Facilitators and Barriers to Nursing Surveillance of Instability in Hospitalized Pediatric Patients: A Grounded Theory Study

Identification of patients at risk for deterioration initially started with studies that focused predictors of cardiopulmonary and neurovascular demise. This spawned research to evaluate the utility of predictor models followed by the performance studies of early warning track and trigger systems in adults. Mandates to provide emergency services early in the course of instability in the 1990s fueled research to analyze the outcomes of rapid response systems and early warning systems in both adults and pediatrics. Recently studies have looked at system and human factors that impact failure to rescue. Given the dearth of systems research in early prevention of deterioration in pediatrics this study was designed to explore what nurses do during deterioration and the factors that impact their actions. Interview and observations of 13 pediatric nurses and 16 parents of pediatric patients admitted to a non ICU environment were conducted at one academic children’s hospital in the Northwest USA. Grounded theory methods were used to guide data collection and analysis. Findings describe nursing actions associated with nursing surveillance of instability as well as factors that facilitate or impede surveillance efficacy. We present a theoretical model for how nurses and parents integrate their roles in surveillance of pediatric patients. We also further developed a sociotechnical model of nursing surveillance

Activating Strengths during the Transition from Community College to University: A Phenomenological Study of Vulnerable Transfer Students

abstract: The transition experience for students who are transferring from community college to university can be an overwhelming experience for any typical student, but can be even greater for students with vulnerable backgrounds. This phenomenological action research study followed the five-month community college to the university transition experience of five students in a scholarship program. The students participated in a three-part intervention in support of their transition experience. Three theoretical perspectives framed the study: community cultural wealth, transition theory, and transfer student capital. This framework enabled me to first identify the strengths the students possessed, despite their vulnerable backgrounds, through participation in individual interviews. The students then participated in pre- and post-focus groups and completed pre- and post-questionnaires. Through these, they identified which transition coping skills were their strongest and which transfer capital they possessed from their community college experience. They also shared how they applied those prior learned skills and capital at the university. This study revealed how these students utilized their strengths at moments when they lacked certain coping skills and transfer capital during their transition experience. One particular strength was how the students accessed the resources of the scholarship program at the center of this study to help them with their sense of the ability to succeed at the university.Dissertation/ThesisDoctoral Dissertation Leadership and Innovation 201

Doctor of Philosophy

dissertationThe cost of medication errors is burdensome to patients, institutions, and frontline providers. Nurses are accountable for and vulnerable to institutional safe medication practices and make this responsibility their highest priority; yet, contextual factors relevant to nurses' work encompassing medication administration are not well understood. The aim of this ethnographic study was to identify and describe nurses' work in the context of medication administration, errors, and organizational safety. Using nonparticipant observation (92 hours) and 37 unstructured interviews with nurses, administrators, and pharmacist in a mid-sized hospital in the United States, I found the nature of nurses' work characterized by: 1) chasing a standard of care, 2) prioritizing practice , and 3) renegotiating routines. These characteristics were inextricably linked to organizational structures, the medication management system, competing obligations, and shifting of priorities. Data were divided into two articles: 1) Nurses' Work in the Context of Medication Administration: Untenable Expectations provides a thick description of everyday experiences on the unit, medication administration, and the potential for errors. From these data, I present an emerging theoretical model. 2) The Paradox of Safety in Medication Management is a microanalysis of the medication use process with a specific focus on patterns of medication errors in the hospital, and the role of the pharmacists as a "stop-gap" between the physicians and patients in the recognition and interception of medication errors. These results enhance our understanding of why present efforts targeting the reduction of medication errors may be ineffective

Let Your Life Speak: Exploring the Lived Experience of Graduate Nurses In an Emergency Department Setting

The purpose of this research was to explore the lived experience of graduate nurses (GNs) who made the transition from academic to practice environment in the high-acuity setting of a Level 1 trauma center. These GNs entered clinical practice through a nurse residency program at Truman Medical Center (TMC) emergency department (ED) in Kansas City, Missouri. The researcher interviewed 6 GNs participating in the nurse residency program with IRB approval from the University of Missouri, Kansas City IRB. The method of inquiry was hermeneutic phenomenology. The basic research question for this study was as follows: As a participant in a graduate nurse residency program, what was it like for you to make the transition from advanced beginner to competent, practicing nurse in the ED setting? The transcribed narratives of the interviews served as the primary data for this research. Themes which emerged from the data informed the findings of this thesis

Philosophy and Practice: Examining Classroom Management in Progressive Education Settings

Are John Dewey\u27s and Lucy Sprague Mitchell\u27s twentieth century hopes for classroom management realized in the early twenty-first century practices in progressive schools? The viewpoints of these two pioneers in progressive education create the backdrop for examining the execution of classroom management in present-day progressive educational settings in this study. In order to examine classroom management in practice, three classroom observations and teacher interviews were conducted in progressive schools in New York City. These observations and interviews are compared and analyzed through the lens of Dewey and Mitchell\u27s thoughts about the functioning of a classroom. The study does not claim to arrive at definitive answers to the questions that have been raised about classroom management in progressive settings, but draws conclusions based on the brief glimpses into the workings of these classroom and the ideas of the teacher participants. This work offers an opportunity to look deeply at how Dewey\u27s and Mitchell\u27s ideas about classroom management might be reflected in the current practices of teachers in progressive schools

Network Alignment in Healthcare: A Socio-Technical Approach to System-Wide Improvement and Patient Safety.

