center for Teaching and Learning (CTL) organizing, managing, and training the UTAs, as well as the faculty role versus the UTA role. Faculty determined their interest in participating in the program by replying to the email invitation. Once faculty agreed to move forward with the program, a 30-minute meeting was scheduled to discuss details, logistical information, and resources so faculty better understood their role and the UTA role. Once the Institutional Review Board approved the research, faculty were informed of the study and invited to participate via email (see Appendix C), if they chose. They were provided with an informed consent form (see Appendix D) and notified that their participation was voluntary, with the ability to withdraw from the study at any time. Faculty were not compensated for being a part of the study. Confidentiality of collected data was noted. 35 Expectations of Faculty The first expectation of faculty was to recommend a student they believed would be a good fit as a UTA in their course, as faculty have a better idea of which students have excelled in their courses. While criteria were outlined to help faculty narrow down their UTA selection, faculty were also encouraged to select someone they felt would be a good fit, overall. In addition, its important to ensure faculty understand how they should interact with their UTA and how best to integrate a UTA into their course. The literature shows that faculty who did not have as impactful an experience with their UTAs were largely attributed to faculty misunderstanding of the UTA role (Herrman & Waterhouse, 2010). A meeting with faculty held before the start of the program helped support their understanding and comfort of their role and the UTA role. In addition, a handbook was created reinforcing the information discussed in the meeting (see Appendix E and Appendix F). Expectations were clearly outlined, including the following: Outlining how to utilize UTAs in the classroom, including types of tasks in which they can engage and interactions inside and outside of the classroom between faculty and UTAs Providing feedback for UTAs Identifying conflicts UTA social concerns, time and schedule pressures, and supporting UTAs with their teaching How to handle situations when things go wrong Moreover, a student-faculty agreement was created (see Appendix G) outlining the specific expectations of the course and faculty members. The agreement included tasks expected in the specific course, the schedule expectations, and expectations regarding how the UTA would interact with students and the instructor. The faculty also outlined their role in the partnership. The student-faculty agreement was submitted to the Center for Teaching and Learning after being signed by the UTAs and the faculty. 36 Inviting Students to Apply to the UTA Program The faculty involved in the program were asked to recommend a student they felt would be a good fit for the UTA role, which is a method of recruitment used by other programs (Owen, 2011; Begley et al., 2019). Faculty were asked to select students who had already taken the course in which they would be a UTA, received an A or B grade in the course, and had good attendance and engagement. In addition, students needed to be a junior or senior with a GPA of 3.5 or more in the major, and a cumulative GPA of 3.0. Students who applied to become a UTA submitted an application to the webbased job board managed by the career development team and attended an interview facilitated by the researcher. The interview emphasized the UTA role, the time involved in the program, as well as the importance of scheduling. Selected students then received an official invitation to be a part of the UTA program and were asked to enroll in the internship course associated with the UTA program, COL-360, Career Exploration Internship. Compensation for UTAs Many UTAs receive a stipend or hourly payment; however, some institutions have relied on other means, such as tuition waivers, course credit, or simply transcript recognition (Luckie et al., 2020; Herrman &Waterhouse, 2010; Begley et al., 2019). One article discussing the best practices for undergraduate teaching assistant programs stated that only offering credit instead of payment took unfair advantage of UTAs. Given the increasing attention to student debt, unpaid internships, and institutional integrity, it hardly seems fair or right to suggest that students work for free (Kinkead et al., 2019). As a result of this information, the UTA pilot program was offered as a pass/fail internship course, COL-360, Career Exploration Internship, and a $500 stipend per semester. The course was offered for variable credit between 1 and 3, which the students determined based on their needs. Students were encouraged to discuss credits with their advisors. The course included weekly 37 development sessions throughout the semester that supported UTAs with their duties. The combination of credit, payment, and experiential professional development all provided a solid compensation package for UTAs in this program. Faculty were not compensated. UTA Responsibilities UTAs are used in a variety of ways, dependent on discipline, level of class complexity, and class size (Kinkead et al., 2019). The pilot program allowed the faculty members to decide how theyd like to use the UTA. Faculty and UTAs were provided with the list of potential responsibilities below. A faculty member could add extra responsibilities as appropriate for their course, the characteristics of their students, and the UTA goals. A student-faculty agreement (see Appendix G) was completed by the faculty and UTA in collaboration to determine the specific tasks in which the UTA engaged, as well as other important logistical information, such as schedules. Possible responsibilities included: Attend all or most classes o Create and teach simple lessons o In-class demonstrations o Teach a class period while being observed by the instructor o Offer support during active learning Assist during labs Hold office hours Grade o Objective exams o Practice assignments needing feedback. o Other appropriate assignments (Straightforward/simple assignments when using a template) Lead review/study sessions 38 Lead small group breakout sessions Tutor Develop straightforward course assignments Administrative/Clerical maintain LMS, take attendance, print handouts, etc. Attend faculty department meetings Provide faculty feedback o Provide feedback about students to faculty o Provide feedback on pedagogical strategies, effectiveness of assignments/activities o Provide input on the design of assignments and lectures Undergraduate Teaching Assistant Training A comprehensive training program organized, managed, and facilitated by the Center for Teaching and Learning (CTL) was conducted throughout the semester. The Friday before the start of the semester, a two-hour orientation was held, and subsequent 1-hour sessions were continued weekly throughout the semester. The purpose of the comprehensive training program was to transfer the responsibility of preparing UTAs off of faculty so they could concentrate on building a collaborative partnership in the classroom with their UTAs. The orientation covered several topics to ensure UTAs were exposed to important information before their experience. Topics included: Clarification of the UTA role and expectations Clarification of the faculty role and expectations How best to interact with the faculty member Pressures and concerns they might encounter as a UTA Ethical behavior and confidentiality Capacity-building behaviors versus dependency-creating behaviors Scheduling expectations and time management 39 Logistics and expectations of the weekly UTA course The weekly sessions throughout the semester had a twofold purpose to provide an opportunity for UTAs to collaborate as they reflected on encountered experiences and challenges, and to cover additional teaching topics and microteaching practices. At the start of the course, UTAs were asked to openly share their UTA experience for the week. The rest of the class time was devoted to covering topics that were taught via various methods to show the UTAs different approaches, including active lecturing, case studies, group work, discussions, reflection activities, demonstrations, and more. A teaching observation checklist was created, which was used by the UTAs for all class sessions as they observed the course facilitator teach. In addition, each UTA was required to create a lesson plan and teach the class their selected topic. Teaching videos were also shown so the UTAs could reflect on teaching approaches that were useful or less effective. The teaching topics that were covered during these sessions included the following, with some topics spanning multiple class sessions: Metacognitive strategies Managing groups Learning strategies and learning science Presenting and explaining material Strategies and resources for difficult situations Safety issues Holding effective office hours Facilitating discussions Grading and feedback Understanding challenging students and individual needs 40 Ensuring UTAs were supporting students from a capacity-building framework was important to help break the student dependency cycle (see Figure 1). The concept of building capacity was introduced in the orientation during which UTAs reflected on what habits and approaches would build capacity and what creating a dependency might look like. This concept was emphasized further in the weekly sessions as students reflected on their interactions with students. UTAs were encouraged to give the work back to students whenever possible, asking probing questions so students could form approaches to challenges on their own. In addition, a lesson specifically focused on capacity building was taught in the course by one of the UTAs. The content for the lesson included: Guiding and preparing students to be independent and empowered Different approaches to handling student questions besides giving them an answer Getting students actively involved in their own learning Asking students to generate their own knowledge instead of UTAs generating it for them How to encourage students in a way that builds capacity In addition, a comprehensive Canvas course was developed with course content reflecting the topics above (see Appendix M), a syllabus (see Appendix H), reflection assignments, and logistical items. Instrumentation The researcher obtained approval from the Institutional Review Board (IRB) in June of 2023 (see Appendix B). Data were collected via interviews and classroom observation. Each participant was interviewed once due to the time constraints of the study. The semi-structured interviews allowed participants to share their in-depth, personal stories about their lived experience, providing their interpretation and meaning to the phenomenon. In addition to interviews, observations in the classroom were conducted to witness classroom interactions in real-time. Since a good portion of the support UTAs offer faculty are within the classroom setting while interacting with students and faculty, 41 observations to gather information within the social situation is likely to reveal behaviors and events that uncover deeper meaning into the phenomenon. Participants were provided an informed consent form and notified that their participation was voluntary with the ability to withdraw from the study at any time. All data were password protected and remained confidential. Pseudonyms were utilized to protect identities, and any information that is too specific, making it personally identifiable, was removed from the findings. Data Collection Observations were completed in September, October, and November of 2023 and interviews were conducted in November and December of 2023. The purpose of the data collection was to illuminate the lived experience of faculty as they engaged in a job resource of an Undergraduate Teaching Assistant (UTA) program. Classroom Observations Classroom observations were conducted twice during the semester. Observations were conducted in two phases an earlier phase in which the researcher observed all four courses and a later phase in which two peers each observed two courses. The observations conducted by the researcher were all scheduled during the week of September 25th, giving the UTAs a full month to integrate into the classroom. To help increase the validity and reliability of captured data, second observations were conducted during October and early November by peers. A professor in the school of education at the institution agreed to observe all four courses, however, two of the courses conflicted with his teaching schedule. The researchers colleague, an Instructional Designer at the Center for Teaching and Learning, conducted observations for the other two courses. See Table 5 for details. Observation notes were taken using an observation rubric (see Appendix I) focused on three main areas, including 1.) the role of the faculty member and reactions and interactions with the teaching 42 assistant and students, 2.) the role of the teaching assistant and their reactions and interactions with the students, and 3.) the role of students and their reactions and interactions with the teaching assistant and faculty. The observation study questions included the following: What does the faculty role look like when a UTA is present? How does the faculty member manage and hold the space when a UTA is present? How does the faculty member and UTA interact? What is the role of the UTA? What tasks are the UTA involved in? How does the UTA role appear to supplement and support the faculty role? What are the interactions like between the UTA and students? How do students appear to respond to the UTA? A short meeting was held before peer observations to discuss the purpose of the observations and to review the observation rubric. It was emphasized that the researcher was not looking for right or wrong answers, but rather, that observers were to simply witness interactions and note what they saw through their lenses using the rubric. Table 5: Observation Schedule Course Course 1 Course 2 Course 3 Course 4 Observation 1 Observation 2 9/29/23 Observer: Mona Kheiry 9/27/23 Observer: Mona Kheiry 9/27/23 Observer: Mona Kheiry 9/29/23 Observer: Mona Kheiry 10/24/23 Observer: Matt Hollowell, Asst. Prof. 11/1/23 Observer: Mary Clifford, Instructional Designer 10/30/23 Observer: Mary Clifford, Instructional Designer 10/18/23 Observer: Matt Hollowell, Asst. Prof. In addition, it was communicated to both faculty and students that the observations were nonevaluative and simply being conducted to observe interactions in the classroom. A whole section in the UTA Canvas course was devoted to what the observations were, what observers would be doing, and the non-valuative nature of the observations (see Appendix L). 43 Interviews Interviews were conducted by the researcher toward the end of the program for each UTA and each faculty member, resulting in eight interviews total (see Table 6). Interview questions included the collection of demographic information for both faculty and UTAs. An additional 14 questions were included for faculty (Appendix J) and 10 questions for UTAs (Appendix K). While follow-up interviews were anticipated, time constraints prevented additional interviews. Before the start of the interviews, a research protocol was followed during which participants were informed that there were no right or wrong answers to the questions and that the purpose of the study was to better understand their perspective and experience of the UTA program. Confidentiality of their answers was emphasized. With participants permission, the audio of interviews was recorded using the Evistr I357 Digital Voice Recorder and transcribed by a transcription service, Writ Large Assistance, LLC. The transcribed data were reviewed by the researcher for accuracy. Table 6: Interview Details Participant Natalie Yasmine Vaughn Brad Hal Leah Sharon Kaylee Role Teaching Assistant Teaching Assistant Teaching Assistant Teaching Assistant Faculty Faculty Faculty Faculty Date of Interview 11/17/23 11/17/23 12/1/23 12/1/23 12/6/23 12/12/23 12/14/23 12/14/23 Duration (Minutes) 19:48 20:47 29:25 19:45 22:47 40:82 34:54 36:45 Validity and Reliability Validity and reliability were considered in the collection of data. To ensure data dependability, interviews were conducted with both faculty and UTAs. The UTA data were supporting information used to corroborate and strengthen faculty data. In addition, data collection was diversified by including 44 classroom observations which provided a more comprehensive understanding of the phenomenon. By including three observers, other lenses were incorporated into the observations which helped mitigate researcher bias and provide a broader understanding of the experiences. To enhance transferability, detailed, rich descriptions were included in the findings. The researcher included two Painting a Picture sections found in the Findings section during which general data were discussed to provide a big-picture overview of the interactions between UTAs, faculty, and students. This lays out the context of the program and sets the stage for the discussion of themes. To ensure the findings were grounded in the experiences of the participants and to mitigate researcher bias, the researcher journaled while dwelling on the data. Reflecting on the data analysis, the researcher noted expectations she had of certain participants, the validity of the expectations, and whether those expectations played a role in how the data was being framed. By critically examining preconceptions, and how that may influence interpretation of the data, the researcher was able to better ensure data were being thoughtfully considered and not potentially discounted or misconstrued. Additionally, journaling helped integrate findings by making connections between emerging themes, the research questions, and the theoretical framework. This refined the interpretation of data by creating a sound narrative that better captured the essence of the participants lived experiences. Finally, transcripts were sent to faculty participants to ensure transparency in the data collection process. Faculty were invited to check the transcripts for accuracy if they felt inclined to do so. Data Analysis The evaluation of data for this study followed the hermeneutic phenomenological method. Since the purpose of phenomenological investigations is to seek to understand a phenomenon as a whole, the hermeneutic circle is used, where the parts inform the whole and the whole informs the parts (Peoples, 2020). As Peoples (2020) describes it, making sense of the phenomenon (the analysis of data) is a spiral 45 process and a constant revision of understanding as the researcher gathers new information. One moves from the different parts and pieces to the whole, and back again to parts and pieces, always taking into consideration the researchers own life experiences. Researcher journaling accompanies the evaluation of data as new conceptions arise and deep reflection occurs (Peoples, 2020). The general data evaluation of the transcribed interviews will occur using 6 steps outlined by Peoples (2021) regarding phenomenological investigations. The steps include: 1. Reading and deleting irrelevant information. 2. Creating preliminary meaning units, or the features and traits of the investigated phenomenon. 3. Breaking down preliminary meaning units into final meaning units or themes. 4. Synthesizing final meaning units into situated narratives for each participant. 5. Synthesizing situated narratives into general narratives, integrating all major themes. 6. Generating a general description. The review of classroom observation data was similar, reviewing the observation writeups to dwell on the experiences and interpret themes. Comparisons of first and second observations were made as well as comparisons between each course. Journaling accompanied the data analysis process, which supported the spiral process of the hermeneutic circle and allowed the researcher to reflect on any potential biases that were surfacing. As the researcher dwelled on the data, journaling allowed the researcher to step back and reflect on how the different themes and subthemes fit into the big picture. This reflection process resulted in the elimination of redundant subthemes and the consolidation of themes to present cohesive data that were more representative of the lived experiences of the participants. Analyzing potential biases resulted in looking at the data through different lenses to ensure information was being thoughtfully considered and not potentially discounted. This back-and-forth process of reviewing parts and pieces 46 and the whole facilitated through journaling allowed the researcher to sufficiently proceed through the hermeneutic circle. Connections to Theoretical Framework This hermeneutic, phenomenological qualitative study specifically investigates the lived experience, or Dasein, of faculty in higher education engaging in an Undergraduate Teaching Assistant (UTA) program. Martin Heideggers (2005) philosophy of hermeneutic phenomenology is used, which focuses on the subjective experience of individuals to view the world as they see it. Hermeneutic phenomenology believes that interpretations are all we have, and the hermeneutic cycle is used by the researcher for this interpretive process (see Figure 3) (Kafle, 2011). Connecting the researchers own Dasein to the theoretical framework emphasizes the researchers subjectivity of interpretation, the context of the experience, and meaning-making (Peoples, 2020). It provides the theoretical lens through which the phenomenon was filtered. Dasein Researcher Existing in the Experience Hermeneutics emphasizes the interpreter's pre-understanding, biases, and personal context as essential components in the interpretation of meaning (von Herrmann, 2013). The researchers process when using this framework is addressed by discussing their background and beliefs. By connecting this information to the theoretical framework, the theoretical lens is intentionally highlighted. Background: The researcher came from an education background, starting her career in the K12 context and then moving into higher education. The researcher has worked at six different universities in the capacity of faculty, instructional designer, or education consultant. Education, teaching, learning, and peer learning are all concepts that she values, which may have impacted her interpretation of the data. 47 Personal Experiences: The researcher encountered challenges in her first year of college, which resulted in stress and feelings of inadequacy. The researcher believes having a TA or other type of student mentor during these struggles would have benefited her, which may have impacted her interpretation of the data. Interpersonal Skills: The researcher can sometimes be hesitant when interacting with others, taking information at face value rather than probing for deeper understanding. While the researcher was aware of this and tried mitigating this phenomenon, this may have impacted how the researcher engaged with participants during interviews, potentially influencing the depth and richness of the data collected. While challenging to carry out, the researcher made an intention to consistently question her own assumptions, prejudices, and perspectives throughout the research process to support a more balanced and valid interpretation of the data. The researcher believes that self-awareness is essential for producing meaningful and contextually grounded findings in hermeneutic research. Using the Hermeneutic Circle The researcher had preconceptions of how the Undergraduate Teaching Assistant (UTA) program would perform regarding the research questions. Given the research of similar programs and her own experiences with education and peer learning, the researcher felt the program would benefit faculty and would positively impact the research questions. As the researcher utilized the hermeneutic circle it enabled her to navigate between the specific details of individual experiences and the broader context of the entire phenomenon. This iterative process fostered a rich and more nuanced understanding of the lived experiences of the faculty in the UTA program. Some preconceptions were revised and refined when navigating the parts and the whole of the hermeneutic circle. For example, it appeared challenging for one faculty member to understand how to 48 best utilize her UTA at the start of the program, as she was newer to teaching and had never had a TA experience before. While the researcher assumed the structure of the UTA program provided adequate faculty support, it appeared that more faculty support would benefit those newer to teaching or those who have never had an assistant before. It is important to revise preconceptions when nuanced situations like this occur to make the UTA program more robust, increasing its impact on faculty. Confidentiality Confidentiality of participants was protected by using pseudonyms and removing any personally identifiable information. In addition, colleagues conducting observations were asked to eliminate any data on their devices after sending the researcher their observation notes. All data from observations and interviews were stored electronically and password-protected. 49 Results Introduction This section presents the results of those participating in the Undergraduate Teaching Assistant (UTA) pilot program in the fall, 2023 semester. The hermeneutic phenomenological method uses the hermeneutic circle during data analysis to gain a deeper and broader insight into the lived experiences and perspectives of participants. The hermeneutic circle emphasizes a back-and-forth process of moving from parts and pieces of data to the data as a whole in a cyclical progression. The parts and pieces are represented by the themes and subthemes. To understand the whole, two Painting a Picture sections precede the themes and subthemes providing a big-picture overview of the interactions between faculty, UTAs, and students. The big-picture overview describes the interactions, circumstances, and conditions of participants so the setting and context are familiar before diving into the details of theme and subthemes. This helps frame the relevance and significance of the themes and subthemes. Painting a Picture - Classroom Observation Findings Classroom observations were conducted twice for each course by the researcher and two peers. An observation rubric was used by all observers (see Appendix I) and study questions helped guide the research. The findings are presented below with each study question. What does the faculty role look like when a UTA is present? How does the faculty member manage and hold the space when a UTA is present? Findings from the classroom observations revealed that the faculty took a lead role in teaching, but most faculty appeared to collaborate with their UTA by discussing teaching strategies, incorporating the UTA into class lessons, and engaging their UTA in other tasks. For example, it was observed that 50 Professor Kaylee considered UTA Yasmines preferences when teaching and involved Yasmine in decision-making. Professor Leah mentioned UTA Natalie several times throughout the course about the extra support Natalie might be able to provide students. Professor Leah, Professor Kaylee, and Professor Sharon each had their UTAs lead the class when teaching lessons or reviewing homework while they sat quietly off to the side, rear, or with their students. There also appeared to be a back-and-forth switching of roles and sharing of tasks with the UTA during active learning in which both faculty and UTA assisted students individually or in groups. One faculty member, Hal, had more of a division of roles with his UTA, Vaughn. Professor Hal was observed taking on more of a traditional teaching role, lecturing and demonstrating at the front. The UTA Vaughn sat at the back of the room during lectures and would occasionally help students during demonstrations and practice. How do faculty and UTAs interact? All faculty were observed interacting with their UTA informally before the start of class, communicating logistics, or simply socializing. Faculty discussed class structure with their UTAs, interacted with their UTAs during active learning activities, utilized their UTA during class demonstrations, and socialized with UTAs before and after class. For example, Professor Kaylee was observed discussing the class structure with UTA Yasmine, making sure Yasmine felt good about the plan. In addition, Professor Leah intentionally interacted with Natalie during the class sessions, including her in a conversation about what students should do if they needed help and having her take part in a demonstration of an upcoming activity. It was observed that the demonstration appeared to be particularly useful and would have been challenging to carry out without a UTA present in the room. It was also noticed that faculty and UTAs briefly interacted with one another at the end of class. Professor Leah was especially excited, letting Natalie know she was pleased that Natalie got a student to participate who normally did not engage in the class. 51 Professor Hal had limited interaction with his UTA, Vaughn. They were observed socializing together with students before the start of the class. While they both supported students during practice time, there was no observed interaction with one another. What is the role of the UTA? What tasks are the UTA involved in? How does the UTA role appear to supplement and support the faculty role? UTAs were observed taking on a student support role, interacting with students, guiding them during practice, and answering questions. In addition, UTAs were observed taking on a teaching assistant role, supporting faculty with various tasks, and a teaching role, independently leading students through lessons. For example, during active learning, UTA Natalie would immerse herself into the student experience, interacting with students during the activities. Natalie was able to provide immediate support to students while engaging with them. It was also observed that UTAs Vaugn, Brad, and Yasmine would all provide support during student individual or group practice, walking around the room while checking in with students. They would answer questions and help students troubleshoot problems. One of the observers suggested that UTAs receive extra training in asking probing questions, as the UTAs werent always effectively engaging with students when walking around the room. Some UTAs were observed taking on the role of assistant to the faculty member. For example, UTAs Natalie and Brad were both observed organizing activities before the start of class and passing out printed documents to students. Finally, UTAs were observed in a teaching role. While Professor Sharon started the class off, UTA Brad was writing several problems on the whiteboard at the front of the room. Once Professor Sharon finished with a few logistics, UTA Brad led students through a series of problems at the board. He worked on the problems, asking students what they thought the next steps might be. He provided 52 feedback and clarification as he and the students worked through the content. UTA Yasmine was observed teaching a lesson, as well. After leading students through a short group activity, Yasmine was at the front of the room, using the whiteboard to step students through a concept. She asked students questions and provided positive reinforcement. While UTA Natalie was not observed independently teaching a lesson, Professor Leah often integrated Natalie into the modeling and demonstration portions of the lessons. UTA Vaughn was not observed in any role other than student support, as he answered student questions during individual and group practice. What are the interactions like between the UTA and students? How do students appear to respond to the UTA? It was observed that students appeared to be receptive and comfortable with their UTAs. Students in all courses readily asked UTAs questions during individual or group practice. In addition, students interacted with UTA Natalie during the active learning activity, discussing content, laughing, and asking questions. There also appeared to be acceptance of the UTA as an authority figure in the room. As UTA Brad and Yasmine taught their lessons, students were attentive, actively listening, taking notes, and answering questions. In addition, UTAs appeared to be embraced by students as a part of their learning. For example, as UTA Yasmine walked around the room, a student group invited her to review the work they had completed. After reviewing their work, Yasmine provided them with praise and positive reinforcement. The students responded with smiles of appreciation. Painting a Picture Descriptions from Participants Further illumination into the experiences of the participants in the UTA program was obtained from interviews with both faculty and the UTAs. In addition to themes and subthemes discovered and outlined in a section further below, descriptions of the UTA experience were compiled to understand the experience as a whole. 53 UTAs carried out several different tasks while assisting inside and outside of the classroom. Table 7: UTA Responsibilities Location Inside Classroom Outside Classroom UTA Tasks Teach lessons Support students with group work Support students one-on-one Answer questions Explain content Engage in active learning activities with students Engage in demonstration activities with faculty Pass out materials Encourage students Hold review sessions for tests Create review packets Create lessons Create documents, such as graphic organizers Tutor Hold office hours Grade assignments or quizzes Provide feedback to faculty Hold weekly recap sessions Update the Canvas course Mentor students Faculty Leah met with her TA weekly to plan that weeks classes. Here she describes these interactions as well as other types of interactions she would have with her UTA. So, we would meet weekly on Mondays to sort of talk through the plan for the week or to do any additional specific work, whether that was brainstorming, an activity she was going to do, or grading together, or giving an overview of how the grading should go. I would say there would usually be like a very brief check in at the beginning of class if there was anything specific that I wanted her to do or that she knew she was going to take on an additional role like leading an activity. I would also spontaneously use her for examples in class so that I wouldn't always let her know, but she was perfectly up to the task. We also texted quite a lot. We emailed as well, but there would be like little questions, maybe something that would come up in her study session. Or if she was preparing something, she might text me. Or if I was planning and I needed, I don't know, a celebrity to include in as an example or something like that. We had a lot of little informal conversations that way. They weren't like, extensive. But just if there was a quick question that came up outside of class time or the meeting time. Faculty Leah goes on to describe her role with her UTA: 54 I think... I basically just...articulated out loud, like did a lot of the planning kind of out loud with her. Like sort of just sharing with her the way that I go about teaching a class. it was just kind of like, okay, this is, this is what we're going to do, here's the plan, what do you think? Just kind of collaborating with her on planning and implementation. Faculty Sharon also described the types of interactions she would have with her UTA: Yeah, most of our interactions were, we had a handful of one-on-one meetings throughout the semester, to touch base and check in. A lot of them were in class, before class, after class, or via email. Especially if we had met and talked about like these are the different topics, these are the ones you seem most interested in and then I would send, these are the materials that I typically teach with for those particular sections. Are you interested in like picking an activity or leading this discussion or that sort of thing. I think most of it was day to day in the classroom, handful of meetings on the side, and then a little bit of emails back and forth. Faculty Sharon appeared to take on more of a mentor role with her UTA, as she describes here: I think I tried to be a bit of a mentor and again, like collaborator in the classroom. So especially in times where my UTA was, you know, presenting a solution to an activity or even, like introducing a worksheet, I tried to be like, "And now, you know, he's the one who's in charge of the classroom, he has the authority role." Faculty Kaylee met with her UTA weekly in the first half of the semester, but this dropped off to every other week after mid-semester. Additional interactions included the following: Well, she came to class. I don't know what the number would be. I bet like 70% of the time. So that was definitely, you know, time to interact before and after and during class. And the other than that, I guess emailing, I mean, emailing a little, text. I gave her my phone number because I wanted especially when she had like, you know, like if she would have had a big group or a situation that, you know, with the whole class that she could just get ahold of me if she needed me. Faculty Kaylee took on a supportive role for her UTA, guiding her through the new experience: Just to offer some, like guidance and support, explain what I was doing. I would also...part of my role would be like I would say like, "Tell me, you know, tell me how your weekly recap and exam reviews are going. Do you have any challenging situations?" And then we would kind of talk through them and some stuff came up. And then I would say, "Well, you know, is that something you want me to follow up on?" Or I gave her some suggestions, do you want to intervene? And even in the beginning of the semester, I think some things came up and I would encourage her, I'd be like, "That's a good thing to talk about. Ask Mona," or her other TAs, just knowing it would be good conversation pieces. In addition to teaching her, I think it was like 55 offering just like guidance and support with that as well. I think too, helping her a lot with just like the time management piece and expectations. Faculty Hal did not meet regularly with his UTA. The UTA role was mostly a support role during his lectures. Yeah. We had a few meetings outside the class. I gave them what is that expectation and what he needs to do in the classSo basically, his role was more like helping me just during my lecture. Help the students and also if other students have a question outside the class just refer to him. Faculty Hals role with his UTA was mostly limited to classroom interactions. He describes his role further here: I think that was very, actually good, professional, in a way that he just interacted with me during the class. I see what are the task and actually just based on that task, like giving the service to the students, I didn't have any challenge. Maybe at the beginning, some communication through the emails, but everything was fine, like really like a smooth with him. Yeah. Themes and Subthemes There are four themes and 10 subthemes outlined in Table 8. The research questions from which the themes and subthemes emerged are also listed. If the theme or subtheme emerged for the faculty participants, an X is placed adjacent to it. If that theme did not emerge for the faculty participant, the cell is left blank. The frequency in which subthemes are mentioned is listed in the final column, implying the strength of the subtheme through the consistency in which it emerges in this study. 56 Table 8: Themes, Subthemes, and Faculty Research Question 1 and 3 1 and 2 1 and 3 2 Theme/Subtheme Extra Layer of Support Shared Workload Sense of Relief Shared Responsibility for High-Needs Students Impact on Time Enhanced Teaching Experience Enjoyment TA as a Partner to Faculty Shared Classroom Dynamics Moments of Increased Faculty Reassurance UTA Bridged a Gap Provides Student Perspective UTA Approachability for Students Professional Growth Through Self-Reflection Faculty Leah Faculty Sharon Faculty Kaylee Faculty Hal Freq. X X X X X X X X X X X X 12 5 4 6 X X X X X X X X X X X X X X X X X X X X X X X Research questions include the following, which correspond to the numbers in the table above: 1. How do faculty experience stress and workload when engaging in an Undergraduate Teaching Assistant program? 2. How does an Undergraduate Teaching Assistant program impact the lived experience of faculty with their job, as a whole? 3. How does an Undergraduate Teaching Assistant program impact the lived experience of faculty in the classroom as it relates to teaching students of varying academic preparedness? In the section below, each research question from which the themes and subthemes emerged is categorized by theme rather than by research question. Grouping by themes illustrates the overlapping nature of the subthemes and the interrelatedness of the faculty's lived experience of the UTA program. 4 4 6 3 3 6 3 57 Theme 1: Extra Layer of Support All faculty participants indicated that their UTA was an extra layer of student support, sharing the workload inside and outside of the classroom. This theme emerged when focusing on two research questions: How do faculty experience stress and workload when engaging in an Undergraduate Teaching Assistant program? How does an Undergraduate Teaching Assistant program impact the lived experience of faculty in the classroom as it relates to teaching students of varying academic preparedness? This extra layer of support impacted faculty in different ways, revealing four subthemes, including the following: 1. Shared workload 2. Sense of relief 3. Shared responsibility for high-needs students 4. Impact on time Extra Layer of Support Subtheme 1: Shared Workload Faculty shared several responsibilities with their UTAs, outlined in Table 7. Sharing these tasks with the UTAs helped faculty spread out their workload, which appeared to increase their job satisfaction and decrease stress levels. For example, when asked which parts of the UTA program felt supportive and enriching, Faculty Leah provided specific examples of the shared responsibilities with her UTA and how that created less worry for her: But we would set up the plan together and she did a lot of the grading of quizzes. Some of the smaller things and so that was helpful. Sometimes she would do simple things like take attendance or put extra credit grades into Canvas. Just one fewer thing that I had to worry about, which was really nice. 58 Faculty felt especially supported by their UTA inside the class when engaged in active learning. Faculty Leah continues to describe this type of support: But it's nice, because especially in a class like that, there are a lot of people who need help. You never just sit back and let them all do it. You're always running from one student to the next who has their hand raised, so just to have someone else there in class to help with that. Faculty Leahs UTA, UTA Natalie, described a similar experience as she supported students in the classroom during active learning: And we would just like kind of walk around and see if they had questions.So usually I just walk around, answer questions, look at their papers, make sure they're on the right track. Classroom observation data indicated that UTA Natalie supported Faculty Leah by completing a task before class before sitting with students to engage in active learning with them: Before class starts, UTA Natalie is involved in a task in which she is cutting up paper in preparation for a student activity. After shes done with the task, she moves to one of the tables amongst the other students. When Faculty Leah has students practice speaking in pairs or groups, UTA Natalie joins in, working with another student close to her, or walking around the room during group work, supporting students and answering their questions. Faculty Sharon also discussed how her UTA helped support the workload during class time. She specifically mentions the challenges of supporting students without additional support: I think especially the way that we teach in the department, with using active learning and group work, it's much more helpful to have someone else in the classroom, like you as an individual, can make it around to maybe 15 students on a manageable way. But especially if you have them working in partners with 20 plus students, it gets really hard to just provide meaningful feedback to all of the groups and keep them in a productive state, right? I think a lot of times if a student gets stuck, then they want to be able to answer a question, but if you're busy answering other questions, then it can be hard to balance that. I think especially for the way that we teach, it's really, really helpful to have someone else there to be able to answer questions and work with groups. During a classroom observation of Faculty Sharons course, it was also observed that UTA Brad was at the front of the room stepping students through content at the whiteboard: 59 He also went through practice problems the students were working on. He was at the front of the board, stepping through the problems, asking students for feedback as he went along. Faculty Sharon goes on to discuss how her UTA helped with workload outside of the classroom: I appreciated especially having a consistent peer for students to reach out to. A number of them were like, "Oh yeah, well, I asked UTA Brad about this at the review session" or "I reached out because I had questions about our writing assignment" or whatever it was. I think there is something about in that class in particular, I tend to have ten to 20 office hour appointments a week with students and that can quickly max out just my capacity and time. I think having someone else that they can go to and especially someone else who might seem more approachable, because they see them on campus and know that they can be available for tutoring potentially. Or that type of service is really helpful for students. Faculty Sharons UTA, UTA Brad, described what he would do during the review sessions outside of class: I usually, the week before, I would kind of create a review guide. This was just kind of a backup. And then students would come to these review sessions and they could work on, we have this homework website called Infinity where you have to complete, I think it's like 80% of the problems correct to get like the point for that homework assignment. If any students had questions over like a homework problem, I would help them with that or on their previous quizzes, tests. And then if they wanted just the review guide, I would, I would give them that review guide where they could work on it and then maybe check answers with me or just check answers using online, and then help them through that too. Faculty Kaylee also mentioned how her UTA helped with her workload when she felt like she was drowning: the exam review process is something that takes a lot of time and once she felt comfortable and able to take that on, that was a really big help. Some of it was I think my own, like I do open library office hours and then she was doing that two-hour recap, and at one point I didn't have enough one-on-one appointments. And instead of like switching [those appointments] out for the Wednesday, I tried to add them on and then I was drowning. And I realize, like, I have UTA Yasmine. She's there on Fridays. Like if we've just had an exam and I need more one-on-one appointments, just like switch that out. I do think that helped too. Faculty Kaylees UTA, Yasmine, echoed this shared workload when asked about her role with Faculty Kaylee, I think I was definitely like a supportive element. Like, if she was like overwhelmed with a lot of meetings, like I could take some of those. 60 During an observation of Faculty Kaylees course, it was also observed that UTA Yasmine taught a short lesson: When teaching a short lesson, UTA Yasmine steps students through a concept, asking questions, providing clues, and giving positive reinforcement. She writes on the board as she steps through the concept, asking questions throughout the process. When students engage in group activities, UTA Yasmine walks around the room, checking in with students and answering their questions. Faculty Hal indicated that his UTA was particularly helpful with the in-class workload. This was especially true when he reflected on his other class, which did not have a UTA: I see my TA help them individually as students to solve the problem they face. Now suppose the case that I don't have that. I have exactly that in my other course. I have a math program with 22 students compared to this class which is 12. I don't have a TA there. I can see the difference because there is no one else to ask to take care about the students when, because it's just me, I cannot make a copy of myself. Right. I cannot...I can go and answer that, but what should I do with others? This support was seen during the classroom observation for Faculty Hal and UTA Vaughn. In contrast to the course he described without a UTA, the shared workload allowed Faculty Hal to continue lecturing when students would encounter issues, which UTA Vaughn would address: When students were involved in practice, UTA Vaughn would immediately stand up and start walking around the room. He would check to see what they were writing and occasionally make corrections. He answered questions and explained content. UTA Vaughn did not teach a lesson, but was in a support role as Faculty Hal taught, helping students, as needed. Extra Layer of Support Subtheme 2: Sense of Relief All faculty participants indicated that having their UTA as an extra layer of support provided a sense of relief. The UTA support appeared to lessen the pressure faculty were feeling and, subsequently, levels of stress. For example, Faculty Leah described the emotional impact of working with students in her class who seemed less engaged. She appeared to blame herself when students were not achieving 61 certain expectations. Having a UTA to talk through certain aspects of the course took this burden off her and provided her with a sense of relief: Maybe because I'm so emotionally committed. I had a challenging semester teaching all general education classes and feeling burned out midway through, like I just cared too much and they didn't... My level of engagement was not equivalent. Students level engagement was not equivalent to my level engagement, let's say that. And that's a challenge. That's always a challenge. I think it was helpful to talk through certain things with my UTA. Like I don't know why this didn't work. And there were several times when she would say, "I think they're getting out of the course exactly what they want." I really appreciated hearing that from her. Because whenever I don't see students comprehending, or just engaging the way that I want them to consistently, I always am thinking, okay, what can I do differently? What did I do? And it was nice to have it from a student perspective to say, well... While Faculty Leah indicated that her UTA shared workload responsibilities, it appeared she did not always get a sense of relief from this type of support. She discussed feeling odd when struggling students did not meet with her for offered support: There is one thing I'm curious about, whether this is a result of the TA-ship or if it's just changing demographics in this new group of students. But the students would not come to talk to me, like the ones who are struggling, who failed quizzes or whatever, I always reach out. Let me know how I can help you, like let's talk about this together. I sent many emails, some of them multiple times, offered to meet with them. I think only one actually came from that class to get help with content. The others always were like, "Oh, I'll go see [the UTA]" or whatever. And I don't know if that's just because they were getting out of the class exactly what they wanted and they didn't want to put in extra time. If it's because there was some barrier that's new as I'm older and they are the same age, like a generational gap. I don't know if it's COVID students, because this new group of students seems really different in the ways they want to interact and their anxieties. A lot of them at the end of the semester said that because I asked them point like why didn't you come? This is weird. Students usually just refuse to come see me. They did it politely, but basically they're like, "Oh, that's ok. I've got this." And I'm wondering if... it's really great that they had [the UTA] and her study sessions. I think some of them really would come to that. I don't know if they wouldn't have come anyway because that's who they are or because that there was someone of their generation there that was just automatically they would go to her instead of talking to me. I'm curious as to whether that is a consequence of having a TA, or if that's just the nature of the class, if that makes sense. That was a little bit of a challenge. But at the same time, I'm really glad that she was there. If they're the group of students who didn't feel like they could relate to me enough to come ask for help or just didn't want to, I'm glad that she was there to provide that support. 