Reflecting on diagnosis: The Metacognitive Diagnostic Reasoning Model©.

BACKGROUND: Diagnostic reasoning is a complex cognitive process that requires intuitive, heuristic processing from knowledge and experience, as well as deliberate and reflective thinking. Evidence on interventions to improve diagnostic reasoning is inconsistent, in part because different terms and models are used to guide research. PURPOSE: To present a model of the factors of diagnostic reasoning in Advanced Practice Registered Nurses (APRNs), based on a review of the literature supporting the Metacognitive Diagnostic Reasoning (MDR) Model©. METHODOLOGY: A review of the literature through systematic database search, historical articles, texts, and documents was conducted from inception through August 2023 (N = 41). RESULTS: The MDR model depicts the following concepts: (1) metacognition is viewed as the driving force of diagnostic reasoning; (2) dual cognitive processing and knowledge representations are used; (3) once a diagnosis, treatment plan, and evaluation are complete, APRNs use metacognition for the next patient encounter, using repetition for improvement of the process. CONCLUSIONS: The model combines key concepts of diagnostic reasoning, providing a framework for researchers to develop and test, and faculty to teach and evaluate this complex process in learners. IMPLICATIONS: The MDR model provides research opportunities to validate its usefulness and effectiveness and a framework to guide educational research, contributing to the body of evidence-based practice in nursing. In addition, it may foster ongoing education and training that could lead to more accurate diagnoses and treatment plans, ultimately improving patient care by reducing diagnostic errors.

Intrinsic Factors and Psychological Safety Among Nursing Students During Simulation-Based Learning-A Correlational Design.

INTRODUCTION: Well-designed simulation-based learning (SBL) experiences enhance students' self-confidence, self-efficacy, clinical judgment, and psychomotor skill development. An emerging concept in SBL research is psychological safety. There is currently no research on factors influencing psychological safety specifically related to the SBL environment, nor is there any literature found to determine whether intrinsic student characteristic, such as self-compassion and resilience, contributes to SBL learning outcomes. The aim of this study is to determine whether there is a relationship between nursing students' intrinsic characteristics (self-compassion, resilience, and anxiety sensitivity) and their psychological safety. METHODS: Bivariate correlation was used to examine associations among sociodemographic variables and outcome variables. Multiple regression was used to determine the predictive nature of the sociodemographic variables. Assumptions for variables in multiple regression models were tested (normal distribution, heteroscedasticity, multicollinearity). All data were analyzed in SPSS, Version 28. The P value of significance was set at 0.05 for all analyses. RESULTS: Most of the 118 participants were non-Hispanic (89%), White (65%), and females (95%). Results of the demographic bivariate analysis revealed no significant differences among this diverse group or semester in the curriculum for psychological safety. The multiple regression found self-compassion (ß = 29, P = 0.004), anxiety sensitivity (ß = -0.16, P = 0.049), and resilience (ß = 0.26, P = 0.004) predict psychological safety. CONCLUSIONS: The importance of creating a psychologically safe learning environment has been recognized as essential to best practices. Our findings suggest that an understanding of student characteristics that impact their perception of psychological safety will allow educators to develop strategies to better support learners in the simulation environment.

Current practices for assessing clinical judgment in nursing students and new graduates: A scoping review.

OBJECTIVE: To map current assessment practices for learning outcomes related to nurses' clinical judgment from undergraduate education to entry to practice. DESIGN: Scoping review using the Joanna Briggs Institute guidelines and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). DATA SOURCES: Electronic databases-Cumulative Index of Nursing and Allied Health Literature (CINAHL Complete; EBSCOhost), EMBASE (Ovid), MEDLINE (Ovid), PsycINFO (Ovid), and Web of Science (Social Sciences Citation Index, Citation Index Expanded)-using a combination of descriptors and keywords related to nursing students, newly graduated nurses, clinical judgment and related terms (e.g., critical thinking, clinical reasoning, clinical decision-making, and problem-solving), and assessment. METHODS: Two reviewers independently extracted study characteristics and, for each outcome relevant to clinical judgment, the concept, definition and framework, assessment tool, and the number and schedule of assessments. Data were synthesized narratively and using descriptive statistics. RESULTS: Most of the 52 reviewed studies examined the outcome of a discrete educational intervention (76.9 %) in academic settings (78.8 %). Only six studies (11.5 %) involved newly graduated nurses. Clinical judgment (34.6 %), critical thinking (26.9 %), and clinical reasoning (9.6 %) were the three most frequent concepts. Three assessment tools were used in more than one study: the Lasater Clinical Judgment Rubric (n = 22, 42.3 %), the California Critical Thinking Skills Test (n = 9, 17.3 %), and the Health Science Reasoning Test (n = 2, 3.8 %). Eleven studies (21.2 %) used assessment tools designed for the study. CONCLUSION: In addition to a disparate understanding of underlying concepts, there are minimal published studies on the assessment of nursing students and nurses' clinical judgment, especially for longitudinal assessment from education to clinical practice. Although there is some existing research on this topic, further studies are necessary to establish valid and reliable clinical competency assessment methods that effectively integrate clinical judgment in clinical situations at relevant time points.