Local process improvement efforts have permeated the healthcare industry, yet the ability to extend these improvements across the system continues to be a challenge. Coordinating services, or patient care, across organizational boundaries can be difficult and can impact leadership’s ability to enable widespread organizational change. This research presents a socio-technical approach to cross-unit coordination and system-wide improvement by forwarding a network alignment methodology that can aid in the identification of gaps throughout a system. The proposed model examines the alignment of patient or diagnostic information flow, the technical flow network, with the ability to clearly define customer requirements and problem solve with suppliers, the safety control network. This research uses a case study approach to assess the current situation and demonstrate an improvement approach to coordinate across organizational boundaries for improved quality in health care. Using both qualitative and quantitative data, we observe empirically a relationship between unit coordination and quality, safety culture, and process improvement efforts. This work provides a method for analyzing value streams that differ from the linear, sequential value stream mapping techniques commonly employed in manufacturing and introduces a coordination assessment measurement approach to quantify mismatches between technical flow and organizational structure. The ability of leadership to understand where breakdowns occur and develop countermeasures can impact the effectiveness of system-wide problem solving which, in turn, becomes the basis for continuous organizational learning and improvement.Ph.D.Industrial & Operations EngineeringUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/91582/1/ballards_1.pd

The Ethical Obligation for Disclosure of Medical Error in the Intensive Care Unit

The very facts that humans are fallible and that they are integrally involved in the delivery of healthcare and medical treatment guarantee that medical errors will occur despite the best of training, skills and vigilance, precautions, or preventive procedures. While medical errors occur across the spectrum of care and treatment, the propensity for their occurrence and the severity of the damage they are likely to inflict are undeniably greatest in the hospital intensive care unit (ICU). The fundamentals of biomedical ethics require nothing less than a thorough systematic analysis of the sources of error in the ICU, along with a comprehensive, coordinated approach to preventing error to the extent humanly possible and to handling and mitigating the effects of error whenever they do occur. Through the chapters of this dissertation, the research and analysis has provided the following: 1) a detailed account, to the extent that it has been documented, of the high frequency of errors occurring in the U.S. in general and specifically in hospital intensive care units, as well as the range and extent of the harm done to patients and family members, both physically and financially; 2) a classification and analysis of the proximate, intermediate and ultimate causes of and contributing factors to medical errors, which in addition to identifying causation has formed the basis for this dissertation’s recommendations aimed at developing procedures and protocols to effectively reduce errors to the greatest degree possible while minimizing their harmful impact; 3) an in-depth analysis of expectations, grounded in biomedical ethics, for dealing with the consequences of medical errors including disclosure and communication, the expectations of patients and family members, the attitudes and concerns of medical professionals, the disconnect between these two groups, and recommendations for procedures and protocols to ensure prompt, complete, and just handling of all consequences of the error; 4) an in-depth framework, based on Western religious and cultural foundations, for both those responsible for and those injured by medical errors to interact in handling the consequences of the error, as well as all of the communication which it engenders; and 5) proposals for numerous procedures and protocols, both for lessening the vulnerability of hospital ICU patients to suffering the effects of an error and for addressing and counteracting the variety of systemic problems which create or heighten the propensity for the occurrence of medical errors

Breadwinner Mothers of School-Aged Children during COVID-19: An Interpretative Phenomenological Analysis

Working mothers have long faced myriad challenges to optimal work-life balance, with evidence of negative consequences to their physical and mental wellbeing. During the COVID-19 pandemic, working mothers reported unprecedented difficulties, though inquiry into breadwinner mothers’ experiences remained lacking. This research focused specifically on the experiences of breadwinner mothers of elementary school-aged children who navigated remote working and remote schooling during the COVID-19 pandemic. A diverse sample of 12 breadwinner mothers across the United States completed semi-structured interviews focusing on the impact of the pandemic on their daily lives, as well as how they understood their experiences in light of dominant cultural norms regarding motherhood, work, breadwinning, and identity areas. Interpretative phenomenological analysis (IPA), intersectionality, and gender theories informed the research design and analysis. Data analyses yielded four overarching themes: (1) Intensification of an Already Non-Stop and Exhausting “Juggling Act” (2), Left to One’s Own Devices, Figuratively and Sometimes Literally (3), Merging of Work and Home Life as a Double-Edged Sword; and (4) Ambivalence about Breadwinner Status. Findings lend support to research indicating breadwinner mothers commonly fulfill a role of outsized responsibility in caretaking and decision-making in ways often invisible, resulting in role strain, cognitive overload, and decreased self-care. Discussion of findings consider limitations, further research, and implications for counseling practice and advocacy to better support breadwinner mothers in the aftermath of the pandemic and beyond

The Bermuda Triangle: Lost in Transition

A capstone submitted in partial fulfillment of the requirements for the degree of Doctor of Education in the College of Education at Morehead State University by Kevin S. Koett and C. Thomas Potter II on July 19, 2013