62 The rest of the faculty indicated that the relief they felt was due to the shared workload with students. For example, Faculty Sharon felt relief during class time when her UTA helped answer questions, Yeah, I think again, there was a little bit of relief of I don't have to feel like I have to jump from one thing to the next, because I had back up. Faculty Kaylee also describes feelings of relief, as sharing the workload with her UTA helped alleviate feelings of nervousness and stress: I knew there was this extra layer of support for the students. And when I look at like my biggest stressors, I think sometimes it is me being nervous. Like I don't have enough time to get the students what they need. So, like having those be so successful, like I do think it took away some like emotional stress. Faculty Hal sometimes felt pressure in the classroom when trying to support students during practice time. Not being able to spend more time helping students to problem-solve issues made him feel bad. He described how his UTA helped relieve this type of pressure: let's say if I know that my student cannot solve the issue and I'm under the time constraint as you mentioned, because I need to finish my lecture and there are two or three students, I cannot fix the issue. And there is no one to ask them for help, then I feel bad. I'm a kind of person that I'd like to get that solved for them as quickly as I can. And I start looking and say, "Okay, I cannot fix that now. It is a little bit more time," and I see other students finish it. That's kind of putting me under pressure now, okay, what should I do? It happened for me in my other class. There were other good students, and I sometimes call them. Say, "Can you go and look at this? Because I'm working with another student. Can you look at this?" That put me definitely under pressure sometimes, but that's the case that I may not have that. But if I have that normally, this relieves, give me that relief in moment. Yeah. Extra Layer of Support Subtheme 3: Shared Responsibility for High-Needs Students In addition to providing a sense of relief for faculty, two faculty indicated that their UTAs were a critical piece to the success of certain students, potentially making a difference in whether the students passed or not. This shared responsibility appeared to support faculty with their goal of helping students 63 succeed in their courses. For example, Faculty Leah discussed the role her UTA took with a student who she felt probably would have dropped without the extra UTA support: But I know the fact that they [the UTA and student] developed that relationship and that she [UTA Natalie] was there helping coach him through, Okay, you can do this, this is how you get on.... That was instrumental to his success. I think he probably would have ended up dropping the class. In addition, Faculty Kaylee had her UTA work with a student who was repeating the course. The student was continuing to struggle, so Faculty Kaylee strategically utilized her UTA to provide extra support for this student. Faculty Kaylee felt the UTA support was a big reason this student was probably going to pass the course: Look, I had a student repeating too, who had repeated the course. Just really lovely, special student. I was meeting with her a lot. I felt like she was still struggling. I reached out to my UTA, even though I appreciate that the system works more, that the student initiates [contact]. But I'm like, "Hey, I want to introduce you guys on an email connect," and I think that student may pass. I was getting my UTA that feedback today, because it's like we always give the student the credit who did the work and made it across the finish line there. But I do think she was probably a big part of her success too, yeah. UTA Yasmine, Faculty Kaylees UTA, supported her statement above as she described how students with less preparation utilized her and how she may have turned some grades around: I definitely think like students who weren't really doing too well in the course came to me a lot. I think a lot of it was just not even about the Patho content, just about like college in general. And being able to support them like studying techniques and just listening to their concerns, but also being like that one person that's like--you have to take charge of your own learning. Nobody's going to do it for you, type thing. I think hearing that from like a student perspective rather than a professor saying that hit a little bit differently because some of them have really taken that to heart and flipped their grades around. Yeah. I think just being able to conquer those barriers with them, not telling them what to do with it kind of added that level of support to get them where they need to be. While Faculty Sharon did not discuss her UTA being critical to her students success, UTA Brad described how some of the students seemed to turn around after attending his review sessions: 64 I would say that a lot of the time the students that came to those review sessions or asked if I was in the library at a certain time and I would help them out usually probably could have prepared a little better. I think throughout the semester, those students that I support that actually came to me that were underprepared at the start, are not the students that were underprepared at the end. So, I think they kind of realized, they kind of changed, they kind of talked to me about it. So, I feel like I supported. There's definitely still some students that are probably unprepared, but they didn't really seek out help, I guess, like some of the students did. Extra Layer of Support Subtheme 4: Impact on Time The subtheme of time contained conflicting perspectives. Two faculty indicated that sharing the workload with their UTA helped mitigate some of their time constraints with their courses. Other faculty werent quite sure. It appeared that time was less of a factor and faculty benefitted from their UTAs in other ways, such as shared workload and responsibilities. For example, Faculty Leah thought her UTA may have helped with time, but she appeared uncertain: I think a little bit. I don't think it was a huge difference, but I don't know, maybe that's the difference if they went to her study sessions instead of coming to talk to me. So, in that case, I guess so. However, she did not feel the UTA took additional time away from her and was less intensive than past student support she has received from other programs: At first, I was not sure whether that additional time during the week would be a burden, but in the end, it didn't feel like a burden because I was going to be doing class planning or whatever anyway. this [program] did not take more time. Versus the others were kind of time intensive. Faculty Sharon felt the time placed toward her UTA balanced out with the time she received back from the UTA support. This made it so it felt like about the same amount of time she would put into teaching a course: But I would probably guess that it balanced about the same, right? Like I spent more time interacting with him and collaborating together on the activities and worksheets and figuring out what that would look like. And also, it saved me a little bit of time to have him doing stuff, and so I think it was probably net about the usual typical working load. 65 Faculty Kaylee felt that having a UTA helped with some time constraints, but that this did not occur until the second half of the semester. Her UTA needed extra support to adjust to the UTA role, which took more time at first. This was faculty Kaylees first time working with a student assistant in a course and UTA Yasmines first time in a UTA role, which may have contributed to the role adjustment. She described her experience as enriching despite any extra time: [The UTA program] was brand new to everyone and brand new to me. I think this semester took a lot of work that doing it in the future wouldnt, even if it was a brand-new person. That doesn't take away from it being enriching, because that's a good process too, because I think in the spring I'll be able to get feedback. Like I got back some time, I was able to do more one-onone appointments and things like that While she states above that she got back some time, Faculty Kaylee goes on to describe how supporting her UTA with preparing a lesson felt stressful and time-consuming: That process was a little tricky and probably a learning curve just because I don't think she realized like how much time it would take. Even with me saying like, okay, we need to come Wednesday and connect. Like I feel like even with me setting deadlines and trying to guide her, I think that ended up causing like maybe stress and more work for me to do that part of it. Faculty Hal indicated that his UTA definitely helped with time constraints surrounding his course: Yeah, definitely it helps. Because if it's not there, then the material going to finish in one session might take longer because we spend more time helping to fix that because they get behind. So, yes. While it was unclear whether the UTA program helped faculty with time constraints, none of the faculty indicated that the UTA program, on average, consistently took more time. This may be due to the UTA program being handled by a central office, including a UTA course in which students were enrolled. This program structure was intentionally created to mitigate the amount of time faculty would need to spend training their students how to be teaching assistants. All four UTAs indicated that the course was helpful. For example, UTA Yasmine described her experience with the course: 66 Yes, I definitely think that like all the topics that we talked about, I used like every single one of them somehow, like being with the students or working with the Professor. I think being able to decide when we talked about what [in the course] was really helpful, too. Because we were able to reflect on our own experience and be like, Oh, I think I need more support in this educationwise. Or I think we should have a discussion about this. I think that was a crucial part of that. Theme 2: Enhanced Teaching Experience All faculty participants indicated that interacting with their UTA enhanced the teaching experience in multiple ways. This theme emerged when focusing on two research questions: How do faculty experience stress and workload when engaging in an Undergraduate Teaching Assistant program? How does an Undergraduate Teaching Assistant program impact the lived experience of faculty with their job, as a whole? Four subthemes emerged from this theme, including: 1. Enjoyment 2. UTA as a partner to faculty 3. Shared classroom dynamics 4. Faculty reassurance Enhanced Teaching Experience Subtheme 1: Enjoyment Having someone else to collaborate with in the classroom who could provide a different perspective appeared to create feelings of enjoyment for the faculty. This enjoyment appeared to help faculty feel more satisfied with their teaching experience. For example, Faculty Leah described how having a UTA was fun and positive: I would say overall, it's been a really positive experience. I've enjoyed working with my UTA. I think it's been helpful both for me and for the students. It's been really fun to have someone who is of the same generation as the students to help brainstorm ideas and to think about 67 what's going to work, and what's not going to work, and have a go-between. Overall, I'd say very positive. Faculty Sharon described how she could chat with her TA during class about course content or collaborate on activities. The open conversations in front of students allowed an opportunity for students to join the conversation. These types of interactions created an appealing atmosphere for Faculty Sharon and her students: I think that helped establish the friendly atmosphere that yeah, made it enjoyable for me too as well, to come to the classroom and even just be able to bounce ideas off each other. Like "Two more minutes for this activity?" "Yeah, okay, sounds good." Faculty Kaylee also described feelings of joy. She specifically discussed how the program gave her a healthy outlet that made her feel good about her work: when I'm involved in things like this that are kind of like outside but not outside like, and I'm really enjoying it. Like for me it's giving me this like good, healthier work... I don't know, situation to be like, well, I really enjoy this and this is a cool thing to follow. So, like for me it was that was nice too. Yeah. Faculty Hal also enjoyed the experience and hopes to have a TA in future courses: I think overall, this was very good. I'm really happy to have the TA. That's the reason I ask you again [laughs] if you have a chance I can have one for my other course, because I feel like special for those other programs with more number of students, I probably need. But yeah, I didn't see anything really challenging or...everything was very positive. Enhanced Teaching Experience Subtheme 2: UTA as a Partner Two of the faculty partnered closely with their UTAs, collaborating with them on teaching and eliciting their feedback to get a different perspective. They both expressed this being a positive aspect of the UTA experience. Having a partner with which to collaborate appeared to provide faculty with beneficial feedback and an improved course. For example, Faculty Julia could turn to her UTA when things didnt go as planned. Obtaining feedback from her UTA in this way created a feeling of collegial rapport: 68 I think it's always nice to have a colleague. I felt like there was that additional collegial feeling of having someone to look at. Like if things go really poorly, they just share a little at the end of class, oh what happened here? Faculty Sharon describes how she provided her TA flexibility and choice because she wanted to be more of a partner: Yeah, I think I tried to give him the freedom of flexibility to say, what topics are you interested in the most? Do you want to have, what are you hoping to get out of this experience? That we were really partnering together, instead of me saying like grade these things, do these things. Faculty Sharons UTA, UTA Brad, described how he perceived their relationship, which he described as more of a partnership: I felt like it was like, what's the best way to say this? Kind of like a mutual relationship or something like that. Just kind of like, we just kind of worked together. It didn't seem like it was like, I guess like a powered dynamic or anything where I was just like, "Oh, I just want you doing all the dirty work like grading" or all this kind of stuff. I got to actually do lessons in the class, which was something that I really wanted to do when I started. While Faculty Kaylee did not indicate that she felt she had a partnership with her UTA, UTA Yasmine felt a collaborative relationship between them: I didn't feel like it was like authoritative and like student type thing. I definitely feel like we collaborated really well and had that like open communication and a good relationship between both of us. I felt heard and appreciated and all the good things. Enhanced Teaching Experience Subtheme 3: Shared Classroom Dynamics Three of the faculty discussed how their UTA modified the classroom dynamics, increasing the level of energy in the classroom. Having an additional teaching presence in the room increased positive interactions with students during activities and with the content, enhancing the teaching experience for faculty. The faculty found this to be a positive aspect of having a UTA. For example, Faculty Leah described how her UTA would encourage students to volunteer answers: 69 I felt glad that she was there to help them. I also think that there were moments where because she was sitting there like, "You can do this, like come on, volunteer to answer," that changed the nature of the classroom experience for them in a positive way. Classroom observation data also indicated that Faculty Leah intentionally worked UTA Natalie into class activities, which appeared to change the teaching dynamic. Modeling of conversations could more easily be demonstrated to students: Faculty Leah was intentional at several points in the lesson to include UTA Natalie. UTA Natalie made the announcement at the beginning of class about leading a review session, and she also modeled the conversation with Faculty Leah that students later tried to recreate based on their own experiences. Faculty Sharon described how it can be exhausting to teach students who are used to passively learning. They can be uncomfortable shifting to an active learning environment and having a UTA helped to keep the energy up: I think [this subject] is notorious for like this is my entire experience of learning, is the person comes in the room and they start writing on the board. You're lucky if [the students] ever turn to face you. I think it can be uncomfortable for students to have a different interaction. And also, it can be really exhausting to be doing that every day. And it's helpful to have someone else to be keeping the energy up and to play off of as well. Classroom observation data showed that Faculty Sharons class was energetic and that UTA Brad was an integral part of the course. The class was engaged, respectful, participating, and appeared motivated to learn the content. Faculty Sharons energy and enthusiasm was evident, as witnessed by her nonverbal cues, which appeared to support student engagement. UTA Brad appeared to be an integral part of the class, going through problems at the board, having his name mentioned several times by the teacher, and interacting with students while walking around the room as they worked on problems. Students responded to both Faculty Sharon and UTA Brad by engaging in their practice problems, taking notes, asking questions, answering questions, and participating with each other. There was also a feeling of familiarity that came from the students, as little guidance was needed to get them actively started on problem-solving. There appeared to be a routine that students understood. They also appeared to have an ease around one another, Faculty Sharon, and UTA Brad. This indicated to me that the highly collaborative environment was more the norm than an exception. 70 Faculty Hal felt engagement was maintained as his UTA helped to answer questions for students who were stuck. This helped students to progress with their work and stay on track: I believe that the one that is very helpful is also the engagement. I think if you, in my case, if the student cannot get the answer on computer, they might get frustrated very easy, very fast. Now if I have my TA always helping with that and get that answer and see what's going on, right? Then I can keep the engagement also positive and high during my class. Faculty Hals UTA, UTA Vaughn, described how he would actively try to increase student involvement in the class: And occasionally, for the students that were above the class or like not above the class but exceeding pretty well in the class, I would give them additional like maybe not assignments, but... "Hey, could you do this in a different way?" or "Can you try to, try to write this code without using this function?" "Can you make it do this?" Additional assignments or additional tasks that are significantly more challenging just to keep them engaged and keep them thinking about the topic. Enhanced Teaching Experience Subtheme 4: Faculty Reassurance Three of the faculty discussed how the UTA perspective gave them moments of increased reassurance with certain aspects of their teaching. This reassurance enhanced the faculty teaching experience by validating their feelings and creating a reciprocal learning process. For example, Faculty Leah found it helpful to talk through lessons with her UTA after they had carried them out. If a lesson didnt go as well as she hoped, she appreciated receiving feedback from her UTA on how she could have handled things differently. Her UTA would sometimes respond with, I think they're getting out of the course exactly what they want." She appreciated this feedback, I think it was helpful to talk through certain things with UTA Natalie. Like I don't know why this didn't work What did I do? And it was nice to have it from a student perspective Faculty Sharon also appeared to gain reassurance from interacting with her UTA in this way: 71 If I'm in an unhealthy place as a person, then I think a lot of the support that students need can feel a little bit too needy. There's something really refreshing about being able to ask and check in with the TA and be like, hey, this is the problem that was on this quiz. Students did not think that they had enough time, they didn't know how to do it. You've been in class. Do you feel like this is me trying to be tricky or anything like that? And he was able to say, "No, we did a problem exactly like that in the review session. This is very reasonable." Faculty Kaylee gained reassurance by having her UTA partner with her to support students with varying academic preparedness. It just gave me some confidence, right, that there's this external support outside of just me to help the students, which is really big, right? And then the helpfulness of the time, right? To try to meet with 15 students one-on-one who are underprepared is really challenging.I think is really time efficient and like good. Theme 3: UTA Bridged a Gap All the faculty participants indicated that their UTA bridged a gap between them and their students. Their UTA provided a student perspective or was an approachable option for their students. This theme emerged when focusing on two research questions: How do faculty experience stress and workload when engaging in an Undergraduate Teaching Assistant program? How does an Undergraduate Teaching Assistant program impact the lived experience of faculty in the classroom as it relates to teaching students of varying academic preparedness? Two subthemes emerged from this theme, including: 1. Provides Student Perspective 2. UTA Approachability for Students 72 UTA Bridged a Gap Subtheme 1: Provides Student Perspective Three of the faculty participants discussed the value of getting feedback from a student perspective when collaborating with their UTA. The student perspective helped translate generational differences and provided insight into students needs and experiences, which helped faculty teach more effectively. For example, Faculty Leah discussed how her UTA would let her know if students might like a learning activity or would interpret generational differences for her, explaining certain cultural aspects of the students in the class: Having someone of their generation to say, yeah, I think that they'd really like this activity or suggest say celebrities that we can use as examples. Like once she helped explain... a couple of students, mentioned a term that I was unfamiliar with, "Dap up," have you heard of this? It's like that kind of handshake that guys do. And when we were talking about how students, how people interact with each other and how they greet, a couple of them had written something like that on their discussion board. And I was looking at it and I texted I was like, "What is this?" And she found like an infographic for me. She was like, "It's the thing guys do." That was fun. We had a couple of those sorts of things. I'm like, I don't know how to interpret this. Please translate. Faculty Sharon found it helpful when her UTA would describe aspects of the content with which he most struggled. As an expert in the field who has taught the course multiple times, this helped Faculty Sharon better understand the needs of her novice learners: I also found it helpful because there are a couple times where I said like, "These are the materials that I used the last time that I taught this particular section that you were interested in teaching, but feel free to use something else," and he would bring in or create a worksheet of "This is what I struggled the most with when I was a student." I thought that was really helpful too because this is my fourth time teaching it at [the university]. And so, it can be really easy to forget, oh right, I know the common student errors, but I forget which pieces of it would be most helpful, especially from their perspective as someone who's encountering it for the first time. Faculty Kaylee found it helpful to turn to her UTA when discussing the textbook website with her students. Having not utilized this tool from the student side of things, Faculty Kaylee could turn to her UTA to clarify aspects of the technology: 73 I think sometimes it would feel helpful if something came up where...this is logistic, but the students use this tool, Kaplan. It's a website, but I don't really have the perspective on like being a student. When I was teaching them about that in the section she was there, I was like, am I right? Can you add? And then she could fill in. I feel like that, it was nice to like, have a student perspective, like in the classroom. UTA Bridged a Gap Subtheme 1: UTA Approachability for Students Three of the faculty participants described how students felt comfortable with their UTA since the UTA was a peer. Faculty felt the UTA approachability for their students was an extra resource in the courses, which helped them better support their students. For example, Faculty Leah described how students struggling with course content seemed to prefer meeting with her UTA. While this felt weird to her, she was glad the students were comfortable meeting with the UTA: Near the end of the semester, hearing from the struggling students who weren't doing their homework and who would say that they have challenges in these particular areas. When I asked them to meet with me and they were it's, "You know, I'll just go to [the UTA]," that felt a little weird like... but I'm not sure that it would have been any different. You know, I'm glad that she was there, that they felt comfortable going to her and they may have been even more checked out without her being there. Faculty Leahs UTA, UTA Natalie, described how she felt students were sometimes more comfortable getting support from her instead from Faculty Leah. She felt some students felt she was more approachable: feedback I've gotten from the students and even when I was her student, she is like intimidating. Not in a negative way, but she just kind of has that. So, a lot of students have said that I've been like more approachable. I said I'm a student too, and I'm also learning. And so, I did feel valuable in the class because they felt more comfortable to come to me sometimes to talk about stuff. And a lot of them do come to office hours consistently as well. Faculty Sharon described how the approachability of the UTA has the potential to support students who might have anxiety over the content or are getting used to the college atmosphere: I think having someone else that they can go to and especially someone else who might seem more approachable, because they see them on campus and know that they can be available for 74 tutoring potentially. Or that type of service is really helpful for students, especially if they're also overcoming content anxiety and getting used to college, and what it's like to have different resources that they maybe didn't have available in high school as well. Faculty Hal felt students would prefer interacting with the UTA over an instructor. He also felt that the UTA approachability potentially helped students better learn the material: But I feel like one great things about TAs is maybe they are better approachable by students compared to the instructors. Could be an age gap, could be other things, I'm not sure. But even though after a couple of few sessions, I feel like they better approach the TAs, in some cases. I know some cases might not be true, but most of the cases, I feel they'd rather ask them a question and communicate with the TA. That's one thing. And another thing is basically when they're better they can easier get approach by the students. They get better if they know the materials very well because we selected them. We know that they know that right? They can help them better to basically learn the materials. Faculty Hals UTA, UTA Vaughn, felt he was a bridge between the instructor and students. However, he also felt it was sometimes challenging to get some students to openly communicate with him: But I think sometimes students would not ask me questions even though like I want to make them feel as comfortable as they can and I want to be like that bridge between, you know, themselves and the teacher. But I think a couple of students opened up towards the end of the semester to me because I'm again, that peer, the bridge between them and the professor. And instead of going to the professor, they, you know, kind of came to me. So, I think I was well respected by the students. But my role, I think, I don't know. It was just hard to get, hard to get people out of their shells. While faculty Kaylee did not discuss UTA approachability, her UTA, Yasmine, described her experiences with the students. She indicated that students may have felt she was a less intimidating option: My role with the students has definitely evolved over the semester. I think I started out as not really sure what to think about it, but it quickly became like a mentor to like undergrad, like the students, and like, I feel like relationships have definitely been formed more. Not just like with an academic thing, but just through like the nursing community. I think there's definitely been like, like they feel confident coming to me and confide in me. And like I feel as though like they can be heard more without like the intimidation of like going to the professor and like talking to 75 them. So, I think it's, I kind of like became an advocate and just like that support person for them. Theme 4: Professional Growth Through Self-Reflection The theme of professional growth through self-reflection emerged when targeting the research question: How does an Undergraduate Teaching Assistant program impact the lived experience of faculty with their job, as a whole? Interactions with UTAs seemed to increase awareness of teaching and roles for three of the faculty participants, appearing to contribute to professional growth. This professional growth helped faculty with their teaching as they would reflect on insights that surfaced during discussions with their UTAs. For example, Faculty Leah reflected on how some students might view her, which does not match how she views herself. Interactions with her UTA appeared to provide insight into Faculty Leahs identity as an instructor: Maybe, I'm trying to reflect on that a little bit more right now and figure out what was going on with those dynamics. And possibly, because again, that's not something that I would necessarily attribute to myself. But I've heard her say that to me too, because we've had conversations about class dynamics and also about how this class might relate to other classes that she's taken and joked around about how I'm apparently the scariest professor, which is hilarious to me. But also, it gives me an indication of, okay, like this, this is maybe where I am right now. I don't know. There's been some insights there, but it's been more in conversation with her. I don't know if that answers your question. I'm not trying to be scary. Faculty Sharon discussed how including the why behind her teaching when mentoring her UTA made her realize that her students would also benefit from this type of information. Having these conversations with her UTA specifically reminded her of this practice: I think that's something that the more that I teach, the more I learn that I need to do a better job of communicating to students the reasons behind the stuff that I'm doing. Because there's often lots of reasons, but I just don't feel like I have time with the content we have to cover to 76 communicate that. And so, I think that was a nice reminder to have those conversations with the TA as well. Faculty Kaylee reflected on how feedback from her UTA made her think about how to deliver higher-quality education to students, which she felt was supportive: I just think the experience of having a, having a student who's like willing to offer some feedback and give ideas, for me, I like that. I think it is a form of support, right? Like how can we improve the class and deliver high-quality education to students? I thought that was supportive. Conclusion This chapter illuminated the results of the hermeneutic, phenomenological qualitative study, exploring the lived experiences of four faculty as they engaged in an Undergraduate Teaching Assistant program. Classroom observations were carried out twice for all four courses and interviews were conducted for eight participants, including four participating faculty and their four UTAs. Utilizing the research questions and the hermeneutic circle, four themes and 10 subthemes emerged. Table 9: List of Themes and Subthemes Theme/Subtheme 1. Extra Layer of Support Shared Workload Sense of Relief Shared Responsibility for High-Needs Students Impact on Time 2. Enhanced Teaching Experience Enjoyment TA as a Partner to Faculty Shared Classroom Dynamics Faculty Reassurance 3. UTA Bridged a Gap Provides Student Perspective UTA Approachability for Students 4. Professional Growth Through Self-Reflection The next section discusses interpretations for each subtheme, limitations of the study, recommendations for future research, and implications for those wanting to recreate the study. 77 Discussion The purpose of this hermeneutic qualitative phenomenological study is to illustrate the lived experience of higher education faculty as they engaged in an Undergraduate Teaching Assistant (UTA) program. This research provides an enhanced understanding of the faculty teaching and learning experience, particularly experiences related to students of varying academic preparedness. The research also helps illuminate how this type of program impacts faculty feelings toward their jobs and gives insight into how faculty experience teaching support in their classrooms. While research was found that focused on the impact of undergraduate teaching assistant programs in higher education institutions, much of the research appeared to target how these types of programs impacted the teaching assistants and/or students. There is limited research on how these programs impact faculty, particularly outside of the classroom experience. Three research questions were focused on to help illuminate the lived experience of faculty as they experienced the UTA program. 1. How do faculty experience stress and workload when engaging in an Undergraduate Teaching Assistant program? 2. How does an Undergraduate Teaching Assistant program impact the lived experience of faculty with their job, as a whole? 3. How does an Undergraduate Teaching Assistant program impact the lived experience of faculty in the classroom as it relates to teaching students of varying academic preparedness? Interpretation of Findings By investigating the lived experience of faculty as they engaged in a UTA program, the research focuses on the faculty perspective rather than the student or UTA perspective. Examining the impact of 78 the themes on faculty, institutions of higher education can better understand how they might support faculty with similar types of programs. Theme 1: Extra Layer of Support Extra Layer of Support Subtheme 1: Shared Workload Studies have indicated that faculty workload has significantly increased over the years (Nakano et al., 2021; Rosser & Tabata, 2010; Townsend & Rosser, 2007). Nakanos et al. (2021) findings showed that academic workload has increased significantly in ten years from 2007 to 2017 with other studies indicating that perceived workload contributes to faculty stress (Donovan, 2018; Adrian et al., 2014). All the faculty in this study indicated that their UTAs assisted with their workload. Faculty sharing responsibilities with their UTAs, inside and outside of the classroom, could lead to faculty perceiving a lower workload, which could increase job satisfaction (Tentama et al., 2019). All four faculty in the study shared part of their workload with their UTAs, which was cited twelve times in the data. This included support inside the classroom, during which UTAs answered student questions during active learning and group work, taught lessons, and passed out materials. In addition, the faculty described several responsibilities their UTAs had outside of the classroom. UTAs tutored students one-on-one, conducted group review sessions before tests, ran group weekly recap sessions, and held general office hours. One faculty member also had her UTA grade assignments. Two of the faculty indicated that this outside help appeared to reduce the number of students who would come see them during their office hours. Faculty Kaylee stated, at one point I didn't have enough one-on-one appointments. And instead of like switching them out for the Wednesday, I tried to add them on and then I was drowning. And I realize, like, I have [my UTA]. She's there on Fridays. Faculty Leah also indicated that when she reached out to struggling students to come see her, they said they would meet with her UTA, which felt odd to Faculty Leah, When I asked them to meet with me and 79 they were it's, "You know, I'll just go to UTA Natalie," that felt a little weird like... but I'm not sure that it would have been any different. One barrier that surfaced surrounding shared workload was hesitancy to potentially overload the UTA. Faculty Sharon did not want to burden her UTA given that UTAs are also taking a full course load. She held back from giving her UTA more work to respect his schedule: there were a number of times where I was like, I would love for you to be more involved or to give you more responsibility or even just to be able to defer some of the work to you because I know that you're responsible and are able and capable of doing it. But I want to respect the fact that you have quite a full course load and you're not being paid to do all of this extra work on top of it. Experience with the program for both faculty and UTAs may help alleviate this concern. If faculty utilize the same UTA for repeated semesters, familiarity with the roles, the UTA schedule, and the UTA capabilities may help faculty feel they can utilize their UTA more fully. Overall, UTA programs can be valuable for supporting faculty with their workload by assisting with a variety of teaching tasks, including clerical, tech support, grading, facilitating discussion groups or labs, or creating and delivering lesson plans (Owen, 2011). Faculty can rely on their UTAs for assistance which can contribute to a sense of satisfaction of working toward common goals. This satisfaction can lead to less burnout (Lee & Lin, 2019; Spector, 1997), allowing faculty to perceive they have more time and energy in their schedule (Donovan, 2018). Increasing job satisfaction via a shared workload with UTAs has implications that go beyond the classroom. According to prominent organizational psychology researcher, Dr. Paul Spector (1997), job satisfaction leads to other positive outcomes, including increased commitment to the organization, higher levels of job performance, and engagement in organizational citizenship behaviors, such as supporting other colleagues. However, effective implementation and management of UTA programs are essential to ensure that certain UTA responsibilities are offloaded from the faculty, as considerable time and energy may be 80 necessary to ensure TAs are effective (Owen, 2011). Faculty investment in work in a UTA program can be mitigated when a central office manages the organization and training of TAs (Begley et al., 2019). This study intentionally structured the UTA program with the Center for Teaching and Learning organizing the program and training the UTAs. Extra Layer of Support Subtheme 2: Sense of Relief Faculty indicated that collaborating with their UTA and having them share a portion of the responsibilities mitigated the pressure they felt which provided a sense of relief. It appeared that social, collaborative support from their UTA reduced pressure when compared to handling tasks alone. Individuals who perceive a higher level of social support are less likely to experience negative outcomes of stressful events (Laskey & Cohen, 2000). All faculty indicated they felt this sense of relief when their UTA supported them, cited five times in the data. Faculty Leah appeared to feel relief when her UTA gave her feedback that alleviated Faculty Leahs self-imposed high expectations of her students engagement. Faculty Leah was disappointed in the level of disengagement of some of her students and felt it could be her fault. Her UTA reassured her, I think they're getting out of the course exactly what they want." This feedback was appreciated by Faculty Leah. While Faculty Leah seemed to feel relief in this situation, she also indicated that she felt weird when struggling students would see her UTA instead of her, This is weird. Students usually dont refuse to come see me. She indicated that this felt challenging for her, but that she was glad that her students felt comfortable obtaining support from her UTA. The other faculty felt a sense of relief having their UTAs be a backup for them inside and outside of the classroom. Faculty Sharon and Faculty Hal felt pressure when helping answer student questions during practice and active learning. Their UTAs helped mitigate this pressure by sharing this responsibility. Faculty Kaylees UTA helped alleviate her stress and nervousness by supporting students 81 outside of class by holding weekly recaps and exam review sessions. While Faculty Kaylees UTA helped alleviate stress, there was an adjustment period at the beginning of the semester that felt challenging for Faculty Kaylee, I think for me what was challenging was like the, well, UTA Yasmine was not feeling confident and not decisive, which is okay. And I think that was a challenge, a little bit to navigate that. Role ambiguity for a new UTA at the start of a program may be a challenge to some faculty, which could lower feelings of relief. Overall, social support via UTAs in the classroom appeared to create a sense of relief by reducing pressure. This is consistent with research by Laskey & Cohen (2000) that social support has a buffering effect on stress that allows individuals to better cope and maintain psychological health. This can play a role in mitigating emotional exhaustion that is commonly associated with burnout (Maslach & Leiter, 2000). A UTA program providing social support could have similar effects, reducing faculty emotional exhaustion and increasing psychological health. This UTA program maximized aspects of social support in several ways. Faculty were encouraged to choose their own UTA to ensure they received the support they needed in terms of content knowledge and a good fit for personality. This personality fit was important, as we wanted faculty to view their UTAs as partners. In addition, emphasis was placed on meaningful collaboration with UTAs, relying on them for a variety of tasks. This collaboration was described to faculty before the start of the program and reiterated in the UTA-Faculty Agreement (see Appendix G). Extra Layer of Support Subtheme 3: Shared Responsibility for High-Needs Students Research surrounding underprepared students and the prediagnostic work for this study indicated that faculty struggle to support underprepared students, which can create feelings of frustration and helplessness (Sachar et al., 2019). Faculty indicated the top teaching strategy in working with underprepared students was individual support (Sachar et al., 2019), which is challenging for 82 faculty due to a lack of time (Quick, 2013). The researcher in this study did not gather data on student academic standards and was unable to identify if underprepared students received targeted support. However, it appeared UTAs were able to provide individual attention inside and outside of the course for higher-needs students. Two faculty and two UTAs indicated that the shared responsibility in supporting higher-needs students was critical to student success, which was cited four times in the data. Both Faculty Leah and Faculty Kaylee discussed how their UTAs worked closely to develop relationships with certain students needing extra assistance. Faculty Kaylee specifically had her UTA work with a student who had to take the class a second time. Both faculty indicated that certain students were unlikely to pass without this assistance. In addition, UTAs Brad and Yasmine also felt they had supported higher-needs students in a significant way. UTA Yasmine felt she had flipped some grades around and UTA Brad felt that some students who worked with him were more prepared by the end of the class. Research shows that 48% of faculty from disciplines other than teacher education indicated that making accommodations for underprepared students decreased their teaching effectiveness (Quick, 2013). Faculty Sharon described her experiences with higher-needs students: A lot of us are also feeling that strain and wanting to be supportive. And especially as our students are arriving less and less prepared, so each year, I'm surprised how much students don't know when they come into class. Like they don't recognize basic concepts. And these are fundamental skills that theoretically they were introduced to in middle school. But they're here, right? They've taken classes to get to that point, a number of courses in between, and yet a lot of these really foundational skills are still confusing them and tripping them up. That adds a lot of work and time and energy to what is required of us as instructors. Through individualized student support, a UTA program appears to help faculty close the gap for higher-needs students, which may reduce the work, time, and energy that is required for faculty to support this population. Closing this gap helps faculty focus on student success with the intended course goals. 83 Extra Layer of Support Subtheme 4: Impact on Time Research shows that faculty feeling time pressure is a contributing factor to stress and that the demands of the job cannot be accomplished within normal working hours (Darabi et al., 2017). Another study discussed extra time involved in supporting the expectations and competing needs of students was a challenge for faculty (Quick, 2013). The data surrounding time was conflicting in this study. While all faculty discussed time, which was cited six times in the data, faculty seemed uncertain that their UTAs provided time relief. However, none of the faculty indicated they felt they had to, on average, put more time into their UTA than what they received back. It appeared that the UTAs were not a technical fix, simply alleviating time constraints. Rather, the UTAs provided support for faculty by assisting in the classroom and supporting students. Faculty Leah appeared hesitant in saying her UTA alleviated time constraints, I think a little bit. I don't think it was a huge difference, but I don't know When discussing interactions with her UTA she goes on to say, At first, I was not sure whether that additional time during the week would be a burden, but in the end, it didn't feel like a burden because I was going to be doing class planning or whatever anyway. Faculty Sharon felt the time placed toward her UTA balanced out with the time she received back from the UTA support. Faculty Kaylee felt her UTA helped with time constraints, but that she had to put in more time with her UTA at the beginning of the semester since there was an adjustment period that she and her UTA went through. Faculty Hal was the only participant who felt time constraints were definitely alleviated. Instead of alleviating time constraints, it is possible that UTAs reduced the cognitive load faculty felt by assisting them with teaching tasks and answering student questions during in-class practice activities. Cognitive load is the load on the cognitive system that results from performing various tasks (Paas & van Merrinboer, 1994). Faculty complete several tasks and have competing responsibilities and 84 multiple roles (Sabagh, et al. 2018). Multitasking contributes to a high cognitive load (Walter et al., 2015). Relying on the support of UTAs may increase the cognitive resources faculty have by reducing the amount of multitasking typically required by faculty and the amount of role conflict faculty feel (Katz & Kahn, 1978). In addition, Owen (2011) cautions faculty about the amount of time and energy that goes into a teaching assistant. Consequently, one of the goals of the researcher was to mitigate the amount of time faculty had to spend getting their UTA prepared for their role. The program was structured so UTAs were enrolled in a UTA course facilitated by the researcher, who is a teaching and learning expert. UTAs were provided support in understanding the UTA role, engaged in discussions surrounding any challenges they were encountering as UTAs, and were trained in teaching and learning techniques. It appears this course may have helped, which is seen in the data. All four UTAs stated that the UTA course was very helpful in supporting them in their roles, including collaborating with other UTAs, learning teaching topics, teaching a lesson, observing others teach, and reflecting on their UTA experiences. Three of the faculty said the UTA course appeared to support their UTAs in varying ways and one faculty member was uncertain. Another study found it beneficial for a separate office to organize, manage, and train TAs. Begley et al. (2019) found that when the management and instructional load of the TAs is not on the faculty, this allows them more time and space to develop the collaborative relationship with the TAs that the faculty values. This appears to be reflected in this study, as well. Theme 2: Enhanced Teaching Experience Enhanced Teaching Experience Subtheme 1: Enjoyment All faculty participants in this study said having a UTA was a positive experience they enjoyed, using words such as fun, happy, enjoyment, and healthy. This was cited 4 times in the data. According to 85 Fredricksons (2004) broaden and build theory, positive emotions promote psychological well-being, resilience, and thriving. In addition, happiness is related to job satisfaction (Watson & Slack, 1993). Faculty Leah described her UTA experience as really positive and that it was really fun interacting with her. Faculty Sharon said her UTA created a friendly atmosphere in the classroom and that she enjoyed interacting with him. Faculty Hal indicated that having a UTA was a positive experience and that he was really happy to have him. Faculty Kaylee also said she really enjoyed her experience with her UTA and that it was a good, healthy situation for her. However, Faculty Kaylee indicated that interacting with her UTA was challenging to navigate at the beginning of the experience. In addition, the UTA program felt tricky for her due to the level of faculty autonomy, Maybe like not having any structure and guidelines was tricky. An initial adjustment period for those inexperienced with students assisting in the classroom may diminish some feelings of enjoyment of the program. Overall, the faculty appeared to enjoy the UTA program. Fredricksons (2004) broaden and build theory describes how positive emotions broaden individuals perspectives, encouraging creative thinking which can lead to increased cognitive flexibility. Positive emotions also build psychological, social, and physical resources that contribute to overall well-being. Overall, experiencing positive emotions initiates an upward spiral of well-being and flourishing (Fredrickson, 2004). Another study showed that social relations predicted positive emotions (Sahu & Srivastava, 2017). Specifically, social contacts and relationships contribute to happiness and well-being (Argyle & Martin, 2000). Faculty enjoying the UTA relationship could contribute to the social capital they experience through an increase in positive emotions, positively impacting their overall well-being. Enhanced Teaching Experience Subtheme 2: TA as a Partner to Faculty Research on TA programs describes rich relationships being established between faculty and their TAs with faculty appreciating both the logistical assistance and the collegial partnership (Begley et 86 al., 2019; Cook-Sather et al., 2014; Owen, 2011). Begley et al. (2019) found in their study that the nature of the faculty-TA relationship was described by faculty as collegial. The faculty viewed their TAs as coteachers or colleagues who provided beneficial feedback and improved the course. They depict TAs as collaborative partners, helping to improve teaching and learning in the classrooms (Begley et al., 2019). The UTA program wanted to intentionally create this partnership between faculty and their assistants by allowing faculty to choose their own UTA and what the UTA role looked like in their course. This appeared to support the partnership, however, past experience with student assistants and feeling comfortable with the program seemed to impact the level of collaboration faculty established with their UTAs. Two of the faculty described having a partnership with their UTAs, cited 4 times in the data. Having a partner with which to collaborate appeared to provide faculty with beneficial feedback and an improved course. For example, Faculty Leah described how she could turn to her UTA when things didnt go as planned in the classroom to get feedback from her, which created a collegial rapport. Faculty Leah had chosen her UTA by putting a callout for students to apply for the position. Several students were interviewed and a final selection was made based on personality, skill set, and scheduling. In addition, Faculty Leah had prior experience relying on undergraduates to assist in her course. This appeared to give Faculty Leah confidence in her UTA. Faculty Sharon discussed how she intentionally created a partnership with her UTA by allowing him a choice and asking him what he was interested in taking on in her course. She also appreciated having conversations about teaching with her UTA. Faculty Sharon had worked with her UTA as a grader in past courses. In addition, she was aware of her UTAs background and skillset, having had him in several of her classes. This prior relationship appeared to kickstart their collaborative relationship. Faculty Sharon also had prior experience with undergraduates assisting in her course. 87 Having collaborative partnerships with UTAs has multiple benefits. Fingerson & Culley (2001) found a collaborative partnership between faculty and UTAs benefitted students by promoting learningcentered approaches, encouraging active learning, and enhancing accessibility and support. They also found benefits for faculty, including a positive impact on instructors perceptions of teaching. Faculty described their UTAs as invaluable and led instructors to adopt a less individualized and more collaborative approach to teaching (Fingerson & Culley, 2001). A collaborative partnership with UTAs enhances the faculty teaching experience and the student learning experience. Two of the faculty in this study did not specifically mention a partner relationship with their UTA. While she had chosen her UTA, Faculty Kaylee had no prior experience having students assist in her course. She also indicated that the open flexibility of the UTA program felt a bit tricky, as the program simply provided suggestions for how to incorporate UTAs into courses rather than a rigid structure. In addition, Faculty Kaylee indicated concerns about her departments willingness to utilize a UTA for teaching and grading. Faculty Hal had no prior experience teaching the course to which the UTA was assigned. In addition, he did not have a prior relationship with his UTA and was unaware of his UTAs skill set and personality. He was also used to having graduate students in this role and felt hesitant about having an undergraduate as a teaching assistant: Because if it's not a graduate, I'm a little bit in doubt about a student first, but...if it's undergraduate, difference now with other kids is low. Maybe I cannot give him that responsibility to take care of... I want to have all control and make everything. Faculty Hals hesitancy is a phenomenon mentioned in the literature. Owen (2011) describes one of the challenges of teaching assistant programs as faculty reluctance to be interdependent with a TA. Perhaps Faculty Hal did not experience his UTA as a partner due to the absence of a prior relationship. Both Faculty Hal and Faculty Kaylee also lacked experience in having undergraduates assist in their courses and appeared to feel low levels of psychological safety in fully utilizing their UTAs. 88 Psychological safety refers to the belief that it is safe to take certain risks without fear of negative consequences (Edmondson & Lei, 2014). When employees feel psychologically safe, they are more likely to engage in certain behaviors, including experimenting with new approaches, without fear. A lack of experience and a lack of support could have contributed to lower levels of psychological safety for faculty engaging in a pilot UTA program. To establish higher levels of psychological safety, a UTA program might consider creating strong partnerships with departments, ensuring familiarity and acceptance of the program within the culture of various schools. The schools can communicate the program to their faculty, establish additional criteria for eligible courses, and create expectations for faculty and UTAs in the program. The acceptance and formally established norms of schools helps their faculty understand how the program fits into the culture of the school, creating a psychologically safe environment in which participants can comfortably operate. In addition, to help faculty who are inexperienced with utilizing undergraduate students in this role, extra resources with tips, expectations, role descriptions, and previous successes could help build trust in the program. Enhanced Teaching Experience Subtheme 3: Shared Classroom Dynamics Three of the faculty indicated that their UTA modified the classroom dynamics which enhanced their teaching experience. These modifications consisted of increased energy in the classroom, increased interactions with students, and increased student interactions with content. This was cited six times in the data and was perceived as a positive aspect of the UTA program, helping faculty teach more effectively. For example, when asked to embody her experience and imagine herself in the physical classroom interacting with her UTA, Faculty Sharon described how it can feel exhausting trying to keep her students actively engaged with the content. She felt having her UTA helped keep the energy up and was someone she could play off of. In addition, Faculty Leahs UTA was intentionally integrated into 89 course activities, which allowed her UTA to interact regularly with students. Her UTA encouraged students to participate as well as modeled certain practices for the students. Faculty Hal felt his UTA was able to increase engagement by keeping students on track. This helped keep the flow of the course moving forward. His UTA also indicated that he would encourage students who finished activities early to try engaging in the content in different ways. Further probing of this topic found research surrounding the impact of teaching assistant programs on classroom dynamics. One study found that UTAs integrated into a first-year seminar experience appeared to impact engagement. Students in the study appreciated UTAs for their peer-topeer teaching style, making the class more comfortable and engaging (Gordon et al., 2013). In addition, another TA study found that TA support and interactions played a crucial role in student engagement, aligning with findings from studies on faculty contributions to engagement (Wilson & Summers, 2020). Fingerson & Culley (2001) found faculty with UTAs developing a collaborative classroom environment through a more dialogue-based, democratically run course. They also found that UTAs can promote a shift in perspective among students, encouraging them to take a more active role in their learning. A UTA program can help create a more dynamic teaching environment, assisting faculty with their teaching which appears to increase teaching effectiveness and student learning. Enhanced Teaching Experience Subtheme 4: Faculty Reassurance Three of the faculty discussed how their UTAs gave them reassurance with certain aspects of their teaching. The increased reassurance received by their UTAs contributed to an enhanced teaching experience by validating faculty with their approach. This reassurance may mitigate faculty stress by reducing self-imposed high expectations (Gmelch et al., 1985; Stolzenberg et al., 2019). It also appeared to boost the positive feelings faculty felt toward the UTA experience. 90 For example, both Faculty Leah and Faculty Sharon found it helpful to talk through lessons or assignments with their UTAs. If they received negative feedback from students or if a lesson did not seem to go well, they could discuss the situation with their UTA. The UTA feedback sometimes felt reassuring to them, which they appreciated. Instead of placing blame on themselves for a disappointing outcome, the faculty were able to gather insight from their UTA that supported their approach. UTAs appeared to remind faculty that students must also take accountability for the learning process. Faculty Kaylee received reassurance when her UTA helped her with her students. It just gave me some confidence, right, that there's this external support outside of just me to help the students, which is really big, right? And then the helpfulness of the time Some research reveals faculty feel reassured by TA insight (Acosta et al., 2019; Marsh & Overall, 1979). Acosta et al. (2019) specifically mention reassurance as it relates to feelings of validation that result from a reciprocal learning process. The TAs validation of the appropriateness of teaching styles helped to reassure faculty. Studies have shown that faculty self-imposed high expectations are one of the top three stressors experienced by faculty (Gmelch et al., 1985; Stolzenberg et al., 2019). Having UTAs reassure and validate faculty when they expect a different outcome in the course may help mitigate stress faculty feel. Theme 3: UTA Bridged a Gap UTA Bridged a Gap Subtheme 1: Provides Student Perspective Owens (2011) review of the literature surrounding teaching assistants lists the benefits and challenges of incorporating teaching assistants into courses. One of the benefits listed includes the insights faculty receive from the teaching assistant on classroom personalities, class dynamics, and comprehension of course materials, helping faculty to customize their teaching to their students needs. This benefit also emerged from the data in this study. 91 Three of the faculty described the value of receiving the student perspective from their UTA, cited three times in the data. Their UTAs helped translate generational differences and provided insight into the students needs and experiences. For example, Faculty Leah appreciated having her UTA interpret cultural interactions that she didnt understand, I'm like, I don't know how to interpret this. Please translate. She also described how her UTA probably enjoyed being a cultural mediator, helping to explain those types of things. Faculty Kaylee leaned on her UTA when working with technology, who let her know how students experience technology. Faculty Sharon found it helpful when her UTA described areas of the course content he struggled with most, as this helped her to see how she could further help her students. I forget which pieces of it would be most helpful, especially from their perspective as someone who's encountering it for the first time. However, Faculty Sharon also indicated that there were a few times when miscommunication occurred between her students and UTA, I think there were a couple moments where there were miscommunications of students thinking one thing when that wasn't what was communicated or at least intended to be communicated. She had to handle this type of miscommunication, making her bridge the gap between students and the UTA. Overall, faculty appreciated the UTA feedback which allowed them to better understand the teaching context related to the student experience. Faculty Leah indicated that she modified examples to be more relevant to the student population. Faculty Kaylee was able to provide more pointed instructions when guiding students through the textbook student portal. Faculty Sharon was able to identify potential struggle points for students more easily, making appropriate pedagogical modifications. UTAs bridging the student gap allowed faculty to teach more effectively by tailoring their pedagogy to meet the needs of their students. 