Comparison of blended versus traditional classrooms among undergraduate nursing students: A quasi-experimental study.

BACKGROUND: Blended learning is a relatively new educational approach that has been introduced into higher education in Palestine. While it has many advantages, there is no empirical evidence, nor any case studies from Palestine to support the use of blended learning over traditional classroom. OBJECTIVES: To compare students' learning outcomes, learning perceptions of their educational environment, and satisfaction of blended learning versus traditional classroom. DESIGN: A quasi-experimental study. SETTING: A public university in Palestine. PARTICIPANTS: 102 Bachelor of Science in nursing students enrolled on the maternal health course. METHODS: Students freely chose to register for the blended teaching section (49 students) or traditional classroom (53 students), then the teaching method for each section was assigned. Student demographics, course component grades, perceptions of the educational environment, measured by the Arabic version of Dundee Ready Education Environment Measurement (DREEM) inventory, and degree of satisfaction were collected in this study. Descriptive statistics and the Independent Sample t-test were used to analyze the data. RESULTS: The sample included 49 students in the blended teaching section and 53 students in the traditional section. Overall DREEM scores, Student Perceptions of Learning, and Student Perceptions of Teachers were significantly higher for students taught with the blended method compared to traditional classroom settings. The total DREEM scores were between 101 and 151 for both sections, indicating that all students, regardless of teaching method, had more positive than negative perceptions of their educational environment. Moreover, there was no significant difference in scores and total course GPA (Grade Point Average), both with and without assignment grades, or between blended and traditional learning in first, second and final exams. However, students taught with the blended format scored significantly higher in assignments than students taught the traditional classroom. CONCLUSIONS: Blended learning can be a useful educational approach in nursing education and Palestinian universities may consider using it for nursing courses.

Strategies to Reenvision Doctor of Nursing Practice Projects to Meet Organization Goals During a Pandemic.

To serve as leaders in health care, Doctor of Nursing Practice (DNP) graduates must implement an innovative DNP project that is relevant to practice organizations during a pandemic. This article discusses pivotal strategies to overcome barriers by implementing types of DNP projects that align with practice organizational goals and demonstrate practice outcomes to stakeholders. [J Contin Educ Nurs. 2021;52(2):61-63.].

Is Anemia in Low Income Pregnant Women Related to Their Infants' Having Anemia? A Cohort Study of Pregnant Women-Infant Pairs in the United States.

OBJECTIVE: Given evidence that anemia in the first year of life is associated with long-term cognitive, motor, and behavioral deficits, reducing infant anemia is important. The primary objective of this research is to examine whether anemia in low income pregnant women in the United States is associated with anemia in the women's infants. METHODS: This cohort study linked Centers for Disease Control and Prevention surveillance data on pregnant women with incomes below 185% of the federal poverty level from 2010 and 2011 with data on 6-11 month olds from 2011, resulting in a sample of 21,246 uniquely matched mother-infant pairs. We examined bivariate and multivariate relationship between anemia severity in pregnant women and in their infants. RESULTS: Seventeen percent of women had anemia (13.1% mild and 3.9% moderate to severe) and 20.1% infants had anemia (16.4% mild and 3.7% moderate to severe). For both women and infants, blacks had substantially higher anemia rates than whites. In bivariate analysis and multivariate analyses maternal anemia showed a dose-response relationship to infant anemia. In predicted probabilities from the multivariate models, 27.2% of infants born to pregnant women with moderate to severe anemia had anemia, compared to 23.3% for infants whose mothers had mild anemia, and 18.3% for infants whose mothers did not have anemia. CONCLUSION: This study provides strong evidence of a relationship between maternal and infant anemia in the United States among people with low incomes. Efforts to reduce anemia during pregnancy may be an important strategy for minimizing childhood anemia.

Facilitators, barriers, benefits, and funding to implement postgraduate nurse practitioner residency/fellowship programs.

BACKGROUND: A current trend to address the increasing numbers of new graduate nurse practitioners (NPs) and the expanding scope of practice of NPs is the emergence of employer-based postgraduate NP residency/fellowship programs. PURPOSE: The purpose of this study was to conduct a comprehensive examination of postgraduate NP residency/fellowship programs in the United States, to gain an understanding of the facilitators, barriers, benefits, and funding of these programs, from the perspective of the program directors. METHODS: This exploratory study used a quantitative design to conduct an online survey, developed by the researchers, of program directors of postgraduate NP residency/fellowship programs. Descriptive statistics were generated for continuous variables: the mean, SD, and minimum, and maximum values, and for categorical variables, frequency and percentage were reported. RESULTS: More than 90% of program directors indicated that NP recruitment and retention were benefits to organizations implementing NP residency/fellowship programs. Decision makers in organizations support postgraduate NP residency/fellowship programs and few barriers exist to implement programs. More than 84% indicated that physician and administrative support were facilitators to program implementation. Less than 50% of program directors identified barriers to implementation. Less than half of programs received funding sources for program implementation. IMPLICATIONS FOR PRACTICE: This study provides data and insight into the emerging industry of postgraduate NP residency/training programs and informs regulators, educators, and employers about how to maximize the facilitators, reduce and decrease barriers, identify sources of funding, and appreciate the benefits of implementing programs.

Improving Pharmacology Standardized Test and Final Examination Scores Through Team-Based Learning.

BACKGROUND: Team-based learning (TBL) is a collaborative teaching and learning strategy emphasizing student engagement and application of knowledge. PURPOSE: The purpose of the study was to compare the differences in scores on pharmacology course final and standardized criterion-referenced examinations between students taught in a traditional lecture-based approach and those taught under the TBL approach. METHODS: Using a before-and-after design, 338 prelicensure students were taught pharmacology using either a traditional lecture-based approach or a TBL approach. RESULTS: Significant differences on course final and standardized examination scores were found between the groups, with students taught using TBL scoring higher than students in the traditional lecture-based group. CONCLUSIONS: Team-based learning had a positive impact on learning outcomes. Moreover, TBL may be a more efficient approach to teaching, as students in the TBL group had only 3 credit hours of content versus students in the traditional lecture-based group, who had 4 credit hours.

Educational characteristics and content of postgraduate nurse practitioner residency/fellowship programs.

BACKGROUND: Nurse practitioner (NP) residency/fellowship programs are an emerging industry across the country. PURPOSE: This study aimed to conduct an in-depth exploration about postgraduate NP residency/fellowship programs in the United States and to gain an understanding of program characteristics, educational content, and implementation methods to assist NPs to transition to practice. METHODS: This exploratory study used a quantitative design to conduct an online survey of program directors of NP residency/fellowship programs to collect data about program characteristics to assist graduates to transition to practice. Descriptive statistics were calculated for continuous variables, whereas frequency and percentage were calculated for categorical variables. RESULTS: Nurse practitioner residency/fellowship programs lack consistency in standards for educational content and delivery methods. Only 26% of the programs were accredited, and the programs were not consistently based on nationally recognized competencies. Ninety percent of the programs relied on didactic and clinical supervision delivery methods. More than 90% of the residents/fellows cared for adults older than 65 years of age and managed chronic diseases. Family Nurse Practitioner was the most commonly cited population track offered (73%). Nurse practitioner residency/fellowship programs are sparsely offered in the most rural states with underserved populations. IMPLICATIONS FOR PRACTICE: This study provides data and insight into the emerging industry of postgraduate NP residency/training programs for educators and employers. In addition, it informs regulators and decision makers about the quality and consistency of programs and the impact of programs on the care delivered by new graduate NPs.

What's Your Style? Enhanced Interprofessional Communication and Practice Using the Communication Wheel.

Today's health care environment requires collaborative teams to provide safe, effective care. This study assessed the extent to which a face-to-face workshop increased nursing and premedical students' awareness of varying communication styles and their potential impact on interprofessional communication and practice. A self-assessment tool was administered before, immediately after, and 1 month after the workshop. Significant increases in familiarity working on interprofessional teams, identifying different communication styles, and ability to apply communication strategies were found immediately after and 1 month after the workshop.

Gender differences in nurse practitioner salaries.

BACKGROUND AND PURPOSE: While male nurses have been shown to earn considerably more than female nurses, there is less evidence on gender disparities in salary among nurse practitioners (NPs). This study examines whether the gender gap in NP salaries persists after controlling for differences in work setting and demographic factors. METHODS: We analyzed the relationship between gender and salary (2011 pretax earnings) among 6591 NPs working as NPs at least 35 h per week, using the 2012 National Sample Survey of Nurse Practitioners. We first conducted bivariate regression analyses examining the relationship between gender and earnings, and then developed a multivariate model that controlled for individual differences in demographic and work characteristics. CONCLUSIONS: Male NPs earned $12,859 more than female NPs, after adjusting for individual differences in demographics and work characteristics. The gender gap was $7405 for recent NP graduates, and grew over time. Male NPs earned significantly more than female NPs across all clinical specialty areas. IMPLICATIONS FOR PRACTICE: The gender disparities in NP salaries documented here regardless of professional seniority or clinical area should spark healthcare organizations to conduct pay equity assessments of their employees' salaries to identify and ameliorate pay inequality.