92 UTA Bridged a Gap Subtheme 2: UTA Approachability for Students Three of the faculty and three of the UTAs felt they were a more approachable option for their students, cited six times in the data. Having UTAs be an approachable option for students inside a course appeared to support the faculty by providing them with an extra resource that students felt comfortable utilizing. This comfort appeared to be due to UTAs being a peer to students, close to their age and in their generation. For example, UTA's approachability for students was described by Faculty Sharon as helpful and Faculty Hal felt it may have increased student learning in his course. While Faculty Leah felt a bit weird that students appeared to approach her UTA more often than her, she was glad that they felt comfortable with her UTA, I'm glad that she was there, that they felt comfortable going to her and they may have been even more checked out without her being there. It was unclear why Faculty Leah felt weird, but Owen (2011) found one of the challenges discussed in the literature is faculty feeling guilt for not earning their keep. This may have contributed to the challenges Faculty Leah mentioned. The approachability was also mentioned by the UTAs, allowing them to take on a mentorship role with students. In this role, UTAs assisted with course content, study skills, and normalizing feelings and experiences. UTA Yasmine felt she became an advocate for students, quickly becoming a mentor. Students felt comfortable confiding in her, which allowed her to help them conquer barriers getting in the way of their success. UTA Natalie also felt that she was a comfortable, approachable option for students, which allowed her to help them with course content during office hours. UTA Vaughn felt a couple of students at the end of the semester opened up to him, helping him bridge a gap with the professor. TA approachability was discussed in the literature in which students described ease of interaction with their UTA and how this helped them feel comfortable asking questions (Mohandas et 93 al., 2020). Owen (2011) describes a similar experience when discussing the benefits of teaching assistants in courses. The study indicates that students benefited from learning from someone who understood their interests and motivations. In addition, faculty found it a benefit to utilize their UTAs as a student mentor (Owen, 2011). Student mentors have been found to reduce stress and increase a sense of self-efficacy and belonging in students (Raymond & Sheppard, 2018). One of the goals of higher education faculty is to help students succeed and increase course retention. UTAs being an approachable option for students could potentially help faculty by enhancing the student experience, which may impact retention (Raymond & Sheppard. 2018). While UTAs were an approachable option for students, the capacity-building theme was emphasized throughout the program during which UTAs were encouraged to put the work back on students (see Appendix M for points emphasized in the training curriculum). It is important to note that students feeling comfortable approaching UTAs is not due to UTAs being less challenging than faculty. This capacity-building approach was important to mitigate or break the dependency cycle by building skills, habits, attitudes, and values that create lasting capacity. Theme 4: Professional Growth Through Self-Reflection Three of the faculty indicated that they received insight from their UTA that enhanced awareness, which was cited three times in the data. Discussions with their UTAs created space for faculty to self-reflect on their teaching, contributing to their professional growth. While faculty insight from their UTA was listed as one of the benefits in Owens (2011) literature review about teaching assistant programs, the insight discussed by Owen was largely related to faculty gaining the student perspective from their UTAs. Insights mentioned included information about classroom personalities, classroom dynamics, and comprehension of course materials (Owen, 2011). The insights discussed in 94 this section go beyond those gained through the student perspective, potentially contributing toward growth that could transfer to the overall professional development of faculty. For example, Faculty Leah reflected on how some students might view her, which does not match how she views herself. Conversations with her UTA appeared to provide insight into Faculty Leahs identity as an instructor, which she indicated was something she was continuing to reflect upon. Faculty Sharon described how communicating with her UTA to explain why she did the things she did when teaching helped her gain insight into her teaching methods. She felt the practice of explaining the why would be beneficial to also communicate to her students. Faculty Kaylee indicated that interactions with her UTA gave her ideas for how to deliver higher-quality education to her students. Donald Schn (1983) introduced his theory of reflection-on-action, in which individuals review and analyze their experiences after a situation occurs. By stepping back to reflect, individuals can see patterns and insights that lead to a deeper understanding of the assumptions and values that inform their approach. This reflective practice is important for learning, growth, and adaptation, which can lead to increased effectiveness (Schn, 1983). Boud et al. (1985) suggest that reflecting with others enriches the process because reflection is inherently social and interactive. Reflecting with others enhances learning and growth through stimulating dialogue, different perspectives, feedback, and co-constructing knowledge (Boud et al., 1985). A UTA program provides faculty with an individual with whom they can specifically discuss course challenges and successes. This discussion can lead to self-reflection and professional growth. Revised Conceptual Assumptions In a hermeneutic phenomenological study, the researcher discusses how previous assumptions, noted while journaling, were revised after analyzing data (Peoples, 2020). Several assumptions were modified or confirmed during the process of evaluating data via the hermeneutic circle. 95 Assumption Modification: Faculty Want UTAs to Grade It was assumed that faculty would utilize their UTAs to help with grading. The researcher has had many personal interactions with faculty discussing various aspects of teaching and curriculum development. During these interactions, the time it takes to grade tests and assignments has often been a topic of conversation. Due to the amount of time grading appears to take, the researcher assumed faculty would be pleased to have UTA assistance with this responsibility. Only one faculty member took advantage of using their UTA for grading purposes. Two of the faculty felt reluctant to use their UTA for grading, fearing that students or their department would be displeased with having undergraduates grading work. Another faculty member decided to not utilize her UTA for grading since he was not interested in this responsibility. Grading, confidentiality, and feedback are all topics covered in the UTA training course and will continue to be an option. Since this is the first experience faculty and UTAs have had with this program, it may take time for faculty to get used to using undergraduate students in this capacity. Perhaps once the program is more established, faculty will feel more comfortable allowing their UTAs to grade. Assumption Modification: Faculty Want UTAs to Teach While three of the faculty had their UTAs teach lessons or lead the class in some other fashion, one faculty member did not. The faculty member indicated that he was used to graduate teaching assistants and was uncertain about the level of responsibility that was appropriate for an undergraduate teaching assistant. The faculty member appeared hesitant to relinquish control of leading the class. This faculty member was also hesitant to have the UTA grade in the course. Teaching and grading are two responsibilities that set UTAs apart from other types of support that undergraduate students offer at the university. For example, Student Instructors at the university do many of the same tasks and responsibilities as UTAs, even attending class sessions regularly. A different program may be more appropriate for faculty who prefer to teach and grade exclusively on their own. 96 Assumption Confirmation: UTAs a Faculty Resource Based on the prediagnostic work and research, the researcher assumed UTAs would be a resource for faculty in some capacity. This assumption appears to be true based on the findings of this study. Several of the subthemes that surfaced also appeared in the literature. For example, faculty sharing the workload with their teaching assistants and teaching assistants bridging a gap in the classroom were themes that were expected. However, enjoyment and faculty reassurance when interacting with their UTA was a surprise. It appears there was a depth and richness that formed in the collaborative relationships between faculty and their UTAs that is a gap in the literature. Limitations Several limitations existed in the research. The pilot program only included four faculty, which is a small sample size, limiting the number of voices and experiences recorded for the study. The faculty involved in the study were also mostly from a single school, the College of Arts and Sciences. While one faculty was from the school of nursing, voices from other professional schools were left out, such as the School of Business or the School of Education. In addition, the pilot was conducted for 16 weeks in the fall semester of the academic school year, limiting the experiences of this study to a single semester rather than a full academic year. While it is likely that the UTA program will continue into the spring semester, data needed to be evaluated immediately after the fall semester due to personal time constraints. The researcher implemented and organized the program as well as data collection. While colleagues helped obtain classroom observation data, interviews were conducted solely by the researcher. As a result, faculty and UTAs may have been hesitant to fully critique the UTA program. Having additional colleagues to collect interview data could have resulted in richer insights and different perspectives. In addition, the researcher was inexperienced in designing interview questions. At times, the interview 97 questions elicited redundant responses. Follow-up interviews would have been beneficial; however, time constraints prevented the researcher from scheduling additional interviews. Classroom observation data was obtained using an observation form that was not specifically intended for observing UTAs in a course (see Appendix I). In addition, certain sections of the observation form did not separate faculty, students, and UTAs for the entered data. An observation form specifically intended for the collection of UTA data with a more granular breakdown of participants being observed has the potential to collect richer data. Finally, the study was conducted at a single institution, making it possible that the results are not generalizable to other institutions with differing characteristics, such as cultural and demographic diversity, the campus setting/location, public versus private, or the size of the institution. Recommendations for Future Research There are several opportunities for further investigation or exploration based on the findings of this study. Future research might consider addressing the impact of undergraduate teaching assistant programs on the lived experience of faculty over a longer period. Having the same UTA for multiple semesters could have different results. For example, perhaps some of the benefits described in this study would be amplified. In particular, it would be interesting to see if the enjoyment of the UTA program persists and, if so, how that impacts faculty perspectives on their job as a whole. Joy, growth, and reliance on a teaching partner are all states that could be further impacted by time. While the data from this study were quite positive, there were some challenges, as well. One faculty member found it challenging to address her UTAs initial indecisiveness. It would be interesting to investigate if these types of role adjustment challenges continue once a UTA has experience in the role and how that may impact facultys lived experience of the program. 98 It was interesting that three of the faculty participants felt reassurance from their UTAs. Feelings of reassurance and validation seemed to contribute to the positive feelings faculty experienced during the UTA program. Some research reveals faculty feel reassured by TA insight (Acosta et al., 2019; Marsh & Overall, 1979). This appears to be connected to the self-imposed high expectations faculty have set for themselves as it relates to student learning. UTAs seemed to be able to mitigate faculty feelings of self-blame when students do not appear to learn content to the level faculty intend, which warrants further investigation. One of the gaps in the literature surrounding test-optional colleges is what modifications schools might need to make in terms of student support services and teaching practices to accommodate incoming students. What practices do colleges need to modify for the changing student body, including underprepared students? It appears that a UTA program could help, as the critical support that UTAs were able to provide for high-needs students is an exciting finding. The research in this study is a promising sign that this type of support could be impactful for underprepared students, however further research is needed. In addition, a possible consequence of UTAs supporting underprepared students could be faculty-increased teaching effectiveness, job satisfaction, and time management. Further investigation would help clarify the data. Implications and Recommendations The literature surrounding UTA programs often emphasizes outcomes and findings surrounding teaching assistants and students (Felege, 2018; Philipps et al., 2016; Oneal et al., 2007). Faculty are not a focus or are left out of the study. This study specifically focuses on the lived experience of faculty as they engage in an Undergraduate Teaching Assistant program, filling a gap in the literature on facultyfocused research for this type of intervention. This study intentionally implemented several practices to 99 help support faculty with the UTA program. There are several recommendations for institutions who would like to recreate this study, including: Using a central office to manage the program, creating strong partnerships with departments and schools, enrolling UTAs into a course that trains them for the role, allowing faculty to choose their UTA, and creating extra resources for faculty inexperienced with having a UTA. To mitigate the amount of time faculty spend on a UTA program, institutions might consider structuring a UTA program so that the organization and facilitation of the program is managed by a central office. All the logistics of hiring, payment, and training UTAs are streamlined by an office, taking this burden off faculty, schools, and departments. This type of model provides UTAs with consistent, uniform support and allows instructors to focus on developing rich relationships with their UTAs and course-specific issues. It also helps with faculty time constraints, which is a source of stress for faculty (Darabi et al., 2017). It is recommended that any central office organizing a UTA program create strong partnerships with departments and schools. Collaborating closely with schools ensures that the UTA program is fully understood, aligns with the needs of the faculty, and is accepted by the various subcultures existing across campus. This partnership can help create the psychological safety that faculty using the UTA program need. This psychological safety may free up faculty to fully utilize their UTAs in ways that faculty may otherwise feel hesitant, such as teaching and grading. Institutions might also consider having UTAs enrolled in a course so they are engaged in ongoing, comprehensive UTA training throughout the experience. The course or training can provide UTAs with topics they can immediately apply in their assigned courses, such as teaching strategies, 100 learning science, facilitating groups, communication techniques, and more. In addition, the training can allow a space for UTAs to collaborate, developing UTA relationships where they can provide each other feedback on any issues that come up. Teaching these topics in a separate course offloads general teaching and learning topics from faculty, allowing them to focus on content-specific topics with their UTAs. In addition, UTAs have an outlet for concerns, gaining support from another source beyond their faculty. In addition, institutions might consider having faculty choose their UTAs to ensure an established relationship exists. It appears that faculty who already have a working relationship with their UTAs feel more comfortable collaborating closely with their UTA and relying on them more heavily with teaching responsibilities. This appears to provide a more meaningful experience for faculty and UTAs. Finally, institutions might consider having extra resources for faculty who are inexperienced with a student assistant in their course. While documentation outlining the details and logistics of the program fulfills certain needs, faculty new to this type of program may need more support. It is suggested that integrating stories from faculty experienced with the UTA program may help contextualize the program for incoming faculty. For example, faculty videos describing their UTA experience and providing tips or recommendations, may help faculty better understand their role and the UTA role. Challenges to Consider While the themes and subthemes emerging from the data are positive, there were several challenges encountered during the study that are worth considering when creating similar programs. Scheduling Issues The Undergraduate Teaching Assistants all took a full load of courses and had extracurricular activities, such as sports. Finding sections of courses that worked well for the UTAs took flexibility on the part of the faculty and the UTA. While UTAs are expected to attend 101 most or all classes of the section to which they are assigned, sometimes that is not possible. In addition, schedules can be challenging to align when finding observers to view a UTA in a course. Having several potential observers can be helpful to mitigate scheduling issues. Power Dynamics Questions might arise around the power dynamics between faculty and UTAs. There could be concerns about UTAs being over relied upon or relied upon in an unhealthy way. While this did not appear in the data, it is an important consideration. Ensuring faculty understand their role, the UTA role, and how not to interact with their UTA can help. It is also important to encourage UTAs to have healthy boundaries, emphasizing that they are students first and UTAs second. UTA as a Burden While the data did not reflect faculty viewing their UTAs as a burden, it is possible certain faculty could view a UTA as net-draining. As discussed in other sections, Faculty Kaylee and her UTA, Yasmine, had an adjustment period at the beginning of the semester. Yasmine had confidence issues in her role as a UTA and Faculty Kaylee had never had a student assist in her course. This required extra faculty support during the first half of the semester, which could have been perceived as a burden. This may be mitigated by having extra resources for faculty engaged in the program and guidance from faculty and UTAs who have already participated in the program in the form of tips or best practices. Course Selection While courses were selected based on DFW rates (courses historically having higher numbers of students receiving letter grades D and F, and/or higher withdrawal rates), the number of students in a course, and faculty interest, concerns may arise surrounding the perceived fairness of the faculty selection process for courses receiving a UTA. Some faculty may wonder why their course was not selected to have a UTA. This may be mitigated by partnering closely with departments and schools to ensure the UTA program is managed and established in a way that works well for the culture of the department. In addition, there were questions that 102 emerged surrounding the helpfulness of the program in other types of courses. For example, a course that did not have higher DFW rates. Collaborating with departments to determine what criteria are useful to consider when assigning courses with a UTA may help. Inclusive Teaching Another potential concern could arise around the ability of UTAs to support students with diverse learning needs, such as neurodiverse students. If the UTA program desired to provide that kind of specific support, additional training and resources would likely need to be provided for the UTA. Keeping these potential challenges in mind can strengthen a UTA program and better support faculty and UTAs engaged in the program. Conclusion The great faculty disengagement has been observed by many. Faculty might not be quitting, but theyve left the building sometimes departure is a state of mind (McClure & Hicklin-Fryar, 2022). My prediagnostic work with higher education faculty into this dissatisfaction revealed that the job demands of high workload and challenges in teaching students with different academic starting points were sources of frustration. Faculty professional development for teaching underprepared students is an overarching common recommendation in the literature for supporting faculty in understanding and effectively teaching this population (Gabriel, 2016; Sachar et al., 2019; Quick, 2013; Shankle, 2016). However, my prediagnostic work indicated that faculty were already emotionally depleted and lacked time in their schedule due to high workloads. The challenge was more complex and needed an adaptive approach instead of a technical fix. The purpose of this hermeneutic phenomenological investigation is to illuminate the lived experience of higher education faculty as they engage in a job resource of an Undergraduate Teaching Assistant (UTA) program. The focus of the study is the faculty perspective as they interacted with their 103 UTAs and the impact on faculty as UTAs supported underprepared students. The data from the study indicates faculty had positive experiences overall, creating rich relationships with their UTAs that benefited faculty, both emotionally and logistically. Administrators, student support centers, and faculty support centers can have a better understanding of the faculty experience when receiving classroom support, and how this impacts faculty inside and outside of the classroom. This study strives to go beyond a technical fix by implementing a meaningful, adaptive intervention that has a long-term impact. 104 References Acosta, L. A., Overgaard, P. M., Pool, N. M., Renz, S. M., & Crist, J. D. (2019). You learn when you teach: a narrative pedagogy for faculty and graduate teaching assistants. The Qualitative Report, 24(11), 2891-2902. Adrian, C. M., Cox, S. S., Phelps, L. D., Schuldt, B. A., & Totten, J. 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International Journal of Scientific and Technology Research, 8(11), 2498-2502. Tienda, M. (2013). Diversity inclusion: Promoting integration in higher education. Educational Researcher, 42(9), 467-475. https://doi.org/10.3102/0013189X13516164 Townsend, B. K., & Rosser, V. J. (2007). Workload issues and measures of faculty productivity. Thought & Action, 23(1), 7-19. Walter, S. R., Dunsmuir, T. M., & Westbrook, J. I. (2015). Studying interruptions and multitasking in situations: The untapped potential of quantitative observational studies. International Journal of Human Computer Studies. Warner, J. (2021, March 22). Demoralization. optimism?: Inside higher ed. Just Visiting. (n.d.). Retrieved February 1, 2023, from https://www.insidehighered.com/blogs/justvisiting/demoralization-optimism Watson, D., & Slack, A. K. (1993). General factors of affective temperament and their relation to job satisfaction over time. Organizational Behavior and Human Decision Processes,54, 181-202. Wawrzynski, M. R., & Lemon, J. D. (2019). Understanding student learning outcomes of peer educators. New Directions for Higher Education, 188, 61-69. https://doi.org/10.1002/he.20346 123 West, E. L. (2012). What are you doing the rest of your life? Strategies for fostering faculty vitality and development mid-career. Journal of Learning in Higher Education, 8(1), 5966. Wilson, D., & Summers, L. (2020). The Importance of Teaching Assistant Support and Interactions in Student Engagement. 124 Appendix A Predisgnostic Interview Questions 1. What is being a faculty-member like for you? 2. When do you feel the most energized whats the experience like and the factors involved? 3. When do you feel the least energized/depleted whats the experience like and the factors involved? 4. What are the top 3-5 things that already exist that feel like resources or sources of support for your job and your teaching? 5. What doesnt exist that would feel supportive for you with your job and teaching (whether it be within your department, from administration, or from the CTL)? 6. Do you feel you have the time and support to do what you want or need to grow and learn in your field or with your teaching? 7. Are there needs your students have that, if fulfilled, would be supportive for you when teaching them? 8. What would feel supportive for you, not just professionally, but personally? 125 Appendix B Approval from Institutional Review Board 126 Appendix C Email Invitation to Faculty to Participate in Study 127 Appendix D Consent to Participate in Research Study Topic: Impact of Teaching Support on Faculty Experiences Researcher: Mona Kheiry Faculty Mentor: Jeff Hannah This is a consent form for research participation. It contains important information about this study and what to expect if you decide to participate. Your participation is voluntary. Please read and consider the information carefully. Please feel free to ask questions before making your decision to participate. If you decide to participate, you will be asked to sign this form. You will receive a copy of the form. Purpose The purpose of this study is to gain an understanding of the impact of an Undergraduate Teaching Assistant program on how faculty experience their jobs and their teaching, particularly experiences related to teaching underprepared students. You have been selected to participate in this project and the researcher believes you would be a helpful source of information based on the objectives. Your opinions, ideas, and experiences (as well as the opinions, ideas, and experiences of approximately 7 others) will be used by the researcher in a cumulative paper, which may or may not be published or presented. Procedures/Tasks Interviews will be audio-recorded, with your permission, so that the researcher may have a more accurate record of your comments than note-taking alone can provide. With your permission, two classroom observations will occur by the researcher or a colleague, with notes taken. If applicable and by your permission, certain email interactions between faculty and teaching assistants will be submitted to the researcher for review. Duration Interviews are expected to last approximately 60 minutes and will occur by appointment. An additional follow-up interview lasting approximately 30 minutes may occur to clarify information. Again, by appointment. Two classroom observations scheduled on an agreed upon time will last the entire duration of the allotted class period. You may leave the study at any time. If you decide to stop participating in the study, there will be no penalty to you, and you will not lose any benefits to which you are otherwise entitled. Your decision will not affect your relationship with the university. Risks and Benefits 128 The research presents minimal risk. However, because you will be asked questions about your teaching, potential challenges surrounding your teaching, and how these challenges impact you personally and professionally, it might present emotional discomfort for you. The risk of this discomfort is unforeseeable. Confidentiality Efforts will be made to keep you and your identity confidential. Real names will be replaced on all documentation and recordings with a pseudonym (with the exception of one master list of pseudonyms and participants real names). Information that is too specific and makes participants identifiable will not be included in reports or other uses of the data to ensure confidentiality. At the end of the study, all identifiable information will be disconnected from its (real name) source. Incentives Participants will not receive any type of payment for involvement in this study. Participation Rights You may refuse to participate in this study without penalty or loss of benefits to which you are otherwise entitled. If you choose to participate in the study, you may discontinue participation at any time without penalty of loss or benefits. By signing this form, you do not give up any personal legal rights you may have as a participant in this study. Contacts and Questions For questions, concerns, or complaints about this study you may contact: Mona Kheiry at 317.955.XXXX or mkheiry@marian.edu If you have questions about your rights or responsibilities as a research participant, please contact the Chair of the Institutional Review Board (IRB) at irb@marian.edu. Signing the Consent Form I have read and understand/been made to understand this form and I am aware that I am being asked to participate in a research study. I have had the opportunity to ask questions and have had them answered to my satisfaction. I voluntarily agree to participate in this study. I am not giving up any legal rights by signing this form. I will be given a copy of this form. ____________________________________ ____________________________________ Printed name of subject Signature of subject ____________________________________ Date and Time 129 Investigator/Researcher I have explained the research to the participant or their representative before requesting the signature above. There are no blanks in this document. A copy of this form has been given to the participant or their representative. ____________________________________ ____________________________________ Printed name of person obtaining consent Signature of the person obtaining consent ____________________________________ Date Consent form adapted from Plumlee, J. (2023, May). Nudging the nudgers: A mixed method study to understand the impact of family engagement on student success. 130 Appendix E Faculty Handbook for UTA Program Undergraduate Teaching Assistant Program Faculty Information Mona Kheiry Director, Center for Teaching and Learning Overview The Center for Teaching and Learning is piloting an Undergraduate Teaching Assistant (UTA) program in the fall of 2023. Certain courses are eligible for this pilot program, including yours! The program is being completely organized and facilitated by the CTL including training, supporting, and compensating student TAs. For this first pilot, TAs are to be selected for a specific section of a course and are to attend all or most class meetings in which they are assisting. TAs are to partner with faculty to support the course in several ways, depending on the needs of the course, the needs of the enrolled students, and the strengths of the TA. This document outlines the details to ensure you and your TAs have a positive start to the program. Compensation for UTAs The UTA program is considered an internship experience. Student TAs are to enroll into an internship course in order to receive credit for their participation in the program. In addition to course credit, students receive a $500 stipend. UTA Selection Process To ensure you receive the best TA, we initially ask faculty to nominate a student for the TA role. You know which students have done well in your course in terms of content, attendance, and motivation. We do ask that you consider the following criteria when recommending a student for the TA role. Will be a junior or a senior during the TA experience Received an A or B grade in the course in which you would like them to TA Had good attendance and engagement in the course in which you would like them to TA Have availability in their schedule to TA in your course section (they will attend all or most of these classes) If you do not have a student in mind, please let us know and we can put a call out to students to see who might be interested in the role. We will rely on your guidance for the final selection to ensure you receive a match that works best. 131 UTA Responsibilities While the CTL hopes UTAs are used in a variety of ways so they are exposed to different experiences, the tasks in which they are involved is ultimately up to you. It is best to collaborate with your UTA when deciding on their role so they are able to provide input. Tasks to consider include the following, although it is not considered a comprehensive list. You are welcome to request additional duties. Attend all or most classes o Create and teach simple lessons o In-class demonstrations o Teach one class period while being observed by instructor o Offer support during active learning o Deliver a lecture Assist during labs Hold office hours Grade o Objective exams o Practice assignments needing feedback. o Other appropriate assignments (Straightforward/simple assignments when using a template) Lead review/study sessions Lead small group breakout sessions Lead group projects or discussions Tutor Develop course assignments Administrative/Clerical Maintain LMS, take attendance, print handouts, etc. Attend faculty departmental meetings Provide faculty feedback o Provide student feedback to faculty o Provide feedback on pedagogical strategies, effectiveness of assignments/activities o Provide input on design of assignments UTA Time Commitment Hours Per Week UTAs are expected to attend a 5-hour orientation prior to the start of the semester. In addition, UTAs are expected to attend all or most of the class sessions for the section in which they are assisting. They are also required to attend a 1-hour weekly reflection/training session through the CTL. This equals approximately 4 hours per week. An additional 5-10 hours of work a week beyond the expected 4 hours is typical. The actual time can vary depending on the curriculum and level of support students need each week. The CTL does not dictate how you utilize the time, as it will differ depending on your discipline, curriculum, TA strengths, your needs, and the needs of your students. 132 Having UTAs Grade and Potential Conflicts The CTL will prepare UTAs to grade with appropriate training. Specifically, they will learn about ethical behavior, confidentiality, and FERPA. There will be sessions covering effective grading techniques and providing feedback. It will be helpful for instructors to provide rubrics, templates, exemplars, or other types of resources to help support TA grading. High-stakes assignments should not be graded by a teaching assistant. In addition, we request teaching assistants not grade the work of those in which a conflict of interest exists. Close friends, significant others, or family members of the teaching assistant would qualify as a conflict of interest. Please discuss this with your TA and determine if there are students in the course that may pose a conflict. Letting Students Know About the UTA Syllabus Mention Students in your course should know your course has a UTA. Please insert a blurb in your syllabus that the course will have a teaching assistant, who the teaching assistant is, and how to contact them. In addition, please include a brief sentence or two about the general role of the teaching assistant. How Do UTAs Differ from SIs? Student Instructors (SIs) are a part of the Center for Academic Success & Engagement- CASE and do not have teaching and grading responsibilities as a part of their role. TAs will be specifically trained by the CTL to take on teaching and grading responsibilities and we hope they have an opportunity to teach a lesson, portions of a lesson, or even entire class periods while being monitored by you. The CTL will also be covering confidentiality, FERPA, ethics, and how to provide effective feedback in the TA training so they can grade simple, straightforward, or objective assignments. While the TAs can be responsible for these types of tasks, it is not a requirement. Please involve your TA in ways you think will work best given your course structure and student population. UTA Training A large goal of the UTA program is to support faculty in their courses and bridge the gap with struggling students. We want to ensure the time and energy of training and supporting UTAs falls on the CTL, allowing faculty to take on more of collaborative partnership with UTAs. While we hope faculty will provide feedback to UTAs and mentor them when needed, much of the teaching and learning support will be managed by the CTL. Any discipline-specific training will be the responsibility of the faculty member, with the CTL covering the topics below. This training will occur during an orientation prior to the semester and weekly sessions throughout the semester. In addition to these items, students will be involved in microteaching practice sessions. Clarification of the role and expectations of a UTA How best to interact with a faculty member Ethical behavior, confidentiality, and FERPA Safety issues Strategies for difficult situations Presenting and explaining Increasing participation Assisting in labs Managing groups 133 Grading and feedback Holding effective office hours Learning strategies and learning science Metacognitive strategies Understanding challenging students and individual needs Providing Feedback for UTAs The CTL will be meeting with teaching assistants on a weekly basis to ensure they have the support they need, providing guidance and feedback. In addition, with faculty permission, the CTL will observe the classroom experience twice in a semester to see how UTAs are doing. Instructors are encouraged to provide informal guidance and informal feedback to ensure teaching assistants are delivering the support you need. However, it is not an expectation that you formally assess your UTA. The CTL will want to know if you are experiencing ongoing challenges, as this will help guide how we support the TA and whether we ask them to be a part of the program in the future. Getting Started with Your UTA Faculty/TA Agreement Ensure you start the UTA experience positively by meeting with your TA to discuss expectations and scheduling. Please fill out the student-faculty agreement provided to you by the CTL in order to outline your specific expectations of the TA in your course. The agreement should include the TA tasks expected in the specific course, the schedule expectations, and any other expectations regarding how the UTA will interact with students and the faculty member. Please complete and submit the agreement to Mona prior to the start of the semester, as this will help the CTL better understand the UTA role in your course. The Faculty Role We hope the UTA program is a rich and collaborative experience for faculty, with the teaching assistant taking on a role that feels meaningful and supportive. To help facilitate this experience, the CTL is taking on much of the organization, training, and support of the teaching assistants. However, faculty will need to consistently engage with their teaching assistant. Please meet with your UTA regularly to ensure they understand your ongoing expectations. It will also be helpful to have a meeting at the start of the semester to orient students to the course and to your teaching philosophy. Establish logistical items as well, such as how often to meet and the best way to communicate with one another. It is not necessary for you to formally assess your teaching assistant, but please provide informal guidance and feedback to ensure you receive the support you desire and the support students in your course need. If you encounter challenges with your UTA, please reach out to Mona to discuss. 134 Appendix F Undergraduate Teaching Assistant Handbook for UTA Program Undergraduate Teaching Assistant Program Student Information Mona Kheiry Director, Center for Teaching and Learning Overview The Undergraduate Teaching Assistant (UTA) Program pairs a student Teaching Assistant (TA) with a faculty member. The TA works closely with that faculty member in a specific course, attending all or most course sessions, become an integral part of the classroom. The hope is that a collaborative relationship develops between faculty and TAs, allowing TAs to support the class and students in a variety of ways, such as co-teaching, co-developing assignments, grading, and more. Compensation of UTAs This program is an internship and a course has been established in which you can enroll for variable credit COL-360: Career Exploration Internship. Variable credit means you choose the number of credits that makes the most sense given your needs 1 to 3 credits. In addition to receiving credit for the internship experience, you will receive a $500 stipend for each semester in which you are a TA. Selection Process Potential TAs are recommended to the program by faculty. The Center for Teaching and Learning (CTL) then makes the final selection, which allows the selected student to apply to the position inside of Handshake and enroll into the internship course. UTA Responsibilities UTAs are used in a variety of ways, which is dependent on discipline, level of class complexity, and class size. Below is a potential list of activities in which TAs may be involved, however, every faculty member and student will decide on what they want out of the experience. Your strengths and the needs of the classroom will be considered when classroom duties are established. Attend all or most classes o Create and teach simple lessons o In-class demonstrations o Teach a class period while being observed by instructor o Offer support during active learning Assist during labs 135 Hold office hours Grade o Objective exams o Practice assignments needing feedback. o Other appropriate assignments (Straightforward/simple assignments when using a template) Lead review/study sessions Lead small group breakout sessions Tutor Develop course assignments Administrative/Clerical maintain LMS, take attendance, print handouts, etc. Attend faculty departmental meetings Provide faculty feedback o Provide student feedback to faculty o Provide feedback on pedagogical strategies, effectiveness of assignments/activities o Provide input on design of assignments UTA Support & Training The CTL is organizing the program and supporting TAs as they go through the experience. There will be an initial orientation on the Friday prior to the start of classes in the fall semester for the Fall 2023 semester, this date is Friday, August 18th. More details for this orientation will be emailed to you. In addition to the initial orientation, TAs will meet once weekly for one hour with the CTL to cover topics, reflect on that weeks teaching experience, and ask questions to ensure they have all the support and resources they need to have a successful experience. Topics being covered during these sessions may include the following: Clarification of the role and expectations of a TA How best to interact with the faculty member Ethical behavior and confidentiality Safety issues Strategies for difficult situations Presenting and explaining Increasing participation Assisting in labs Managing groups Grading and feedback Holding effective office hours Learning strategies and learning science Metacognitive strategies Understanding challenging students and individual needs Microteaching practice sessions 136 Important Next Steps If you would like to move forward with the TA experience, there are next steps to consider in order to get hired and get enrolled. Apply to the Job Posting Please apply to the job posting in Handshake. This will require you to have a resume inside the system. Contact the Exchange if you have questions about this. You can find the job inside Handshake by searching for the Job ID: 7744450. Always feel free to reach out to me, as well. I am here to help. Enroll into the Course If you would like course credit for this experience, you will need to enroll into the course. The course is COL-360: Career Exploration Internship, Section MM02. The course will have a visible note on it stating that it is for the TA program, which will help you choose the right section to enroll into. Dont forget to select the number of credits you want for this experience. It defaults to 1 credit, but you can choose 2 or 3 credits for the course. 137 Appendix G UTA/Faculty Agreement Form Undergraduate Teaching Assistant Program This is an agreement between the instructor and teaching assistant. The document is meant to be discussed and agreed upon together. It is expected that the TA attend all or most class sessions to assist in a variety of ways. While the CTL hopes TAs are involved in a variety of tasks, the duties in the course are an agreement between faculty and TA, depending on wants, needs, and strengths. Please submit the agreement to Mona prior to the start of the semester. Semester/Year: Course Number/ Section: Course Title: Days Section Meets: Time Section Meets: Student Name: Instructor: Please discuss and put an X next to the TA duties that are agreed upon. Leave blank if the item is not an expectation or possible expectation. The notes column is an optional section to fill out, if needed. Duty Create and teach simple lessons In-class demonstrations Teach an entire class period while being observed by instructor Offer in-class support during active learning Lead small group breakout sessions Assist during labs Hold office hours Expectation Possible Expectation Notes 138 Grade objective exams Grade practice assignments Grade other types of assignments Lead review/study sessions Tutor Develop course assignments Administrative/Clerical maintain LMS, take attendance, print handouts, etc. Attend faculty departmental meetings Provide feedback to instructor, such as student feedback, feedback on teaching strategies, or input on design of assignments, etc. Other duties (please list): 139 Schedule Expectations Please list any expectations outside of the course meeting times. These might include faculty-UTA meetings, UTA office hours, review sessions, etc. To lessen potential time conflicts, the UTA should share timeslots when they are regularly available to fulfill these expectations. For TAs Who Will Grade It is considered a conflict of interest to grade the work of fellow students you know well. Good friends, significant others, or family members are all considered conflicts of interest. For ethical reasons, it is important for you to identify to your instructor if such conflicts exist and to remove yourself as a grader of their work. Please ensure this is a conversation once the student roster is known. Student Signature: Date: Faculty Signature: Date: 140 Appendix H UTA Course Syllabus COL-360: Career Exploration Internship: Being an Undergraduate Teaching Assistant Instructor: Mona T. Kheiry Course Location: Second Floor of Library in the Center for Teaching and Learning (Behind Elevator) Course Meeting Times: Every other Friday, 1:30-2:30pm Credit: Variable Credit of 1-3 credits per semester. Discuss with your advisor what works best. Text: No text. We will utilize the content inside Canvas as our main resource. Course Description: The internship is designed to give students an opportunity to explore career options not directly related to the students major area of study. Three class meetings with the director of internships are required for completion of the course. This is an internship experience as a teaching assistant (TA) to help teach a college course. Only students who have been recommended by faculty and approved by the Center for Teaching and Learning can enroll. Minimum 60 hours of work experience required per credit. Internship credits do not count toward credits required in a specific major. Graded S/U. Learning Outcomes: 1. Evaluate interactions with students to determine strategies that are capacity-building versus dependency-creating. 2. Evaluate student engagement of course content in order to recommend appropriate metacognitive strategies. 3. Implement effective group facilitation to promote learning. 4. Communicate effectively with different people from many backgrounds in order to support all levels of learning. 5. Integrate best-practice presentation skills when teaching a lesson. 6. Implement active learning best practices when teaching a lesson. 7. Develop effective feedback skills and objective grading for multiple types of formative and summative assessments. 8. Apply confidentiality and ethics to teaching in order to holistically respect all students. Methods and Procedures: This is a very hands-on internship course that serves as a companion course for the Teaching Assistant (TA) experience. As you TA in the course to which you are assigned, this course will serve as a source of support in multiple ways. We course will be a place in which we check-in regularly on how your TA experience is progressing and vet any issues or concerns that come up. The course will also teach important topics in order to ensure you have the skills and background knowledge to be an effective TA. Topics will include but are not limited to the following: Your role and responsibilities as a TA 141 Ethical behavior, confidentiality, and FERPA Capacity building in order to support student learning Metacognitive strategies Managing groups and facilitating group discussions Holding effective office hours Learning strategies and learning science Active learning Presenting and explaining Grading and feedback Course Assessment: We will use a variety of methods to achieve learning with these topics, including reflections, selfassessment, peer assessments, micro-teaching lessons, and more. Grading Criteria: This is an S/U course satisfactory or unsatisfactory. Good attendance and engagement in the course assessments listed above will result in a satisfactory grade. Attendance Policy: It is expected that you attend class sessions, as the only way we can learn these topics and apply them effectively to the course you are TAing is by actively engaging in the material. Active engagement is critical for growing your teaching skills. That being said, sometimes life happens. If you need to miss a class, please communicate this in advance so we can discuss options for ensuring you have the information and resources you need to be a successful TA. 142 Appendix I Observation Rubric Undergraduate Teaching Assistant Program Observation Form Instructions: Please note that not all columns have to be filled out. Please fill out the information that is relevant for your experience. Please include detailed descriptions of the participants, including the identification of the frequency and duration of interactions. Also notice who talks to whom, anyone who may be excluded from conversations, and/or any power shifts that may occur. Note anything that was expected to happen but did not. When appropriate, include exact quotes or significant statements. If an activity occurs, describe it in chronological order. Course: Name of Observer: Date/Time: Number of Participants: Setting: Participants: Who are the participants, what are they doing, and how are they acting/interacting? Participants Individual Behaviors Group Behaviors Nonverbal Cues Conversation Topics/Threads Group Behaviors Nonverbal Cues Conversation Topics/Threads Teaching Assistants Faculty Students Researcher Notes/Reflections: Use of Space: What is the setting, what objects are central to the setting, and how is the space being utilized by participants? Individual Behaviors 143 Researcher Notes/Reflections: Types of Individual Activities: Behaviors In what types of formal or informal activities did participants participate? Researcher Notes/Reflections: Group Behaviors Nonverbal Cues Conversation Topics/Threads Demographic Individual Details: Behaviors What details, such as place, time, setting, lighting, mood, number of participants, etc. impacted the experience? Researcher Notes/Reflections: Group Behaviors Nonverbal Cues Conversation Topics/Threads Overall Researcher Reflections: Adapted from Qualitative Data Collection Tools: Design, Development, and Applications (P. 138) by F. Billups, 2021, Sage Publications. 144 Appendix J Faculty Interview Questions 1. Demographic Information: a. How many years have you been teaching? b. Have you had a TA or SI before? Please explain. c. Is your course a required course for students? d. How many students? e. Do you have a sense of the ratio of majors and non-majors in your course? f. What made you want to be a part of the UTA program? 2. What was your experience with the Undergraduate Teaching Assistant Program? What felt supportive and enriching? What felt challenging? 3. Did your teaching assistant feel like they helped mitigate your time constraints with the course? 4. Did having a TA in the course provide any emotional support or a sense of relief? 5. What was your role with your UTA and how did it feel? 6. What types of interactions did you and the teaching assistant have? What was that experience like? 7. How did your role feel with your students? Did you notice changes to your role with your students from past experiences? 8. How did it feel being in the physical classroom with your teaching assistant present? What did you notice about your thoughts, feelings, and body language? 9. What were the interactions like between your teaching assistant and your students? How did it feel when observing the interactions? 10. Did the teaching assistant support underprepared students? 11. If yes, what did that support look like? What was that experience like? How did that impact your role? How did you feel about the support? 12. If no, what was that experience like? How did that impact your role? How did you feel about the lack of support? 13. How has the Undergraduate Teaching Assistant program impacted you personally and professionally? 14. How has the Undergraduate Teaching program impacted your job, as a whole? 15. Are there any critical experiences or critical moments that were particularly important or meaningful that have shaped your opinions and feelings about the Undergraduate Teaching Assistant program? 145 Appendix K UTA Interview Questions 1. Demographic information: a. Grade Level: b. Majors/Minors: c. Have you had other roles where you worked with students? In what capacity? 2. What was your experience with the Undergraduate Teaching Assistant Program? What felt supportive and enriching? What felt challenging? 3. What was your role with your faculty and how did it feel? 4. What types of interactions did you and your faculty member have? What was that experience like? 5. How did your role feel with the students? Did you feel fully utilized? 6. How did it feel being in the physical classroom? What did you notice about your thoughts, feelings, and body language? 7. Did you support underprepared students? 8. If yes, what did that support look like? What was that experience like? How did that impact your role? How did you feel about the support? 9. If no, what was that experience like? How did that impact your role? How did you feel about the lack of support? 10. Are there any critical experiences or critical moments that were particularly important or meaningful that have shaped your opinions and feelings about the Undergraduate Teaching Assistant program? 11. Did you feel the UTA course helped to prepare you for your TA role? If so, how? Was there any other support you received that helped you feel prepared for your role? 146 Appendix L Canvas Information About Classroom Observations What Are They? Classroom observations for Undergraduate Teaching Assistants are a non-evaluative, low pressure observation conducted by me inside your course while you are present in your TA role. You don't have to be teaching or doing a task in front of the class. It's simply a way for me to observe the interactions between you, your instructor, and the students. It's a way for me to better understand the experiences that are happening in the course you are TAing. What Will You be Doing? I will simply sit quietly at the back of the room and jot down notes of what I see. I take a lot of notes, but that's because I write down pretty much everything that's happening. This is different from the teaching observation forms that you have filled out because I'm not going to be specifically looking at your teaching. I'm simply observing interactions in the classroom and jotting down what I see. It helps my understanding when I see how the students and faculty interact with you in your TA role. Will My Grade be Impacted? Not at all. Non-evaluative means that I won't be evaluating your skills or progress toward anything. Observations are simply a way for me to better understand the experiences happening in your courses. When Will They Happen? There will just be one observation this semester. I will conduct it at a time when you will potentially be teaching or involved in an active learning activity. We will discuss and agree upon a date. 147 Appendix M Capacity Building Topics in UTA Course Capacity Building Vs. Creating Dependency Building capacity in your students is about turning the learning back on them. You already have the knowledge, skills, and abilities to do well in this course. Your students are learning these skills and they can only do this through experience. Do not create a student dependency on you, as that dependency teaches students that they can't do it on their own. We are here to GUIDE students and to PREPARE them to be independent and empowered. Empower them by trying the following: Let them know that you here as a guide to empower them. You want them to feel confident and empowered in the class, which is why you intentionally use certain methods. This can help mitigate frustration when you don't immediately fulfill a need they might have. Don't provide immediate answers for students, as this creates a dependency on you. Try these methods, instead: o If a student asks a question, determine if it's the type of question you can answer with a guiding question to get them thinking about the topic on their own. o Ask students to think about their own methods and what else might work better for them. Create a space for self-reflection. o Give students options and have them determine what might be best. Get students actively involved in their own learning. If you're creating something for your students, ask yourself if it's appropriate for them to be creating that item (or something similar). For example, if you're creating an infographic, a table, or some other visual aid, can students create it instead of you? What might they need to create this item on their own? Ask students to generate their own knowledge instead of you generating it for them. Ask them to predict, reflect, make connections to their own lives, discuss their own approaches, or summarize information in their own words. Encourage students and let them know that they can do it. They have the power to do well in the course and you are here to give them the tools to be successful. Your encouragement in their abilities can help this process.  ...

... 1 REDUCING ANESTHESIA WORKSTATION CONTAMINATION Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report Reducing Anesthesia Workstation Contamination Kristine G. Moncada Date of Submission: March 9, 2024 2 REDUCING ANESTHESIA WORKSTATION CONTAMINATION Table of Contents Abstract4 Introduction..5 Background......6 Problem Statement...9 Needs Assessment and Gap Analysis....10 Review of the Literature11 Literature Search Methodology.13 Theoretical or Conceptual Framework..14 Knowledge Creation..14 Action.15 Project Aims and Objectives..15 Project Design16 Project Site and Population17 Measurement Instruments..18 Data Collection and Procedure..18 Project Evaluation Plan..18 Ethical Considerations...19 SWOT Analysis.19 GANTT Chart20 Data Analysis and Results.20 Conclusion.21 References..23 Appendices Appendix A27 Appendix B32 Appendix C33 Appendix D36 3 REDUCING ANESTHESIA WORKSTATION CONTAMINATION Appendix E37 Appendix F.38 Appendix G....39 4 REDUCING ANESTHESIA WORKSTATION CONTAMINATION Abstract In the intraoperative setting, the intersection of hand hygiene practices and contamination of the anesthesia workstation presents a critical juncture for reducing hospital acquired infections that ultimately lead to increased patient morbidity and mortality. Microbiological contamination of the anesthesia workstation, most notably during routine tasks such as induction and airway management, has been directly linked to an increase in patient morbidity and mortality. The absence of standardized protocols to minimize contamination of the anesthesia workstation signals a crucial opportunity to improve the anesthetic workflow. This Doctor of Nursing project focused on educating student registered nurse anesthetists about intraoperative hand hygiene and ways to counter the contamination of their workstation, such as double gloving during induction and airway management. A pre-test survey was created to assess baseline knowledge of the topic and current hand hygiene practice during airway management. An evidence-based PowerPoint presentation was provided as an educational intervention, followed by a post-test survey to assess retention of knowledge and willingness to apply suggested methods to reduce contamination. The results showed that there was a significant improvement in the students awareness, confidence, and willingness to apply the recommendations to reduce contamination of the anesthesia workstation. This project underscores the importance of targeted educational interventions in elevating healthcare quality through an improved anesthetic workflow that includes better hand hygiene and workstation cleanliness. 5 REDUCING ANESTHESIA WORKSTATION CONTAMINATION Introduction Patient safety lies at the crux of an effective, well-rounded plan for healthcare delivery. This is especially notable in the intraoperative environment, where great attention to patient safety in the form of time-out protocols and constant double checks is exercised during all procedures, regardless of how benign the case may seem. The desire to prevent the transmission of hospital acquired infections (HAI) plays a major role in why these stringent protocols exist (Lo Giudice et al., 2019). For this reason, strict cleanliness and sterility is enforced. However, the operating room (OR) is a multidisciplinary environment that employs staff hailing from various backgrounds and training, making the maintenance of cleanliness a difficult issue to tackle if strict guidelines are not in place. Failure to comply with measures that prevent HAIs therefore place the patient at risk for increased morbidity and mortality (Lo Giudice et al., 2019). While numerous efforts are made to ensure a clean intraoperative working environment, universal anesthesia-specific infection prevention and control policies do not exist. As a result, it has been noted that the anesthesia workstation is culpable in increasing the risk of HAIs and patient mortality (Munoz-Price et al., 2019). Improper hand hygiene and infrequent disinfection of frequently used anesthetic equipment are common factors that promote the transmission of HAIs (Porteous et al., 2018). The anesthesia workstation consists of multiple equipment that aid in the delivery of oxygen, anesthetic gases and medications, and ventilatory support. Some examples of components that comprise the anesthesia workstation include stopcocks and syringes, equipment for airway instrumentation such as laryngoscope blades and laryngeal masks, and documentation platforms such as touchscreens and keyboards (Munoz-Price et al., 2019). Due to the constant vigilance that anesthesia providers maintain when monitoring their patients, quick interventions 6 REDUCING ANESTHESIA WORKSTATION CONTAMINATION are often necessary and may be performed at the expense of contaminating the anesthesia workstation. In addition to the lack of an anesthesia-specific universal protocol to help guide expected practices and behaviors for cleanliness, the absence of routine audits that assess these practices and behaviors perpetuate the problem at hand. Providing anesthesia staff with specific recommendations for practices and behaviors that revolve around hand hygiene and environmental disinfection can reduce hospital acquired infections and improving patient safety. Just as importantly, education regarding this topic and reinforcement of proper hand hygiene or techniques to prevent contamination of the anesthesia workstation should be instituted and heavily reinforced in student registered nurse anesthetists (SRNAs) during their training. By adopting these positive behaviors as they develop their anesthetic routine and flow, students can curb maladaptive behaviors that would lead to improper hand hygiene and contamination of the workstation (Jaffe & Moriber, 2019). Background The increased risk of patient morbidity and mortality that accompanies hospital acquired infections is reason enough to mitigate precipitating factors, behaviors, and practices that heightens that risk. Furthermore, the proliferation of antibiotic-resistant pathogens has garnered much attention to the development of practical interventions that combat their growth (Porteous et al., 2018). Countless research and evidence-based practice have consistently proven the importance of basic hand hygiene in preventing pathogen transmission. Despite the abundant literature that supports this, compliance with effective hand hygiene remains poor amongst anesthesia providers (Porteous et al., 2018). The possibility of inadequate cleaning practices within the OR further compounds this issue by promoting the existence of multiple bacterial reservoirs (Porteous et al., 2018). In a study done on 19 anesthesia providers, it was noted that 7 REDUCING ANESTHESIA WORKSTATION CONTAMINATION out of 1000 times that they contacted their work environment, only 13 hand hygiene events were witnessed (Porteous et al., 2018). Another study found that adherence to the World Health Organizations recommendations for 5 Moments for Hand Hygiene was approximately three percent (Porteous et al., 2018). These data are significant in highlighting the behaviors of anesthesia providers that contribute to the development of hospital acquired infections (Loftus et al., 2015b). Moreover, a direct pathway of intraoperative pathogen transmission occurs within the anesthesia workstation. This pathway links the anesthesia providers hands to the syringe, the patients intravenous line, and finally, the patients bloodstream, further solidifying the risk of a hospital acquired infection (Porteous et al., 2018). Failing to consistently use gloves during airway instrumentation as well as skipping hand hygiene after removing gloves have been observed as problematic practices that exacerbate this possibility since they lead to contamination of equipment with secretions (Munoz-Price et al., 2019). Due to the presence of several factors that contribute to contamination of the anesthesia workstation, it can be challenging to encourage anesthesia providers to adopt behaviors that mitigate bacterial spread especially during stressful situations such as intubation and emergence (Porteous et al., 2018). Many providers feel that the pressure of completing tasks within an expected timeframe poses the greatest barrier in abiding by infection prevention measures. Identifying the most frequent offenders of infection prevention within the anesthesia workstation, such as ineffective hand hygiene and infrequent disinfection of equipment, allows institutions to implement specific protocols to combat the issue. For instance, used medications syringes and the top of the anesthesia cart have been shown to be major mechanisms for pathogen transmission (Porteous et al., 2018). Based on this, medication preparation within the anesthesia workstation and any subsequent actions can be examined and tailored to include effective hand 8 REDUCING ANESTHESIA WORKSTATION CONTAMINATION hygiene and disinfection in between delivering steps of anesthetic care. Stethoscopes and laryngoscope handles, in addition to other reusable equipment, have also been cited as frequently contaminated equipment and are responsible for spreading infection if they have not been properly cleaned (Porteous et al., 2018). The implementation of a contaminated space and a clean space has been demonstrated to reduce microbiological contamination of the anesthesia workstation without negatively affecting workflow, which makes this an attractive consideration for providers (Porteous et al., 2018). By driving attention to this data, a heightened awareness can be exercised when developing cleanliness protocols that involve the anesthesia workstation. A reduction in cross-contamination of the anesthesia workstation after performing tasks can be achieved through several ways. Bringing awareness to prevalence and ways of contaminating the anesthesia workstation through common tasks is essential to furthering this discussion. The consequences of contaminating the workstation should then be elucidated, since doing so will bring gravity to the matter. Education centered on evidence-based practice should be provided to anesthesia staff that details the benefits of implementing recommended guidelines to improve patient safety. For instance, one study showed that the use of double gloves compared to single gloves during induction has been proven to reduce cross-contamination (Jaffe & Moriber, 2019). The chances of being a vector for pathogen transmission are significantly reduced when the contaminated gloves are immediately disposed of after securing the airway. Providing data that substantiate new practices as illustrated with this double gloving technique provides more pause for thought and challenges anesthesia providers to reconsider their role in preventing infection (Loftus et al., 2015b). It is also important to note that practices amongst anesthesia providers may vary. In the same double gloving study, it was found that SRNAs were more likely to cross-contaminate the anesthesia workstation (Jaffe & Moriber, 2019). This was 9 REDUCING ANESTHESIA WORKSTATION CONTAMINATION attributed to inexperience and thus, a lack of a smoothly planned induction sequence compared to seasoned certified registered nurse anesthetists. The study also acknowledges that differences in the order and technique that anesthetic induction is done also exist amongst experienced providers. This further lends credence to the fact that the practice of anesthesia carries significant variability amongst providers and that standardizing infection control practices may prove to be a challenge. Based on this, it would behoove the anesthesia community to raise awareness regarding this topic and to reinforce techniques that guard against contamination while students are being trained. By addressing this issue with SRNAs during their training, the chance that they will develop unfavorable behaviors is lessened (Jaffe & Moriber, 2019). Current standards dictate that ventilation of the patient immediately after airway instrumentation should be prioritized above all else (American Association of Nurse Anesthesiology [AANA], 2015). However, the AANA also recommends the practice of double gloving and the performance of hand hygiene during stable situations to mitigate bacterial transmission. The inclusion of specific recommendations, such as double gloving to prevent the spread of infection, amplifies the fact that anesthesia providers play a significant role in helping to curb transmission by reducing anesthesia workstation contamination. Problem Statement The intraoperative environment exposes the surgical patient to an increased risk of morbidity and mortality through the possibility of transmitting hospital acquired infections. Literature has shown that these infections are preventable and refining current practices can mitigate the risk of bacterial spread. Inadequate cleaning practices in the OR may lead to the proliferation of reservoirs that house harmful pathogens. Another consideration recognizes the fact that anesthesia providers may play a role in worsening this risk of pathogen transmission 10 REDUCING ANESTHESIA WORKSTATION CONTAMINATION through routines that are deficient in hand hygiene and equipment disinfection. This leads to microbiological contamination of the anesthesia workstation, most notably after securing a patients airway due to presence of secretions. Studies have shown poor compliance in hand hygiene and disinfection practices amongst anesthesia providers. Additionally, differences in levels of training contribute to practices that increase the risk of workstation contamination. The purpose of this project would be to educate SRNAs on the prevalence and consequences of anesthesia workstation contamination, identify common practices that aggravate contamination, and provide solutions to reduce contamination, namely double gloving. This led to the following PICO: Among SRNAs, what is the effect of raising awareness on anesthesia workstation contamination and methods to reduce this occurrence? Needs Assessment and Gap Analysis The lack of a universal infection prevention protocol in anesthesia leads to variability in practice that impacts patient safety. A negative consequence of this variability in practice is the development of a HAI. A contributing factor to this may be pathogen transmission from a contaminated anesthesia workstation. Anesthesia providers may not be aware of how impactful their practices around a contaminated anesthesia workstation are in terms of contributing to a HAI. The AANA does reinforce the adoption of habits that emphasize cleanliness, such as double gloving and frequent hand hygiene; but ultimately, the greatest emphasis is placed on securing a patent airway during induction. This may encourage providers to relinquish the act of infection prevention for the sake of obtaining a secure airway. 11 REDUCING ANESTHESIA WORKSTATION CONTAMINATION Efforts have been made to educate anesthesia providers on their role in infection prevention. Studies that show demonstrable improvements in prevention of pathogen transmission should be utilized as educational material in addressing this knowledge gap. Since current practice foregoes a standardized approach in reducing anesthesia workstation contamination, this project aims to improve the literacy of SRNAs regarding practices that instigate anesthesia workstation contamination and methods that can be done to reduce that incidence, namely through double gloving during intubation, and ultimately, prevent escalation of a patients risk of morbidity and mortality. Review of the Literature The increased patient mortality that arises from HAIs deserves special attention in the realm of anesthesia since anesthesia providers have been implicated as sources of intraoperative pathogen transmission (Loftus et al., 2015a). The overarching theme found in the literature review highlighted the need for improved compliance with proper hand hygiene amongst most anesthesia providers (Lo Giudice et al., 2019; Loftus et al., 2015a; Munoz-Price et al., 2018; Paul et al., 2019). This practice problem is compounded when poor hand hygiene contributes to contamination of the anesthesia workstation (Munoz-Price et al., 2019). Furthermore, there is a lack of universal infection prevention practices and audits in the OR. The traits and behaviors of individual anesthesia providers when administering care are unique, which makes the implementation of an infection prevention bundle beneficial in reducing behaviors that lead to anesthesia workstation contamination (Porteous et al., 2018). Continued research pointed to the presence of frequently contaminated sites on the anesthesia workstation and their contribution to pathogen transmission (Loftus et al., 2015a). Finally, while there is a dearth of studies that explicitly link the efficacy of double gloving during induction to reduce anesthesia workstation 12 REDUCING ANESTHESIA WORKSTATION CONTAMINATION contamination, the evidence that does exist in support of this practice is significant. However, it is important to note that double gloving is not a substitute for proper sterilization and disinfection of equipment, and that both measures should be used to prevent contamination of the anesthesia workstation. Lo Giudice et al. (2019) provided an observational descriptive study citing the low adherence that OR staff showed in regard to abiding by international guidelines for the prevention of HAIs, including hand and workplace hygiene. This is especially significant when evidence has shown that the hands of anesthesia providers are common sources of harmful pathogens, such as enterococci (Loftus et al., 2015a). A prospective randomized clinical trial led by Loftus et al. (2020) showed that by proving anesthesia practitioners with direct recommendations to reduce bacterial transmission, a decrease in perioperative S. aureus transmission was observed. This lends credence to the establishment of an infection prevention bundle in the OR setting to help reduce contamination of the anesthesia workstation (Porteous et al., 2018). The anesthesia workstation serves as a major vector for HAIs and therefore increases patient mortality (Plemmons et al., 2019). Sites of frequent contamination on the workstation include the circuit, APL valve, and manual ventilation bag (Hunter et al., 2017). Contamination of these sites often results from the lack of proper hand hygiene after certain phases of the anesthesia workflow, most notably induction or airway management (Munoz-Price et al., 2019). Several studies were developed to address the origins of anesthesia workstation contamination and measures that can be taken to reduce this occurrence. Biddle et al. (2016) highlighted the use of double gloves during airway management as a significant contributor in decreasing contamination of airway equipment, the breathing system, intravenous access ports, and the roll of tape used to secure the endotracheal tube (p<0.001). Birnbach et al. (2015a) 13 REDUCING ANESTHESIA WORKSTATION CONTAMINATION recommends double gloving during laryngoscopy and removing the outer set immediately after intubation to reduce contamination of the intraoperative environment (p<0.001). While the aforementioned studies involved simulated cases, a non-simulated study done by Jaffe & Moriber (2019) emphasized that level of training could be a factor in how efficient a double gloving method is in reducing contamination. It was posited that due to the lack of clinical experience that SRNAs possessed compared to experienced CRNAs, their induction sequences may not be as well-choreographed and timed, leading to higher chances of errors and contamination. This further strengthens the argument for early education and intervention in cultivating behaviors that prevent workstation contamination. Another study done by Birnbach et al. (2015b) offered the solution of sheathing the laryngoscope directly with the outer glove after endotracheal intubation to further reduce intraoperative environmental contamination (p<0.001). See Appendix A for the literature review matrix. Literature Search Methodology This literature review was performed to establish the significance between ineffective hand hygiene and the resultant contamination of the anesthesia workstation which, in turn, leads to an increased incidence of HAIs and patient morbidity and mortality. This search was conducted between September 2022 through December 2022. The main database used to support this search was OVID-Medline. The keywords used to conduct the search were anesthesia, equipment, contamination, cross infection, hand hygiene, induction, and intubation. Truncation of the terms anesthesia, double glove, and intubation allowed for more variation in the search while continuing to respect the main concept being studied. Various combinations of the aforementioned terms along with the BOOLEAN operator AND yielded the most definitive results. Exclusion criteria to eliminate confounding variables include non-English articles and 14 REDUCING ANESTHESIA WORKSTATION CONTAMINATION articles published before 2012. Inclusion criteria include full-text English articles published no earlier than 2012. After applying these criteria to the searches, 136 total articles were procured. Of those articles found, 19 articles from the database search were deemed to be most pertinent to the project. An additional 4 articles were hand-picked from various sources to support this research. Theoretical or Conceptual Framework The Knowledge-to-Action framework (KTA) will serve as the foundation for this project. The KTA model was developed in 2006 by Dr. Ian Graham and his colleagues at the University of Ottawa in an effort to streamline the process of knowledge acquisition and its eventual translation into practice (Graham et al., 2006). The two main concepts that ground the framework are knowledge creation and action. The knowledge creation funnel entails knowledge inquiry, knowledge synthesis, and knowledge tools or products. The action cycle has seven phases that guide the knowledge application: 1: identifying a problem that necessitates change; 2: adapting knowledge to local context; 3: assessing barriers and facilitators to knowledge use; 4: selecting and tailoring interventions; 5: monitoring knowledge use; 6: evaluating outcomes; and 7: sustaining the change or use of knowledge (See Appendix B). In relation to this project, the framework will be carried out as follows: Knowledge Creation The step of inquiry presents the overarching issue of the HAIs and causative factors. Knowledge synthesis provides evidence that details specific causative factors, such as improper hand hygiene leading to anesthesia workstation contamination and eventual pathogen 15 REDUCING ANESTHESIA WORKSTATION CONTAMINATION transmission to the patient. The knowledge tools used to obtain this information are clinical practice guidelines and peer-reviewed journals. Action The problem identified is the lack of proper hand hygiene that leads to anesthesia workstation contamination. The use of gloves aids in reducing contamination. Encouraging anesthesia providers to double glove during intubation displays knowledge adaptation on a local level. Common barriers to implementation should be addressed and then followed with recommended interventions. Retention of knowledge from the educational material will be monitored by a post-test survey. Ongoing knowledge use will have to be carried out through selfaccountability or by the anesthesia providers respective institutions if applicable. Project Aims and Objectives The purpose of this project is to increase awareness regarding ways through which the anesthesia workstation can be contaminated and to introduce the concept of double gloving as a means to reduce the incidence of contamination. The contamination of the anesthesia workstation with pathogens that lead to HAIs increases the chances of patient morbidity and mortality (Loftus et al., 2015b). While the vehicle through which contamination occurs varies depending on the task that the anesthesia provider is performing, one major culprit behind most forms of contamination is improper hand hygiene (Porteous et al., 2018). The aim of this project lies in delivering educational material that increases awareness of ways through which anesthesia workstation contamination occurs and how double gloving can reduce those incidences. The objectives of this project will involve creating educational material to disseminate the information stated above. SRNAs will be surveyed on their familiarity with anesthesia 16 REDUCING ANESTHESIA WORKSTATION CONTAMINATION workstation contamination and their current practices that influence this occurrence. After providing educational material, the SRNAs will be surveyed to assess their understanding of the material provided and their willingness to adopt a change in their practice (i.e., double glove for intubation). By encouraging double gloving as a cornerstone in reducing contamination, better hand hygiene practices can be adopted by anesthesia providers, leading to reduced incidences of anesthesia workstation contamination. Project Design This DNP project is utilizing an educational and quality improvement/program evaluation design to spread awareness concerning how frequently the anesthesia workstation is contaminated through improper hand hygiene and measures that can be taken to combat this. Rather than using direct observation to assess anesthesia providers hand hygiene practices in the operating room, a pre- and post-test self-assessment survey will be provided to consenting SRNAs through Qualtrics to obtain quantitative data to support this project. The pre-test survey will establish the participants baseline knowledge and attitudes of their hand hygiene practices in the perioperative setting, particularly during intraoperative procedures such as intubation, and the resulting contamination of the anesthesia workstation, particularly areas that are frequently touched. Subsequently, an educational PowerPoint will be provided to disseminate information regarding practices that lead to anesthesia workstation contamination and measures that can be taken to improve this, such as double gloving. After viewing the PowerPoint material, a post-test survey will be conducted to assess whether the educational material was effective in raising awareness regarding anesthesia workstation contamination and encouraging the adoption of certain practices, such as double gloving, as a means of reducing contamination. Project Site and Population 17 REDUCING ANESTHESIA WORKSTATION CONTAMINATION The study will be conducted online through a Qualtrics survey and will focus on SRNAs at a small, private Catholic university in the Midwest who are training in inpatient and outpatient settings in Indiana, Ohio, Illinois, and Tennessee. The SRNAs surveyed have an expected graduation year of 2024, 2025, and 2026. Those in the 2024 cohort will have almost completed their clinical experience while those in the subsequent cohorts will have had varying degrees of exposure to clinical experience. All cohorts will have undergone training and practice through clinical simulation scenarios as part of their curriculum prior to entering the actual clinical arena. During training, SRNAs under the supervision of a CRNA or MDA will be involved in airway management and as such, will have opportunities to double-glove when doing so. Resources needed to complete the project include access to Qualtrics and valid email addresses from the participants. Key stakeholders in this project include the consenting participants and the project chairpersons. Measurement Instruments To measure the outcomes of this DNP project, an online self-assessment survey generated through Qualtrics will be used. The survey will consist of 10 quantitative questions to test knowledge and 2 questions that assess current and future hand hygiene practice, as well as a total of 13 questions taken from National League of Nursings (NLN) Student Satisfaction and Self-Confidence in Learning to gauge the survey takers overall impression of the learning process (see Appendices C and D). Participants will be provided with an email that contains the following links: a pre-test survey on Qualtrics to assess their baseline knowledge regarding anesthesia workstation contamination; an educational 15-minute PowerPoint presentation which will explicate the importance of combating contamination of the workstation and methods to do so, namely double gloving; and a post-test survey on Qualtrics for comparative data collection. 18 REDUCING ANESTHESIA WORKSTATION CONTAMINATION The students will be asked to use the same student identification number on both surveys. The data will be collected over the course of two weeks. Anonymity will be maintained by eliminating any uniquely identifiable information. The common themes encountered in the literature review will serve as the basis for developing the questions used in the surveys. Data Collection and Procedure The invitation to participate in data collection is voluntary and anonymous and will be done through e-mail. The e-mail will contain an anonymous link for the Qualtrics survey. These steps will ensure that no personally identifiable data is collected and that the reputation of participants will be protected. The e-mail addresses will be obtained with the help of the project site contact person. Participants will be given two weeks complete the surveys. Based on the samples expected to be collected, statistical data analysis for the first 12 questions will be conducted through the use of a parametric paired t-test. The subsequent responses from the NLN survey will be analyzed using a non-parametric approach with the Wilcoxon signed rank test. Project Evaluation Plan The benefit of using Qualtrics is the anonymity it provides and the feasibility of exporting data directly to SPSS, CSV, PDF, and Microsoft Word, PowerPoint, and Excel. Statistical data analysis will be done by comparing pre- and post-test answers and discerning whether providers intend to implement a practice change to reduce their chances of contaminating the anesthesia workstation. Using an Excel spreadsheet allows for easier comparison of these answers. The use of inferential statistical analysis, such as performing a paired t-test, helps to determine whether the relationship amongst the variables is statistically 19 REDUCING ANESTHESIA WORKSTATION CONTAMINATION significant. If the p-value is less than the significance level, then a determination can be made that the educational material was effective in disseminating the intended information. Ethical Considerations Approval from the Marian University Internal Review Board was obtained prior to moving forward with this project (see Appendix E). By using the link provided in the email, participants acknowledged their informed consent and voluntary involvement in the project. There was no patient data collection, making the Health Insurance Portability and Accountability Act of 1996 (HIPPA) inapplicable. There was no personally identifiably data collected from the participants. There were no appreciable ethical concerns or risks associated with this DNP project. SWOT Analysis Key stakeholders in this project include SRNAs, practicing anesthesia providers, patients, and facilities that favor adoption of double gloving when intubating as part of their infection prevention policy. The prevention of HAIs is central to numerous discussions and research in the medical community. The strengths of this project lie in bringing awareness to the role that a contaminated anesthesia workstation plays in contributing to HAIs and recommendations to decrease that incidence. Gloves are readily available in the healthcare setting, making the intervention of double gloving easily implementable. Some barriers to this project include differences in habits across anesthesia providers. Differences in experience levels can inform different practices and priorities, leading some providers to possibly relinquish infection prevention through double gloving in favor of securing a patent airway and confirming ventilation with contaminated gloves. There is also a lack of abundant research that relates 20 REDUCING ANESTHESIA WORKSTATION CONTAMINATION specifically to double gloving during intubation, which may cause providers to hesitate in adopting this practice. Opportunities exist to improve current practice guidelines related to hand hygiene within the anesthesia workstation. Facility protocols and didactic curricula can be adapted to include this practice and further reduce the incidence of HAIs. Threats to this project include a lack of interest amongst SRNAs in changing habits and practices that they have methodically developed to ascertain patient safety when securing an airway. Understandably, the priority of securing an airway in an emergent situation may override the infection prevention that double gloving provides. However, it benefits the anesthesia provider to consider adopting and mastering the double gloving technique to optimize patient safety and wellness. See appendix F for a table outline of the SWOT analysis conducted for this project. GANTT Chart See Appendix G for the GANTT chart. Data Analysis and Results The three cohorts invited to participate in this study were composed of a diverse group of 99 SRNAs. Of those 99 SRNAs, 16 valid responses were obtained, resulting in a survey completion rate of roughly 16%. All of the participants were aware of how HAIs continue to be a major public health concern that greatly increases patient morbidity, mortality, overall healthcare costs, and potential liability. In the pre-test survey, 88% of respondents were aware that bacterial contamination of the anesthesia workstation can occur as early as 4 minutes of starting a case, but they assumed that out of an average 149 opportunities to perform hand hygiene, anesthesia providers had a 10% compliance rate when in fact, it was closer to 3%. Additionally, 88% of respondents believed that most of the contamination occurs during induction and intubation and 21 REDUCING ANESTHESIA WORKSTATION CONTAMINATION that every surface of the anesthesia workstation becomes contaminated during the process. Despite being one of the most frequently contaminated items on the anesthesia workstation, the circuit was not chosen by any respondents as a viable option. Prior to the educational intervention, 38% of participants believed that the encouragement of frequent hand hygiene in isolation should be enough to reduce contamination during airway management. In the post-test survey, 100% of participants believed that double gloving and sheathing the laryngoscope immediately after intubation was the best way to mitigate contamination of the anesthesia workstation. There was an improvement in the understanding of the use of low-level chemical disinfection after each patient as well. Of note, there was a marked difference in the responses for questions 4 and 8 (p < 0.05) which demonstrates that hand hygiene compliance is often overestimated in anesthesia providers. Prior to the PowerPoint presentation, 88% of respondents did not include double gloving in their practice compared to 100% of respondents who claimed to be more willing to adopt this technique after the presentation. Although a limitation of this project includes subjective data from a small sample size in a single institution (n = 16), the post-test survey showed a notable enhancement in the students self-perception of competence regarding anesthesia workstation contamination (p < 0.05). The participants reported a greater ability to leverage the presentation as a tool to augment their clinical experiences. Future research, ideally involving larger cohorts across multiple institutions and objective measures such as direct observation and simulation-based assessments, can be performed to validate and build upon these preliminary insights. Conclusion This DNP project underscores the significance of educating SRNAs regarding the role that the anesthesia workstation plays in contributing to HAIs and proven methods the mitigate 22 REDUCING ANESTHESIA WORKSTATION CONTAMINATION that risk. Despite the challenge of a modest response rate, the findings illuminate a clear pathway towards improving patient safety and clinical outcomes in the perioperative settings. Before the intervention, there was a notable gap between the perceived and actual practices of hand hygiene and equipment handling among anesthesia providers. The project demonstrated that a targeted educational program could significantly alter SRNAs future practices, particularly regarding double gloving and proper handling of the laryngoscope during airway management to offset contamination risks. The unanimous endorsement of double gloving and improved knowledge of equipment disinfection highlights the effectiveness of educational strategies in fostering behavioral change. 23 REDUCING ANESTHESIA WORKSTATION CONTAMINATION References American Association of Nurse Anesthesiology. (2015). Infection prevention and control guidelines for anesthesia care. https://www.aana.com/docs/default-source/practice-aanacom-web-documents-(all)/professional-practice-manual/infection-prevention-andcontrol-guidelines-for-anesthesia-care.pdf?sfvrsn=850049b1_6 Biddle, C., Robinson, K., Pike, B., Kammerman, M., Gay, B., & Verhulst, B. (2016). Quantifying the rambunctious journey of the anesthesia providers hands during simulated, routine care. American Journal of Infection Control, 44(8), 873878. https://doi.org/10.1016/j.ajic.2016.02.014 Birnbach, D. J., Rosen, L. F., Fitzpatrick, M., Carling, P., Arheart, K. L., & Munoz-Price, L. S. (2015). Double gloves: a randomized trial to evaluate a simple strategy to reduce contamination in the operating room. Anesthesia and Analgesia, 120(4), 848852. https://doi.org/10.1213/ANE.0000000000000230 Birnbach, D. J., Rosen, L. F., Fitzpatrick, M., Carling, P., Arheart, K. L., & Munoz-Price, L. S. (2015). A New Approach to Pathogen Containment in the Operating Room: Sheathing the Laryngoscope After Intubation. Anesthesia and Analgesia, 121(5), 12091214. https://doi.org/10.1213/ANE.0000000000000854 Graham, I. D., Logan, J., Harrison, M. B., Straus, S. E., Tetroe, J., Caswell, W., & Robinson, N. (2006). Lost in knowledge translation: Time for a map?. The Journal of Continuing Education in the Health Professions, 26(1), 1324. https://doi.org/10.1002/chp.47 Hunter, S., Katz, D., Goldberg, A., Lin, H.-M., Pasricha, R., Benesh, G., Le Grand, B., & DeMaria, S. (2017). Use of an anaesthesia workstation barrier device to decrease 24 REDUCING ANESTHESIA WORKSTATION CONTAMINATION contamination in a simulated operating room. British Journal of Anaesthesia, 118(6), 870875. https://doi.org/10.1093/bja/aex097 Jaffe, G., & Moriber, N. (2019). Use of a double gloving technique to decrease crosscontamination by anesthesia providers. AANA, 87(4), 307-312. Lo Giudice, D., Trimarchi, G., La Fauci, V., Squeri, R., & Calimeri, S. (2019). Hospital infection control and behaviour of operating room staff. Central European Journal of Public Health, 27(4), 292295. https://doi.org/10.21101/cejph.a4932 Loftus, R. W., Brown, J. R., Koff, M. D., Reddy, S., Heard, S. O., Patel, H. M., Fernandez, P. G., Beach, M. L., Corwin, H. L., Jensen, J. T., Kispert, D., Huysman, B., Dodds, T. M., Ruoff, K. L., & Yeager, M. P. (2012). Multiple reservoirs contribute to intraoperative bacterial transmission. Anesthesia and Analgesia, 114(6), 12361248. https://doi.org/10.1213/ANE.0b013e31824970a2 Loftus, R. W., Koff, M. D., Brown, J. R., Patel, H. M., Jensen, J. T., Reddy, S., Ruoff, K. L., Heard, S. O., Yeager, M. P., & Dodds, T. M. (2015). The dynamics of Enterococcus transmission from bacterial reservoirs commonly encountered by anesthesia providers. Anesthesia and Analgesia, 120(4), 827836. https://doi.org/10.1213/ANE.0000000000000123 Loftus, R. W., Koff, M. D., & Birnbach, D. J. (2015). The dynamics and implications of bacterial transmission events arising from the anesthesia work area. Anesthesia & Analgesia, 120(4), 853860. https://doi.org/10.1213/ane.0000000000000505 25 REDUCING ANESTHESIA WORKSTATION CONTAMINATION Loftus, R. W., Dexter, F., Goodheart, M. J., McDonald, M., Keech, J., Noiseux, N., Pugely, A., Sharp, W., Sharafuddin, M., Lawrence, W. T., Fisher, M., McGonagill, P., Shanklin, J., Skeete, D., Tracy, C., Erickson, B., Granchi, T., Evans, L., Schmidt, E., Brown, J. R. (2020). The Effect of Improving Basic Preventive Measures in the Perioperative Arena on Staphylococcus aureus Transmission and Surgical Site Infections: A Randomized Clinical Trial. JAMA Network Open, 3(3), e201934. https://doi.org/10.1001/jamanetworkopen.2020.1934 Munoz-Price, L., Bowdle, A., Johnston, B., Bearman, G., Camins, B., Dellinger, E., . . . Birnbach, D. (2019). Infection prevention in the operating room anesthesia work area. Infection Control & Hospital Epidemiology, 40(1), 1-17. https://doi.org/10.1017/ice.2018.303 National League for Nursing (2004, December 22). Student satisfaction and self-confidence in learning. National League for Nursing. https://www.nln.org/docs/defaultsource/uploadedfiles/default-document-library/instrument-2-satisfaction-and-selfconfidence-in-learning.pdf Paul, E. T., Kuszajewski, M., Davenport, A., Thompson, J. A., & Morgan, B. (2019). Sleep safe in clean hands: Improving hand hygiene compliance in the operating room through education and increased access to hand hygiene products. American Journal of Infection Control, 47(5), 504508. https://doi.org/10.1016/j.ajic.2018.10.021 Plemmons, M. M., Marcenaro, J., Oermann, M. H., Thompson, J., & Vacchiano, C. A. (2019). Improving infection control practices of nurse anesthetists in the anesthesia 26 REDUCING ANESTHESIA WORKSTATION CONTAMINATION workspace. American Journal of Infection Control, 47(5), 551557. https://doi.org/10.1016/j.ajic.2018.12.009 Porteous, G. H., Bean, H. A., Woodward, C. M., Beecher, R. P., Bernstein, J. R., Wilkerson, S., Porteous, I., & Hsiung, R. L. (2018). A simulation study to evaluate improvements in anesthesia work environment contamination after implementation of an infection prevention bundle. Anesthesia and Analgesia, 127(3), 662670. https://doi.org/10.1213/ANE.0000000000002764 27 REDUCING ANESTHESIA WORKSTATION CONTAMINATION Appendix A Citation Research Design & Level of Evidence Randomized control trial, Level I Population/Sample size n=x Major Variables Instruments/Data Collection Results Convenience sample of experienced anesthesia providers; n=20 (control group [n=10], experimental group [n=10]) High fidelity simulation of anesthetic induction with SimMan 3G, surrogate biologic contamination (DAZO), UV light, and photographs of SimMan and workstation where dye was displaced; 2-group t test to test hypothesis Group 1 (single pair of gloves) contaminated more of the workstation compared to group 2 (double pair of gloves, especially with airway management (p<0.001). However, there were similar rates of contamination in both groups for airway equipment, breathing system, intravenous access ports, and the roll of tape used to secure the endotracheal tube. (Birnbach et al., 2015a) Double-blinded randomized control trial; Level I Anesthesiology residents (PGY 2-4); at the University of Miami Miller School of Medicine n=45 Experience in anesthetic induction, single vs. double gloving, contamination of various anesthetic equipment, effectiveness of workspace disinfection between cases; phases of induction sequence; prolific contamination sites Single vs. double gloving and its effects on contaminating OR equipment; OR sites of frequent contamination Double gloving during laryngoscopy and intubation and removing the outer set immediately after intubation drastically reduces contamination of the intraoperative environment (p< 0.001). (Birnbach et al., 2015b) Blinded randomized control trial; Level I Anesthesiology residents (PGY 2-4) at the University of Miami-Jackson 22 total individual and group simulation sessions of anesthetic induction and tracheal intubation; 11 sessions required single gloves and 11 sessions required double gloves; DAZO used as surrogate biological pathogen/blood, UV light; Poisson regression to analyze total number of contaminated sites; 2 or Fisher exact test to analyze proportion of objects positive for fluorescent markers 45 total identical simulation sessions involving anesthetic induction and endotracheal intubation lasting 6 minutes (Biddle et al., 2016) Single vs. double gloving vs. double gloves with sheathing of All 3 conditions used for simulation were statistically different from one another (p<0.001); sheathing the laryngoscope immediately after endotracheal intubation 28 REDUCING ANESTHESIA WORKSTATION CONTAMINATION Memorial Hospital Center for Patient Safety between December 2013 and December 2014; n=45 laryngoscopy handle/blade in glove after endotracheal intubation and their effects on contamination of the work area and IV hub; laryngoscope handle/blade Physical barrier device covering the anesthesia workstation during induction and intubation and its effects on reducing contamination of 14 target sites; level of training (15 sessions with control group using single gloves; 15 sessions with double gloves and outer pair removed after intubation; 15 sessions with double gloves and sheathing of laryngoscope in one of outer gloves after intubation); DAZO and mannequin; Poisson regression to analyze results Simulated OR scenario requiring induction and a barrier device on the anesthesia workstation; barrier device was removed with the barrier group after induction and then examined for the presence of Glo-Germ fluorescent dye Evaluation of double gloving during induction in the experimental group in a nonsimulated OR; evaluation was conducted thrice (pre/post-education on double gloving and 1 month posteducation); 5-question survey post-education to evaluate learning; UV blacklight used to observe for inoculation before and after induction; 402 surgical procedures were randomly selected for observation wherein healthcare personnel involved in the operations were monitored for (Hunter et al., 2017) Prospective randomized control trial; Level I Attending anesthetists (n=19) and resident anesthetists (n=23) at the Mount Sinai Department of Anesthesiology Simulation Center (Jaffe & Moriber, 2019) Prospective quasiexperimental study, Level III SRNAs (2nd and 3rd year of training) and CRNAs at an inner-city level 2 trauma center; n=30 Single vs. double gloving and impact on crosscontamination of equipment; level of training (Lo Giudice et al., 2019) Observational descriptive study, Level III Operating room personnel at a University hospital in southern Italy; n=308 OR personnel profession and level of training; OR apparel; number of personnel in the reduces contamination of the IV hub, patient, and intraoperative environment (p<0.001) There was a significant reduction in the number of sites contaminated in the barrier group compared to the control group (p<0.001); residents demonstrated a lower site contamination rate compared to attending anesthetists in the control group; in the barrier group, overall contamination rates were similar between residents and attendings; sites with the highest rate of contamination were the circuit, APL valve, and manual ventilation bag; Double gloving during induction decreases cross-contamination of the of anesthesia equipment by more than 50% (p<0.01). OR staff displayed low adherence to international guidelines for prevention of healthcare associated infections, including hand hygiene and workplace hygiene (OR sanitation). 29 REDUCING ANESTHESIA WORKSTATION CONTAMINATION OR; adherence to international guidelines for infection prevention; surgical procedures (Loftus et al., 2012) Prospective randomized observational study, Level II Operating room case pairs in a multicenter study, n=548 Stopcock contamination; anesthesia provider hands; environment to stopcock contamination (Loftus et al., 2015a) Systematic review of previously conducted RCT, Level I Environmental bacterial culture sites, n=2170; health care provider hand cultures, n=2640; patient skin cultures in 274 casepairs representing 548 ORs across 3 major academic medical centers, n=1087 Anesthesia reservoir isolates; contamination of frequently touched surfaces by anesthesia providers (Loftus et al., 2015b) Systematic review of randomized clinical trials, Level III n/a n/a compliance with international guidelines for infection prevention; trained healthcare workers performed the observation and data was collected using a special form and no prior notice was given to the OR team 274 operating rooms were observed for stopcock transmission events; reservoir bacterial cultures were collected and compared to stopcock set isolates to determine source of contamination From a previous RCT, enteroccocus isolates were previously obtained from bacterial reservoirs that anesthesia providers frequently encountered (patient nasopharynx and axilla, anesthesia provider hands, and the adjustable pressure-limiting valve and agent dial of the anesthesia machine) by gross morphology and simple rapid tests; A systematic review of multiple clinical trials was conducted to confirm the hypothesis that the anesthesia workstation serves as a direct source of HAIs and a multimodal approach should be used to combat contamination. All 3 reservoirs (64% environment, 12% patient, 21% provider) contributed to increased stopcock transmission, which is associated with an increased risk for patient mortality. Compared to the providers hands, the environment was a more likely source of stopcock contamination (p=0.029). Anesthesia provider hand contamination is a common source of enterococcus transmission in the anesthesia work area. HAIs have been directly associated with bacterial transmission from anesthesia workstations; considerations should be made to attenuate bacterial transmission during the provision of anesthesia, including intraoperative hand hygiene and environmental decontamination. 30 REDUCING ANESTHESIA WORKSTATION CONTAMINATION (Loftus et al., 2020) Prospective randomized clinical trial, Level I (MunozPrice et al., 2019) Expert guidance, Level V (Paul et al., 2019) Pretest-posttest design/quasiexperimental study, Level III Adult patients scheduled to undergo orthopedic total joint, orthopedic spine, oncologic gynecological, thoracic, general, colorectal, open vascular, plastic, and open urological surgery requiring general and/or regional anesthesia at a major academic medical center, n=236 n/a Serially collected bacterial cultures obtained from each patient; baseline and post-case anesthesia environment; hands of anesthesia provider; intravascular catheter samples Provision of CDC recommendations regarding basic preventive measures to reduce bacterial transmission on 236 patients; those patients were followed for 60 postoperative days to observe for evidence of SSI. Improved perioperative basic preventive measures can be taken to decrease perioperative S aureus transmissions and SSIs (p=0.002). n/a To develop this expert guidance, surveys were sent to providers who were members of the ASA, AANA, and AAAA regarding practices in the OR. PICO questions guided research. Increased access to hand hygiene products; educational intervention; hand hygiene indications; phases of anesthesia; professional categories Observation of anesthesia providers hand hygiene compliance while administering various anesthetics; pretest-posttest design and educational intervention. Infection prevention/control policies related to anesthesia in the OR are not universal in the US; audits of infection prevention and control practices are not routine; anesthesia work areas are not thoroughly cleaned/disinfected between each patient and the anesthesia cart poses a risk for cross contamination; anesthesia providers showed <100% gloving for airway management and lack of hand hygiene after removing gloves as well as using cart drawers without proper hand hygiene. Multiple recommendations are made to address these issues, including the use of double gloves during airway management. Preimplementation results revealed very low compliance with hand hygiene among anesthesia providers in the OR, especially during induction. Postimplementation phase revealed a marked increase in sustained compliance with hand hygiene (p<0.001). Anesthesia providers in the main ORs of a university-affiliated community hospital in the Southeastern U.S.; n=60 31 REDUCING ANESTHESIA WORKSTATION CONTAMINATION (Plemmons et al., 2019) Direct observation, Level III Convenience sample of nurse anesthetists who work in the main OR of a 957-bed medical center in the Southeastern U.S.; n=35 Baseline hand hygiene practices; 3 modifiable practices; educational interventions; improvement in clean workspace behaviors postimplementation (Porteous et al., 2018) Nonrandomized simulation scenario crossover design study, Level II Anesthesiology residents (PGY 3 and 4), attending anesthesiologists, and CRNAs from the Department of Anesthesiology at Virginia Mason; n=25 Infection prevention bundle (double gloving, isolating airway equipment to a single area, increased hand hygiene); 20 frequently contaminated anesthesia workstation sites; high-risk events for contamination, including induction and airway management Nurse anesthetists were observed for hand hygiene practices in 3 areas of anesthesia practice (hand hygiene after airway instrumentation, medication administration, and separation of clean and contaminated items in the workspace) before/3 weeks after/3 months after education using a Fisher exact test; self-assessment tool was provided to determine baseline practices. Simulations of cases at baseline without implementing the infection prevention bundle initially followed by simulations of cases that required implementation of the infection prevention bundle. Cross-contamination of the anesthesia workspace increases the risk of HAIs. The provision of education, visual reminders, and standardized infection control guidelines increase compliance with hand hygiene after airway instrumentation (p=0.29) and the practice of separating clean from contaminated items in the anesthesia workspace (p=0.0001). Implementing an infection prevention bundle reduced contamination by 27% (p=<0.001); clinician hands were a major source of intraoperative pathogen transmission in the anesthesia work area. 32 REDUCING ANESTHESIA WORKSTATION CONTAMINATION Appendix B Knowledge-to-Action Framework (Graham et al., 2006) 33 REDUCING ANESTHESIA WORKSTATION CONTAMINATION Appendix C Qualtrics survey questions 34 REDUCING ANESTHESIA WORKSTATION CONTAMINATION 35 REDUCING ANESTHESIA WORKSTATION CONTAMINATION 36 REDUCING ANESTHESIA WORKSTATION CONTAMINATION Appendix D National League of Nursing Student Satisfaction and Self-Confidence in Learning Survey 37 REDUCING ANESTHESIA WORKSTATION CONTAMINATION Appendix E Marian University IRB Approval Letter 38 REDUCING ANESTHESIA WORKSTATION CONTAMINATION Appendix F SWOT Analysis Table Strengths Increased awareness of contaminated anesthesia workstations contributing to HAIs Gloves are readily available, making double gloving an easily implementable intervention Weaknesses Opportunities Improve current practice guidelines related to hand hygiene within the anesthesia workstation Adapt facility protocols and didactic curricula to include the practice of double gloving to reduce the incidence of HAIs Differences in habits and experience levels across anesthesia providers could hinder consistent implementation Lack of abundant research specifically related to double gloving uring intubation may cause hesitation in adopting this practice Threats Lack of interest among SRNAs in changing habits and practices for securing an airway The priority of securing an airway, especially in emergent situations, may override the infection prevention benefits provided by double gloving 39 REDUCING ANESTHESIA WORKSTATION CONTAMINATION Appendix G GANTT Chart Start Date: 9/1/2023 End Date: 4/29/2024 Task Number Completion Date Assignment 1 9/19/2022 PICOT 2 9/26/2022 Needs Assessment & Gap Analysis 3 10/10/2022 Background & Significance 4 10/31/2022 Proposal Draft 1 5 11/10/2022 Aims & Theoretical Framework 6 11/12/2022 SWOT/GANTT 7 11/17/2022 Proposal Draft 2 8 11/20/2022 Methods Development, Tools & Outcomes 9 11/25/2022 Data Analysis 10 11/29/2022 Literature Review 11 12/15/2022 Proposal Draft 3 12 1/25/2023 IRB Approval 13 3/1/2023 Data Collection 14 3/30/2023 Complete Analysis 15 4/2/2023 Methods & Analysis Sections 16 4/10/2023 Academic Paper 17 4/15/2023 Abstract & Executive Summary 18 4/20/2023 Revise Project Report 19 4/25/2023 Disseminate EBP 20 4/29/2024 Poster Presentation 40 REDUCING ANESTHESIA WORKSTATION CONTAMINATION  ...

... MICROAGGRESSION IN THE OPERATING ROOM Coping with Microaggression in the Operating Room: Education for Student Registered Nurse Anesthetists Supreet Kaur Marian University Leighton School of Nursing Chair: Marie Goez, DNP, CRNA Dr. Marie Goez, DNP, CRNA (Signature) Team Member: Derrianne Monteiro, DNP, CRNA (Signature) 1 MICROAGGRESSION IN THE OPERATING ROOM 2 Table of Contents Abstract ...4 Introduction..5 Background..5 Problem Statement ..8 Needs Assessment/ Gap Analysis....9 Review of the Literature..9 Theoretical Framework..16 Project Aims and Objectives..17 SWOTT Analysis...17 Project Design/ Methods19 Population and Setting...19 Measurement Instruments..19 Data Collection Procedures21 Ethical Considerations...22 Project Evaluation Plan..23 Results23 Discussion..25 Conclusion.26 References..28 Appendix A- Literature matrix..33 Appendix B- Theory framework....37 Appendix C- GANTT chart...38 MICROAGGRESSION IN THE OPERATING ROOM 3 Appendix D- SWOTT analysis..39 Appendix E- Measurement Instruments....40 Appendix F- IRB Approval letter..44 Appendix G- Student Satisfaction and Self-Confidence in Learning Survey...45 MICROAGGRESSION IN THE OPERATING ROOM 4 Abstract A common theme among Student Registered Nurse Anesthetists is an impact on their mental and physical wellbeing during didactic and clinical education. This DNP project is aimed for the current Marian University graduate nursing students in the Nurse Anesthesia Program. An evidence-based educational intervention was developed to enhance Student Registered Nurse Anesthetists (SRNAs) confidence and knowledge on how to prevent microaggression in the operating room. Over four weeks, the survey was administered to the class of 2024, 2025 and 2026. To investigate this, an online survey was administered using the survey software program Qualtrics. Qualtrics was utilized to deliver the survey link to respondent emails and collect responses electronically. The participants for this project were required to complete a pretest assessing their baseline knowledge on microaggression. After viewing a 20-minute educational PowerPoint presentation, participants were required to complete a posttest. In addition, participants confidence will be assessed by the Student Satisfaction and Self-Confidence in Learning. This is a 13-item instrument designed to measure student satisfaction with simulation activity and self-confidence in learning using a five-point scale (Pence, 2022). This questionnaire was distributed with the pre-and posttest. The results of this project indicated that the educational intervention improved SRNAs confidence and knowledge related to microaggression in the operating room. KEYWORDS: microaggression, depression, graduate students and depression, awareness, nurse anesthesia students, microaggression prevention Introduction MICROAGGRESSION IN THE OPERATING ROOM 5 Microaggression occurs daily in a healthcare setting. It is defined as everyday subtle put-downs directed towards a marginalized group which may be verbal or non-verbal and are typically automatic (Espaillat et al., 2019). Microaggression is categorized into three groups: microassault, microinsults, and microinvalidations. Microassaults are conscious bias towards a person's heritage or identity (Ehie et al., 2021). Microinsults are unconscious messages, nonverbal, and environmental communications towards an individual that conveys rudeness and insensitivity towards marginalized groups (Ehie et al., 2021). Microinvalidations are behaviors and statements that are meant to exclude, negate, and dismiss one's personal feelings, thoughts, and experiences (Ehie et al., 2021). Microaggression has shown negative effects on healthcare providers in multiple ways. Research has shown that healthcare providers who work in the perioperative setting tend to experience distress due to microaggression during training. Furthermore, workplace ill-treatment leads to increased percentages in burnout and high suicidality rates (Ehie et al., 2021). The prevalence of microaggression towards students in the medical field has increased significantly (Espaillat et al., 2019). Research has shown how the role of microaggression in the workplace setting can affect students' ability to learn, emotional and mental health, and how it can affect the victims well-being. The purpose of this project is to identify, educate and teach students on how to combat workplace microaggression during their clinical training. These interventions are designed to encourage everyone to take action, motivate institutions to further equity, and to generate institutional accountability. Background A study conducted at the University of Florida College of Medicine gained insight on how students deal with microaggression. A survey was sent out to 351 students that consisted of MICROAGGRESSION IN THE OPERATING ROOM 6 nine questions. The survey questions consisted of demographic information, understanding of the term microaggression, standard definition of microaggression, and lastly if students ever experienced microaggression (Espaillat et al., 2019). Of the respondents, 39% were males and 61% were females. The results indicated that 56% had heard of the term microaggressions while 44% had not heard the term (Espaillat et al., 2019). Furthermore, 54% of the students reported microaggression during school and 50% reported experiencing microaggression during clinical (Espaillat et al., 2019). Lastly, 73% of the students experienced microaggression during their medical education (Espaillat et al., 2019). In the survey, students mentioned how microaggression caused them to feel powerless, devalued, and uncomfortable. Furthermore, minorities are only 4% of the population in medical schools, the results indicated that microaggression towards minorities was due to race, religion, ethnicity, and sexual orientation (Espaillat et al., 2019). The first step for students to understand microaggression is to recognize and react in a professional manner. Women and underrepresented minorities in the medical field typically experience the greatest amount of discrimination (Torres et al., 2019). Although there are a rising number of women in the healthcare and residency programs, only 39% of women are currently faculty at medical schools (Torres et al., 2019). Due to years of research, researchers have implicated that microaggression proposes the risk of mental health, physical health, creates a toxic learning environment within education, healthcare, and workplace (Ehie et al., 2021). However, there are interventions that may be used in order to combat the adverse effects of microaggression. The first step is for institutions to establish a culture of openness and respect upfront (Ehie et al., 2021). Healthcare departments and institutions' priority should be to advocate for MICROAGGRESSION IN THE OPERATING ROOM 7 diversity and equity. Diversity can begin with a new cohort cycle, new clinical rotation, and during family or patient encounters (Ehie et al., 2021). It has been noted that diversity is considered the best defense against the effects of microaggression (Parikh & Leschied, 2022). The next step is the ability to develop skills in order to disrupt microaggressions. Institutions should provide education skills, tools and workshops for students to educate them on what to see and hear during microaggression (Ehie et al., 2021). This will give an opportunity to anyone who witnesses microaggression to take action. There are two different strategies: indirect and direct (Ehie et al., 2021). Direct strategies can be difficult to articulate if someone hasnt had experience or seen microaggression before. Indirect strategies will also prevent microaggression, however communication is indirect. The Diversity, Equity, and Inclusion (DEI) Committee of the Department of Anesthesiology focuses and acknowledges the belief that diverse perspectives and experiences improves the strength of an organization (Estime et al., 2021). The drive to increase diversity and prevent microaggression in the anesthesia world needs to occur first at the institutional level. Work must be done to drive DEI principles through committees especially those that are responsible for workforce hiring, promotion, and retention (Estime et al., 2021). Organizations that favor the principles of DEI witnessed a 66% increase in the proportion of women expecting to remain in academic medicine and a 57% increase among men (Estime et al., 2021). Furthermore, there has been an increase from four to 26 in the number of female associate professors (Estime et al., 2021). Institution leaders can create accountability and adhere to processes to mitigate bias and reduce disparities in health care clinicians. Academic programs such as Yale University, Duke University, University of California San Francisco, Washington University School of Medicine in St. Louis, and University of North Caroline are initiating the MICROAGGRESSION IN THE OPERATING ROOM 8 policies and practices of DEI to support students and create an environment which promotes equitable and inclusive success. Problem Statement A common theme among Student Registered Nurse Anesthetists is an impact on their mental and physical well-being during didactics and clinical education. Multiple factors are involved in students well-being such as longer duration of education, more clinical hours, doctorate or masters level coursework, extended practicum hours, and higher financial debt (Mesisca, 2021). In a cross-sectional mixed-methods study, 76 SRNAs currently enrolled in a small urban university participated in this study (Mesisca, 2021). Report from the study indicated that 67% of the participates reported low well-being and presented a high risk for adverse outcomes such as poor mental quality of life, suicidal ideation, burnout, severe fatigue, and risk of dropping out (Mesisca, 2021). 50% of the SRNAs believed that their preceptors and clinical faculty did not acknowledge students well-being (Mesisca, 2021). Due to the nature of the job, anesthesia providers are in constant stress. Research has shown that women and minorities in the surgical field tend to experience microaggression more frequently (Sprow et al., 2021). Gender role disparities and discrimination play a huge role in individuals to prevent medical professions to advance their careers in the operating rooms. Data has shown that women in the operating room have experienced treatment such as second-class citizen, assumptions of traditional gender roles, sexual objectification, assumptions of inferiority, leaving gender at the door, and use of sexist language (Sprow et al., 2021). In fact, 68% of the women applying for residency programs tend not to apply for surgery residencies due to gender biases (Sprow et al., 2021). To prevent gender biases and microaggressions it is important to advance diversity and achieve equity in the operating room. In order to raise awareness and shed MICROAGGRESSION IN THE OPERATING ROOM 9 light on this topic, the following PICOT question was developed: In Student Registered Nurse Anesthetists, what is the effect of providing education on coping and preventing microaggression in the OR compared with no education within a one-month time frame. Needs Assessment/ Gap Analysis This project will be dedicated to the current Marian University graduate nursing students in the Nurse Anesthesia Program. Learning to become a competent Certified Registered Nurse Anesthetist is a difficult and stressful journey. High levels of stress in nurse anesthesia education cause negative health consequences as well as impair patient safety (Megan, 2015). A study reported that 47% of nurse anesthesia students reported depression and 21% reported suicidal ideation (Megan, 2015). To provide support to students in their educational journey, guiding students through their clinical experience will help decrease students stress levels. Confidence levels will be evaluated before and after the education session to measure stress. Due to the lack of understanding of the term microaggression an educational tutorial and resources will be gathered to provide students with useful tools. The goal for this project would be to educate these scholars the proper way to cope and prevent microaggression in the operating room. By shedding light on how microaggression can impact on an individual's mental and physical wellbeing, this project will teach Marians student registered nurse anesthetists on how to apply their skills they learned during the educational training in clinicals and didactics. Literature Search Methodology This literature review was done to examine how microaggression can cause a negative learning environment for Student Registered Nurse Anesthetists. To successfully look up literature review articles, keywords such as microaggression, perioperative department, workplace incivility, certified registered nurse anesthetist, perioperative nurses, surgeons, stress, MICROAGGRESSION IN THE OPERATING ROOM 10 mental health, professional performance, program leadership, gender-based microaggression, ethical inequality and psychological disorders were used. The literature review was done from September 2022 to December 2022. BOOLEAN phrases used for this literature review were microaggression AND mental health, microaggression AND Student Registered Nurse Anesthetist, and operating room violence AND mental health. 550 database search results came up when looking for literature review. From the 550 articles, 13 literature review articles were used in order to support the PICOT question. From these 550 articles, some were placed in the exclusion or inclusion criteria. Articles that were excluded were if they were older than five years, articles that were not in English, and participants who refused to give consent. The inclusion criteria consisted of articles that were published within five years, articles that were translated to English, participants who worked in the perioperative department, student registered nurse anesthetist education and clinical experience, and articles that had a randomized control trial. Articles needed to discuss how microaggression can have a negative impact on a students education. (See APPENDIX A) Literature Review Synthesis of Information Gender-Based and Ethical Microaggression in Medicine Medical providers experiencing workplace mistreatment from microaggression can cause chronic, severe distress. Microaggressions are subtle, insulting, discriminatory comments or actions that communicate a demeaning or hostile message to nondominant groups. Studies have shown that workplace microaggression has an impact on burnout. Medical provider burnout is considered a global crisis, with prevalence as high as 80% (Sudol et al., 2021). In medicine, gender-based microaggression has been considered the most common type. In a survey study on surgeons and anesthesiologists, 91% of reported sexist microaggressions and 84% reported MICROAGGRESSION IN THE OPERATING ROOM 11 racial/ ethnic microaggressions (Sudol et al., 2021). This was a cross-sectional survey that evaluated microaggression and physician burnout. 259 females experienced sexist microaggression and 299 respondents experienced racial/ethnic microaggression (Sudol et al., 2021). A survey completed by 297 participants detailed that female provider experience a significantly higher frequency of gendered microaggressions compared with male providers (Sarah et al., 2022). Microaggression can impact job satisfaction, burnout, perceived career impacts and behavioral modifications. Furthermore, a study reported that trainees experienced more microaggressions and burnout than faculty (Sarah et al., 2022). In a study done on 124 faculty members, 79 women and 45 men participated (Periyakooil et al., 2020). Women reported higher frequencies of microaggression than men in 33 of the 34 videos describing microaggressions (Periyakooil et al., 2020). This study showed that microaggressions fell into 6 themes: encountering sexism, encountering pregnancy and childcare related bias, having abilities underestimated, encountering sexually inappropriate comments, and feeling excluded or insignificant (Periyakooil et al., 2020). Lack of diversity in anesthesiology has become a common theme. According to the American Nurses Association (AANA), there are currently 50,000 CRNAs practicing. Of the 50,000 CRNAs, 12 percent are considered minorities. This means that 7,080 current CRNAs working are minorities. One approach to help improve the field of anesthesiology is to engage underrepresented minoritized students to attract them to medicine, involve medical students to anesthesiology, offer mentorship and support to residents and students, and enhance knowledge on diversity and antiracism in the anesthesiology. It has been reported that females and minorities are underrepresented in the American Society of Anesthesiologists. Although, 13.4% MICROAGGRESSION IN THE OPERATING ROOM 12 of the United States population identifies as being African American, about 3-5% of United States anesthesiologists are African Americans (Milam et al., 2021). The lack of diversity in cardiothoracic anesthesiology may have been due to multiple factors such as lack of mentorship, microaggression and discrimination during residency training, isolation, discouragement from attending physicians, and biases during interview process (Milam et al., 2021). There are many benefits increasing diversity in the medical field such as improvement in patient care, patient satisfaction and reduction in healthcare disparities. Even though there has been an increased awareness of microaggression occurring during medical training, it is still prevalent in plastic surgery training. A survey was distributed by the American Society of Plastic Surgeons Resident Representatives from March and May 2021. One hundred twenty-five participants completed the survey. Those who responded, 68.8% experienced microaggression and female trainees experienced microaggression more frequently than male trainees (p<0.05) (Goulart et al., 2022). Furthermore, Asians had a higher odd to be a target of microaggression as compared to Caucasians (p=0.013) (Goulart et al., 2022). This study mentioned how approximately 7 in 10 trainees have mentioned that they have experienced microaggression in the past year (Goulart et al., 2022). Multiple studies need to be implemented to address the problem in order to resolve inequities. The learning environment in medical training involves multiple participants: a learner, an educator, and a caregiver. Microaggression aggression in medical education may occur daily for many trainees. These difficult encounters may lead students with a sense of not fit for a certain specialty, setting or occupation. A study conducted in United Kingdom reported that 30% of the surgical residents experienced gender and racial discrimination at least a few times per week (Hastie et al., 2020). A study done on medical students across the United States was conducted MICROAGGRESSION IN THE OPERATING ROOM 13 in 2019. A total of 217 students participated in the study. Of the 217 responses, 148 were underrepresented minorities (URM). URM respondents reported experiencing race-related microaggressions during medical school (55%), feelings of burnout (62%), and compromised learning (64%) (Chisholm et al., 2021). Furthermore, these students were not provided with adequate resources to address microaggression (39%) (Chisholm et al., 2021). In addition, another study conducted on medical students had 759 respondents. Of the respondents, 61% experienced at least one microaggression weekly (Anderson et al., 2022). The most cited reasons for experiencing microaggression was gender (44%), race/ethnicity (60.5% and age (40.9%) (Anderson et al., 2022). These students who experienced microaggression were considering transferring schools, withdrawing from the program, and believed microaggression was a normal part of medical school culture (Anderson et al., 2022). Underrepresented medical and nursing students from Yale University and University of California, Davis participated in interviews that were conducted from November 2017 to June 2018 (Ackerman-Barger et al., 2020). The sample size was thirty-seven participants: twenty-two medical students, fourteen nursing students, and one physician assistant. Based on the interview, the most common themes were students felt devalued by microaggression, students mentioned how microaggression affected their learning, academic performance, and personal wellness (Ackerman-Barger et al., 2020). The goal of this study was to understand what students experienced throughout their educational experience and their insight on racial microaggressions (Ackerman-Barger et al., 2020). It will help educators and academic leaders learn appropriate steps on how to support students and create a safe learning environment. Operating Room Environment MICROAGGRESSION IN THE OPERATING ROOM 14 Effective teamwork in the operating room decreases the risk of surgical errors and complications for patients by up to 14 percent. Marian Universitys SRNAs rotate through 55 possible different clinical sites and in many states. Because students are required to rotate to multiple clinical sites, they may be exposed to different personalities and different expression of microaggression depending on the site. This can lead to a stressful psychosocial and learning environment for the student. It has shown than ineffective teamwork in the operating room is the primary contributing factor to patient complications. It is appealing to understand how gender can affect interprofessional practice in the operating room. There are many reasons why effective teamwork can be threatened due to power and hierarchy. Recent research has drawn attention in surgery and anesthesia the importance of gender shaping and outcomes of healthcare professionals. Studies have shown that women providers experience bias and harassment in surgery and anesthesia. In a study conducted in Ontario, Canada, sixty-six interviews were conducted on operating room healthcare professionals (Etherington et al., 2021). Participants were anesthesia providers (n=17), nurses (n=19), perfusionists (n=2), and surgeons (n=26) (Etherington et al., 2021). Both men and women recognized the difficulties women face in the operating room (Etherington et al., 2021). In order to provide safe practice to patients, operating room team members should be aware how communication and effective teamwork can benefit patients health. Disruptive behavior in the operating rooms is an issue within healthcare teams. It has negatively impacted personal well-being, patient safety and organizational climate. Disruptive behaviors are verbal or physical alteration, which can interfere with healthcare teams ability to work with each other. Repeated disruptive behavior can lead to emotional exhaustion, depression, burnout, and potential suicidal ideation (Campos et al., 2022). Participants in this MICROAGGRESSION IN THE OPERATING ROOM 15 study were surgeons (n=12), anesthetists (n=2), residents (n=2), nurses (n=2), and technicians (n=2) (Campos et al., 2022). The behaviors noted by these participants were verbal aggression, physical aggression, and lack of professionalism. This study confirmed the importance of hierarchy in disruptive interactions (Campos et al., 2022). It was noted that there were alterations between those with less power positions than those with superior positions (Campos et al., 2022). Empowerment and Leadership Initiative Students in the medical field often experience microaggression during their clinical and didactic education. A recent study was conducted on how impactful a two-hour workshop can be to help students recognize and respond to microaggression in clinical practice (Sandoval et al., 2020). The goal of the session was for students to recognize instances of microaggression and discrimination in the clinical setting, describe the impact of microaggression, and explain challenges to responding to microaggression. The workshop consisted of a PowerPoint presentation and a small-group session where students work through two cases by applying the presented frameworks and role-playing scenarios. Of the 163 students participated in the workshop, 77% had witnessed or experienced microaggressions in the clinical setting, and 69% reported very good or excellent familiarity with the concept of microaggressions (Sandoval et al., 2020). The workshop was beneficial in many ways such as students were able to identify microaggressions, brought awareness to the negative effects from microaggressions, and improvements in familiarity with institutional support systems (Sandoval et al., 2020). A workshop dedicated to the residents of Internal Medicine utilized the Microaggression Response Toolkit (MRT). This was a fifty-minute workshop that was designed to help describe strategies for responding to microaggressions as a target or witness (Fisher et al., 2021). An MICROAGGRESSION IN THE OPERATING ROOM 16 electronic pre- and post-surveys were distributed to assess the success of the workshop. The results from this workshop indicated that 89% of the residents felt more comfortable in identifying microaggression, 97% of the residents improved the understanding of the impact of microaggression and 70% increased confidence in responding to microaggression (Fisher et al., 2021). Residents from the workshop suggested to incorporate microaggression as part of the curriculum and mentioned that MRT and practice scenarios were the best part of the workshop (Fisher et al., 2021). The goal of this project is to make SRNAs more comfortable in identifying microaggression and gaining confidence in responding to microaggression after the educational tutorial. Theoretical Framework Using the best evidence to guide clinical practice plays an important role in advocating change. The Iowa model of evidence-based practice is to improve quality care and help guide healthcare professionals in decision-making (Melnyk & Fineout-Overholdt, 2019). (See APPENDIX B). The first step of the Iowa Model is to identify a problem-focused trigger. Problem-focused triggers are problems obtained from risk management data, process improvement data, internal/external benchmarking data, financial data and identification of clinical data (Melnyk & Fineout-Overholdt, 2019). This model was developed by nurses to help develop research projects. This guide helps with clinical decision-making and evidence-based practice process from both the clinician and systems perspectives (Buckwalter et al., 2017). The use of the Iowa model has increased dramatically and is being utilized by clinicians, educators, administrators and researchers from all 50 states and 130 countries (Buckwalter et al., 2017). This model fits the criteria of this project because it will help identify the problem-focused MICROAGGRESSION IN THE OPERATING ROOM 17 trigger of microaggression. In addition, the model will help guide the student registered nurse anesthetist with steps to help cope and identify microaggression exposure in the operating room. Project Aims and Objectives The primary aim of this project is to improve recognition of microaggression and knowledge skillset on how to handle difficult situations in the operating room. This project is directly towards Marian Universitys student registered nurse anesthetists from the class of 2024 and 2025. The objective of this project was to develop a comprehensive 19-minute educational PowerPoint. Before the Marian graduate nursing students view the PowerPoint, a pretest will be distributed via email to understand their baseline knowledge of microaggression. After viewing the PowerPoint, a posttest will then be conducted to analyze the effectiveness of the educational PowerPoint. In addition, participants will be receiving a Student Satisfaction and SelfConfidence in Learning questionnaire with the pre-and posttest. This will help determine if students are more comfortable and confident in the topic of microaggression. The goal for this posttest survey is to see an improvement in the participants ability to describe microaggression after viewing the educational PowerPoint. These results will evaluate the qualitative question on the pre- and posttest. The second goal is to see an increase in the participants ability to recognize correct answers to the multiple-choice questions on the posttest. These results will evaluate the quantitative questions on the pre- and posttest. GANTT Chart APPENDIX C. SWOT Analysis This project will be conducted at Marian University located in Indianapolis, Indiana. The key stakeholders for this project are currently enrolled student registered nurse anesthetist MICROAGGRESSION IN THE OPERATING ROOM 18 attending Marian University, instructors teaching at Marian University and preceptors. Students will be provided with a pre and post survey regarding their understanding on microaggression. Along with the pre-and posttest, a questionnaire assessing confidence will be distributed. Furthermore, students will be provided with a PowerPoint that will identify key points on how to recognize and cope with microaggression. Evidence-based practice and recent research will be gathered to help identify the problem. The advantages are that all the key stakeholders are within in contact through email. Technology and Qualtrics are strengths to this project because the distribution of surveys, PowerPoint presentation, and contacting participants can be easily circulated. Another strong advantage is that SRNAs at Marian University gain their experiences from over 30-40 clinical sites. By representing multiple states of the US, there will be more diverse responses. The total participants for this project is less than one hundred students. Negative factors regarding this project are students not taking the time to complete surveys in a timely manner. Due to the stress of education and clinical, surveys tend to be the last priority for students. Another weakness regarding this project is providing surveys to students from only one institution. By involving more than one institution can help identify other problems and researchers can have a better opportunity to help guide students in a better direction. By providing resources to students in an educational manner can offer better outcomes in the clinical workplace. This way students can use their skills they have developed during their education and utilize them in their practice. Marian University students will be asked on the presurvey if they have ever experienced microaggression. This will help publish percentage to present to others how often microaggression occurs in a SRNAs educational career. As previously mentioned, microaggression occurs frequently in the workplace setting that can cause MICROAGGRESSION IN THE OPERATING ROOM 19 harm to an individuals wellbeing. Students one day can be leaders in their institution and provide a positive impact on their colleagues journey in the operating room. The threats regarding this project are lack of support or response from Marian Universitys students, technology issue, and participants are not interested in this topic. (See APPENDIX D) Project Design/ Methods The project design will consist of an educational intervention and process improvement. Students are expected to complete a pre and posttest assessment that will include demographic and qualitative questions. After completing the pretest, graduate nursing students are expected to view an educational PowerPoint presentation regarding microaggression and how to identify and manage microaggression in an educational environment such as in clinical. Once the participants have viewed the PowerPoint, they will complete the posttest questionnaire to assess whether the PowerPoint was a successful education intervention. Students are also expected to complete a Student Satisfaction and Self-Confidence in Learning questionnaire that will assess their confidence level before and after viewing the educational tutorial. This projects main goal is to educate students and how to improve the culture of the healthcare system in the longer run. Population and Setting This project will be conducted at a small, private, Catholic university in the Midwest. This setting offers graduate programs such as Nurse Anesthetist, Family Nurse Practitioner, Osteopathic Medicine, and Organizational Leadership. The individuals participating in the project will be those who are seeking an advanced nursing practice doctoral degree in nurse anesthesia. These individuals partaking in the project will be students from the class of 2024, 2025 and 2026. The participants age will vary from their early 20s to greater than 50 and will include all gender preferences. MICROAGGRESSION IN THE OPERATING ROOM 20 Measurement Instruments The measurement tool for this is a DNP student created questionnaire that includes two demographic questions and fourteen qualitative questions (See APPENDIX E). Participants will be expected to complete a pretest to assess their baseline knowledge on microaggression. Participants will then be introduced to a 20-minute PowerPoint presentation that will discuss topics on identifying microaggression, how to cope with microaggression, and how to manage microaggression in educational setting. Once participants are exposed to the PowerPoint presentation, they will be required to complete the posttest right after. The first question will ask for the students last four digits of their student identification card. Then the next two questions will be regarding their gender and ethnic or racial preference. The posttest questionnaire will have no demographic questions; however, students are expected to use their student identification number as well as the same qualitative questions for analysis. Participants will receive their presurvey and PowerPoint Presentation by the first week of January 2024. Students will receive a reminder to complete their surveys every two weeks. The purpose of the study was to determine if the PowerPoint presentation was beneficial to students regarding their understanding on the topic of microaggression. Survey is a strong tool to utilize during studies to compare results. It gives valuable feedback, and the conductor can measure and establish a benchmark to compare results over time. By analyzing results, researchers can recognize topics that are important to review, rather than wasting time and resources on areas with a minor concern. The goal for this study is for students to score higher on the posttest than they did on the pretest. For this project, participants confidence will be assessed by the Student Satisfaction and Self-Confidence in Learning. This is a 13-item instrument designed to measure student MICROAGGRESSION IN THE OPERATING ROOM 21 satisfaction with simulation activity and self-confidence in learning using a five-point scale (Pence, 2022). This questionnaire will be distributed with the pre-and posttest. The questions asked on the on this tool are all student self-reports of their perception and reactions to the simulation (Pence, 2022). Based on the question, students will pick strongly disagree (SD), disagree (D), undecided (UN), agree (A), and strongly agree (SA). The reliability was tested using Cronbachs alpha: satisfaction= 0.94; self-confidence= 0.87 (Pence, 2022). The National League for Nursing is offering this tool and instrument for use in nursing education (Pence, 2022). Data Collection Procedures Measuring the efficacy of any project relies on data analysis. Data analysis provides a statistical measurement that ensures the effectiveness of a project (White et al., 2016). The participants from this project will complete the pre and posttest on Qualtrics website. Qualtrics is an online survey tool that allows survey building, distribute surveys and analyze responses in a convenient manner. The benefits of Qualtrics is that there is no need to install a software, over eighty-five different question types can be formed, many questions and survey template options, multiple surveys can be posted at the same time, capability for respondents to stop in mid-survey and resume later where they left off, and ability to export data directly to SPSS, CSV, PDF, Word, Excel, and PowerPoint. For this project, the sample size is small therefore a non-parametric test will be utilized to collect nominal data. Based on the statistical testing, research conductors will be able to assess the most incorrectly answered question on the pretest as well as the most correctly answered question on the posttest. Because participants are required to enter their last four student identification digits for the pre and posttest, each participants overall score can be MICROAGGRESSION IN THE OPERATING ROOM 22 compared based on the results of pre and posttest. The goal is to determine if there is an increase in scores, which will then indicate if the educational PowerPoint was a successful tool for educating student registered nurse anesthetists from Marian University. The Wilcoxon signed-rank test is a frequently used nonparametric test for paired data (Rosner et al., 2006). This test can be utilized because it can assess pre and posttest measurements based on independent units of analysis. The Wilcoxon signed-rank test is best to measure the differences between two related samples and determine statistically significant differences (White et al., 2016). Furthermore, it is favorable because it can be accustomed to "compare two sets of scores that come from the same participants'' (White et al., 2016). Wilcoxon signed-rank tests offers project conductors a better visualization on evaluating the score from pre and posttest. This way, project conductors can determine improvements and positive outcomes based on the data provided. After obtaining data collection, the Wilcoxon signed-rank test will be used to measure the participant's knowledge gap regarding microaggression. This test can also estimate the populations median and compare it to a target value (Rosner et al., 2006). Furthermore, each pre and posttest will be compared closely, and the goal is to see an upward trend in answers. Goal is to see an increase in participants ability to recognize correct answers to the multiple-choice questions on the posttest. In addition, the objective is for the participants to gain confidence in this topic, so that they can make use of their skillset in the operating room. Ethical Considerations To maintain the participants privacy, they are expected to provide the researchers with their student identification number. Marian Universitys Internal Review Board (IRB) approval was obtained before initiating the implementation phase of this DNP project. IRB Determination MICROAGGRESSION IN THE OPERATING ROOM 23 Form Letter of Approval can be found in Appendix F. The data will be stored on the Qualtrics website and an excel spreadsheet that will only be accessed by the conductors of the study. Once the dissemination is complete, all data results will be deleted. The goal for this project is an educational intervention, which requires no physical or mental activity. Project Evaluation Plan The application of Lincoln and Guba's evaluative criteria will be used to appraise the quality of this project. Trustworthiness of a research study is important to evaluating its worth and it involves: credibility, dependability, transferability, and conformability of this project (Melnyk et al., 2019). These trustworthy criteria will help demonstrate accuracy and validity through research, opinion, biases, and peer debriefing (Melnyk et al., 2019). This is also known as the Four-Dimensions Criteria (FDC). Credibility means confidence in the truth of the findings (Forero et al., 2018). Transferability is showing that the findings have applicability in other contexts (Forero et al., 2018). Dependability is showing that the findings are consistent and could be repeated (Forero et al., 2018). Lastly, confirmability is a degree of neutrality to which the results of the project are shaped by respondents and not researcher bias, motivation or interest (Forero et al., 2018). After implementing this educational intervention, the goal is that Marian University graduate nursing students have a better understanding of how to combat the negative effects from microaggression. Results For this DNP project, surveys were sent to students from the DNP class of 2024, 2025, and 2026. Surveys were sent to 99 SRNAs from Marian University. There were a total of 20 responses. Of the 20 responses, three responses were excluded because the participants did not complete the post-survey. In addition, two responses were excluded as the participants MICROAGGRESSION IN THE OPERATING ROOM 24 completed the post-survey but did not complete the pre-survey. Data analysis for this DNP project was conducted on 15 participants who completed both the pre and post survey for a 15% completion rate. Of the remaining 15 participants, there were five males and ten females. Data analysis was conveniently and automatically performed using Qualtrics. The questionnaire consisted of 30 questions in both pre and post-test. Fourteen questions on the survey were regarding understanding and coping with microaggression. For question four, what year was the term microaggression first used, only 40% of the respondents answered the question correctly. With regards to survey question seven, what is your understanding of the term microaggression, only 53% of the respondents answered the question correctly. In addition, question number five, what are the different types and forms of microaggression, only 33% of the participants knew the different types of microaggression. Lastly, question 15 asked about, how can students contact the Health Center at Marian University, only 65% of the respondents knew how to contact the health center correctly. Based on the results, knowledge improvement from pre-test to post-test was statistically significant. The mean of the SRNAs pre-test was 62% and the mean of the post-test was 83.8%. After performing the paired t-test, the p-value was 0.004. Since the p-value was <0.05, this indicated that the post-test test results are significantly higher than that of the pre-test. Furthermore, an NLN Student Satisfaction and Self-Confidence survey was administered to participants. The Student Satisfaction and Self-Confidence in Learning is a 13-item instrument designed to measure student satisfaction with the simulation activity and selfconfidence in learning. Students responded to a Likert-type scale from 1= strongly disagree, 2=disagree, 3=undecided, 4=agree, and 5= strongly agree. Based on the results from the NLN survey, the participants were satisfied with the simulation and felt confident in identifying MICROAGGRESSION IN THE OPERATING ROOM 25 microaggression in the clinical area. The post-test results are significantly higher than those of pre-tests with a p value of 0.026. (See APPENDIX G) Survey Items SD D UN A Satisfaction with current learning Teaching methods helpful and effective 0 (0%) 1 (6.6%) 0 (0%) 8 (53%) 6 (40%) 15 Variety learning materials and activites promote learning 0 (0%) 1 (6.6%) 0 (0%) 8 (53%) 6 (40%) 15 Enjoyed how instructor taught simulation 0 (0%) 2 (13.3%) 0 (0%) 7 (46%) 6 (40%) 15 Teaching materials motivating and helped learning 0 (0%) 1 (6.6%) 0 (0%) 8 (53%) 6 (40%) 15 Way taught suitable way to learn 0 (0%) 2 (13.3%) 0 (0%) 7 (46%) 6 (40%) 15 Self-confidence in learning Confident mastering content 0 (0%) 0 (0%) 1 (6.6%) 8 (53%) 6 (40%) 15 confident simulation covered critical content 0 (0%) 2 (13.3%) 0 (0%) 7 (46%) 6 (40%) 15 confident developing skills, knowledge to perform clinical tasks 0 (0%) 0 (0%) 9 (60%) 6 (40%) 15 Intructor used helpful resources 0 (0%) 2 (1.33%) 1 (6.6%) 6 (40%) 6 (40%) 15 It is my responsibility to learn what I need to know from simulation 0 (0%) 0 (0%) 0 (0%) 8 (53%) 7 (46%) 15 I know how to get help when I do not understand concepts 0 (0%) 0 (0%) 0 (0%) 9 (60%) 6 (40%) 15 I know how to use simulation to learn critical aspects of skills 0 (0%) 1 (6.6%) 0 (0%) 9 (60%) 5 (33%) 15 Intructors responsibility to tell me what I need to learn of simulation content 0 (0%) 4 (26%) 4 (26%) 3 (20%) 4 (26%) 15 0 (0%) SA Total Discussion The results of this DNP project indicate that educational interventions can positively impact SRNAs confidence and knowledge related to microaggression in the operating room. The results from the posttest indicate that students have a better understanding on how to cope and assess signs of microaggression. The success of the educational intervention in this project has important implications for practice. SRNAs curriculum should incorporate similar MICROAGGRESSION IN THE OPERATING ROOM 26 educational modules to help better prepare students mentally and physically during their clinical rotations. It is important that students feel supported and safe during their education journey to help them become competent providers. There are several limitations to this study. First, the projects sample size is small (n=15). Second, the data collection for this project comes from a single institution, which limits generalizability. Future research should include a larger sample size from multiple institutions to determine if these results are consistent amongst student registered nurse anesthetists. Time management is essential for project success, and there are various time constraints a project will face during each phase of the project. Having the survey extended for a longer period can help with increasing the sample size. Participants for this project were given one month to complete the pre and the posttest. Lastly, the project relied on self-reported assessments of confidence and knowledge, which may be subject to bias. Future project should incorporate objective measures of performance, such as direct observation or simulation-based evaluations. Conclusion In conclusion, the prevalence of microaggression towards students in the medical field has increased significantly (Espaillat et al., 2019). Research has shown how the role of microaggression in the workplace setting can affect students' ability to learn, emotional and mental health, and how it can affect the victims well-being. Graduate students in anesthesia are prone to physical and emotional stressors. To create inclusive, welcoming, and healthy workplaces, we must actively combat microaggressions. This begins with understanding how microaggression is introduced and how to respond appropriately. A safe workplace contributes a positive outcome to students well-being and mental and physical health. The results demonstrated that provided targeted education materials, such as the evidence-based PowerPoint MICROAGGRESSION IN THE OPERATING ROOM 27 presentation, can enhance participants ability in overcoming challenges associated with microaggression in the operating room. The projects positive outcome emphasizes the value of educational interventions and the need for continuous reinforcement on sensitive topics. Institutions should provide students with necessary tools to promote a healthy experience during their anesthesia training. MICROAGGRESSION IN THE OPERATING ROOM 28 References Ackerman-Barger, K., Boatright, D., Gonzalez-Colaso, R., Orozco, R., & Latimore, D. (2020). Seeking Inclusion Excellence: Understanding Racial Microaggressions as Experienced by Underrepresented Medical and Nursing Students. Academic medicine : journal of the Association of American Medical Colleges, 95(5), 758763. https://doi.org/10.1097/ACM.0000000000003077 Anderson, N., Lett, E., Asabor, E. N., Hernandez, A. L., Nguemeni Tiako, M. J., Johnson, C., ... & Boatright, D. (2022). The association of microaggressions with depressive symptoms and institutional satisfaction among a national cohort of medical students. Journal of General Internal Medicine, 37(2), 298-307. Buckwalter, K. C., Cullen, L., Hanrahan, K., Kleiber, C., McCarthy, A. M. (2017). Iowa model of evidencebased practice: Revisions and validation. Worldviews on EvidenceBased Nursing, 14(3), 175-182. Campos, M., Lira, M. J., Mery, P., Caldern, M., Seplveda, M., Pimentel, F., & Ziga, D. (2022). Disruptive behavior in the operating room: Systemic over individual determinants. International Journal of Surgery Open, 100492. Chisholm, L. P., Jackson, K. R., Davidson, H. A., Churchwell, A. L., Fleming, A. E., & Drolet, B. C. (2021). Evaluation of racial microaggressions experienced during medical school training and the effect on medical student education and burnout: a validation study. Journal of the National Medical Association, 113(3), 310-314. Ehie, O., Muse, I., Hill, L., & Bastien, A. (2021). Professionalism: microaggression in the healthcare setting. Current opinion in anaesthesiology, 34(2), 131136. https://doi.org/10.1097/ACO.0000000000000966 MICROAGGRESSION IN THE OPERATING ROOM 29 Espaillat, A., Panna, D. K., Goede, D. L., Gurka, M. J., Novak, M. A., & Zaidi, Z. (2019). An exploratory study on microaggressions in medical school: What are they and why should we care? Perspectives on Medical Education, 8(3), 143151. https://doi.org/10.1007/s40037-019-0516-3 Estime, S. R., Lee, H. H., Jimenez, N., Andreae, M., Blacksher, E., & Navarro, R. (2021). Diversity, equity, and inclusion in anesthesiology. International anesthesiology clinics, 59(4), 8185. https://doi.org/10.1097/AIA.0000000000000337 Etherington, C., Kitto, S., Burns, J. K., Adams, T. L., Birze, A., Britton, M., Singh, S., & Boet, S. (2021). How gender shapes interprofessional teamwork in the Operating Room: A qualitative secondary analysis. BMC Health Services Research, 21(1). https://doi.org/10.1186/s12913-021-07403-2 Fisher, H. N., Chatterjee, P., Shapiro, J., Katz, J. T., & Yialamas, M. A. (2021). Lets Talk About What Just Happened: a Single-Site Survey Study of a Microaggression Response Workshop for Internal Medicine Residents. Journal of General Internal Medicine, 36(11), 3592-3594. Forero, R., Nahidi, S., De Costa, J., Mohsin, M., Fitzgerald, G., Gibson, N., McCarthy, S., & Aboagye-Sarfo, P. (2018). Application of four-dimension criteria to assess rigour of qualitative research in emergency medicine. BMC health services research, 18(1), 120. https://doi.org/10.1186/s12913-018-2915-2 MICROAGGRESSION IN THE OPERATING ROOM 30 Goulart, M. F., Huayllani, M. T., Samora, J. B., Moore, A. M., & Janis, J. E. (2022). 2. Microaggressions in Plastic Surgery Training: Current Status And Recommendations. Plastic and Reconstructive SurgeryGlobal Open, 10, 1. Hastie, M. J., Jalbout, T., Ott, Q., Hopf, H. W., Cevasco, M., & Hastie, J. (2020). Disruptive Behavior in Medicine: Sources, Impact, and Management. Anesthesia & Analgesia, 131(6), 1943-1949. Megan , C. (2015). Self-efficacy, stress, and social support in retention of student registered nurse anesthetists. AANA journal. Retrieved February 10, 2023, from https://pubmed.ncbi.nlm.nih.gov/26016172/ Melnyk, B. M., & Fineout-Overholt, E. (2019). Evidence-based practice in Nursing & Healthcare: A guide to best practice. Wolters Kluwers. Mesisca, J. (2021). Stress, Anxiety, and Well-being in Nurse Anesthesia Doctoral Students. AANA Journal, 89(5), 396402. Milam, A. J., Oliver, A. P., Smith, S. A., Davis, T., & Essandoh, M. (2021). When Are We Going to Address the Lack of Diversity in Cardiothoracic Anesthesiology?. Journal of Cardiothoracic and Vascular Anesthesia, 35(10), 3148-3149. Parikh, A. K., & Leschied, J. R. (2022). Microaggressions in our daily workplace encounters: A barrier to achieving diversity and inclusion. Pediatric Radiology, 52(9), 17191723. https://doi.org/10.1007/s00247-022-05307-9 Pence, P. L. (2022). Student satisfaction and self-confidence in learning with virtual simulations. Teaching and Learning in Nursing, 17(1), 31-35. MICROAGGRESSION IN THE OPERATING ROOM 31 Periyakoil, V. S., Chaudron, L., Hill, E. V., Pellegrini, V., Neri, E., & Kraemer, H. C. (2020). Common types of gender-based microaggressions in medicine. Academic Medicine, 95(3), 450-457. Rosner, B., Glynn, R. J., & Lee, M. L. T. (2006). The Wilcoxon signed rank test for paired comparisons of clustered data. Biometrics, 62(1), 185-192. Sandoval, R. S., Afolabi, T., Said, J., Dunleavy, S., Chatterjee, A., & lveczky, D. (2020). Building a tool kit for medical and dental students: addressing microaggressions and discrimination on the wards. MedEdPORTAL, 16, 10893. Sarah R. Ahmad, Tessnim R. Ahmad, Vidhya Balasubramanian, Shelley Facente, Cindy Kin, and Sabine Girod. Are You Really the Doctor? Physician Experiences with Gendered Microaggressions from Patients.Journal of Women's Health.Apr 2022.521532.http://doi.org/10.1089/jwh.2021.0169 Sprow, H. N., Hansen, N. F., Loeb, H. E., Wight, C. L., Patterson, R. H., Vervoort, D., Kim, E. E., Greving, R., Mazhiqi, A., Wall, K., Corley, J., Anderson, E., & Chu, K. (2021). Gender-based microaggressions in surgery: A scoping review of the global literature. World Journal of Surgery, 45(5), 14091422. https://doi.org/10.1007/s00268-021-05974z Sudol NT, Guaderrama NM, Honsberger P, Weiss J, Li Q, Whitcomb EL. Prevalence and Nature of Sexist and Racial/Ethnic Microaggressions Against Surgeons and Anesthesiologists. JAMA Surg. 2021;156(5):e210265. doi:10.1001/jamasurg.2021.0265 MICROAGGRESSION IN THE OPERATING ROOM 32 Torres, M. B., Salles, A., & Cochran, A. (2019). Recognizing and reacting to microaggressions in medicine and surgery. JAMA Surgery, 154(9), 868. https://doi.org/10.1001/jamasurg.2019.1648 White, K. M., Dudley-Brown, S., & Terhaar, M. F. (2016). Translation of Evidence into Nursing and Health Care, Second Edition. Springer Publishing Company. https://doi.org/10.1891/9780826147370 MICROAGGRESSION IN THE OPERATING ROOM 33 Appendix A Citation Research Design & Level of Evidence Crosssectional descriptive Study, Level VI Population / Sample size n=x Major Variables Instruments / Data collection Results University of California, Davis and Yale University nursing students N=37 Independent: Questionnaire on microaggression and conductors interviewed students Electronic questionnaire and interviewing students According to the results from the study, the three major themes that were noted were students felt devalued by microaggression; students identified how microaggressions influenced their learning, academic performance, and well-being; and students had suggestions for promoting inclusion. (Anderson et al., 2022) Crosssectional descriptive Study, Level VI US medical students N=759 Independent: online 2-item Patient Health survey Questionnaire; chi-squared statistic to test associations between microaggression exposure and medical school satisfaction Out of 759 respondents, 61% experienced at least one microaggression weekly. Medical students who experienced at least one microaggression weekly were considering medical school transfer (14.5%), withdrawal (18.2%), and more likely believed that microaggression was a norm in medical school (62.3%). (Campos et al., 2022) Qualitative Study, Level VI Sample included nurses, surgeons, anesthesiologists, residents, anesthetists, technicians N=20 Independent: operating room issues, favorable operating room working conditions, typical disruptive behaviors, Problems of infrastructure, interpersonal relationships, and organizational failures had most density of citations and trigger the most disruptive behavior narrated events. (AckermanBarger et al., 2020) In-depth interviews conducted by two interviewers MICROAGGRESSION IN THE OPERATING ROOM 34 characteristics of disruptive people. (Chisholm et al., 2021). Randomized Crosssectional study, Level II Medical students across the United States, students identifying as underrepresented minority medical students N=217 Independent: microaggression, Education, racial discrimination, under-represented minorities Survey (Espaillat et al., 2019) Randomized Crosssectional study, Level II Medical students from the University of Florida College of medicine (n=351) Independent: survey microaggression towards minorities, gender roles, sexual orientation (Etherington et al., 2021) Qualitative Study, Level VI OR healthcare professionals N=66 Independent: gender roles, norms, stereotypes Semi-structured interviews with OR team members conducted between November 2018 and July 2019. (Fisher et al., 2021) Qualitative Study, Level VI Total internal medicine residents N=85 Independent: Microaggression, confidence, An electronic pre- and postsurveys were distributed to assess the success of the workshop. Of the 217 responses, 148 were underrepresented minorities (URM). URM respondents reported experiencing race-related microaggressions during medical school (55%), feelings of burnout (62%), and compromised learning (64%). Furthermore, these students were not provided with adequate resources to address microaggression (39%). The results indicated that 56% had heard of the term microaggressions while 44% had not heard the term. Furthermore, 54% of the students reported microaggression during school and 50% reported experiencing microaggression during clinical. Lastly, 73% of the students experienced microaggression during their medical education. Participants in the study agreed that women face more challenges in the OR, such as being perceived negatively for displaying leadership behaviors. Furthermore, staff members noted that interactions and behaviors varied depending on team gender composition, social identities, such as age and race. The results from this workshop indicated that 89% of the residents felt more comfortable in identifying microaggression, 97% of the residents MICROAGGRESSION IN THE OPERATING ROOM 35 microaggression response toolkit (Goulart et al., 2022) Randomized Crosssectional study, Level II Plastic surgeon residents N=125 Independent: stereotypes, bias, microaggression, mental health A survey was distributed by the American Society of Plastic Surgeons Resident Representatives from March and May 2021. (Hastie et al., 2020) Qualitative Study, Level VI Perioperative healthcare workers N=7000 Survey (Megan, 2015) Qualitative Study, Level VI Student registered nurse anesthetists N=40 Independent: Racial discrimination, Gender discrimination Independent: stress, clinical stress (Mesisca, 2021) Randomized Crosssectional study, Level II Student Registered Nurse Anesthetists N=76 Independent: Suicidal ideation, low wellbeing, poor mental health Survey (Periyakoil et al., 2020) Randomized Crosssectional study, Level II Medical staff members N=124 Independent: Gender, occupation medicine 34 videos of real-life microaggression and 34 corresponding fictional control versions of the same situations Survey improved the understanding of the impact of microaggression and 70% increased confidence in responding to microaggression. Those who responded, 68.8% experienced microaggression and female trainees experienced microaggression more frequently than male trainees (p<0.05). Furthermore, Asians had a higher odd to be a target of microaggression as compared to Caucasians (p=0.013). 30% of all surgical residents reported experiencing gender discrimination and more than 16% reported racial discrimination. A study reported that 47% of nurse anesthesia students reported depression and 21% reported suicidal ideation. Report from the study indicated that 67% of the participates reported low well-being and presented a high risk for adverse outcomes such as poor mental quality of life, suicidal ideation, burnout, severe fatigue, and risk of dropping out. 50% of the SRNAs believed that their preceptors and clinical faculty did not acknowledge students well-being. Women reported higher frequencies of microaggressions than men in 33 of the 34 videos. (P<0.001 to 0.042) MICROAGGRESSION IN THE OPERATING ROOM (Sandoval et al., 2020) (Sarah et al., 2022) (Sudol et al., 2021) Randomized Crosssectional study, Level II Medical and dental students Randomized Crosssectional study, Level II Physicians at a academic health care institution Randomized Crosssectional study, Level II Surgeons and Anesthesiologists N=163 N=297 N=588 Independent: Microaggression, female genders, Male gender, Medical students, Dental students Independent: Gender, Race, microaggression, Job satisfaction, burnout, behavioral modification Independent: Surgeons, Anesthesiologists, microaggression, Physician burnout 36 2 hour workshop to prepare preclinical medical and dental students to recognize and respond to microaggressions in clinical practice. They were provided with a pre and post workshop survey Mixed-methods survey, twosample t-test 77% of the students witnessed or experienced microaggression. And 69% reported a very good or excellent familiarity with the concept of microaggressions. Sexist Microaggression Experience and Stress Scale and Racial Microaggression Scale A total of 245 of 259 female respondents (94%) experienced sexist microaggressions, most commonly overhearing or seeing degrading female terms or images. Racial/ethnic microaggressions were experienced by 299 of 367 racial/ethnicminority physicians (81%), most commonly reporting few leaders or coworkers of the same race/ethnicity. Female physicians experienced higher frequency of gendered microaggressions compared with male physicians. Trainees experienced more microaggressions (p = 0.009) and burnout (p = 0.009) than faculty. MICROAGGRESSION IN THE OPERATING ROOM Appendix B Iowa Model Collaborative. (2017). Iowa model of evidence-based practice: Revisions and validation. Worldviews on Evidence-Based Nursing, 14(3), 175-182. doi:10.1111/wvn.12223 37 MICROAGGRESSION IN THE OPERATING ROOM 38 Appendix C GANTT Chart for Project Proposal Start Date: 8/29/2022 End Date: 04/29/2024 Position Start Date End Date Milestone/ Activity 1 8/29/2022 8/30/2022 Start 2 8/30/2022 9/15/2022 Project Development 3 9/15/2022 10/01/2022 Team Development 4 10/01/2022 10/29/2022 Introduction/Background 5 10/01/2022 10/29/2022 Problem Statement 6 10/01/2022 10/29/2022 7 10/30/2022 11/21/2022 Needs Assessment/ Gap Analysis Theoretical Framework 8 10/30/2022 11/21/2022 Aims and Objective 9 10/30/2022 11/21/2022 GANTT Chart 10 10/30/2022 11/21/2022 SWOT Analysis 11 11/21/2022 12/05/2022 Literature Review 12 11/21/2022 12/05/2022 Project Design/ Methods 13 11/21/2022 12/05/2022 Evaluation Plan 14 12/12/2022 1/11/2023 Revise Project proposal 15 1/11/2023 1/23/2023 IRB submission 16 1/8/2024 2/8/2024 Data Collection 17 2/12/2024 3/2/2024 Data Analysis 18 4/20/2024 4/29/2024 Poster Presentation 19 4/20/2024 04/29/2024 Final Project Report MICROAGGRESSION IN THE OPERATING ROOM 39 Appendix D Coping with Microaggression in the Operating Room: Education for Student Registered Nurse Anesthetists SWOT Analysis Strengths Weaknesses Opportunities Threats Technology being utilized to distribute emails, PowerPoint presentation, and to contact participants Close to 100 participants Easy access to contact students Using only one site to collect data Bring awareness Technology issues Students lack interest to participate Students not completing the surveys in a timely manner Education on microaggression Goal is to make students more comfortable in their working environment Students becoming leaders in the future Lack of support from students Technology issues MICROAGGRESSION IN THE OPERATING ROOM 40 Appendix E 1. Enter the last 4 digits of your Student ID 2. What gender do you identify as? o Male o Female o Non-binary o Prefer not to say 3. What is your racial or ethnic identification? (Mark all that apply) o o o o o o White Black or African American American Indian or Alaska Native Asian Native Hawaiian or Pacific Islander Other 4. What year was the term Microaggressions first used? o o o o 1970 1989 1880 1945 5. What are the different types and forms of microaggression? o o o o Microinsults, microinvalidation, microassaults Microinvalidation, bias, unintentional Stereotypes, microinsults, bias Discrimination, abusive language, microassaults 6. Which psychiatrist first used the term microaggression? o o o o Dr. Derald Wing Sue, PhD Dr. Chester Peirce Dr. James MacDonald Dr. George W. Cook 7. What is your understanding of the term microaggression? o everyday subtle put-downs directed towards a marginalized group which may be verbal or non-verbal and are typically automatic o conscious bias towards a person's heritage or identity MICROAGGRESSION IN THE OPERATING ROOM 41 o unconscious messages, nonverbal, and environmental communications towards an individual that conveys rudeness and insensitivity towards marginalized groups o behaviors and statements that are meant to exclude, negate, and dismiss one's personal feelings, thoughts, and experiences 8. Microaggression can lead to__. o o o o Depression Substance use disorders Post-traumatic stress disorder All of the above 9. Females are more likely to experience microaggression than men. o True o False 10. Of the 50,000 CRNAs, what percent are considered minorities? o o o o 30% 24% 10% 12% 11. Medical provider burnout is considered a global crisis, with prevalence as high as 80%. o True o False 12. Which population has a higher rate of being affected by microaggression? o o o o Underrepresented minorities Instructors Surgical technologist Hospital director 13. How should you respond to Microaggressions as a witness? o o o o Ignore it Speak up Report it to HR Both B &C 14. What are the three aspects of The Microaggressions Triangle Model? MICROAGGRESSION IN THE OPERATING ROOM o o o o Recipient, Bystander, Participant Recipient, Source, Bystander Institution, Participant, Recipient Recipient, Bystander, Institution 15. How can students contact the Health Center at Marian University? (Select two) o o o o 317-955-6154 317-955-6152 healthservices@marian.edu Marianhealthservices@marian.edu 16. How can individuals educate themselves about microaggressions? o o o o Read books and articles Attend workshops Engage in open conversations All of the above 17. How confident are you in identifying microaggression? o o o o o Not well at all Slightly well Moderately well Very well Extremely well 42 MICROAGGRESSION IN THE OPERATING ROOM 43 Student Satisfaction and Self-Confidence in Learning Instructions: This questionnaire is a series of statements about your personal attitudes about the instruction you receive during your simulation activity. Each item represents a statement about your attitude toward your satisfaction with learning and self-confidence in obtaining the instruction you need. There are no right or wrong answers. You will probably agree with some of the statements and disagree with others. Please indicate your own personal feelings about each statement below by marking the numbers that best describe your attitude or beliefs. Please be truthful and describe your attitude as it really is, not what you would like for it to be. This is anonymous with the results being compiled as a group, not individually. Mark: 1 = STRONGLY DISAGREE with the statement 2 = DISAGREE with the statement 3 = UNDECIDED - you neither agree or disagree with the statement 4 = AGREE with the statement 5 = STRONGLY AGREE with the statement Satisfaction with Current Learning SD D UN A SA 1. The teaching methods used in this simulation were helpful and effective. 1 2 3 4 5 2. The simulation provided me with a variety of learning materials and activities to promote my learning the medical surgical curriculum. 1 2 3 4 5 3. I enjoyed how my instructor taught the simulation. 1 2 3 4 5 4. The teaching materials used in this simulation were motivating and helped me to learn. 1 2 3 4 5 5. The way my instructor(s) taught the simulation was suitable to the way I learn. 1 2 3 4 5 UN A SA Self-confidence in Learning SD D 6. I am confident that I am mastering the content of the simulation activity that my instructors presented to me. 1 2 3 4 5 7. I am confident that this simulation covered critical content necessary for the mastery of medical surgical curriculum. 1 2 3 4 5 8. I am confident that I am developing the skills and obtaining the required knowledge from this simulation to perform necessary tasks in a clinical setting 1 2 3 4 5 9. My instructors used helpful resources to teach the simulation. 1 2 3 4 5 10. It is my responsibility as the student to learn what I need to know from this simulation activity. 1 2 3 4 5 11. I know how to get help when I do not understand the concepts covered in the simulation. 1 2 3 4 5 12. I know how to use simulation activities to learn critical aspects of these skills. 1 2 3 4 5 13. It is the instructor's responsibility to tell me what I need to learn of the simulation activity content during class time.. 1 2 3 4 5 Copyright, National League for Nursing, 2005 Revised December 22, 2004 MICROAGGRESSION IN THE OPERATING ROOM Appendix F 44 MICROAGGRESSION IN THE OPERATING ROOM 45 Appendix G Survey Items SD D UN A Satisfaction with current learning Teaching methods helpful and effective 0 (0%) 1 (6.6%) 0 (0%) 8 (53%) 6 (40%) 15 Variety learning materials and activites promote learning 0 (0%) 1 (6.6%) 0 (0%) 8 (53%) 6 (40%) 15 Enjoyed how instructor taught simulation 0 (0%) 2 (13.3%) 0 (0%) 7 (46%) 6 (40%) 15 Teaching materials motivating and helped learning 0 (0%) 1 (6.6%) 0 (0%) 8 (53%) 6 (40%) 15 Way taught suitable way to learn 0 (0%) 2 (13.3%) 0 (0%) 7 (46%) 6 (40%) 15 Self-confidence in learning Confident mastering content 0 (0%) 0 (0%) 1 (6.6%) 8 (53%) 6 (40%) 15 confident simulation covered critical content 0 (0%) 2 (13.3%) 0 (0%) 7 (46%) 6 (40%) 15 confident developing skills, knowledge to perform clinical tasks 0 (0%) 0 (0%) 9 (60%) 6 (40%) 15 Intructor used helpful resources 0 (0%) 2 (1.33%) 1 (6.6%) 6 (40%) 6 (40%) 15 It is my responsibility to learn what I need to know from simulation 0 (0%) 0 (0%) 0 (0%) 8 (53%) 7 (46%) 15 I know how to get help when I do not understand concepts 0 (0%) 0 (0%) 0 (0%) 9 (60%) 6 (40%) 15 I know how to use simulation to learn critical aspects of skills 0 (0%) 1 (6.6%) 0 (0%) 9 (60%) 5 (33%) 15 Intructors responsibility to tell me what I need to learn of simulation content 0 (0%) 4 (26%) 4 (26%) 3 (20%) 4 (26%) 15 0 (0%) SA Total (SD=Strongly Disagree; D=Disagree, UN=Undecided, A=Agree, SA= Strongly Agree)  ...

... Use of the MyPossible Self App in Care and Management of Depression Jenna Minnix, Kate Lynch, Chloe Niesen, Caroline Roop Introduction App Analysis Conclusion Modern technology has allowed for countless improvements in access to mental health resources. One way in which this has been improved is through the use of smart phone applications that allow for tracking of symptoms, management techniques, education, and improved availability of resource. MyPossible Self is an app which allows all of these functions and supports multiple different aspects of mental health, not only depression. MyPossible Self offers a holistic approach to mental health by offering a variety of tasks, materials, and experiences tailored to each user's input, struggles, and goals. - Use of Cognitive Behavioral Therapy to help make problems feel more manageable by breaking them down into 5 categories: situations, thoughts, emotions, physical feelings and actions. - Mood tracking: daily check in to see how your mood fluctuates over time, at different times of day, and with different stressors. - Journaling: Offers space for mood, sleep, diet, activity, grief, anxiety, and thought journaling. - Relaxation Exercises: Guided breathing, meditation, yoga, sleep meditation, sounds, and stories. - Nutrition: Articles, recipes, exercise, podcasts all on mental health and nutrition. - Lifestyle: Podcasts, articles, and sessions focused on lifestyle changes and improvements. - Self-Love: Motivation through articles, podcasts, and affirmations. (My Possible Self, 2021). My Possible Self is completely free to use, there are no premium resources, all are included making it accessible to more populations. All these resources allow for a multifaceted approach to mental health. Implementing consistency through tracking, allowing for in the moment intervention in times of need, and allowing for reflection on patterns and tendencies. In the case of depression, all of these things are necessary to help individuals to access their minds and allow for growth and symptom improvement. For patients, this app may provide a sense of control over their mental health. My Possible Self was created by Joanne Wilkinson with collaboration from Priority Healthcare a leader in Mental Health Services. My Possible Self is a great tool for nurses to refer to clients who are diagnosed with mental illness or raise concern about their mental health. Its cohesive approach allows for easy access to a variety of resources and offers immediate help in the event of a mental health emergency. This app also encourages consistency and application of care behaviors into patients' daily routines. As a user My Possible Self is incredibly easy to use and navigate, completely free of charge, and attractive to the eye encouraging use and engagement. Many aspects of this app encourage personalization with the ability to target different behaviors, thoughts, and patterns making it ideal as a mental health resource. Diagnostic Criteria What is depression? Depression is classified as a mood disorder under the DSM-5 criteria. DSM-5 outline that depression includes 5 or more of the following symptoms: depressed mood, loss of interest or pleasure, significant unintentional weight loss, sleep disturbance, psychomotor changes, fatigue, sense of worthlessness, impaired thinking or concentration, or recurrent thoughts of death. These symptoms occur most of the time for at least 2 weeks (Substance Abuse and Mental Health Services Administration). Epidemiology Depression has an estimated worldwide effect on 5% of the world population. It is seen that women have a greater prevalence than men, however we also know that men are less likely to receive a diagnosis. Depression is known to increase levels of suicide, the 4th leading cause of death for 1529-year-olds. Due to lack of resources, social and economic barriers, over 75% of people in low-income countries do not seek or receive treatment (WHO, 2023). MARS Scale Section Engagement Functionality Aesthetics Information App Quality Mean Mean Score 4.2 5 5 3.9 4.5 (Young and Well Cooperative Research Center) References Amy Morin, L. (2022, April 19). How many people are actually affected by depression every year?. Verywell Mind. https://www.verywellmind.com/depression-statisticseveryone-should-know-4159056 Substance Abuse and Mental Health Services Administration. (n.d.-b). Table 9, DSM-IV to DSM-5 major depressive episode/disorder comparison - DSM-5 changes - NCBI bookshelf. DSM-5 Changes: Implications for Child Serious Emotional Disturbance [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK519712/table/ch3.t5/ The Mental Health App; self-help learning, Mood Tracking and insights. My Possible Self. (2021, March 11). https://www.mypossibleself.com/how-it-works/ World Health Organization. (n.d.). Depressive disorder (depression). World Health Organization. https://www.who.int/news-room/fact-sheets/detail/depression Young and Well Cooperative Research Center. (n.d.). MARS App Classification Scale.  ...

... Running head: PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION Marian University Leighton School of Nursing Doctor of Nursing Practice Pediatric Airway Educational Intervention and Simulation Landon Lauber and Wesley Soutar Marian University Leighton School of Nursing Chair: Dr. Marie Goez, DNP, CRNA __________________________ (Signature) Committee Member: Dr. Christina Pepin, Ph.D., RN, CNE __________________________ (Signature) Date of Submission: February 2, 2023 1 PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 2 Pediatric Airway Educational Intervention and Simulation Table of Contents Abstract....4 Introduction..6 Background..6 Problem Statement...7 Organizational Gap Analysis....8 Review of Literature9 Search Methodology9 Results......9 Theoretical/Conceptual Framework...15 Project Aims/Objectives....16 Project Design....18 Project Site and Population....18 Measurement Instruments......19 Data Collection Procedure.....20 Ethical Considerations...20 Data Analysis.21 PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 3 Results....22 Demographics22 Knowledge Test.22 Self -Confidence Test23 Discussion..26 Strength and Limitations26 Recommendations..27 Implications for Practice and Future Research..27 Conclusion.28 References..30 Appendix A36 Appendix B....37 Appendix C....43 Appendix D....44 Appendix E....45 Appendix F.46 PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 4 Abstract Background: The most common causes of morbidity during general anesthesia in pediatrics are airway and respiratory complications that commonly occur in both healthy children and infants. The high stress environment of pediatric anesthesia makes pediatric airway education paramount for the best opportunity of wanted outcomes. Marian University first-year SRNAs enter the clinical field without yet receiving hands on pediatric training. By providing an educational workshop and hands-on simulation training opportunity, SRNAs will have increased knowledge and confidence upon entrance into the clinical field. Purpose: This DNP project is an educational intervention aimed at improving the knowledge and confidence level of first-year SNRA students to successfully secure a pediatric airway. Methods: Quantitative data was collected with pre-education intervention test and post-education test questionnaires as well as a three-question pre-simulation self-confidence and post-simulation self-confidence survey. The data was used to assess differences in knowledge scores before and after the educational intervention and self-confidence scores before and after the hands-on simulation. Implementation Plan/Procedure: First-year Marian University SRNAs received an education module via the campus-wide Canvas learning platform. Once completed, participants were offered an opportunity to participate in a hands-on pediatric airway simulation. The education interventions were evaluated quantitatively for statistical relevance using a pretest and posttest knowledge-based assessment before and after the Canvas module via Qualtrics survey. In addition, a confidence level assessment was made available after the completion of the Canvas module and the post-simulation experience for those who chose to participate. PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 5 Implications/Conclusion: A pediatric airway educational intervention via voice-over PowerPoint presentation statistically increased participants knowledge scores (p < 0.05) from pre- to post-education. Participants had a significant increase in confidence ( p < 0.05) in each of three NLN adapted confidence questions demonstrated in a pre- and post-simulation survey. Keywords: Phrases, keywords, and mesh terms airway, management, anesth$, and pediatric. PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 6 Pediatric Airway Educational Intervention and Simulation Many of the negative outcomes during airway management are preventable, yet one of the most common causes for mortality in children during the perioperative period is due to respiratory complications (Krishna et al., 2018). The anatomy of a childs airway is unique due to their large tongue and head, small mouth, narrow airway, and low functional residual capacity (Amaha et al., 2021). In addition, their propensity to consume oxygen at a higher rate leads them prone to oxygen desaturation at a more rapid rate (Karsli, 2015). Pediatric anesthesia can prove to be a high stress environment for even the seasoned provider, let alone the student registered nurse anesthetist (SRNA) making pediatric airway education paramount for the best opportunity of wanted outcomes. Background The most common causes of morbidity during general anesthesia in pediatrics are airway and respiratory complications that commonly occur in both healthy children and infants (Adewale, 2009). Having a solid foundation in pediatric airway knowledge and management is key to preventing untoward outcomes. With increasing recognition of breathing disorders in the pediatric population, there is an increase in the procedures being performed (McNiece & Dierdorf, 2004). The pediatric population has unique anatomy of the airway, which is everchanging in size, shape, and position throughout their development (Adewale, 2009). Additional knowledge must be possessed by providers in the management of the airway that starts with a comprehensive assessment and a detailed medical history (Adewale, 2009). These children are not merely small adults yet offer a variety of management differences ranging from positioning, physiological, as well as the previously mentioned anatomical differences (Harless PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 7 et al., 2014). Even with all the pre-mentioned differences, there are still more things to take into consideration such as the increased prevalence of childhood obesity as well as a many congenital and acquired conditions (Best, 2012). In addition to the differences in anatomy, long periods of fasting are not always required before surgery and intravenous access may not be obtained before induction of anesthesia (LeSaint & Hemmen, 1995). The pediatric patient is at an increased propensity of adverse outcomes with airway and respiratory complications during anesthesia for even the most seasoned provider. So, what does that mean for the SRNA that is entering their first clinical rotation? The pediatric education and simulation units for Marian University SRNAs are not completed until over halfway through the fifth semester, which is two semesters after students have entered their clinical rotations. Unfortunately, some students begin performing pediatric anesthesia in clinical rotations during their junior year before these units have occurred. Having pediatric knowledge and exposure prior to the clinical rotations would better prepare the junior student for success. Although there is no evidence of an association between increased airway and respiratory complications in the pediatric population and SRNAs, additional education could prove beneficial. With a dynamic environment in patient types, equipment, recommendations, and techniques, the knowledge of the pediatric airway and how to manage it are always changing (Harless et al., 2014). In fact, the still-taught anatomical description of a "funnel-shaped" airway that is narrowest at the cricoid ring has even been found to be inaccurate through video bronchoscope images (Dalal et al., 2009). Problem Statement Managing the airway of a pediatric patient can be difficult for all providers, especially those who have little to no firsthand training in the matter. This leaves first-year SRNA students PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 8 as a particularly vulnerable population as they will soon be entering the clinical field while lacking firsthand pediatric training. By providing an educational workshop that includes not only a lesson on pediatric airway differences and pitfalls, but also a hands-on interactive training opportunity, it is believed that these students will be better prepared for the immersion into the clinical field. This will not only give experience and confidence to the SRNA, but more importantly ensure better care and safety for the patients. This leads to the PICO question: In first-year SRNAs, what is the effect of having a pediatric airway education and simulation workshop on the competence level of the SRNA, in managing the pediatric airway compared through a pre and post workshop test? Needs Assessment and Gap Analysis There is a lack of pediatric airway exposure to the SRNA as evidenced by the current didactic curriculum. SRNAs currently begin clinical rotations during the fourth semester and are required to perform anesthesia on pediatrics patient during this time. Pediatric anesthesia is introduced during the fifth semester at week 11. To be well prepared for performing pediatric anesthesia, the SRNA should be introduced to the anatomical differences, equipment differences, and the navigation of airway problems in this patient population. This knowledge deficit sets the stage for an inept SRNA to successfully manage a pediatric airway and associated complications. Exposing first-year SRNA students to the differences in anesthesia case management along with the variations of anatomical differences between the pediatric and adult airways may better prepare the student to manage pediatric cases during the clinical setting. Through access via Canvas learning platform and the Marian University simulation lab, students will be provided PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 9 an ideal setting to acquire techniques on how to manage the pediatric airway. Combined, these two platforms will assist the SRNA with a favorable learning environment to safely practice newly acquired skills. In addition, discussion boards will help facilitate open discussions relating the management of the pediatric airway. Through education and hands-on teaching, the first-year SRNAs will gain competence in their abilities to successfully intubate a pediatric airway by familiarizing themselves with the pediatric equipment and practicing these techniques on the pediatric mannequins. Literature Review This literature review was performed to analyze articles concerning pediatric airway anatomy, management of the pediatric airway, and educational interventions to help prepare anesthesia or medical providers. Methods The review search was conducted using the following phrases, keywords, and mesh terms airway, management, anesth$, and pediatric. The review used the PubMed database and was conducted in October and November 2022. The references of pertinent reviews and retrieved articles were checked for further studies, with none being identified. The 168 database results were reduced to 40 after the initial screening to exclude adult patients, product comparison studies, questionnaires, opinion articles, and retrievable articles. The inclusion criteria included studies published within the last seven years, pediatric population, anesthesia, and English language. This reduced the number to 19 research articles as shown in a PRIMSA flow chart (Appendix A) to be used in this literature review. Results PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 10 An initial literature search using PubMed database resulted in 168 original articles that were further screened and reduced to 19. The determination and factors resulting in the final 19 articles can be seen in the PRISMA flow chart in Appendix A. The literature review matrix in Appendix B provides more specific information related to each study. Anatomy Five of the 19 research articles utilized were based on pediatric airway anatomy (Holzki et al., 2018; Jain et al., 2020; Liu et al., 2020; Luscan et al., 2020; Kim et al., 2015). Three of the four references focus on the narrowest part of the pediatric airway and the cricoid cartilage shape, with all agreeing that the narrowest portion is the cricoid cartilage, but offered different outcomes on shape (Holzki et al., 2018; Liu et al., 2020; Luscan et al., 2020). Two of the research articles found that the cricoid cartilage is a funnel shape in pediatric patients (Holzki et al., 2018; Liu et al., 2020). A systematic review of published literature, University Libraries, and authoritative textbooks with key search words and phrases utilized 672 pediatric cadavers aged preterm to 17-years-old, and in vivo studies of 553 patients aged one-month-old to 13years-old found that there was a majority consensus that the cricoid cartilage was funnel-shaped (Holzki et al., 2018). A retrospective study of 1346 pediatric patients aged one-year-old to 20years-old utilized a radiology database and NEUPACS software to determine the cricoid cartilage shape (Liu et al., 2020). This study found a significant difference in the anteroposterior diameter of the inlet of the cricoid cartilage compared to the anteroposterior diameter of the outlet showing that it is funnel-shaped (Liu et al., 2020). When an LMA is anatomically placed properly into the esophageal inlet, it causes an equal degree of ventral displacement among the arytenoid cartilages (Kim et al., 2015). This placement helps facilitate an adequate seal and proper ventilation (Kim et al., 2015). When an LMA is not properly positioned or rotates it can PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 11 result in asymmetric elevation of the arytenoid cartilage relative to the LMA and may affect the quality of ventilation (Kim et al., 2015). Unfortunately, when this scenario occurs, the provider should reposition the LMA device (Kim et al., 2015). Kim and colleagues performed an observational study of 100 pediatric patients and evaluated the degree of LMA malposition, rotation, and arytenoid cartilage asymmetry using ultrasound (US) and fiberoptic bronchoscope (FOB) equipment. There was a 50% incidence of asymmetric arytenoid cartilage elevation (95% confidence interval [CI], 40%-60%), LMA malposition was 78% (95% CI, 69%-86%), and LMA rotation was 43% (95% CI, 33%-53%) (Kim et al., 2015). In addition, this study found that there was no change in the shape throughout the development of the participants' lifespan (Liu et al., 2020). In a separate retrospective study utilizing a CT database collection and GE Revolution HD scanner, there was a significant correlation between the airway measurements and patient age with the researchers identifying that the cricoid cartilage is round-shaped independent of the studied age (Luscan et al., 2020). The final anatomy-based study utilized in this literature review was a prospective observational study that found a positive correlation in the 60 participants aged two-years-old through eight-years-old between the incisor-manubriosternal joint length and the incisor to carina length offering valuable information for ETT depth placement (Jain et al., 2020). Difficult Airway Four of the 19 articles were focused on pediatric patients with a difficult airway with three focusing on recognizing a potentially difficult airway and the other discussing successful endotracheal intubation despite a difficult airway (Amaha et al., 2021; Burjek et al., 2017; Disma et al., 2021; Park et., 2019). Pediatric patients have several disadvantages that put the anesthesia provider and patient in a challenging position with one being prone to hypoxemia due to their PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 12 high oxygen consumption, low functional residual capacity, and small closing capacity (Disma et al., 2021). Additional disadvantages include an increased risk of airway collapse after induction of anesthesia as well as the addition of a difficult airway (Disma et al., 2021). The anesthesia provider and the patient are placed in an undesirable position in either of these situations. When compounding these disadvantages with the addition of an unanticipated difficult airway, a provider is put in a very problematic situation. Entering a pediatric unanticipated difficult airway as a junior student with limited firsthand training produces an even more challenging and stressful scene. A prospective observational study of 4,683 planned tracheal intubations in neonates and infants up to 60-weeks post-conceptual age found that 5.8% of patients required three or more attempts for tracheal intubation (Disma et al., 2021). This study also found that there were predictive factors that correlated to this high number of attempts. It found that close to half of these patients had congenital abnormalities and 40% had an ASA class of 3 or greater (Disma et al., 2021). In addition, it found that 13% of the difficult intubations were also difficult to ventilate via face mask before the attempt (Disma et al., 2021). A retrospective comparative study utilized 1295 patients under the age of 18-years-old who were deemed as difficult intubation defined by one of four criteria; grade three or higher Cormack and Lehane Classification, anatomical limitations making direct laryngoscopy impossible, previous failed direct laryngoscopy attempt within six months, and when attending anesthetist deemed direct laryngoscopy as a poor chance of success (Park et al., 2019). The study found a significantly higher initial success rate of intubation with video laryngoscopy compared to direct laryngoscopy (Park et al., 2019). Both studies found that infants that were less than 10 kilograms in weight or less than 60-weeks post-conceptual age had an increased risk of difficult PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 13 and failed intubations no matter what type of laryngoscope was used (Disma et al., 2021; Park et al., 2019). A multi-centered cross-sectional study of 290 patients ranging from newborn through five-years-old labeled as ASA class I and II were utilized to determine prevalence and associated factors of a difficult airway (Amaha et al., 2021). An airway was deemed difficult if the anesthetist encountered difficulty with mask ventilation, laryngoscopy, or tracheal intubation (Amaha et al., 2021). The study concluded that 19.7% of patients undergoing surgery were a difficult airway with a significant correlation of the following predictive factors; less than twoyears-old, underweight, anticipated difficult airway, history of a difficult airway, and anesthetists with less than four years of pediatric experience (Amaha et al., 2021). The last study was a retrospective study of 1,603 pediatric patients with difficult airways which found that using supraglottic airway devices to facilitate a fiberoptic intubation had higher first-pass success rates and fewer complications in children less than one-year-old compared to intubating using video laryngoscopy, but no differences in pediatric patients greater than one-year-old (Burjek et al., 2017). Equipment Four of the 19 reviewed articles focus on equipment for intubating pediatric patients (Garcia-Marcinkiewicz et al., 2020; Kaji et al., 2020; Lingappan et al., 2018; Park et al., 2019). A systematic review of three randomized control trials compared video laryngoscopy with direct laryngoscopy for endotracheal intubation in newborns by trainees and found that video laryngoscopy increases the success of intubation in the first attempt (Lingappan et al., 2018). In addition, this study found that video laryngoscopy does not decrease the time to intubation nor the number of attempts for intubation (Lingappan et al., 2018). A randomized PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 14 control trial of 564 infants found significance in the use of video laryngoscopy utilized for endotracheal intubation with fewer esophageal intubations compared to direct laryngoscopy (Garcia-Marcinkiewicz et al., 2020). Another retrospective study of 625 patients comparing direct laryngoscopy and video laryngoscopy found a higher first-time success utilizing video laryngoscopy (Kaji et al., 2020). A third retrospective study of 1,295 pediatric patients came to the same conclusion finding success rates for video laryngoscopy were significantly higher than direct laryngoscopy, while showing no differences in complication rates per attempt compared to direct laryngoscopy (Park et al., 2019). Teaching and Technique Six of the 19 studies focused on techniques to utilize during pediatric anesthesia to promote wanted outcomes while one of the 19 studies focused on education before clinical immersion (Aghdashi et al., 2017; Glvez et al., 2019; Koo et al., 2018; Lee, et al., 2017; Powell et al., 2022; Soneru et al., 2019; Vukovic et al., 2019). A systematic review and meta-analyses of 17 randomized trials of 1881 pediatric patients found significance in the reduction of airway complications and desaturation by utilizing deep extubation over awake extubation (Koo et al., 2018). This study, however, did not find a significant difference in the incidence of laryngospasm and breath-holding between the two groups (deep vs. awake extubation), but did find an increased incidence of airway obstruction in the deep extubation group (Koo et al., 2018). Two of the studies were prospective observational studies regarding the use of apneic nasal oxygenation in preventing hypoxemia (Soneru et al., 2019; Vukovic et al., 2019). Both studies found significance in the reduction of hypoxemia via the apneic nasal oxygenation route when compared to not utilizing apneic nasal oxygenation (Soneru et al., 2019; Vukovic et al., 2019). PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 15 A retrospective cross-sectional study of 4,683 planned pediatric tracheal intubations found that although multiple attempts of laryngoscopy are associated with an increased risk of hypoxemia, 35% of all intubations resulted in hypoxemia and 8.9% in bradycardia, verifying the need for a good technique for securing the airway in a quick manner (Glvez et al., 2019). One randomized control trial of 116 ASA class I and II patients aged two-months-old to eight-yearsold undergoing lower abdominal surgery compared insertion techniques of LMAs (classic versus rotary method) finding no significant difference in success rates between them (Aghdashi et al., 2017). A prospective observational study of 154 pediatric patients aged 15 utilized a manometer and fiberoptic bronchoscope to determine a calculation utilizing height and weight (insertion depth of FLMA (cm) = 7.0 + 0.04height (cm) + 0.05 weight (kg)) to best predict insertion depth of a flexible laryngeal mask airway (Lee, et al., 2017). Finally, a cross-sectional study of 20 second and third-year student registered nurse anesthetists focused on high-fidelity pediatric simulation of managing common pediatric complications compared to confidence levels (Powell et al., 2022). Using a Likert scale with ordinal variables, the study showed a significant correlation in the improvement of confidence scores from pre-simulation to post-simulation and post-simulation to pediatric rotation (Powell et al., 2022). Theoretical or Conceptual Framework This projects theoretical framework is the Jeffries Simulation Model. In 2005 Jeffries published A Framework for Designing, Implementing, and Evaluating Simulations Used as Teaching Strategies in Nursing. This framework was selected for guidance in the design, evaluation, and implementation of a simulation-based education project that would promote positive impacts on learning outcomes for student participants. The Jeffries Simulation Model further depicts the importance of combining clinical expertise with a guided simulation to PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 16 increase learning outcomes for participants (Jeffries et al., 2015). Jeffries lists five components that constitute the framework and consist of: educators, students, educational practices, simulation design characteristics, and outcomes (Jeffries, 2005). Please see Appendix C for a visual representation of Jeffries simulation model. The foundation of this DNP project is focused on improving the readiness and competence of SRNAs in their ability to manage the pediatric airway through active participation in an additional educational simulation. Project Aims and Objectives This DNP projects objective is to provide first-year SRNAs with high-quality, highfidelity simulation-based training that enhances their knowledge and competence in navigating the anatomical nuances associated with the pediatric airway. This projects specific aims are to increase first-year SRNAs' knowledge of the anatomical variations associated with the pediatric airway and increase their competence in managing an unpredicted difficult pediatric airway. The goals of the project are to demonstrate that students who chose to participate in the pediatric airway simulation will exhibit higher posttest knowledge-based scores and possess higher levels of confidence in their abilities to successfully secure a pediatric airway compared to those who follow traditional didactic instruction. SWOT Analysis To evaluate the projects strengths, weaknesses, opportunities, and threats, the SWOT Analysis framework was utilized. Please see APPENDIX D to view the table. Strengths One great strength of this project is the access to the state-of-the-art simulation lab located on the Marian University campus. Additionally, the technological access granted via PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 17 Marian University regarding building a Canvas page for educational instruction and Qualtrics for compilation and quantification of digital data are strengths of this project. Finally, the cohort of 2025 is another strength as they are stakeholders in this project as it will benefit them in preparation for clinical situations. Weaknesses Although there is access to a state-of-the-art simulation lab at the disposal of this project, not having the ability for hands-on education on live patients is a weakness of this project as there is a gap between the simulation of a manikin and a live patient. In addition, having a small sample size and utilizing a single cohort is a weakness of this project. Lastly, a lack getting the motivation for participants to partake in the project is a weakness. Opportunities The advancement of simulation technology and simulation materials offers an opportunity to improve this project. There is currently one pediatric manikin for educational purposes. Having multiple manikins or greater lifelike capabilities would provide the opportunity for more applicable education and the ability to meet the needs of multiple participants at once. In addition, having an enticement for buy-in from participants, such as bonus points, to get better participation would be an opportunity to better this project. Additional clinical time for project owners with pediatric airway management is another opportunity for the improvement of this project. Threats One threat for this project includes inexperience by project designers in utilizing the Canvas education-based technology in distributing the educational material. Another threat is the lack of substantial clinical experience regarding the pediatric airway. Furthermore, the PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 18 spring semester has proven to be a difficult semester for first-year Marian University SRNAs, which has the potential of leading to less participation. Another threat would be the inaccessibility to the simulation lab as it is being utilized for multiple DNP projects as well as normal class times. Finally, COVID-19 pandemic shutdowns as well as attrition from the cohort of 2025 serve as threats to this project. Project Design and Methods Project Design This DNP project is an educational intervention aimed at improving the knowledge and confidence level of first-year SNRA students to successfully secure a pediatric airway. Firstyear SRNAs received education on the pediatric airway along with common techniques to increase their success at managing a pediatric airway and common complications. All participants received an education module via the campus-wide Canvas learning platform. Once completed, participants were offered an opportunity to participate in a hands-on pediatric airway simulation following the best practice guidelines set by the International Nursing Association for Clinical Simulation and Learning (INACSL). The education interventions were evaluated quantitatively for statistical relevance using a pretest and posttest knowledge-based assessment before and after the Canvas module. In addition, a confidence level assessment was offered that was made available after the completion of the Canvas module and the post-simulation experience for those who chose to participate. Population and Setting The project site was located on the main campus at Marian University of Indianapolis. The Marian University Certified Registered Nurse Anesthetist Program PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 19 Simulation Lab located on campus was utilized to measure the proposed intervention. There are two simulation labs, two pediatric airway mannequins, and adult mannequins for students to practice skills. Simulation debriefing and posttest survey distribution were done using a small office adjacent to the simulation lab. The Marian University Certified Registered Nurse Anesthetist Program is a Bachelor of Science in Nursing to DNP in Nurse Anesthesia tract. Following completion of the program, students will be given the ability to obtain their Certified Registered Nurse Anesthetist license by taking the national board exam. The program has one cohort matriculate per year. The cohort that will be studied consists of 36 SRNAs. We recruited participants by utilizing the cohort email list that is provided by the Leighton School of Nursing CRNA Program to all CRNA students. Each student was given the option following completion of the education intervention to participate in an elective pediatric airway simulation to elaborate upon his or her newly acquired knowledge and skills. The students who did participate in the simulation were given an additional posttest to see if they reported higher levels of confidence and recall of knowledge compared to their peers who only received the educational intervention. Participants were required to be SRNAs from the graduating class of 2025 who are enrolled in the Anesthesia Principles Simulation I Course. Measurement Instruments This DNP project measured the SRNAs knowledge and confidence through administering pretest and posttest questionnaires utilizing Qualtrics software. A personal identifier consisting of the last four numbers of the student ID was used to determine trends based on each participant. The posttest assessment was formulated to determine if there were PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 20 any measurable changes in students baseline scoring. The pretest and posttest consisted of 15 educational-based questions assessing for retention of key topics addressed in the Canvas educational module and three questions to measure confidence level post-Canvas module and post-simulation. Students were provided with a voice-over PowerPoint presentation focusing on key topics related to the pediatric airway, management strategies, and techniques to care for the pediatric population. Following completion of the educational intervention, students were offered an additional opportunity to participate in a pediatric airway simulation to solidify their knowledge and skills. There was an infant pediatric airway mannequin, two adult mannequins, and an anesthesia machine utilized for students to practice skills. The students that attended the simulation were asked to complete a post-simulation confidence questionnaire to evaluate for any changes to their baseline results in comparison to non-simulation participants. Data Collection Procedures Data collection of information was obtained electronically using Qualtrics software surveys, which was provided via the Canvas module to every participating student. The Canvas module was shared with all CRNA students in the 2025 cohort upon committee chair approval. The pretest and posttest surveys were made available via the module. Email reminders were sent out to the cohort to aid in participation on a weekly basis following granted access to the module via Canvas. Optional pediatric airway simulation training dates were included in the Canvas module and started one week after the module opened with multiple days and times to choose from. Prior to simulation, a QR code was available for students who did not take the posteducational intervention self-confidence survey via Qualtrics. Upon completion of the simulation, participants were given a QR code that took them to the post-simulation selfconfidence survey via Qualtrics. An email reminder was sent two days after completion of the PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 21 final simulation to turn in all survey results and survey collection was concluded six days after the final simulations. Ethical Considerations Marian Universitys IRB approval for this project was sought before commencement and researchers were awarded exempt status due to the nature of the project. Participants survey responses were kept anonymous to the data collectors. Due to the nature of the teaching, the DNP project team did know the identities of those who participated in the volunteer simulation. The simulation participant identities were kept confidential and their optional responses to the following confidence scale questions were anonymously collected via Qualtrics survey after the simulation. The data collected via password protected Qualtrics was transferred and stored on a personal computer that was password protected and only accessible by the DNP project team. Additionally, only utilizing a personal identifier based on the last four numbers of the participants student ID concealed the confidentiality of the participants identity. Raw data will be deleted 24 months after collection. Data Analysis The data was analyzed using Microsoft Excel software. The statistical analysis utilized a Wilcoxon Signed Rank Test to compare the 15 knowledge question results from the pre-canvas education test and post-canvas education test. The National League for Nursing's (NLN) Student Satisfaction and Self-Confidence in Learning (SSSL) is a tool that utilizes five questions to determine student satisfaction and eight to measure self-confidence, which has been reliability tested through Cronbach alpha measuring satisfaction of 0.94 and self-confidence of 0.87 (NLN, 2022). The questions use response use a 5-point Likert scale which range from 5 to 1, with 5 = PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 22 strongly agree, and 1 = strongly disagree. Questions in each section were totaled and averaged to determine the overall average with higher results correlating with higher satisfaction and selfconfidence. This project was granted permission to utilize this tool from the NLN website permissions and used a modified SSSL tool to determine self-confidence using the results of a post-canvas versus post-simulation questionnaire with a Wilcoxon Signed Rank Test. The NLN tool has been modified to fit the project needs. View the original SSSL in Appendix E and the modified version in Appendix F. Results Demographics Due to the nature of the project and small sample size, demographics outside of participants being part of the 2025 Marian University SRNA cohort were not obtained to ensure anonymity of participants. Demographic information was not prevalent for the completion of this study. Knowledge Test There were 11 participants who completed the educational intervention portion of this project. This included a 15 question pre-educational intervention knowledge test, a pediatric airway educational intervention via voice-over PowerPoint, followed by a 15 question posteducational intervention knowledge test. Scores were resulted as percentage correct with all participants scores increasing on knowledge test from pre-intervention to post-intervention. The scores were found to be statistically significant through a Wilcoxon Signed Rank Test (p < 0.05). Additional descriptive statistics were obtained between the two groups. The mean percent score of the pre-educational intervention group was 55.15 percent (SD =9.03, Mdn=60%, range 40- PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 23 66.67%), and the mean of the post educational intervention group mean was 87.27 percent (SD = 8.26, Mdn=86.67, range 73.33-100%). A significant increase in the score between the two groups was observed which further supports findings provided by the Wilcoxon Signed Rank Test. Descriptive statistics between the two groups is listed in Table 2. Table 1 Pre-Educational Intervention and Post-Educational Intervention Results of 15 Knowledge Based Questions Pre-Educational Intervention Participant Knowledge Test (Percentage Correct) Participant 1 60 Participant 2 66.67 Participant 3 60 Participant 4 66.67 Participant 5 60 Participant 6 40 Participant 7 60 Participant 8 46.67 Participant 9 53.33 Participant 10 53.33 Participant 11 40 *Note. Wilcoxon Signed Rank Test (p < 0.05) Post -Educational Intervention Knowledge Test (Percentage Correct) 73.33 80 80 93.33 86.67 80 100 86.67 93.33 100 86.67 Mean Difference 13.33 13.33 20 26.67 26.67 40 40 40 40 46.67 46.67 Table 2 Pre-Educational Intervention Knowledge Test Post-Educational Intervention Knowledge Test Mean = 55.15% Mean = 87.27% SD = 9.03 SD = 8.26 Note: n=11 PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 24 Self-Confidence Test To determine the self-confidence levels of the first-year students to successfully navigate a pediatric airway, participants reported their confidence level on a 5-point scale that ranged from 1 to 5. There were ten participants who completed the post-educational self-confidence and post-simulation self-confidence assessments. This involved a three-question self-confidence survey taken both before and then after the simulation portion of the project. The first question quantifies the participants confidence in mastering the content presented to them. The second question is aimed to gauge whether participants confidence of if the content that is critical to the pediatric airway was covered in both the education and simulation setting. The final question was to assess the confidence in the personal development of skills and knowledge in regard to utilizing them in the clinical setting. The three self-confidence questions were broken down individually and each found to have a statistically significant difference in pre- to postsimulation scores demonstrated through the Wilcoxon Signed Rank Test (p < 0.05). Individual results to each question can be found below in Tables 3 through 5. Questions utilized can be found in APPENDIX F. Question responses utilized a 5-point Likert scale which ranges from 5 to 1, with 5 = strongly agree, and 1 = strongly disagree. Although confidence level was unchanged between pre- and post-simulation for some participant responses, there was no regression in any participants results. Additional descriptive statistics for each of the confidence level questions were analyzed and revealed improvements in the participants overall confidence as the mean, standard deviation, and median results improved. Descriptive data for each question is provided in Table 6. PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 25 Table 3 Pre-Simulation and Post-Simulation Results of Self-Confidence Based Question on 5 Point Scale (Question 1 of 3) Participant Participant 1 Participant 2 Participant 3 Participant 4 Participant 5 Participant 6 Participant 7 Participant 8 Participant 9 Participant 10 Pre-Simulation Confidence Question 1 4 4 4 3 3 4 2 2 2 3 Post-Simulation Confidence Question 1 4 4 5 4 4 5 4 4 4 5 Mean Difference 0 0 1 1 1 1 2 2 2 2 Table 4 Pre-Simulation and Post-Simulation Results of Self-Confidence Based Question on 5 Point Scale (Question 2 of 3) Participant Participant 1 Participant 2 Participant 3 Participant 4 Participant 5 Participant 6 Participant 7 Participant 8 Participant 9 Participant 10 Pre-Simulation Confidence Question 1 5 4 4 5 5 4 3 3 4 3 Post-Simulation Confidence Question 1 5 4 4 5 5 4 4 4 5 5 Mean Difference 0 0 0 0 0 0 1 1 1 2 PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 26 Table 5 Pre-Simulation and Post-Simulation Results of Self-Confidence Based Question on 5 Point Scale (Question 3 of 3) Participant Participant 1 Participant 2 Participant 3 Participant 4 Participant 5 Participant 6 Participant 7 Participant 8 Participant 9 Participant 10 Pre-Simulation Confidence Question 1 4 4 4 3 4 4 4 3 2 3 Post-Simulation Confidence Question 1 4 4 5 4 5 5 5 5 4 5 Mean Difference Table 6 Question 1 Question 2 Question 3 Note: n=10 Pre-Simulation Post Simulation Confidence Score Confidence Score Mean = 3.1 Mean = 4.3 SD = 0.83 SD = 0.46 Median = 3 Median = 4 Mean = 4.0 Mean = 4.5 SD = 0.77 SD = 0.50 Median = 4 Median = 4.5 Mean = 3.4 Mean = 4.6 SD = 0.67 SD = 0.49 Median = 4 Median = 5 0 0 1 1 1 1 1 2 2 2 PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 27 Discussion Demonstrated through this DNP project, the effect of having a pediatric airway education and simulation on the competence level of the SRNA, in managing the pediatric airway compared through a pre- and post-intervention surveys is a statistically significant increase in knowledge and confidence. Each participants scores improved after receiving the educational portion of the study. Although confidence level was unchanged between pre- and post-simulation for some participant responses, there was no regression in any participants results. Additionally, there were improvements in the mean and standard deviation of the confidence scoring when analyzed as a group. Analyzed responses through Qualtrics software identified three questions that were commonly missed. The questions ranged in topics and asked students to correctly identify the key anatomical differences between the pediatric and the adult airway, how to calculate the appropriate depth of endotracheal tube in pediatric populations, and the intramuscular dose of Succinylcholine. The question involving the fundamental anatomical variances in the pediatric airway needs further revision, as there were multiple possible correct answers. The importance of education and hands-on training to provide tactical feedback has shown to be beneficial in aiding SRNAs by improving both confidence and competence to secure the pediatric airway. Strengths and Limitations Strengths noted in this project are the continued participant anonymity through data collection and offering multiple dates for participation during simulation portion of project. In addition, by utilizing the Canvas platform to implement the educational intervention, participants had the opportunity to complete this portion of the project at their own convenience in a setting of their choice. The project was beneficial in participants progression and clinical immersions PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 28 as this topic was not covered prior to the start of clinical. Finally, the location of simulation was convenient for participants as it was on campus in a familiar location (simulation lab). Limitations of this project include a small sample size and participant fatigue due to other DNP projects asking for participation during the same timeframe. The simulation structure of allowing four participants per group limited the amount of hands-on time per participant. Finally, the timing of the project being near final examinations may have led to a lower amount of participation. Recommendations The study would benefit from a higher number of participants. By offering additional opportunities in the simulation lab and lengthening the amount of time the educational intervention portion was open, there may be an increase in participants. Future projects would benefit from better correlation of the timing between the project implementation with participants final examinations. Implications for Practice and Future Research This project demonstrates that online education interventions work and the utilization of hands-on simulation prove to be an effective tool to increase the confidence level of participants performance of skills. Although it is difficult to ensure all simulation training and education is obtained prior to SRNAs being immersed into their clinical rotations, this project demonstrates that a condensed education and simulation can be effective in building confidence and knowledge. Future research could utilize these interventions to prepare SRNAs for clinical rotation and reconnect with participants after clinical experience to determine the overall benefit gained from the intervention. PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 29 Conclusion This project demonstrates the effectiveness of an educational intervention on the pediatric airway utilizing a voice over PowerPoint presentation on first-year SRNAs that are heading into their first clinical rotation. In addition, it demonstrates the gain of self-confidence through a high-quality, high-fidelity simulation-based training navigating the anatomical nuances associated with the pediatric airway and tools utilized. Heading into the first clinical rotation for an SRNA can be daunting on its own, but the addition of experiencing a pediatric patient without prior hands-on training or didactic education can be overwhelming. The knowledge and confidence gained through a short online education intervention and hands-on simulation can better prepare the SRNA and equip them for success. PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 30 References Adewale, L. (2009). Anatomy and assessment of the pediatric airway. Paediatric Anaesthesia, 19 Suppl 1, 1-8. https://dx.doi.org/10.1111/j.1460-9592.2009.03012.x Aghdashi, M. M., Valizade Hasanloei, M. A., Abbasivash, R., Shokouhi, S., & Salehi Gharehvaran, S. (2017). Comparison of the Success Rate of Laryngeal Mask Air Way Insertion in Classic & Rotatory Methods in Pediatric Patients Undergoing General Anesthesia. Anesthesiology and pain medicine, 7(2), e38899. https://doi.org/10.5812/aapm.38899 Amaha, E., Haddis, L., Aweke, S., & Fenta, E. (2021). The prevalence of difficult airway and its associated factors in pediatric patients who underwent surgery under general anesthesia: An observational study. 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Pediatric laryngeal dimensions: an age-based analysis. Anesthesia & Analgesia, 108, 1475-9. https://dx.doi.org/10.1213/ane.0b013e31819d1d99 Disma, N., Virag, K., Riva, T., Kaufmann, J., Engelhardt, T., Habre, W., NECTARINE Group of the European Society of Anaesthesiology Clinical Trial Network, AUSTRIA (Maria Vittinghoff), BELGIUM (Francis Veyckemans), CROATIA (Sandra Kralik), CZECH REPUBLIC (Ji urek), DENMARK (Tom Hansen), ESTONIA (Reet Kikas), FINLAND (Tuula Manner), FRANCE (Christophe Dadure, Anne Lafargue), GERMANY (Karin Becke, Claudia Hoehne), GREECE (Anna Malisiova), HUNGARY (Andrea Szkely), IRELAND (Brendan OHare), ITALY (Nicola Disma), Management Team (2021). Difficult tracheal intubation in neonates and infants. NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE): a prospective European multicentre observational study. British journal of anaesthesia, 126(6), 1173 1181. https://doi.org/10.1016/j.bja.2021.02.021 Glvez, J. 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Lancet (London, England), 396(10266), 19051913. https://doi.org/10.1016/S0140-6736(20)32532-0 Harless, J., Ramaiah, R., Bhananker, S. M. (2014). Pediatric airway management. International Journal of Critical Illness and Injury Science, 4, 65-70. https://dx.doi.org/10.4103/22295151.128015 Holzki, J., Brown, K. A., Carroll, R. G., & Cot, C. J. (2018). The anatomy of the pediatric airway: Has our knowledge changed in 120 years? A review of historic and recent investigations of the anatomy of the pediatric larynx. Paediatric anaesthesia, 28(1), 13 22. https://doi.org/10.1111/pan.13281 Jain, A., Wadhwa, B., & Saxena, K. N. (2020). Preventing inadvertent Endobronchial intubation: Upper incisor to manubriosternal joint length as a predictor of airway length in children. Paediatric anaesthesia, 30(11), 12401244. https://doi.org/10.1111/pan.14023 Jeffries P. R. (2005). A framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nursing Education Perspectives, 26(2), 96103. https://journals.lww.com/neponline/pages/articleviewer.aspx?year=2005&issue=03000&article= 00009&type=abstract Jeffries, P. R., Rodgers, B., & Adamson, K. (2015). NLN Jeffries simulation theory: Brief narrative description. Nursing Education Perspectives, 36(5), 292-293. Kaji, A. H., Shover, C., Lee, J., Yee, L., Pallin, D. J., April, M. D., Carlson, J. N., Fantegrossi, A., & Brown, C. A., 3rd (2020). Video Versus Direct and Augmented Direct Laryngoscopy in Pediatric Tracheal Intubations. Academic emergency medicine: official journal of the Society for Academic Emergency Medicine, 27(5), 394402. https://doi.org/10.1111/acem.13869 PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 33 Karsli C. (2015). Managing the challenging pediatric airway: Continuing Professional Development. Canadian journal of anaesthesia, 62(9), 10001016. https://doi.org/10.1007/s12630-015-0423-y Kim, J., Kim, J. Y., Kim, W. O., & Kil, H. K. (2015). An ultrasound evaluation of laryngeal mask airway position in pediatric patients: an observational study. Anesthesia and analgesia, 120(2), 427432. https://doi.org/10.1213/ANE.0000000000000551 Koo, C. H., Lee, S. Y., Chung, S. H., & Ryu, J. H. (2018). Deep vs. Awake Extubation and LMA Removal in Terms of Airway Complications in Pediatric Patients Undergoing Anesthesia: A Systemic Review and Meta-Analysis. Journal of clinical medicine, 7(10), 353. https://doi.org/10.3390/jcm7100353 Krishna, S., Bryant, J., & Tobias, J. (2018). Management of the Difficult Airway in the Pediatric Patient. Journal of pediatric intensive care, 7(3), 115125. https://doi.org/10.1055/s0038-1624576 Lee, J. H., Oh, H. W., Song, I. K., Kim, J. T., Kim, C. S., & Kim, H. S. (2017). Determination of insertion depth of flexible laryngeal mask airway in pediatric population-A prospective observational study. Journal of clinical anesthesia, 36, 7679. https://doi.org/10.1016/j.jclinane.2016.10.012 LeSaint, P. W., Hemmen, M. S. (1995). Pediatric anesthesia. Seminars in Perioperative Nursing, 4(2), 117-9. Retrieved from http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med3&NEWS=N&AN =7780415. PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 34 Lingappan, K., Arnold, J. L., Fernandes, C. J., & Pammi, M. (2018). Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in neonates. The Cochrane database of systematic reviews, 6(6), CD009975. https://doi.org/10.1002/14651858.CD009975.pub3 Liu, S., Qi, W., Zhang, X., & Dong, Y. (2020). The development of the cricoid cartilage and its implications for the use of endotracheal tubes in the pediatric population. Paediatric anaesthesia, 30(1), 6368. https://doi.org/10.1111/pan.13772 Luscan, R., Leboulanger, N., Fayoux, P., Kerner, G., Belhous, K., Couloigner, V., Garabedian, E. N., Simon, F., Denoyelle, F., & Thierry, B. (2020). Developmental changes of upper airway dimensions in children. Paediatric anaesthesia, 30(4), 435445. https://doi.org/10.1111/pan.13832 McNiece, W. L., Dierdorf, S. F. (2004). The pediatric airway. Seminars in Pediatric Surgery, 13, 152-65. National League for Nursing. (2022). Description of available instruments. https://www.nln.org/education/teaching-resources/tools-and-instruments Park, R., Peyton, J. M., Fiadjoe, J. E., Hunyady, A. I., Kimball, T., Zurakowski, D., Kovatsis, P. G., PeDI Collaborative Investigators, & PeDI collaborative investigators (2017). The efficacy of GlideScope videolaryngoscopy compared with direct laryngoscopy in children who are difficult to intubate: an analysis from the paediatric difficult intubation registry. British journal of anaesthesia, 119(5), 984992. https://doi.org/10.1093/bja/aex344 Powell, C., Mermigas, J., & Neft, M. (2022). Simulation for Student Registered Nurse Anesthetists: Common Pediatric Anesthesia Complications. AANA journal, 90(4), 288 292. PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 35 Soneru, C. N., Hurt, H. F., Petersen, T. R., Davis, D. D., Braude, D. A., & Falcon, R. J. (2019). Apneic nasal oxygenation and safe apnea time during pediatric intubations by learners. Paediatric anaesthesia, 29(6), 628634. https://doi.org/10.1111/pan.13645 Vukovic, A. A., Hanson, H. R., Murphy, S. L., Mercurio, D., Sheedy, C. A., & Arnold, D. H. (2019). Apneic oxygenation reduces hypoxemia during endotracheal intubation in the pediatric emergency department. The American journal of emergency medicine, 37(1), 2732. https://doi.org/10.1016/j.ajem.2018.04.039 PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION Appendix A Screening Identification Identification of Studies via Database Records identified from: PubMed Databases (n = 1) Records before screening: (n = 168) Records screened (n =168) Records excluded (n =128) Reports sought for retrieval (n = 41) Reports not retrieved (n = 1) Included Reports assessed for eligibility (n =40) Reports excluded: Not within 7 years (n = 9) Not in English language (n = 1) Not applicable to anesthesia and airway and or management (n =10) Not pediatric (n=1) Studies included in review (n =19) From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71 For more information, visit: http://www.prisma-statement.org/ 36 Running head: PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 37 Appendix B Literature Review Matrix Reference Research Design & Level of Evidence Purpose / Aim Population / Sample n=x Variables Instruments / Data Collection Results Aghdashi et al., 2017 Randomized control trial; level 1 Compare the success rate of, classic versus rotational, in the correct placement of laryngeal mask airway in pediatric patients. N=116 ASA class I and II aged 2 months to 8 years undergoing lower abdominal surgery. LMA insertion technique, success rate, patient age, patient gender, and patient weight. There is no statistical difference between the success rates of the classic LMA insertion technique versus the rotational technique. Amaha et al., 2021 Cross-sectional study; level 3 Determine prevalence of a difficult airway and associated factors in pediatric patients. N=290 ASA class I and II newborn to 5 years in age. Patient age, patient weight, ASA class, Patient sex, provider experience, laryngoscopy difficulty, and difficult airway. LMA, visual of symmetric chest movement, stethoscope for symmetric sound of both lungs, and ventilator to monitor resistance in ventilation and capnography. Laryngoscope, endotracheal tube, and face mask. Burjek et al., 2017 Retrospective observational study; level 3 Compare the success rates of fiber-optic intubation via supraglottic airway to video laryngoscopy in children with difficult airways. Our secondary aim is to compare the N=1,603 pediatric patients Patient age, intubation technique, success per attempt, use of continuous ventilation, and complications were recorded for each case. First-attempt success and complications were compared in subjects Database collection Close to 20% of patients were labeled as difficult airways. Significant associated of a difficult airway with one or all of following; age less than 2 years, underweight, anticipated difficult airway, history of difficult airway, and anesthetists pediatric experience of less than 4 years. Fiber-optic intubation via supraglottic airway and video laryngoscopy had similar firstattempt success rates. In subjects less than 1 yr old, fiber-optic intubation via supraglottic airway was more successful on the first attempt than video laryngoscopy. PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION complication rates of these techniques. Disma et al., 2021 Prospective Observational study; level 2 Glvez et al., 2019 Retrospective cross-sectional cohort study; level 3 GarciaMarcinkiewi cz et al., 2020 Randomized controlled trial; level 1 Holzki et al., 2018 Systematic Review Analyze occurrence of difficult intubations (2 failed attempts) and interventions related to anesthesia tracheal intubations and identify their clinical consequences. Determine the incidence of multiple tracheal intubations attempts in anesthetized infants in an academic childrens hospital and the associated risks of hypoxemia or bradycardia. Investigate whether video laryngoscopy improves the first-attempt success rate of orotracheal intubation and reduces the risk of complications when compared with direct laryngoscopy. Clarify the shape of the cricoid cartilage and the location of the narrowest portion of the larynx through systematic review. 38 managed with fiberoptic intubation via supraglottic airway and video laryngoscopy. N=4,683 planned pediatric tracheal intubations Age, ASA status, difficult face-mask ventilation, and intubation attempts. Database collection via secondary analysis from participating European health centers. Difficult tracheal intubation in children less than 60 weeks postconceptual age occurred in 5.8% of patients and commonly resulting in severe hypoxemia. N=1,341 Infants 12 months or less. Age, sex, ASA classification, encounter location, induction medication, duration of induction, hypoxemia, bradycardia, laryngoscopy attempts, and baseline vital signs before induction. Age, intubation technique, and gender. Database collection. 84% were intubated with one attempt, hypoxemia occurred in 35%, and bradycardia occurred in 9% of infants. Infants with two or more attempts of laryngoscopy had significantly higher rate of hypoxemia than single attempt. Video laryngoscope and direct laryngoscope. video laryngoscopy group, infants were more successfully intubated on the first attempt compared with direct laryngoscopy, video laryngoscopy had fewer severe complications, and few esophageal intubations compared to DL. Study type, age, and condition at time of evaluation. Comprehensive review There was a majority consensus that the narrowest portion of the infant larynx is the cricoid cartilage, and it is in fact funnel shaped. N= 564 Infants without difficult airways abnormalitie s requiring orotracheal intubation. 9 invitro studies of 672 cadavers aged preterm gestation to 17 years old and 6 in PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION Jain et al., 2020 Prospective observational study; level 2 Kaji et al., 2020 Retrospective comparative study; level 3 Kim et al., 2015 Prospective observational study; level 2 Determine whether the upper incisormanubriosternal joint length in the extended head position can be used as a predictor of airway length to guide the depth of insertion of endotracheal tube in children. Primary outcome was the difference in first-attempt success for DL and augmented DL versus VL. Secondary outcomes included adverse events. Compare the incidence of LMA malposition between US and fiber optic bronchoscopy (FOB) vivo studies of 553 pediatric patients aged 1 month to 13 years. N=60 Pediatric patients aged 2-8 years. 39 Age, weight, upper incisor-carina length, and upper incisormanubriosternal joint length. Standard metallic measuring tape, pediatric fiberoptic bronchoscope, and ETT. The incisor-manubriosternal joint length is a simple surface landmark technique that can be used as a predictor of tracheal length and the depth of insertion of ETT in children. N= 625 Pediatric patients. Variables patient demographics, body habitus, impression of airway difficulty, intubating position, reduced neck mobility, airway characteristics, device, medications, and operator characteristics. Database collection VL was associated with higher first-pass success in this pediatric population. N= 100 Pediatric patients Patient age, patient weight, patient height, patient sex, symmetry of the arytenoid cartilages, elevation of an arytenoid cartilage in reference to the glottic midline, LMA size, and success rate. LMA, ultrasound machine, and fiberoptic bronchoscope. Incidence of asymmetrical elevation of an arytenoid was 50% With FOB, the incidence of LMA malposition was 78%, and that of LMA rotation was 43%. PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION Koo et al., 2018 Systematic review; level 1 Lee, et al., 2017 Prospective observational study; level 2 Lingappan et al., 2018 Systematic review; level 1 Liu et al., 2020 Retrospective study; level 3 Compare the incidence of airway complications between extubation under deep anesthesia (deep extubation) and extubation when fully awake (awake extubation) in pediatric patients after general anesthesia. Determine the ideal insertion depth of the flexible laryngeal mask airway (FLMA). Determine the efficacy and safety of video laryngoscopy compared to direct laryngoscopy in decreasing the time and attempts required for endotracheal intubation and increasing the success rate at first intubation in neonates. Determine changes in the internal diameter and shape of the cricoid cartilage during development and explore the implications of those changes for the selection of ETT type and size for children. 40 N=1881 Pediatric patients. Cough, airway obstructions, desaturation, breath holding, laryngospasm. Comprehensive review Deep extubation reduces the risk of overall airway complications in cough, desaturation in children after general anesthesia. No difference was observed in the incidence of laryngospasm and breath-holding between the two groups. N= 154 ASA I or II patients aged 15 years or younger undergoing ophthalmic surgery. N= 467 Pediatric patients. Patient age, patient weight, patient sex, and FLMA size. FLMA, manometer, and fiberoptic bronchoscope. FLMA insertion depth can best be predicted using height and weight with continuous monitoring of intracuff pressure during insertion as a useful alternative when resistance is difficult to sense. Video laryngoscopy, direct laryngoscopy, and time number of attempts. Comprehensive review Video laryngoscopy increases the success of intubation in the first attempt but does not decrease the time to intubation or the number of attempts for intubation N=1346 Age 1-20 years. Age, dimension of cricoid cartilage, gender. Radiology database collection and NEUPACS software. Cricoid cartilage remains funnel shaped during development without a transition to a "column shape". PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION Luscan et al., 2020 Retrospective study; level 3 Park et al., 2019 Retrospective comparative study; level 3 Powell et al., 2022 Cross-sectional study; level 3 Soneru et al., 2019 Prospective observational study; level 2 Determine the anatomical development and size of airway structures from birth to adolescence using high-resolution computed tomography scans. aims of comparative success and complication rates between direct laryngoscopy and GlideScope video laryngoscopy, secondary aims, were to evaluate the effect of weight on intubation success and the success of direct laryngoscopy with poor visualization of the laryngeal inlet. Determine if perceived self-confidence level and ability to identify and manage/treat common pediatric anesthesia complications is affected by providing a highfidelity pediatric simulation for SRNAs prior to their pediatric rotation. Determine if apneic nasal oxygenation would prolong the time to desaturation during intubation on pediatric patients among inexperienced learners. 41 N= 192 Pediatric patients aged 1 day to 14 years Age, weight, gender, and airway measurements. CT database collection utilizing GE Revolution HD scanner. The cricoid shape is round, regardless of the child's age. Its diameter is smaller than the anteroposterior diameter of the glottic area, but the glottic area is smaller than the cricoid area. N=1295 Pediatric patients. Age, body weight, ASA classification, and anticipated airway difficulty. Database collection Success rates for GlideScope were significantly higher than direct laryngoscopy and show no differences in complication rates per attempt compared to direct laryngoscopy. N=20 Second and third year SRNAs. Confident scores and simulation training. Likert scales with ordinal variables, Friedman test, and Wilcoxon signed rank tests. Improvement in confidence scores from pre-simulation to postsimulation and at end of their pediatric rotation. N=371 Pediatric patients aged 1.2 to 5 years old. ASA level, emergent status, age, gender, intubation attempts, premedication, use of paralytic, use of apneic oxygenation, and Sp02 level. Pulse oximeter, nasal cannula, fisher's Exact test, chisquare test, and WilcoxonMann Whitney test Apneic nasal oxygenation improved time to desaturation and all other observed outcomes during endotracheal intubation. PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION Vukovic et al., 2019 Prospective observational study; level 2 Determine association between apneic oxygenation and hypoxemia in pediatric patients undergoing ETT placement N=149 Pediatric patients aged 0 to 20. Age, use of apneic oxygenation, Sp02 before intubation, attempts of intubation, proceduralist training level, and method of intubation. 42 Pulse oximeter and nasal cannula. Apneic oxygenation was associated with reduced odds of hypoxemia during endotracheal intubation. Running head: PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 43 Appendix C The Jeffries Simulation Model "Jeffries Simulation Model," by P. R. Jeffries, 2005, Nursing Education Perspectives, 26(2), 96-103. (https://journals.lww.com/neponline/pages/articleviewer.aspx?year=2005&issue=03000&article=00009&ty pe=abstract) Copyright 2005 by National League for Nursing Inc. Reprinted with permission. PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION 44 Appendix D SWOT Analysis Strengths State-of-the-art simulation lab Technological access to Canvas Access to Qualtrics Cohort of 2025 (stakeholders) Weaknesses Opportunities Additional simulation material and technology Enticement for participant buy-in (bonus points) Additional pediatric airway clinical time for project owners Exposure to previously learned techniques for participants No live patients Small sample size Motivation for participant buy-in Dyssynchronous with pediatric didactics Threats Inexperience with developing on Canvas technology Insubstantial experience in clinical setting with pediatric airway Lack of functioning equipment Low participation due to difficult semester for participants Inaccessibility to simulation lab (used for multiple other purposes) COVID-19 pandemic shutdowns PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION Appendix E 45 PEDIATRIC AIRWAY EDUCATIONAL INTERVENTION AND SIMULATION Appendix F 46  ...

... 1 Improving Pharmacologic Preparedness of First Year SRNAs Prior to Clinical William Zane Johnson III Marian University Leighton School of Nursing Chair: Dr. Derianne Monteiro _______________________ Project Team Member: Dr. Lee Ranalli _______________________ William Zane Johnson III _______________________ Date of Submission: 2 Table of Contents Abstract4 Introduction......5 Background..5 Problem Statement..6 Needs & Gap Analysis.6 Review of the Literature..7 Results.8 Conceptual Framework........10 Project Aims & Objectives.11 SWOT Analysis.... 12 Project Design... 13 Project Site and Population.14 Measurement and Data Collection......15 Ethical Considerations16 Data Analysis and Results..16 Conclusion..19 GANTT Chart....19 Appendix A (PRISMA Flowchart)....23 Appendix B (Literature Review Matrix)24 Appendix C (SWOT Analysis Chart)....26 Appendix D (GANTT Chart).....27 3 Appendix E (Project Site Agreement Letter)..28 Appendix F (Needs Assessment)....29 Appendix G (Pre-Test)....31 Appendix H (Post-Test)...33 4 Abstract The Marian University Nurse Anesthesia program offers two pharmacology courses prior to students entering the clinical setting. The pharmacology I course provides students with foundational knowledge of medications used daily. This includes common doses, their mechanism of action, indications for use, contraindications, and special considerations for each. This knowledge is key for safe and successful practice of Anesthesia providers. The six-month gap between the completion of the pharmacology I course and the start of clinicals for Marian University SRNAs potentially risks students ability to retain information learned. In an effort to prevent this, first year SRNAs at Marian University were provided a lecture covering most common pharmacologic agents used in the operating room aimed at enhancing both knowledge and confidence level. First, a literature review was conducted to help highlight the most efficacious ways of enhancing students knowledge and confidence. A total of ten articles were selected and found to contribute to the purpose of the project; enhancing students knowledge and confidence level. The educational intervention took place on May 10th, 2023 on the campus of Marian University. The presentation was composed of 41 slides and was presented throughout the duration of an hour and composed of a pre and post-test. Topics included, most common induction agents, vasopressors, vasodilators, neuromuscular blockers, reversal agents, and cardiac medications. The pre and post-test were composed of seven questions, five knowledgebased questions, one measuring quantifying confidence level, and one asking for the last four digits of their Marian University student ID number. After implementation, it was found that the mean confidence level of students increased from 5.1 to 7 (on a scale of 1-10). Furthermore, students improved overall average scores for knowledge-based questions from 78% to 96%. 5 Improving Pharmacologic Preparedness of First Year SRNAs Prior to Clinical 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, Anesthesia track. First-year Student Registered Nurse Anesthetists (SRNAs) at Marian University undergo three semesters of didactic work prior to entering clinical rotations. As part of this first year, students are enrolled in a Pharmacology I course their second semester where they are educated on anesthetic agents and special considerations for each medication. This course is taken two semesters prior to students entering clinical. This gap in time between the Pharmacology I course and the start of clinical has the potential to decrease students recollection of medications and considerations covered. This project aims to bridge this gap, improving first year students familiarity with common anesthetic agents utilized in the clinical setting, concentration of these medications, doses administered, and unique considerations for each. Background SRNAs undergo a significant amount of stress throughout the duration of the three-year curriculum for schooling. Much of this stress can come as a result clinical rotations, working with preceptors, and various operating room staff. According to a study conducted by Bruun et al. (2021), SRNAs report their stress level at an average of 7.1 on a scale of one to ten. Considering this high level of stress, having a good understanding of medications used can provide students with a good foundation and augment stress experienced secondary to the clinical setting. Furthermore, if students are provided a good foundation of information on medications administered, focus can be placed on flow of induction, maintenance, emergence, and the patients response to surgical manipulation. This can allow students to quickly build rapport with 6 preceptors and operating room staff, as they realize students are able to provide safe patient care. For example, with induction students are faced with multiple tasks: applying monitors, administering oxygen and medications, communicating with the patient and preceptor, observing the patients response, and adjusting doses of medications appropriately. Given that this often occurs simultaneously, students can place focus on the patient and effectively communicating with their preceptor instead of focusing on trying to remember the dose, concentration, and onset of medications used. Insufficient knowledge of medications used also increases the risk of medication errors. According to Wahr et al. (2016), human error accounts for approximately 400,000 patient deaths every year. Of these errors, 5.3% of them involved patients that were in the operating room (Wahr et al., 2016). Furthermore, 70% of the errors that resulted in a patients demise were considered preventable (Wahr et al., 2016). This underlines the importance of a strong understanding of medications utilized and the possible consequences of insufficient preparation. Problem Statement First year SRNAs are taught and tested on the most common medications used in the operating room 5 months prior to starting clinical rotations. This gap in time from fall semester to the following summer semester, makes students vulnerable to forgetting various considerations/characteristics of common medications. Providing first year SRNAs an educational lecture on most common medications used prior to entering clinical, can help improve students knowledge and confidence level heading into the first semester of clinical. Needs Assessment & Gap Analysis To identify specific areas that need addressed, SRNAs from all cohorts at Marian University were provided a survey to assess areas they felt most weak when entering clinical. 7 This helped identify any areas of weakness between each cohort and highlighted topics that were most helpful for first year students. Surveys were provided to students via Qualtrics and entries remained anonymous. A total of forty responses were recorded from the three cohorts in the Nurse Anesthesia program. 93% of students felt an educational lecture covering common pharmacologic agents would be beneficial for first year students. Furthermore, 50% of participants stated that they felt most comfortable with induction agents while 75% of subjects felt they were most unfamiliar with antibiotics. Regarding overall confidence level on a scale of one to ten (ten being most confident and one being no confidence) the mean confidence level of subjects was 5.39. Based on the data obtained, a PowerPoint presentation was constructed covering most common intravenous and volatile agents utilized throughout all phases of care by anesthesia providers. Review of the Literature A literature review was conducted to analyze articles collected, assessing the importance of adequate knowledge of most common anesthetic agents utilized in the operating room. This review was conducted in November and December of 2022 using the databases PubMed and CINAHL complete. The review search was carried out using the keywords student registered nurse anesthetist, pharmacology, medication safety, anesthetic agents, and operating room safety. Searches on PubMed and CINAHL complete were carried out utilizing the BOOLEAN phrases medication safety for nurse anesthetists AND student registered nurse anesthetists, pharmacology AND safety education for student registered nurse anesthetists, anesthesia education, and prevalence of medication errors. The 201 results were narrowed down with the exclusion of studies conducted prior to 2018, took part outside the United States, Europe, and Malaysia, did not include full text of the article, not provided in English, and were not academic 8 journals. Inclusion criteria was composed of clinical trials, meta-analysis, randomized control trials, and systematic reviews. With use of this criteria, ten articles were selected as demonstrated in the PRISMA flow chart (Appendix A). Results The literature review was conducted and resulted in 201 articles. With implementation of inclusion and exclusion criteria, ten articles were found to pertain to improving pharmacologic preparedness of student registered nurse anesthetists. The criteria utilized is provided on the PRISMA flowchart. Details of each study, author, and topics covered is demonstrated in the literature review matrix located in Appendix B. Classroom Curriculum Of the articles utilized, four of the articles looked at the effectiveness of various teaching strategies in pharmacology courses (Murnane et al., 2019, Norazlina et al., 2019, Khan & Hood, 2018, and Kennedy, 2019). While this project is not necessarily looking to recreate the curriculum pharmacology courses at Marian University, the most effective delivery methods can be determined for providing information. In the study conducted by Daniel Kennedy (2019), he was able to determine that utilizing an active teaching strategy can improve students level of knowledge to a greater extent universities traditional lecture strategy. Specifically, with implementation of active learning strategies such as team-based problem solving, and trivia competitions students overall grades improved by 6% (Kennedy, 2019). Two of the articles included in the literature review looked at effectiveness of simulation training for transesophageal echocardiogram and cricothyrotomy (Johnston et al., 2022 and Shields & Gentry, 2020). The study conducted by Shields & Gentry (2020), showed that students retained more information when provided a variety of teaching methods. This was demonstrated 9 by subjects who underwent both a lecture and hands-on activities receiving the highest post-test scores (Shields & Gentry, 2020). Given these findings, use of both an educational lecture and hands-activities would likely benefit students most. Perceived Level of Knowledge In addition to methods of teaching, it is also important to consider students comfort level with the information taught and potential impacts on their overall confidence in the clinical setting. Three of the articles chosen look at students perceived level of knowledge and the potential impact it has on their perceived ability to succeed in clinical scenarios (Norazlina et al., 2019, Bruun et al., 2022, and Khan & Hood, 2018). In the study conducted by Norazlina et al. (2019), they were able to determine a distinct link between level of knowledge and confidence level. In their study 70% of subject stated that adequacy of pharmacology teachings aided in their ability to adjust to the clinical setting and manage patients appropriately (Norazlina et al., 2019). This directly related to this project as the overarching purpose is to increase students preparedness and confidence level prior to entering the clinical setting (Norazlina et al., 2019). Furthermore, they found that 71.8% of students involved in their study felt it would be efficacious to be taught pharmacology during their clinical rotations in addition to pre-clinical courses (Norazlina et al., 2019). While this project is not advocating to teach students pharmacology throughout clinical semesters, it shows there is the potential gaps in the current curriculum that could benefit from a review course that highlights applicable topics. Overall, the articles included in the literature review provided the groundwork for the underlying need to provide students with information regarding pharmacology and methods of providing the information. The information gathered showed that students would benefit from being provided an educational lecture on the medications utilized and involvement of group 10 activities ensured that they remained engaged, and information is retained. This not only offered the opportunity to allow students to have an increased knowledge of medications utilized but improve their confidence level and performance in the clinical setting. Conceptual Model The conceptual framework that was used to guide the project is Kotter and Cohens model of change. This model consists of eight steps and has been proven effective in implementing change throughout organizations (Melnyk & Fineout-Overholt, 2019). The eight steps include urgency, team selection, vision, communication of the vision, empowerment, interim success, ongoing persistence, and nourishment (Melnyk and Fineout-Overholt, 2019). The first step of urgency involves an initial motivation to implement change (Melnyk & Fineout-Overholt, 2019). For example, in this project the initial motivating factor was the insufficient knowledge of the most common pharmacologic agents used in the operating room. Step two involves developing a team of individuals who are motivated and informed on the topic (Melnyk & Fineout-Overholt, 2019). This helped ensure that the information provided to the target audience was accurate and provided in a convincing manner (Melnyk & Fineout-Overholt, 2019). Following the development of a team, the third step was constructing a vision that helped outline the goal of the project and the strategy to attain it (Melnyk & Fineout-Overholt, 2019). In this project, the overall vision was to improve knowledge of common medications utilized and fulfilling that with a pre-test, presentation, and post-test. Next is the communication of the vision to the target audience (Melnyk & Fineout-Overholt, 2019). This is further explained as when people are provided the information, process it, and begin to quantify the importance associated with the material provided (Melnyk & Fineout-Overholt, 2019). The presentation 11 provided in this project directly relates to this, providing information in a direct manner that is succinct and easily understood by the general population. The last four steps of Kotter and Cohens change model each entail reinforcement of the message provided and actions to ensure that the change is sustained (Melnyk & FineoutOverholt, 2019). These steps are further explained to be critical with the implementation of change in an organization but not with small scale educational projects (Melnyk & FineoutOverholt, 2019). Despite each of these steps not being directly used, the post-test provided did offer reinforcement of the information discussed. Goals, Objectives, and Expected Outcomes The overarching goal for this project was to provide first year SRNAs at Marian University with adequate understanding of the most common pharmacologic agents utilized in the operating room by nurse anesthetists. Most information regarding the common pharmacologic agents administered in the operating room are taught one semester prior to entering clinical and the goal of this project was aimed at providing this information again prior to entering clinical. Specifically, objectives of this educational intervention include; subjects improving their average scores by 10% between pre and post-tests after being provided the educational lecture and students demonstrating an increased confidence level with an improvement in mean by at least one point. Overall, the expected outcomes is that this enhanced knowledge ultimately helps optimize students confidence and performance, starting their first semester of clinical. This outcome can be specifically measured by a 10% improvement in knowledge-based questions and improvement of mean confidence level by at least one point after being provided an hour lecture on May 10th, 2023 via PowerPoint on the most common pharmacologic agents utilized in the operating room. 12 SWOT Analysis With implementation of this project there were a variety of factors and individuals that were involved with each phase. The project chair: Dr. Monteiro, primarily oversaw the project at each phase and provided constructive feedback through dissemination. Dr. Ranali also played a crucial role, being responsible for instructing the pharmacology courses at Marian University. He was utilized as a resource for the project to ensure information provided builds off his courses. Furthermore, Dr. Stelflug was consulted with development of the project to ensure it aligned with program objectives and a time and location was able to be determined for implementation. Stakeholders within the university also included SRNAs who were depended on for feedback regarding their level of pharmacologic knowledge when entering the clinical setting. Strengths of the project included that it directly applies to what first year students will be doing during their clinical rotations, information was be provided by a second year SRNA who is familiar with their circumstances, information was provided in a succinct fashion via PowerPoint, and information provided pertains to didactic and board exam preparation. Barriers for the project would include students stress level regarding their upcoming clinical rotations and possible inability of some students to attend the in-person presentation. Providing an educational lecture regarding most common pharmacologic agents opened the opportunity for students to build their confidence entering their first semester of clinical, decrease stress, and improve familiarity with most common medications used. Threats to the project included the potential inability to obtain a space on campus to provide the presentation, participants failing to complete pre and/or post-test, and a potential change in schedule for clinical rotations. The full SWOT analysis chart can be found on Appendix C. 13 Project Design & Methods The educational lecture was provided via power point and in person during orientation week for 2023 summer semester on May 10th, 2023. Included in the lecture, was information covering topics stated in the needs assessment surveys provided to all three cohorts of the nurse anesthesia program. Information provided included concentration, mechanism of action, duration of action, side-effects, and special considerations for the most common medications used. The most common medications can be broken down into categories based on clinical use and indications for administration. Prior to starting the educational lecture, subjects were provided a pre-test that was composed of five questions; three knowledge based, one measuring confidence level, and one asking for the last four of their student ID number. Following the pre-test, the educational lecture was provided over an hour duration. The main categories that were focused on included induction agents, volatile anesthetics, neuromuscular blockers, neuromuscular blocker reversal agents, antiemetics, vasopressors, and vasodilators. Medications discussed included the most common medications utilized in the operating room and highlighted information on each that pertained to their use in the clinical setting. Hands-on activities and trivia over topics discussed were incorporated into the lecture. This allowed students to not just understand characteristics of medications but what syringes are appropriate to use and remain engaged with questions. Providing information with a variety of teaching methods helped students retain information and helped them remain interested. Throughout the duration of the lecture, students were asked if they have any questions or information is not being communicated clearly. 14 Following the presentation, a post-test was also provided to subjects. The post-test was also composed of five questions, with three of them being knowledge based, one measuring confidence level, and one asking again for the last four digits of their student ID number. Both pre and post-test entries were recorded anonymously online via Qualtrics and was accessed via a QR code that could be scanned from students smartphones. All data obtained was quantitative, allowing for direct comparison of results from the pre and post-test. Project Site and Population The population targeted for this project was first year nurse anesthesia students at Marian University. This cohort was specifically targeted as they were approaching their first semester of clinical rotations where they apply information taught in the classroom to cases in the operating room. The amount of information applied in the clinical setting can be overwhelming and this project is aimed at easing this transition. The educational lecture took place on campus at the Marian University Evans Center in room 134 at 1:00pm on May 10th, 2023. This room was utilized due to its convenient location on campus and ability to seat all members of the first-year cohort. Holding the presentation on campus and in person allowed for direct interaction with students and ensured effective delivery of information. Dr. Brad Stelflug was consulted leading up to delivery of the education presentation, working with staff at the Evans Center to arrange the reservation of the room and organizing the overall week of orientation. As part of this effort, a project site agreement letter was obtained prior to the educational lecture that is included in Appendix E. In addition, Dr. Lee Ranalli was also consulted in the days leading up to the presentation providing constructive feedback on the 15 information included and ensuring that information provided was congruent with information he provided as part of the Pharmacology I course. Resources utilized for delivery of the educational presentation included the digital projector provided in Evans Center room 134, Qualtrics survey software for both the pre and post-test, and staff of the Nurse Anesthesia program as mentioned previously. Barriers for the project included the one-hour time limit provided for the room and the large amount of information provided to students throughout the day. These barriers were overcome by condensing the presentation into 41 slides, providing the slide show to students via email to also review at a later time, and only included information that pertained to clinical practice. Measurements & Data Collection Prior to educating students, surveys were sent to students of all cohorts in the Marian University nurse anesthesia program. Questions were focused on highlighting areas of pharmacology that students felt least confident about. Sending surveys to all cohorts helped identify differences between cohorts and see how changes in the curriculum have improved or worsened students confidence. The needs assessment consisted of seven questions total, with three questions asking which pharmacology topics would most benefit first-year students, one question measuring students confidence level when they first entered clinical rotations, two covering demographic information, and one directly asking if they felt a pharmacology lecture would benefit students. The needs assessment survey utilized can be found in Appendix F. Once data from the initial survey was collected, analyzed, and used to develop the presentation, students were be provided a pre-test immediately before the presentation. In addition to knowledge-based questions, students were asked to quantify their confidence level regarding pharmacology. Specifically, the pre-test was composed of five questions, three 16 knowledge-based questions, one measuring confidence level, and one asking for the last four of their Marian University student ID number to help match entries. The pre-test utilized can be found in Appendix G. Once all pre-test entries were completed, students were provided the educational lecture. Following the lecture, they were provided a post-test that contains similar questions to assess effectiveness of the teaching. Specifically, the post-test was composed of seven questions total. Of the seven questions, five were knowledge-based, one asked students to quantify confidence level, and one asking for subjects to provide the last four digits of their Marian University student identification number. The same five knowledge-based questions were used to allow for effectiveness of teaching to be quantified. The post-test can be found in Appendix H. Data received from both the pre and post-test will then be recorded and analyzed. Ethical Considerations Prior to implementation of the project approval was obtained from the Marian Internal Review Board (IRB). The IRB approval letter can be found in Appendix I. Any potential bias based on sex, race, or cultural differences was addressed by providing the educational lecture to all first-year students together. This allowed for all students to be provided the same information and prevent potential influence on data entries. Subjects were also not asked their sex or race to help further diminish the likelihood of compromising anonymity. Data Analysis and Results The effectiveness of the education was assessed by observing to see if students consistently reported an increase in confidence level after the presentation and if there was an increase in correct answers recorded. With completion of the educational intervention, all data from the pre and post-tests was entered into Qualtrics and analyzed. All 33 subjects involved in 17 the study completed a pre-test and 31 completed a post-test. Of the 33 pre-test entries, six subjects failed to enter in the last four digits of their student ID number, and five additional subjects submitted their pre-test as incomplete. The entries that didnt have a corresponding posttest were able to be identified and discarded by matching the last four digits of subjects student identification numbers. After eliminating tests that were incomplete and didnt have a corresponding pre or post-test, the total number of subjects was brought to 21. Paired sample t-testing was utilized to assess the significance of the change in number of correct answers and confidence levels recorded. The hypothesis tested was that there would be an improvement in test scores from the pre to post-test versus the null hypothesis that there would be no difference. Table 1 includes data from Pre and Post-Test scores and Table 2 compares the confidence level of subject before and after the educational intervention. All analyses were carried out by testing for a significance determined by a p-value <0.05. Table 1 Pre-Test & Post-Test Results (n=21) Of the five knowledge-based questions included in the pre and post-test surveys the mean number of correct answers improved from 3.9 to 4.8 with the median improving from 4 to 5. 18 Furthermore, the results provided a p-value < 0.001 allowing the null hypothesis to be rejected with confidence. This offers evidence that suggests the educational intervention was effective in enhancing the knowledge level of all 33 students who participated in the lecture. Table 2 Confidence Level Before and After Education Regarding subjects confidence level, the hypothesis tested entailed that there would be an improvement in confidence level from pre to post-test. Overall, students reported an increase in confidence level after the completion of the lecture with the mean confidence level increasing from 5.1 to 7.05. With analysis of the results the improvement in confidence level was associated with a p-value <0.001 allowing the null hypothesis to be rejected with confidence. The increase in confidence level was correlated with an increase in knowledge level of the medications discussed. This increase in knowledge level was demonstrated by an improvement in the percentage of correct answers of knowledge-based questions from 84.8% to 96.7%. Discussion With completion of the educational intervention, effectiveness was able to be quantified and determined effective with improvements in students confidence level and test scores. There was also found to be a correlation between increased knowledge level and higher level of 19 confidence among subjects. This reinforces the notion that providing students with adequate education can set them up for success and provide them with confidence when entering the clinical setting. The strengths of the project include a sample size of 21 subjects, required few resources to implement, knowledge-based questions allowed for effectiveness of teaching to be directly measured, and confidence level was able to be quantified immediately before and after the intervention. Limitations of the project included the hour timeslot provided. Given the vast number of medications SRNAs administer during their clinical rotations, condensing this information into an hour is challenging. Maintaining a focus on the most common medications utilized helped address this issue but couldve been expanded upon with more time. Moving forward this project could expand upon this project and measure students confidence level after this first clinical rotation. Furthermore, collaboration with the pharmacology course instructors could be also expanded upon, tying in course materials with the lecture. Conclusion The curriculum for Marian Universitys Nurse Anesthesia program aims to provide students with the knowledge and skills to provide safe and effective care to patients in the clinical setting. The gap in time between the Pharmacology II course and the start of clinical rotations risks compromising this knowledge and students confidence level. This was reinforced by the needs assessment that demonstrated students mean confidence level at 5.39 on a scale of 1-10. After implementation of the educational intervention, the improvement in mean confidence level from 5.1 to 7.05 and average test scores from 78% to 96% echo the need for a pharmacology lecture immediately prior to students entering their clinical rotations. This can aid 20 in equipping students with a strong knowledge base of pharmacologic agents utilized and ultimately enhance their performance in the clinical setting. Overall, integration of a pharmacology lecture the week prior to the start of clinical rotations for SRNAs at Marian University would be beneficial for both students and the program, aiding in fulfilling its overall mission. GANTT Chart The GANTT chart can be found in Appendix D. The GANTT chart outlines the timeline for the project, detailing the development of the topic, planning, submission of project proposal, conduction of literature review, data collection and analysis, delivery of presentation, and dissemination. 21 References Bruun, A. M. G., Valenberg, B. T., & Leonardsen, A.-C. L. (2022). Moral courage: Student registered nurse anesthetist experiences on the operating team. AANA, 90(2), 121126. Elisha, S., Bonanno, L., Porche, D., Mercante, D. E., & Gerbasi, F. (2020). Development of a common clinical assessment tool for evaluation in nurse anesthesia education. AANA Journal, 88(1). Flynn, F., Bing-Jonsson, P. C., Sorum, R., Tonnessen, S., & Taraldsen, B. (2022). Educating for excellence: A cohort study on assessing student nurse anesthetistnon-technical skills in clinical practice. AANA Journal, 90(1), 715. Johnston, S., Rice, A. N., Martin, G., & Simmons, V. C. (2022). Mobile cricothyrotomy simulation cart improves anesthesia providers confidence, technical skills, and procedure time. AANA Journal, 90(3), 206214. Kennedy, D. R. (2019). Redesigning a pharmacology course to promote active learning. American journal of pharmaceutical education, 83(5), 875881. https://doi.org/10.5688/ajpe6782 Khan, E. U., & Hood, P. A. (2018). Nurses perspectives on pharmacology: Why, what and at which point of the curricula should education be delivered? British Journal of Nursing, 27(10), 546553. Mauldin, B. (2021). Bringing clinical context to the classroom in nursing pharmacology: A case study. Nursing Education Perspectives, 44(1), 5758. https://doi.org/10.1097/01.nep.0000000000000919 Melnyk, B. M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing & healthcare (4th ed.). Wolters Kluwer. 22 Murnane, K. S., Augustine, J. M., Quesnel, M., Marshall, L., & Strom, G. (2019). A classroom activity to increase student pharmacists confidence in dealing with the opioid epidemic. American Journal of Pharmaceutical Education, 83(9), 19481957. Nagelhout, J. J., & Elisha, S. (2018). Nurse Anesthesia (6th ed.). Elsevier. Norazlina, M., Mariam, S., Mohamad-Sharif, M., Norain, M., Muhammad, A., Hazlina, M., & Darishini, G. (2019). Medical students perceptions on the adequecy and effectiveness of pharmacology teaching during preclinical years. Med & Health, 14(2), 109119. https://doi.org/10.17576/MH.2019.1402.10 Shields, J., & Gentry, R. (2020). Effect of simulation training on cognitive performance using transesophageal echocardiography. AANA Journal, 8(1), 5965. Wahr, J. A., Abernathy, J. H., Lazarra, E. H., Keebler, J. R., Wall, M. H., Lynch, I., Wolfe, R., & Cooper, R. L. (2017). Medication safety in the operating room: Literature and expertbased recommendations. British journal of anaesthesia, 118(1), 3243. Weggemans, M. M., Custers, E., & Cate, O. (2017). Unprepared retesting of first year knowledge: How much do second year Medical Students remember? Medical science educator, 27, 597605. https://doi.org/10.1007/s40670-017-0431-3 23 Appendix A Appendix B Citation 24 Population / Sample size n=x Major Variables Instruments / Data collection Results Bruun et al., 2022 Research Design & Level of Evidence Case Study & Level III n = 40 Students experience in the operating room and level of moral courage. Students participated in educational lectures on ethical issues and then were asked to describe a scenario they personally experienced. SRNA narratives identified 18 situations involving lack of moral courage, 20 situations including moral courage, and two situations including both. Elisha et al., 2020 Case Series & Level IV n = 133 Domains regarding SRNAs clinical performance and administrators expressed level of significance. Anesthesia education and non-technical skills. Education on cricothyrotomy and ability to perform proper steps. Course format and students level of knowledge. Nurses education and opinion on Each subject rated relevance of each domain in the survey utilizing the 5-point Likert scale. Average content validity index of 83% for the three rounds of surveys. Each subject was provided a survey and utilized the NANTS rating scale. Students underestimated their clinical performance compared to assessments completed by preceptors. Subjects were rated using a modified Likert scale during their performance of a simulated cricothyrotomy. Increase in median scores after education from 14 to 22.5. Exam scores were recorded before and after changes to the curriculum and compared. Nurses were provided a survey and asked about the relevance of pharmacology The average grade increased from 81.3% to 83.8% after change was made to the curriculum. Flynn et al., Cohort 2022 Study & Level II n = 22 Johnston et al., 2022 Case Study & Level IV n = 58 Kennedy, 2019 Cohort Study & Level II n = 75 Khan, 2018 Cohort Study & Level II n = 46 Majority of subjects stated that they felt face-to-face lectures early in the program would be most beneficial. 25 timing of curriculum Pharmacology education and confidence in the clinical setting Mauldin, 2021 Case Study & Level II n = unknown Murnane et al., 2019 Cohort Study & Level II n = 157 Education and students level of confidence Norazlina et al., 2019 Crosssectional Cohort Study & Level III Cohort Study & Level III n = 459 Pharmacology education and students perceived level of effectiveness. Simulation training and performance in performing a TEE. Shields & Gentry, 2020 n = 71 education received using a 5point Likert scale. Nurses were provided an educational lecture on pharmacology and confidence level was recorded after the presentation and compared to answers recorded prior to the lecture. Data was collected via a questionnaire that covered information covered in the lecture. Students were provided a survey and recorded responses utilizing the 5 point Likert scale. Students were provided a pre and post-test regarding information provided in simulation training. Students reported, an increased confidence and understanding of pharmacology. There were no significant differences between the pre and post-intervention assessment. 70% agreed that lessons were adequate and 8.9% felt it was inadequate. The mean of post-test scores were significantly higher, increasing from 42.3 to 69.4. 26 Appendix C Weaknesses Strengths Clinically Relevant Limited to Pharmacology Direct & Comprehensive One SRNA Presenting Information Information Provided by Peer Limited Time to Provide Information Pertinent to Board and Course Exams Opportunities Decrease Students Stress Level Improve Familiarity with Medications Threats Inability to Obtain Space for Presentation Lack of Interest from Students 27 Appendix D 28 Appendix E Leighton School of Nursing Nurse Anesthesia Program 3 February, 2023 To whom it may concern, Zane Johnson has my permission to conduct his DNP project at Marian University. 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) 29 Appendix F 30 31 Appendix G 32 33 Appendix H 34  ...

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METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2024 Methocarbamol: Effect on Postoperative Pain Following Laparoscopically Assisted Vaginal Hysterectomy (LAVH) Carlie Grubbs Marian University Leighton School of Nursing Chair: Lee Ranalli, DNP, CRNA (Signature) Co-Chair: Traci Castelli, DNP, CRNA _____________________ (Signature) Date of Submission: February 5, 2024 1 METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 2 Table of Contents Abstract4 Introduction..5 Background..6 Problem Statement...7 Needs Assessment7 Review of Literature8 Search Methodology8 LAVH Procedure.9 Advantages of Methocarbamol..11 Disadvantages of Methocarbamol..17 Theoretical Framework..18 Project Aims/Objectives19 SWOT Analysis.20 Project Design/Methods.21 Project Site and Population21 Measurement Instrument(s) ..22 Data Collection Procedures22 Ethical Considerations...23 Data Analysis and Results.24 Discussion..26 Strengths and Limitations..26 Conclusion.27 METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 3 References..28 Appendices.32 Appendix A32 Appendix B33 Appendix C34 Appendix D35 Appendix E36 METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 4 Abstract Background and Review of Literature: Laparoscopically assisted vaginal hysterectomy (LAVH) is a minimally invasive surgical procedure commonly performed to remove the uterus. While the LAVH technique offers many advantages, management of perioperative pain continues to be a concern. Methocarbamol, a centrally acting antispasmodic, has gained popularity by many anesthesia providers as a multi-modal pain adjunct. Purpose: This project was developed to evaluate the effect of intraoperative methocarbamol administration on post operative pain scores in patients undergoing an LAVH procedure. Methods: A retrospective chart review of patients who underwent an LAVH procedure was performed to analyze and compare postoperative pain scores between patients who received methocarbamol intraoperatively to those who did not receive methocarbamol. Implementation: The medication administration record (MAR) of 80 patients was reviewed to determine if the patient received methocarbamol intraoperatively. Intraoperative and postoperative opioid administration were recorded separately. A two-sample t-test was utilized to compute significance of total opioid consumption and average post anesthesia care unit (PACU) pain scores between the two groups. Results: The total intraoperative and postoperative opioid consumption between the methocarbamol (+) and methocarbamol (-) groups revealed no significance. Patients who received 1000 mg of methocarbamol intraoperatively had significantly lower pain scores at the 5, 15, and 30-minute time intervals (p=0.03, p=0.01, p=0.03) in the PACU. Key words: laparoscopic assisted vaginal hysterectomy, methocarbamol, pain METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 5 Methocarbamol: Effect on Postoperative Pain Following Laparoscopically Assisted Vaginal Hysterectomy (LAVH) 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. Laparoscopically assisted vaginal hysterectomy (LAVH) is a common gynecological procedure performed to remove the uterus through the vagina, with the aid of a laparoscope for surgical visualization (Choi, 2016). The LAVH procedure was introduced in 1989 as a new combined approach using vaginal and laparoscopic techniques to hysterectomy (Eggemann et al., 2018). Laparoscopic assisted operations offer several advantages for the patient such as lower morbidity, faster recovery times, and reduced blood loss (Sesti et al., 2014). Although gynecological laparoscopic surgery is less traumatic than more traditional approaches, such as a total abdominal hysterectomy, acute postoperative pain continues to remain a concern (Chen et al., 2021). In recent years, emphasis has been placed on the implementation of opioid-sparing multimodal analgesic strategies to better improve patient outcomes during the perioperative period (Smith et al., 2019). Methocarbamol (Robaxin) is an antispasmodic agent that has progressed in popularity among anesthesia personnel as part of their intraoperative pain management plan (Chen et al., 2021). Nevertheless, opioids will continue to play a critical role in acute pain management, however, if anesthesia professionals can play a greater role to mitigate opioid-related side effects, unwarranted outcomes in the immediate postoperative period may be reduced (Smith et al., 2019). This project will examine the effectiveness of intraoperative methocarbamol administration on post operative pain scores in patients who have undergone an LAVH procedure. METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 6 Background Compared to more traditional approaches, LAVH offers a variety of advantages, which include lower morbidity, shorter duration of hospitalization, and faster recovery time (Choi, 2016). Despite advances in surgical technique, the incidence of moderate to severe postoperative pain following gynecological laparoscopic surgery remains between 25% and 35% (Wong et al., 2018). In patients undergoing LAVH, misperception of pain among anesthesia personnel may lead to inadequate pain medication coverage, resulting in higher postoperative pain scores, increased opioid administration and longer hospital stay (Choi, 2016). During an LAVH, the surgeon will make small incisions into the abdominal viscera for insertion of trocars, devices used by the surgeon to help manipulate organs into view (Hickman & Propst, 2022). An additional incision will be made for insertion of the laparoscope, a small telescope like device that brings light into the abdomen to allow view of the pelvic organs (Hickman & Propst, 2022). Carbon dioxide (CO2) is a colorless, inexpensive, nonflammable gas utilized by the surgeon to create a pneumoperitoneum, filling of the abdomen with gas, to further increase operative visualization (Orhurhu et al., 2022). Lastly, the surgeon will make an incision into the vagina for the uterus to be removed (Hickman & Propst, 2022). An LAVH procedure, even though less surgically invasive, still brings a variety of opportunities for pain that must be taken into consideration by the anesthesia provider. In addition to incisional pain, the patient might experience discomfort from creation of the pneumoperitoneum, stretching of the abdominal cavity, and manipulation of the intra pelvic region (Choi, 2016). Methocarbamol is a centrally acting muscle relaxant that may have some benefit as part of a multimodal pain management strategy for LAVH procedures (Walters, 2017). While the exact mechanism of action is unclear, methocarbamol has been described as an METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 7 indirect inhibitor of the interneural junction of the spinal cord, having no direct action on the motor nerve fiber (Sibrack & Hammer, 2022). As the main effect of methocarbamol is to reduce muscle spasm, it may be hypothesized that relaxation of the abdominal and pelvic floor muscles will reduce post operative pain. Problem Statement Relief of post operative pain continues to be one of the most common challenges for healthcare providers (Murphy & Szokol, 2019). Traditionally, short-acting opioids are given to treat moderate to severe pain in the immediate postoperative period (Murphy & Szokol, 2019). However, clinical response to opioids can be labile, generating reactions that range from inadequate pain relief to severe sedation or respiratory depression (Murphy & Szokol, 2019). Methocarbamol is a centrally acting muscle relaxant that works by blocking nerve impulses (or pain sensations) that are sent to the brain (Aljuhani et al., 2017). Due to its comparatively long elimination half-life, and decreased risk of sedation and respiratory depression, methocarbamol administration intraoperatively has grown in popularity among anesthesia providers (Aljuhani et al., 2017). Discovering a lack of research and reported techniques regarding methocarbamol administration and its impact led to the following question to be developed: In patients who underwent a laparoscopically assisted vaginal hysterectomy, what was the effect of intraoperative methocarbamol administration on post operative pain scores compared to patients who did not receive methocarbamol? Needs Assessment Each year, in the U.S. alone, surgeons perform approximately 600,000 hysterectomies, making it the second most common surgical procedure for women (TriHealth, 2023). The hospital organization for this DNP project routinely performs hysterectomies, specifically LAVH METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 8 procedures, ranking in the top three surgeries they perform annually (TriHealth, 2023). In addition, anesthesia personnel at this organization commonly administer methocarbamol to patients intraoperatively. After observation, the organization appears to administer methocarbamol to a much greater degree in select cases, such as spinal procedures. When discussing with anesthesia providers at this facility, the majority reported having positive patient outcomes with methocarbamol administration and support the idea of its administration to patients undergoing gynecological procedures. In addition, after speaking with PACU registered nurses, they reported better overall post operative pain scores by patients who received methocarbamol intraoperatively. Review of Literature Search Methodology Research for evidence to support this project was provided through the Cumulated Index to Nursing & Allied Health Literature (CINAHL) and PubMed databases. A PRISMA diagram detailing the selection of research evidence can be found in Appendix A. The initial database search created 12,506 articles and abstracts. However, only 110 articles were eligible for inclusion. Results were narrowed to include abstracts with full text published in English within the past five years (2017-2022). The review analyzes 10 articles in total. Inclusion criteria consisted of being female, ages 30-60 years old, human, and having an LAVH procedure. Exclusion criteria to this review were animal laboratory studies and being a male. There were no exclusion criteria for sample size or drug dose. Keywords and search terms included Robaxin, methocarbamol, LAVH, and visceral pain. Boolean searches included methocarbamol pain, methocarbamol intravenous, methocarbamol mechanism, abdominal visceral pain, postoperative visceral pain, laparoscopic visceral pain, and LAVH pain. METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 9 LAVH procedure In the United States, almost 70% of hysterectomies are carried out abdominally (Mohammed et al., 2017). However, within the past five years there has been a trend towards less invasive surgery, owing to the increased popularity of surgeons utilizing vaginal and laparoscopic techniques (Mohammed et al., 2017). Prior to introduction of LAVH, total laparoscopic hysterectomy (TLH) and vaginal hysterectomy (VH) were the alternative techniques to a total abdominal hysterectomy (AH) (Sesti et al., 2014). To compare operative data between surgical techniques, a study in 2014 selected 108 women who required a hysterectomy (Sesti et al., 2014). Using a computer-generated list, the women were randomly assigned an operative technique: TLH (n=36); LAVH (n=36); VH (n=36) (Sesti et al., 2014). Using a visual analog scale (VAS) which consisted of a 100-millimeter (mm) line ranging from zero (no pain) to 100 (pain as bad as it can be), women were asked to report pain over a 24-hour period (Sesti et al., 2014). Overall, 17 (47%) women reported no pain (VAS = 0) after VH, 19 (53%) after TLH, and five (14%) after LAVH (Sesti et al., 2014). Subsequently, ten (28%) women reported moderate pain after VH (VAS 1-25), eleven (30%) after TLH, and twenty-two (61%) after LAVH (Sesti et al., 2014). After VH, four women (11%) complained of moderate pain (VAS = 26-50), two (6%) complained of severe pain (VAS = 51-75), and three reported very severe pain (VAS 76-100) (Sesti et al., 2014). After TLH, two women (6%) reported moderate pain, three (8%) reported severe pain, and one reported (3%) very severe pain (Sesti et al., 2014). Four women (11%) reported moderate pain, four (11%) severe pain, and one (3%) very severe pain following LAVH (Sesti et al., 2014). Researchers found no significant differences for postoperative pain over a 24-hour period among these three different methods (p = 0.32) (Sesti et al., 2014). METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 10 Another prospective, randomized, double-blind study was designed to investigate postoperative pain after VH and LAVH with and without peritoneal closure, when the upper portion of the vagina is sutured shut after removal of the uterus (Eggemann et al., 2018). A total of 192 patients were divided into four groups: LAVH and VH with and without peritoneal closure (PC), respectively (Eggemann et al., 2018). Postoperative pain was assessed three times a day until patient discharge, using a 10-centimeter (cm) VAS scale (0-10), where zero indicated no pain and ten indicated unbearable pain (Eggemann et al., 2018). In addition, pain was assessed at months one, six and twelve during postoperative check-ups (Eggemann et al., 2018). Patients in the LAVH group (LAVH PC, n=48; LAVH + PC, n=47) were significantly younger than those patients in the VH group (VH PC, n=45; VH + PC, n=47), otherwise the patients parity, BMI, previous abdominal operations, and uterine weight were reported as well balanced between the groups (Eggemann et al., 2018). Operative time was significantly longer after LAVH (LAVH + PC 106 29 min; LAVH PC 99 30) (p < 0.0001) and significantly shorter after VH (VH + PC 59 17; VH PC 56 19) (Eggemann et al., 2018). The first three days after surgery, patients in the LAVH group (n=95) reported more pain than those in the VH group (n=92) (VAS score day 1: p = < 0.0001; VAS score day 2: p = 0.021; VAS score day 3: p = 0.039) (Eggemann et al., 2018). Peritoneal closure did not seem to have any influence on postoperative pain (+PC versus -PC: VAS score day 1, p = 0.9399) (Eggemann et al., 2018). After day three, researchers did not find any significant difference in pain scores between the groups (VAS score day 4: p = 0.494) (Eggemann et al., 2018). A third, prospective observational cohort study was designed to compare the differences of acute postoperative pain between patients undergoing LAVH, laparoscopic myomectomy METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 11 (LM), and laparoscopic adnexectomy (LA) (Chen et al, 2021). Unlike LAVH, where the surgeon uses a laparoscope to guide removal of the uterus through the vagina, LM and LA solely use a laparoscope approach through the abdomen to remove uterine fibroids and ovaries, respectively (Chen et al, 2021). Data of 669 patients were analyzed, including 249 from the LAVH group, 210 from LM, and 210 patients from the LA group (Chen et al, 2021). Researchers in this study analyzed pain scores as well as the type of pain the patient was experiencing (visceral pain, incisional pain, low back pain, shoulder pain) (Chen et al, 2021). Visceral pain occurs due to stretching of the abdominal cavity, and is the pain felt when internal organs are inflamed, damaged, or injured (Chen et al, 2021). Visceral pain had the highest incidence and most severe rating in the LAVH and LH groups, followed by low back pain (Chen et al, 2021). Of the patients in the LAVH group, up to 73.1% of patients reported moderate (n=64, 25.7%) to severe (n=49, 19.7%) visceral pain, and 61% of patients in the LM group reported moderate (n=46, 21.9%) to severe pain (n=40, 19%) (Chen et al, 2021). However, in the LA group, incisional pain was reported to be the most severe, with up to 39% of patients reporting moderate (n=26, 12.4%) to severe pain (n=9, 4.3%) (Chen et al, 2021). Opioid consumption in the PACU was highest in the LAVH group compared to both the LM or LA groups (Chen et al, 2021). Advantages of methocarbamol Opioids continue to be the mainstay of pain management in the perioperative setting (Aljuhani et al., 2017). However, nonopioid adjuncts have been recommended to provide more options for pain control and to reduce or eliminate the need for opioid medications (Aljuhani et al., 2017). Methocarbamol is a central nervous system depressant with both muscle relaxant and sedative properties (Aljuhani et al., 2017). The exact mechanism of action is unclear; however, it METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 12 is hypothesized that analgesia from muscle relaxation may be due to the inhibition of spinal transmission of noxious stimuli (Aljuhani et al., 2017). A single-blinded clinical trial was performed at a hospital in New York to investigate the efficacy methocarbamol for post operative pain control in patients undergoing breast augmentation (Hidalgo & Pusic, 2005). Like LAVH, breast augmentation surgery is generally performed in an outpatient manner with quick recovery times, yet patients still tend to report significant pain in the immediate post operative period (Hidalgo & Pusic, 2005). The study was performed in two phases with a total of four treatment groups (n=100) (Hidalgo & Pusic, 2005). In the first phase, patients were randomly placed into two groups 24 hours before their surgery (Hidalgo & Pusic, 2005). One group received a preoperative intercostal neve block with 40 cc of 0.25% bupivacaine and pre/postoperative oral methocarbamol (Hidalgo & Pusic, 2005). The second group received pre/postoperative methocarbamol, but no intercostal nerve block (Hidalgo & Pusic, 2005). In the second phase, patients were randomly placed into two groups, where one group received intercostal nerve blocks but no methocarbamol, and the second group did not receive nerve blocks or methocarbamol (Hidalgo & Pusic, 2005). To maintain consistency with placement of the intercostal nerve blocks, a single surgeon was assigned to perform all blocks (Hidalgo & Pusic, 2005). Patients who received the oral methocarbamol were given 1500 mg preoperatively and then continued to take the drug every six hours in 500 mg tablets (Hidalgo & Pusic, 2005). Since the intercostal nerve block was performed by the surgeon in the operating room (OR), the PACU nurses were blinded to the treatment group assignments, however, PACU nurses and selected patients were aware that they were receiving methocarbamol (Hidalgo & Pusic, 2005). METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 13 Researchers primarily used a VAS tool to assess postoperative pain, however, they also measured narcotic use (Hidalgo & Pusic, 2005). Pain scores and narcotic use were recorded by PACU nurses at one and three hours after surgery, and then at 6 hours a study nurse called the patients at home to record pain and medication use (Hidalgo & Pusic, 2005). Patients who received methocarbamol had significantly lower VAS pain scores and reduced narcotic use in the first few hours after surgery than those who did not (P= 0.03). Beyond 6 hours after surgery there was no significant difference seen among those who received methocarbamol and those who did not (P= NS, not significant) (Hidalgo & Pusic, 2005). There was no significant difference in pain scores and narcotic use seen in patients who received intercostal nerve blocks compared to those who did not (P=NS) (Hidalgo & Pusic, 2005). A retrospective cohort study was performed at an urban academic medical center in the United States to evaluate the effect of methocarbamol on hospital length of stay in patients with closed rib fractures (Patanwala et al., 2017). Using an electronic hospital database, patients 18 years and older who were admitted to the hospital for a closed rib fracture between April 2014 and December 2015 were selected for review (Patanwala et al., 2017). Variables relevant to the study included age, sex, race, ethnicity, need for endotracheal intubation, need for chest tube, discharge status, hospital length of stay, and injury severity scores (Patanwala et al., 2017). Patients were divided into two groups based on whether they received oral methocarbamol during their hospital stay (Patanwala et al., 2017). Severity of injury was considered because it is possible that the effect of methocarbamol may have been limited with a certain level of trauma (Patanwala et al., 2017). A total of 592 patients were included in the final study cohort, 329 received methocarbamol and 263 did not receive methocarbamol (Patanwala et al., 2017). The mean METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 14 overall age was 55.6 18.5 years, and 67.7% were male (Patanwala et al., 2017). The average time for discharge was 5 days in the methocarbamol group (P < 0.001) and 8 days for the methocarbamol negative group (Patanwala et al., 2017). Although the primary outcome of this study was length of hospital stay, researchers addressed pulmonary complications as a secondary outcome (Patanwala et al., 2017). Pulmonary complications consisted of bacterial pneumonia, ventilator associated pneumonia, aspiration pneumonia, and atelectasis (complete or partial collapse of a lung or lobe of the lung) (Patanwala et al., 2017). Patients who received methocarbamol were less likely to have pulmonary complications (11.3%, n = 37 compared to patients not receiving methocarbamol 23.2%, n = 61; P = < 0.001) (Patanwala et al., 2017). A double-blinded, randomized placebo-controlled trial was conducted in 2019 to assess the efficacy of indomethacin (NSAID) and methocarbamol versus indomethacin alone in patients with acute low back pain (Zoofaghari et al., 2021). A total of 64 patients were randomly categorized into two groups (32 in each group) (Zoofaghari et al., 2021). Group one (I-M) received indomethacin 25 mg every 8 hours and placebo capsules every 8 hours, whereas group two (I+M) received 25 mg of indomethacin every 8 hours in addition to 500 mg methocarbamol tablets every 8 hours (Zoofaghari et al., 2021). Prior to initiation of treatment, researchers obtained baseline patient function using the Back Pain Function Scale (BPFS) and a baseline pain score using a VAS (Zoofaghari et al., 2021). Researchers contacted patients a week after treatment to assess if instructions were followed, pain level, BPFS status, and possible side effects the patient may have experienced (Zoofaghari et al., 2021). Ten females (31.3%) and 22 males (68.7%) with an average age of 42.69 8.89 years were in group one (indomethacin alone) (Zoofaghari et al., 2021). In group two, the indomethacin with methocarbamol group, there were 16 females (50%) and 16 males (50%) with METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 15 an average age of 39.22 11.37 years (p > 0.05) (Zoofaghari et al., 2021). Before initiation of the intervention, pain scores and sex between both groups did not differ significantly (p > 0.05) (Zoofaghari et al., 2021). Both groups had significantly lower pain scores after the intervention, however, patients in group two (I + M) had significantly higher pain reduction than that of group one (3.66 3.17 vs. 1.84 1.53; P < 0.001) (Zoofaghari et al., 2021). In addition, the average BPFS score, or functional status, increased in group two (I + M) significantly higher than group one (I-M) (19.44 8.66 vs. 4.75 4.35; P < 0.001) (Zoofaghari et al., 2021). A randomized, placebo-controlled, double-blind study was conducted in 2017 to evaluate the safety and efficacy of methocarbamol administration (Abd-Elsalam et al., 2019). The clinical trial included 100 patients with liver cirrhosis, with complaint of frequent muscle cramps (AbdElsalam et al., 2019). Patients were randomly assigned to a placebo and a control group via a computer-generated system (Abd-Elsalam et al., 2019). Group one was the drug group where 50 patients received 500 mg methocarbamol twice daily for one month, and group two consisted of 50 patients who received a placebo dose twice daily for one month (Abd-Elsalam et al., 2019). Muscle cramps were evaluated using a questionnaire, which included analysis of the nature, intensity (1-10 analog scale), duration (in minutes), and frequency of cramps (times/week) (AbdElsalam et al., 2019). Researchers obtained a baseline response from all participants to the questionnaire prior to beginning the study, and there were no significant differences in muscle cramps, severity, duration, and frequency (P > 0.05) (Abd-Elsalam et al., 2019). After one week, participants in group one showed a significant decrease in the mean number of muscle cramps from 11 4 (median 10.0) to 0.5 1 (median 0.0) per week (Abd-Elsalam et al., 2019). The mean score of pain severity decreased from 6.52 1.29 to 0.66 1.18 compared to those receiving the placebo METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 16 (P < 0.001 for each) (Abd-Elsalam et al., 2019). Few side effects of methocarbamol were reported, which included dry mouth (P = 0.0026) and drowsiness (P = 0.0002) (Abd-Elsalam et al., 2019). When a patient is transferred to the PACU, there is potential that opioids will be given in addition to methocarbamol. A valid concern with concomitant use of prescription opioids and skeletal muscle relaxants is opioid overdose (Khan et al., 2022). A cohort study spanning from 2000 to 2019 using healthcare data was conducted to compare the risk of opioid overdose in patients who concurrently take skeletal muscle relaxants (Khan et al., 2022). Various skeletal muscle relaxants were studied, including methocarbamol (Khan et al., 2022). A 30-day analysis was performed to evaluate the acute risk of opioid overdose after initiation of skeletal muscle relaxant therapy (Khan et al., 2022). Researchers assessed comorbidities, pain conditions, and other active prescriptions to exclude any outliers from data retrieval (Khan et al., 2022). The mean age of participants was 53 years, with most being female (62%) (Khan et al., 2022). Opioid overdose was defined using the International Classification of Diseases, ninth revision (ICD-9), in incidences that resulted in an emergency department (ED) visit or hospitalization (Khan et al., 2022). In the first 30 days, the highest number of opioid overdose events occurred with the cyclobenzaprine (n = 278) and baclofen (n = 266) groups (Khan et al., 2022). The hazard ratio (HR) for opioid overdose relative to methocarbamol was 1.00 (95% CI 0.45-2.20, adjusted P value > 0.99) (Khan et al., 2022). Compared to cyclobenzaprine and baclofen, no other muscle relaxants, such as methocarbamol, were correlated with an increased risk of opioid overdose (Khan et al., 2022). METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 17 Disadvantages of Methocarbamol A retrospective cohort study was performed at an academic medical center in the United States observing adults (age greater than or equal to 18-years-old) who were admitted to the hospital because of a traumatic injury (Aljuhani et al., 2017). Data was collected from medical records, which included baseline demographics, vital signs, Glasgow Coma Score, pain scores, injury location, opioid use before admission, history of drug abuse, analgesics administered during hospital stay, surgeries performed, and adverse effects (Aljuhani et al., 2017). Pain scores were recorded on a zero to ten (0 = no pain, 10 = worst possible pain) scale (Aljuhani et al., 2017). All data was collected and recorded for the first three days after methocarbamol administration (Aljuhani et al., 2017). Patients who received methocarbamol were matched to a control group, consisting of patients who did not receive methocarbamol (Aljuhani et al., 2017). The International Classification of Disease (ICD) is a propensity score that was used to calculate severity of injury based on age and sex to ensure similarity between the two groups (Aljuhani et al., 2017). A total of 200 patients were included in the cohort (100 in each group) with the majority being men (67%) (Aljuhani et al., 2017). In the treatment group, the most common dose of methocarbamol was 750 mg every eight hours (Aljuhani et al., 2017). Patients in the methocarbamol group had higher opioid consumption on the first day (p<0.001) (Aljuhani et al., 2017). Mean baseline pain scores were 7.4 2.6 and 6.8 3.2 in the methocarbamol and control groups, respectively (P=0.191) (Aljuhani et al., 2017, p. e205). A randomized, double-blind trial was conducted in two urban EDs to assess the effectiveness of methocarbamol with naproxen (non-steroidal anti-inflammatory drug) for acute low back pain (Friedman et al., 2018). Patients admitted with acute low back pain were enrolled in the study at discharge from the ED (Friedman et al., 2018). Every patient (n=240) received METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 18 naproxen and a brief low back pain educational session, and then were randomized to methocarbamol or a placebo (Friedman et al., 2018). Patients who received methocarbamol were instructed to take naproxen 500 mg tablets twice per day + methocarbamol 750 mg up to three times per day (Friedman et al., 2018). Researchers utilized the Roland Morris Disability Questionnaire (RMDQ) to assess back pain at one week, three months, and 6 months (Friedman et al., 2018). The primary outcome researchers were looking for was improvement in the RMDQ score between discharge from the ED and one week follow-up (Friedman et al., 2018). One week after the ED visit, patients randomized to methocarbamol improved their RMDQ score by a mean of 8.1 points (95% CI 6.1 to 10.1) and patients with the placebo improved by a mean of 10.9 RMDQ points (95% CI 8.9 to 12.9) (Friedman et al., 2018). The difference between methocarbamol and the placebo was 2.8 (95% CI 0 to 5.7) suggesting that methocarbamol has no significant effectiveness when added to naproxen for the treatment of acute low back pain (Friedman et al., 2018). Theoretical Framework Betty Neumans Systems Model is a nursing theoretical framework that will be used to guide this project (See Appendix B). Neumans theory focuses on response of the patient to actual or potential environmental stressors, and the use of nursing intervention to improve patient well-being (Petiprin, 2016). The model suggests that every patient has individualistic characteristics and responses to their environment (Petiprin, 2016). Neuman emphasizes three components to her Systems Model, intrapersonal, interpersonal, and extra-personal stressors, which all surround a person, affecting stability of the system (Petiprin, 2016). Intrapersonal stressors are those contained within the patient, interpersonal stressors arise from interaction METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 19 surrounding the individual, and extra-personal stressors include all uncontrollable interactions outside of the individual (Ahmadi & Sadeghi, 2017). For this project, pain will be viewed as the stressor, whether it be intrapersonal, interpersonal, or extra personally driven. To address the stressor, or pain, Neumans Model incorporates primary, secondary, and tertiary interventions (Ahmadi & Sadeghi, 2017). Primary interventions are aimed at preventing exposure to stressors, secondary interventions involve treatment immediately after response to a stressor, and tertiary interventions support recovery (Ahmadi & Sadeghi, 2017). Intraoperative methocarbamol administration represents a primary intervention. The goal of methocarbamol administration intraoperatively is to prevent and/or reduce the severity of post operative pain. If successful, methocarbamol will prevent the patient from experiencing intrapersonal and interpersonal stressors, and the necessity of secondary intervention, such as post operative narcotic administration. Project Aim/Objectives The primary aim of this project is to determine the benefit of intraoperative methocarbamol administration on pain scores to patients undergoing LAVH procedures. 1. To determine the impact of methocarbamol administration on post operative pain scores in comparison to short-acting opioid medications. 2. To compare the relationship between intraoperative methocarbamol administration and intraoperative opioid/nonopioid pain medication administration. 3. To determine the relationship between intraoperative methocarbamol administration and post operative opioid use. METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 20 SWOT Analysis Strengths The hospital organization where the project will be conducted regularly performs LAVH procedures, which will allow for a greater sample size. Performing a retrospective chart review is a relatively low cost compared to prospective clinical trials (Kaasalainen et al, 2014). In addition, advances in technology have made access to medical charts readily available, with less risk of illegible data and missing charts. Weaknesses Incomplete data, unclear data abstraction, and inconsistency or mistakes in coding adequate pain scores are all potential weaknesses to this project (Kaasalainen et al, 2014). Together, these may negatively impact the validity and reliability of the retrospective chart review method (Kaasalainen et al, 2014). Opportunities Many of the anesthesia providers already use and support intraoperative methocarbamol administration. Key stakeholders such as PACU nurses and patients serve to benefit, especially if data suggests that methocarbamol administration reduces post operative pain and less narcotic administration. In addition, performing a retrospective chart review allows the patient to not be burdened with actively participating in the research process (Kaasalainen et al, 2014). Threats One threat to this project is the subjectivity of pain scores. Patients manifest pain differently and may under report or over report the amount of pain they are experiencing. Since anesthesia providers at this hospital organization regularly administer methocarbamol, there may not be enough patients who did not receive the medication for comparison. Global pandemics METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 21 and health crises, such as a COVID-19 outbreak, could cause surgery cancellations and hospital shutdowns, resulting in lack of access to data for this project (Appendix C). Project Design/Methods A retrospective chart review was conducted to analyze data of patients who underwent an LAVH procedure between April 1, 2021, and April 1, 2023. Pain scores were compared between patients who received methocarbamol intraoperatively to those who did not receive methocarbamol. Postoperative pain scores listed in the quantitative 0-10 (0 = no pain; 10 = most severe pain) grading scale will be evaluated and averaged for each patient while in the PACU. Using a standard data collection form, data will be abstracted from the electronic medical record (EMR). Data will be de-identified by the primary investigator to include pain scores, operation type, intraoperative and postoperative intravenous (IV) narcotic administration, intraoperative IV nonsteroidal anti-inflammatory medication administration, and intraoperative IV methocarbamol administration. Surgical diagnoses for this study will include polycystic ovary syndrome (PCOS), endometriosis, gynecologic cancer, and uterine fibroids. Collection of data will occur during the preoperative, intraoperative, and postoperative periods to ensure pertinent information is collected. Project Site and Population The project will be completed at a level II trauma medical center in the Midwest. The hospital chosen is one of two other medical centers which operate under a single organization. The main surgical suite of the hospital has 20 operating rooms (ORs), serving a variety of specialties such as cardiothoracic, vascular, gynecology, urology, and general surgery. In addition, attached to the medical center is a 10,000 square foot minimally invasive surgery center with four ORs, designed to focus on outpatient gynecology and general surgery cases. METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 22 The patient population includes adult female patients with an American Society of Anesthesiologist (ASA) physical status classification of 1, 2 or 3, between 30 and 60 years of age, who underwent an LAVH procedure and general anesthesia during the selected timeframe. The intervention was conducted by trained anesthesia professionals, including anesthesiologists and certified registered nurse anesthetists (CRNAs). Postoperative pain score documentation and postoperative narcotic administration was performed by PACU nurses. Measurement Instruments All data for this DNP project was manually and systematically collected from the EMR and inserted into an Excel spreadsheet. To test the hypothesis on the effect of intraoperative IV methocarbamol administration on post operative pain scores, a two-sample t-test was used to compare the means. Intraoperative and postoperative opioid consumption were recorded and converted to quantitative IV morphine milliequivalents (MME) to create a standardization due to the possibility of patients who received multiple types of opioids. Intraoperative Toradol, an NSAID commonly administered by anesthesia providers as a multi-modal pain adjunct, was also recorded for each patient in both groups. The groups were then compared using a two-sample ttest via SPSS software to determine statistical significance across multiple variables. Data Collection Procedures Data for this project was manually collected via a retrospective chart review utilizing patient EMRs. Patient charts were reviewed over a 2-year time frame, beginning April 1, 2021, through April 1, 2023. Patients between 30-60 years old who underwent an LAVH during the specified timeframe were included for review. Collected data was de-identified and entered into a Microsoft Excel sheet. The Excel sheet was saved to a password protected file on the primary investigators private computer. METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 23 Upon access to patient EMRs, the preoperative evaluation was reviewed to determine patient age, ASA status, and surgical diagnosis. Next, the patients MAR was reviewed to determine if the patient received methocarbamol intraoperatively, and if so, what dose of the medication the patient received. Patients were then be divided into two different groups, one group who received methocarbamol and one group who did not receive methocarbamol. The MAR was assessed to document each opioid the patient received. Opioids given were recorded separately, into intraoperative administration and postoperative administration. Lastly, the primary investigator reviewed the MAR to determine if Toradol was given, and a dose was recorded for each patient. PACU pain scores were then be documented and calculated for each patient. Ethical Considerations The Institutional Review Board (IRB) of the site facility approved this project before it was implemented. In addition, Marian University IRB approval was obtained prior to initiation. The official IRB determination form was submitted upon project proposal is approval (Appendix E). All participants were protected by the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (OCR, 2021). HIPPA sets national standards for the protection and confidentiality of individually identifiable electronic patient health information by healthcare providers (OCR, 2021). Patient confidentiality was assured by coding the participants using individual identification numbers. A check mark was given to identify other study variables (opioid administration, methocarbamol administration, Toradol administration, surgical diagnosis) specific to each patient reviewed for this project. The Excel spreadsheet containing data was kept on a password protected computer, only accessible to the primary investigator. All information METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 24 collected for this project will be displayed in a manner that upholds the organizations values and privacy statement. Results The EMRs of 80 patients who underwent an LAVH procedure during the period of April 1, 2021, through April 1, 2023, were reviewed to determine the impact of intraoperative methocarbamol administration on post operative pain scores. The sample was divided into two groups, patients who received methocarbamol intraoperatively (n=40) and patients who did not receive methocarbamol (n=40). Of the total sample, 1 patient was classified as an ASA 1 (1.25%), 64 patients were classified as an ASA 2 (80%), and 15 patients were classified as an ASA 3 (18.8%). Surgical diagnoses for this study were coded and analyzed (see Table 1.1). Some patients had 2 diagnoses (n=22), but between both groups, menorrhagia, heavy or prolonged menstrual bleeding (n=48), was the most common diagnosis. Table 1.1 NUMBER OF PATIENTS DIAGNOSIS PCOS ENDOMETRIOSIS GYNECOLOGIC CANCER UTERINE FIBROIDS MENORRHAGIA UTERINE PROLAPSE PELVIC PAIN NUMBER OF PATIENTS (+) METHOCARBAMOL (-) METHOCARBAMOL 0 7 8 8 21 1 9 0 5 3 7 27 3 2 The MAR for each group was analyzed to determine if patients received Toradol, and other opioids intraoperatively. Patients who received Toradol were all given a dose of 30mg (methocarbamol (-), n=18, 45%; methocarbamol (+), n= 21, 52.5%). Intraoperative opioids were recorded for each group, (Table 2.1 and Table 2.2) and then converted to MMEs. In both groups, fentanyl was the most frequently administered intraoperative opioid (methocarbamol (-), METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 25 n=34, 85%; methocarbamol (+), n=38, 95%). Hydromorphone was given to 72.5% of the methocarbamol (-) group and 47.5% of the methocarbamol (+) group. Morphine was not given to any of the patients intraoperatively. Of the patients who received methocarbamol, a range of 3 doses were administered (500mg, 750mg, 1000mg). Dose choice was assumed to be provider preference, where 3 patients received 500mg, 1 patient received 750mg, and the remainder of patients were given 1000mg (n=36) of methocarbamol. Intraoperatively, the methocarbamol (-) group had a total opioid consumption of 630.4mg, whereas the methocarbamol (+) group had a total opioid consumption of 572.4mg (p=0.38). Table 2.1 Intraoperative opioid administered methocarbamol group (-) IV OPIOID NUMBER OF PATIENTS FENTANYL 34 HYDROMORPHONE 29 MORPHINE 0 Table 2.2 Intraoperative opioid administered methocarbamol group (+) IV OPIOID NUMBER OF PATIENTS FENTANYL 38 HYDROMORPHONE 19 MORPHINE 0 TOTAL MME (MG) 470 160.4 0 TOTAL MME (MG) 480 92.4 0 Postoperative opioid consumption in the first hour of PACU stay was also converted to MMEs. In the PACU, the methocarbamol (-) group had a total of 339.6mg of opioids, and the methocarbamol (+) group had a total of 327.5mg of postoperative opioids. The total MME per patient is lower for the methocarbamol (+) group, although the difference is not statistically significant (p=0.42). Postoperative pain scores for each group were recorded by PACU nurses (0-10 scale) at the 5-minute, 15-minute, 30-minute, and 1-hour time intervals after being admitted to the unit (Appendix D). An initial two sample t-test was performed at each respective METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 26 time interval to compare postoperative pain scores between the two groups. At the 5-minute and 15-minute intervals, patients who received methocarbamol reported significantly lower postoperative pain scores (p=0.04, p=0.03). However, pain scores at the 30-minute and 1-hour intervals were not significant between the two groups (p=0.1, p=0.08). A second two sample ttest was conducted between the two groups, eliminating the 4 patients who received less than 1000mg of methocarbamol. Patients who received 1000mg had significantly lower postoperative pain scores at the 5-minute, 15-minute, and 30-minute intervals (p=0.03, p=0.01, p=0.03), however, at 1-hour there was no significance (p=0.09). Discussion Overall, patients who received methocarbamol intraoperatively reported a significant improvement in postoperative pain scores compared to patients who did not receive methocarbamol. Initial data analysis, which included all patients who received methocarbamol, regardless of dose, suggested that improvement in postoperative pain scores was significant up to the first 15 minutes in the PACU. A second t-test was performed to exclude patients who received a dose of methocarbamol less than 1000 mg. Results from the second analysis suggested a more significant improvement in postoperative pain scores for a longer period. Intraoperative IV Toradol was given to more patients in the methocarbamol (+) group (n=21, 52.5%) than to those who did not receive methocarbamol (n=18, 45%). The methocarbamol (-) group received more intraoperative and postoperative opioids, however, the difference between the two groups was not significant. Strengths A strength of this project was the inexpensive ability to research and analyze existing data while providing a simplistic description of results. Upon initial investigation, there was METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 27 minimal data and research available regarding the efficacy of methocarbamol and its impact on postoperative pain following LAVH procedures. The hypothesis generated from this project may be used as an initial study to generate hypotheses for further, larger prospective studies. Limitations This project was designed to analyze pre-existing data, making the validity of data reliant on the availability and accuracy of the medical record. In addition, this project was subject to confounding evidence and biases. Although the ASA physical classification status and diagnoses were included, there is potential for other individual patient risk factors that were not measured. Pain is subjective and can present differently in every patient, resulting in a response bias that may influence accuracy of results. Conclusion Shorter recovery times, better cosmetic results, and less pain are benefits that have attracted many surgeons to perform minimally invasive surgical techniques. Specifically, the LAVH procedure is one of the most common hysterectomy techniques utilized by surgeons annually. After a thorough review of literature, there is evidence to suggest postoperative pain following an LAVH procedure continues to pose a challenge for anesthesia providers. A centrally acting skeletal muscle relaxant, such as methocarbamol, may provide pain relief while reducing PACU pain scores that may lead to decreased total opioid consumption. The results obtained from this project are limited but may yield to the development of a hypothesis for a much larger study, better suited to determine a causal relationship. To lessen the risks and side effects associated with opioids, while maintaining optimal pain control, future research of intraoperative pain management using methocarbamol should be considered. METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 28 References Abd-Elsalam, S., Arafa, M., Elkadeem, M., Elfert, A., Soliman, S., Elkhalawany, W., & Badawi, R. (2019). Randomized-controlled trial of Methocarbamol as a novel treatment for muscle cramps in cirrhotic patients. European Journal of Gastroenterology & Hepatology, 31(4), 499502. https://doi.org/10.1097/meg.0000000000001310 Ahmadi, Z., & Sadeghi, T. (2017). Application of the Betty Neuman Systems Model in the nursing care of patients/clients with multiple sclerosis. Multiple Sclerosis Journal Experimental, Translational and Clinical, 3(3). https://doi.org/10.1177/2055217317726798 Aljuhani, O., Kopp, B. J., & Patanwala, A. E. (2017). Effect of methocarbamol on acute pain after traumatic injury. American Journal of Therapeutics, 24(2). https://doi.org/10.1097/mjt.0000000000000364 Calculating total daily dose of opioids for safer dosage. CDC.gov. (2018). https://www.cdc.gov/opioids/providers/prescribing/pdf/calculating-total-daily-dose.pdf Chen, S., Du, W., Zhuang, X., Dai, Q., Zhu, J., Fu, H., Wang, J., & Huang, L. (2021). Description and comparison of acute pain characteristics after laparoscope-assisted vaginal hysterectomy, laparoscopic myomectomy and laparoscopic adnexectomy. Journal of Pain Research, Volume 14, 32793288. https://doi.org/10.2147/jpr.s335089 Choi, J. B., Kang, K., Song, M. K., Seok, S., Kim, Y. H., & Kim, J. E. (2016). Pain characteristics after total laparoscopic hysterectomy. International Journal of Medical Sciences, 13(8), 562568. https://doi.org/10.7150/ijms.15875 Eggemann, H., Ignatov, A., Frauchiger-Heuer, H., Amse, T., & Costa, S. D. (2018). Laparoscopic-assisted vaginal hysterectomy versus vaginal hysterectomy for benign METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 29 uterine diseases: A prospective, randomized, multicenter, double-blind trial (lava). Archives of Gynecology and Obstetrics, 297(2), 479485. https://doi.org/10.1007/s00404017-4647-7 Friedman, B. W., Cisewski, D., Irizarry, E., Davitt, M., Solorzano, C., Nassery, A., Pearlman, S., White, D., & Gallagher, E. J. (2018). A randomized, double-blind, placebo-controlled trial of naproxen with or without orphenadrine or Methocarbamol for acute low back pain. Annals of Emergency Medicine, 71(3). https://doi.org/10.1016/j.annemergmed.2017.09.031 Gynecologic Surgery. TriHealth. (2023). https://www.trihealth.com/services/trihealth-surgicalcare/robotic-assisted-surgery/gynecologic-surgery Hickman, L., & Propst, K. (2022). Total laparoscopic hysterectomy: Procedure steps and evidence. Laparoscopic Urogynecology, 155161. https://doi.org/10.1017/9781009128377.020 Hidalgo, D., & Pusic, A. (2005). The role of Methocarbamol and intercostal nerve blocks for pain management in breast augmentation. Aesthetic Surgery Journal, 25(6), 571575. https://doi.org/10.1016/j.asj.2005.09.003 Kaasalainen, S., Wickson-Griffiths, A., Ploeg, J., & McAiney, C. (2014). Revisiting retrospective chart review: An evaluation of nursing home palliative and end-of-life care research. Palliative Medicine & Care: Open Access, 1(2). https://doi.org/10.15226/23748362/1/2/00110 Khan, N. F., Bykov, K., Barnett, M. L., Glynn, R. J., Vine, S. M., & Gagne, J. J. (2022). Comparative risk of opioid overdose with concomitant use of prescription opioids and METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 30 skeletal muscle relaxants. Neurology, 99(13). https://doi.org/10.1212/wnl.0000000000200904 Mohammed, W. E., Salama, F., Tharwat, A., Mohamed, I., & ElMaraghy, A. (2017). Vaginal hysterectomy versus laparoscopically assisted vaginal hysterectomy for large uteri between 280 and 700 g: A randomized controlled trial. Archives of Gynecology and Obstetrics, 296(1), 7783. https://doi.org/10.1007/s00404-017-4397-6 Murphy, G. S., & Szokol, J. W. (2019). Intraoperative methadone in surgical patients. Anesthesiology, 131(3), 678692. https://doi.org/10.1097/aln.0000000000002755 Office for Civil Rights (OCR). (2021, August 16). HIPAA for professionals. HHS.gov. Retrieved from https://www.hhs.gov/hipaa/for-professionals/index.html Orhurhu, V., Gao, C., & Ku, C. (2022). Carbon dioxide embolism. National Library of Medicine. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK539885/ Patanwala, A. E., Aljuhani, O., Kopp, B. J., & Erstad, B. L. (2017). Methocarbamol use is associated with decreased hospital length of stay in trauma patients with closed rib fractures. The American Journal of Surgery, 214(4), 738742. https://doi.org/10.1016/j.amjsurg.2017.01.003 Petiprin, A. (2016, June 6). Neuman's systems model. Nursing Theory. Retrieved from https://nursing-theory.org/theories-and-models/neuman-systems-model.php Sesti, F., Cosi, V., Calonzi, F., Ruggeri, V., Pietropolli, A., Di Francesco, L., & Piccione, E. (2014). Randomized comparison of total laparoscopic, laparoscopically assisted vaginal and vaginal hysterectomies for myxomatous uteri. Archives of Gynecology and Obstetrics, 290(3), 485491. https://doi.org/10.1007/s00404-014-3228-2 METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 31 Sibrack, J., & Hammer, R. (2022). Methocarbamol. National Library of Medicine. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK565868/ Smith, J., Probst, S., Calandra, C., Davis, R., Sugimoto, K., Nie, L., Gan, T. J., & BennettGuerrero, E. (2019). Enhanced recovery after surgery (ERAS) program for Lumbar Spine Fusion. Perioperative Medicine, 8(1). https://doi.org/10.1186/s13741-019-0114-2 Walters, M. (2017). Muscle relaxants in multimodal pain management. Surgical Critical Care Evidence-Based Medicine Guidelines Committee. https://www.surgicalcriticalcare.net/Guidelines/Muscle%20Relaxants%202017.pdf Wong, M., Morris, S., Wang, K., & Simpson, K. (2018). Managing postoperative pain after minimally invasive gynecologic surgery in the era of the Opioid epidemic. Journal of Minimally Invasive Gynecology, 25(7), 11651178. https://doi.org/10.1016/j.jmig.2017.09.016 Zoofaghari, S., Samsamshariat, S., Sharifi-Sade, M., Mehr, A. M., & Sabzghabaee, A. M. (2021). Efficacy of the combination of indomethacin and Methocarbamol versus indomethacin alone in patients with acute low back pain: A double-blind, randomized placebo-controlled clinical trial. Journal of Research in Pharmacy Practice, 10(2), 96. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8420930/ METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH Appendix A Included Screening Identification Identification of studies via databases and registers Records identified from*: Databases CINHAL (n=1,176) PubMed (n=11,330) Records removed before screening: Records marked as ineligible by automation tools (n=5,387) Records removed for other reasons (n = 1,795) Duplicate records removed (n = 52) Records screened (n = 5,272) Records excluded** (n = 4,217) Reports sought for retrieval (n = 1,055) Reports not retrieved (n = 945) Reports assessed for eligibility (n = 110) Reports excluded: Research objective is not applicable (n =74) LAVH technique not used (n = 26) Studies included in review (n =10) 32 METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH Appendix B 33 METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH Appendix C 34 METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH Appendix D AVERAGE POSTOPERATIVE PAIN SCORE POSTOPERATIVE PAIN SCORE 10.0 8.0 5.5 6.0 4.8 4.6 4.0 3.6 3.3 4.7 3.9 2.4 2.0 0.0 Methocarbamol (+) all doses Methocarbamol (-) MINUTES 5 15 30 60 AVERAGE POSTOPERATIVE PAIN SCORE POSTOPERATIVE PAIN SCORE 10.0 8.0 5.5 6.0 4.3 4.0 2.2 4.8 4.7 3.9 3.6 2.9 2.0 0.0 Methocarbamol (+) 1000mg Methocarbamol (-) MINUTES 5 15 30 60 35 METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 36 Appendix E Citation Research Design & Level of Evidence Population / Sample size n=x Major Variables Instruments / Data collection Eggemann, H., Ignatov, A., Frauchiger-Heuer, H., Amse, T., & Costa, S. D. (2018). Laparoscopicassisted vaginal hysterectomy versus vaginal hysterectomy for benign uterine diseases: A prospective, randomized, multicenter, double-blind trial (lava). Archives of Gynecology and Obstetrics, 297(2), 479485. https://doi.org/10.1007/s00404017-4647-7 Randomized control trial (RCT) N=192 Postoperative pain VAS Peritoneal closure Level 4 Parity, BMI, uterus weight, previous abdominal surgery, age Operating time Results Operative time was significantly longer Statistical after LAVH (LAVH analysis + PC 106 29 min; systems LAVH PC 99 30) (SAS) (p < 0.0001) and significantly shorter Two oneafter VH (VH + PC sided (TOST) 59 17; VH PC 56 equivalence 19). test The first three days after surgery, patients in the LAVH group (n=95) reported more pain than those in the VH group (n=92) (VAS score day 1: p = < 0.0001; VAS score day 2: p = 0.021; VAS score day 3: p = 0.039). Peritoneal closure did not have any influence on postoperative pain (+PC versus -PC: VAS score day 1, p = 0.9399) METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH Sesti, F., Cosi, V., Calonzi, F., Ruggeri, V., Pietropolli, A., Di Francesco, L., & Piccione, E. (2014). Randomized comparison of total laparoscopic, laparoscopically assisted vaginal and vaginal hysterectomies for myxomatous uteri. Archives of Gynecology and Obstetrics, 290(3), 485491. https://doi.org/10.1007/s00404-014-32282 Randomized control trial (RCT) Level 4 N=108 37 Hospital discharge time Operating time, blood loss, paralytic ileus time, postoperative time, intraoperative complications, early postoperative complications Standard preoperative assessment with transvaginal ultrasound VAS The Students ttest for analysis of continuous variables Uterine size ^2 test or Fischers exact test for discrete variables General linear model (GLM) used to perform a regression analysis for dependent variables All analyses performed using SPSS Overall, 17 (47%) women reported no pain (VAS = 0) after VH, 19 (53%) after TLH, and five (14%) after LAVH (Sesti et al., 2014). Subsequently, 10 (28%) women reported moderate pain after VH (VAS 1-25), eleven (30%) after TLH, and 22 (61%) after LAVH. No significant differences were found for postoperative pain over a 24-hour period among these three different methods (p = 0.32). METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH Chen, S., Du, W., Zhuang, X., Dai, Q., Zhu, J., Fu, H., Wang, J., & Huang, L. (2021). Description and comparison of acute pain characteristics after laparoscope-assisted vaginal hysterectomy, laparoscopic myomectomy and laparoscopic adnexectomy. Journal of Pain Research, Volume 14, 32793288. https://doi.org/10.2147/jpr.s335089 Cohort study N=669 38 Postoperative pain Level 3 Preoperative: Age, BMI, level of education, occupation, exercise habits, individual medical history, obstetric history, previous surgery history, preop chronic pain history, medical insurance type, indication for surgery, level of anxiety Intraoperative: number of trocars, intraoperative diagnosis, duration of surgery, blood loss, complications Postoperative: nausea and Numerical rating scale (NRS) Stata 15 for statistical analysis KolmogorovSmirnov test to determine normality Chi-squared test to compare measurement data Bonferroni test for multiple comparisons Visceral pain had the highest incidence and most severe rating in the LAVH and LH groups, followed by low back pain. Of the patients in the LAVH group, up to 73.1% of patients reported moderate (n=64, 25.7%) to severe (n=49, 19.7%) visceral pain, and 61% of patients in the LM group reported moderate (n=46, 21.9%) to severe pain (n=40, 19%). However, in the LA group, incisional pain was reported to be the most severe, with up to 39% of patients reporting moderate (n=26, 12.4%) to severe pain (n=9, 4.3%). Opioid consumption was highest in the LAVH group than the LM or LA group in the PACU. METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH Hidalgo, D., & Pusic, A. (2005). The role of Methocarbamol and intercostal nerve blocks for pain management in breast augmentation. Aesthetic Surgery Journal, 25(6), 571575. https://doi.org/10.1016/j.asj.2005.09.003 Randomized control trial (RCT) N=100 39 vomiting, pelvic drainage time, indwelling catheter time, and 24-h pelvic drainage Postoperative pain Narcotic use Level 4 VAS Wilcoxon 2sample test with a 0.05 2-sided significant level KruskalWallis test for overall differences among the 4 groups Aljuhani, O., Kopp, B. J., & Patanwala, A. E. (2017). Effect of methocarbamol on acute pain after Cohort study N=200 Age, sex, injury severity, International Classification Patients who received methocarbamol had significantly lower VAS pain scores and reduced narcotic use in the first few hours after surgery than those who did not (P= 0.03). Beyond 6 hours after surgery there was no significant difference seen among those who received methocarbamol and those who did not (P= NS, not significant). There was no significant difference in pain scores and narcotic use seen in patients who received intercostal nerve blocks compared to those who did not (P=NS). Patients in the methocarbamol group METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH traumatic injury. American Journal of Therapeutics, 24(2). https://doi.org/10.1097/mjt.0000000000000364 Level 3 40 history of drug abuse, vital signs, Glasgow coma scale, injury location, opioid use before admission, surgeries performed, analgesics used during admission, and adverse effects of Disease ninth Editionderived Injury Severity Score (ICISS) Methocarbamol Mean pain scores on day 1, 2, 3 ^2 test or Fischers exact test for categorical variables Opioid consumption Hospital length of stay Patanwala, A. E., Aljuhani, O., Kopp, B. J., & Erstad, B. L. (2017). Methocarbamol use is associated with decreased hospital length of stay in trauma patients with closed rib fractures. The American Journal of Surgery, 214(4), 738742. https://doi.org/10.1016/j.amjsurg.2017.01.003 Cohort study Level 3 N=592 Age, sex, race, ethnicity, need for endotracheal intubation, need for blood The Student t-test for analysis of continuous variables Linear regression analyses to determine effect of methocarbam ol on mean pain score for each day Log-rank test to compare methocarbam ol and no methocarbam ol groups had higher opioid consumption on the first day (p<0.001). The mean baseline pain scores were 7.4 2.6 and 6.8 3.2 and in the methocarbamol and control groups, respectively (P=0.191) (Aljuhani et al., 2017, p. e205). There was no significant difference in opioid consumption on days 2 and 3. The mean length of hospital stay was similar for the methocarbamol and control groups (4.92.8 vs. 5.43.9 days, P 0.376). The average time for discharge was 5 days in the methocarbamol group (P < 0.001) and 8 days for the no methocarbamol METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 41 component transfusion, need for chest tube, in hospital mortality, discharge status, ICD-9CM diagnosis codes, Charlson Comorbidity Index, Injury Severity Score Cox Proportional Hazards Model to determine likelihood of discharge group. Patients who received methocarbamol were less likely to have pulmonary complications (11.3%, n = 37 versus 23.2%, n = 61; P = < 0.001). ^2 test or Fischers exact test for categorical variables Hospital length of stay Abd-Elsalam, S., Arafa, M., Elkadeem, M., Elfert, A., Soliman, S., Elkhalawany, W., & Badawi, R. (2019). Randomized-controlled trial of Methocarbamol as a novel treatment for muscle cramps in cirrhotic patients. European Journal of Gastroenterology & Hepatology, 31(4), 499502. https://doi.org/10.1097/meg.0000000000001310 Randomized control trial (RCT) Level 4 N=100 Pulmonary complications Methocarbamol SPSS version 23 Muscle cramps The Student t-test to compare quantitative variables ^2 test or Fischers exact test for qualitative variables There were no significant differences in muscle cramps, severity, duration, and frequency (P > 0.05). After one week, participants in group one showed a significant decrease in the mean number of muscle cramps from 11 4 (median 10.0) to 0.5 1 (median 0.0) per week. The mean METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 42 MannWhitneys test for nonnormally distributed data Friedman, B. W., Cisewski, D., Irizarry, E., Davitt, M., Solorzano, C., Nassery, A., Pearlman, S., White, D., & Gallagher, E. J. (2018). A randomized, double-blind, placebo-controlled trial of naproxen with or without orphenadrine or Methocarbamol for acute low back pain. Annals of Emergency Medicine, 71(3). https://doi.org/10.1016/j.annemergmed.2017.09.031 Randomized control trial (RCT) N=240 Low back pain, naproxen, methocarbamol RMDQ scores RolandMorris Disability Questionnair e (RMDQ) Level 4 SPSS version 21 Results reported as means with 95% CI score of pain severity decreased from 6.52 1.29 to 0.66 1.18 compared to those receiving the placebo (P < 0.001 for each). Few side effects of methocarbamol were reported, which included dry mouth (P = 0.0026) and drowsiness (P = 0.0002) One week after the ED visit, patients randomized to methocarbamol improved their RMDQ score by a mean of 8.1 points (95% CI 6.1 to 10.1) and patients with the placebo improved by a mean of 10.9 RMDQ points (95% CI 8.9 to 12.9). The difference between methocarbamol and the placebo was 2.8 (95% CI 0 to 5.7) suggesting that methocarbamol has no significant effectiveness when added to naproxen for METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 43 the treatment of acute low back pain. Khan, N. F., Bykov, K., Barnett, M. L., Glynn, R. J., Vine, S. M., & Gagne, J. J. (2022). Comparative risk of opioid overdose with concomitant use of prescription opioids and skeletal muscle relaxants. Neurology, 99(13). https://doi.org/10.1212/wnl.0000000000200904 Cohort study N=544 Level 3 Skeletal muscle relaxants: baclofen, cyclobenzaprin e, metaxalone, methocarbamol , tizanidine, and chlorzoxazone Multinomial logistic regression model Opioids Cox proportional hazards model weighted by matching weights to estimate the HRs Demographics, comorbidities, pain conditions, and other prescription fills, previous opioid utilization Zoofaghari, S., Samsamshariat, S., Sharifi-Sade, M., Mehr, A. M., & Sabzghabaee, A. M. (2021). Efficacy of the combination of indomethacin and Methocarbamol versus indomethacin alone in patients with acute low back pain: A double-blind, randomized placebo-controlled clinical trial. Journal of Research in Pharmacy Practice, 10(2), 96. https://doi.org/10.4103/jrpp.jrpp_21_31 Randomized control trial (RCT) Level 4 N=64 Low back pain, Indomethacin, methocarbamol Comorbidities: kidney failure, mental illness, heart disease, liver disease, active peptic Matching weight (all of probabilities estimated) SPSS software Chi-square test Back pain function scale In the first 30 days, the highest number of opioid overdose events occurred with the cyclobenzaprine (n = 278) and baclofen (n = 266) groups. The hazard ratio (HR) for opioid overdose relative to methocarbamol was 1.00 (95% CI 0.452.20, adjusted P value > 0.99). Compared to cyclobenzaprine and baclofen, no other muscle relaxants, such as methocarbamol, were correlated with an increased risk of opioid overdose. Before initiation of the intervention, pain scores and sex between both groups did not differ significantly (p > 0.05). Both groups had significantly lower pain scores after the intervention, however, patients in METHOCARBAMOL EFFECT ON POSTOPERATIVE PAIN AFTER LAVH 44 ulcer, and hemorrhoids. Age, sex, BMI group two (I + M) had significantly higher pain reduction than that of group one (3.66 3.17 vs. 1.84 1.53; P < 0.001). In addition, the average BPFS score, or functional status, increased in group two (I + M) significantly higher than group one (19.44 8.66 vs. 4.75 4.35; P < 0.001).  ...

... DISASTER MANAGEMENT PLAN SteP- 1: Mitigation Measures taken to eliminate hazards, stop threats, or limit impact of incidents Prevention: Information sharing with local, regional, state, and national public safety, public health, healthcare, and homeland security stakeholders. Video surveillance camera systems. Protection: Personal protection and guest relations staff at hospital entry points. SteP- 2: PreP-aredness Program activities which facilitate a continuous cycle of taking correct action to ensure effective coordination during incident response. Planning; Developing a plan framework and distributing the plan Organization: Incident command/emergency response teams and the executive leadership structure Training; IU Health E-learning Management System EguiP-ment: Personal protective equipment and detection/decontamination screening HAZARDOUS SPILL DISASTER: IU METHODIST By: Lauren Rinehart, JD Farrell, Peyton Dethy COMMUNITY ENGAGEMENT Pe:v.ton interviewed the Manager of the ED: Continuous care nurse steps up to be head of department while nurse manager, tech, AA come to help with clearing unit and triage of mass casualty and hazardous incident. If patient enters ED AND ARE CONTAMINATED staff guides them externally to the decontamination room to decontaminate and decontaminate potential areas patient came into contact within triage area. MET!-10:DISli lilOSPITJ'l,l - Sept 2023 M;i,s Cdsu dt~ A< Hv1lion M ETHODIST HOSPITAL - Sept 2023 AMBULAN~E TRIAGE HAZARDOUS MATERIALS INCIDENT QUICK REFER I NU IF DE-C(l N NHOEO, S.H HAlMAT C[UIC K KEY QUESTION S REFHENCE AMBUL ANCE T RIAGE ANDFIRONT TRIIAGE PROVIDER WILL DE:TERM INI: W,HERE PATIENTS WII.L. GO - INFORM Rl!!:GISTRATION STAFF OF BED# CONTACT IU POLICE TO SECURE BOTH AMBULANCE AN D ED, ENTRANCE. MAVE IU I-IEALTH POLIIC1E D IRECT AMBl.l!.AtllC E TRAFFIC 1 ..__.:..: PA :.;;TIE_N_T _ I The deployment and coordination of hospital staff, resources, and systems in hazardous waste spills -~ -"":" NON-AMBULATORY PATIENT ._____ __. __ __, I A.Mf!lUL ~NCE: ENiT"RA N ( IE f O FR

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