Flipping around the classroom: Accelerated Bachelor of Science in Nursing students' satisfaction and achievement.

BACKGROUND: The flipped classroom approach is based on shared responsibility for learning by students and teachers, and empowers students to take an active role in the learning process. While utilization of this approach has resulted in higher exam scores compared to traditional approaches in prior studies, the flipped classroom has not included learners in Accelerated Bachelor of Science in Nursing (ABSN) programs. OBJECTIVE: To examine differences on exam scores and satisfaction of teaching between a 3-week flipped and traditional classroom approach. DESIGN: Mixed methods, crossover repeated measures design. SETTINGS: Private school of nursing located in the eastern United States. PARTICIPANTS: 76 ABSN students. METHODS: Two separate sections of a Pharmacology course received either 3-weeks of flipped or traditional classroom during Period 1, then switched approaches during Period 2. Two exam scores measuring knowledge and a questionnaire assessing satisfaction of teaching were collected. Focus groups were conducted to learn about students' experience in the flipped classroom. Descriptive statistics, Wilcoxon rank sum test, and stepwise linear mixed model were used to analyze quantitative data. Focus group data were transcribed, coded, and categorized in themes. RESULTS: Students in the flipped classroom achieved significantly higher scores on the first Pharmacology exam than students in the traditional classroom, but there was no significant difference on the second exam. Three themes emerged from focus groups on student perception of integrating the flipped approach: don't fix what isn't broken; treat me as an adult; and remember the work is overwhelming. CONCLUSIONS: Both traditional and flipped classroom approaches successfully prepared students for the Pharmacology exams. While results support the use of the flipped approach, judicious use of this instructional pedagogy with dense or difficult content, particularly in accelerated programs, is recommended. Instructors should also provide students with enough information and rationale for using the flipped classroom approach.

Motivated Strategies for Learning in Accelerated Second-Degree Nursing Students.

Students in a second-degree accelerated BSN program experience a rigorous curriculum and fast-paced introduction to the nursing profession. This study examined the relationships among self-esteem, motivation, learning strategies, demographic characteristics, and academic achievement. The results indicated that all of the students had good self-esteem; some demographic characteristics influenced the type of motivation and learning strategies they endorsed but did not influence their current academic performance.

Nurses' health promoting lifestyle behaviors in a community hospital.

PURPOSE: To examine nurses' health-promoting lifestyle behaviors, describe their self-reported engagement in employee wellness program benefit options, and explore relationships between nurse demographic factors, health characteristics and lifestyle behaviors. BACKGROUND: Nurses adopting unhealthy lifestyle behaviors are at significantly higher risk for developing a number of chronic diseases and are at increased susceptibility to exhaustion, job dissatisfaction and turnover. Strengthening professional nurses' abilities to engage in healthy lifestyle behaviors could serve as a valuable tool in combating negative workplace stress, promote improved work-life balance and personal well-being, and help retain qualified health-care providers. METHODS: In a 187-bed community hospital in the Washington D.C. metropolitan area, we conducted an IRB-approved exploratory descriptive study. We examined 127 nurses' demographic characteristics, self-reported employer wellness program use, and measured their healthy lifestyle behaviors using the 52-item Health-Promoting Lifestyle Profile-II (HPLP-II) survey instrument. Nurse demographic and HPLP-II scores were analyzed in SPSS v20.0. Inferential univariate statistical testing examined relationships between nurse demographic factors, health and job characteristics, and HPLP-II score outcomes. RESULTS: Nurses over 40years old were more likely to report participation in hospital wellness program options. Statistically significant age differences were identified in total HPLP-II score (p=0.005), and two subscale scores-spiritual growth (p=0.002) and interpersonal relations (p=0.000). Post-hoc testing identified nurse participants 40-49years old and ≥50years old experienced slightly lower total HPLP-II score, subscale scores in comparison to younger colleagues. CONCLUSIONS: Nurses ≥40years old may benefit from additional employer support and guidance to promote and maintain healthy lifestyles, personal well-being, and positive interpersonal relationships.

How important are autonomy and work setting to nurse practitioners' job satisfaction?

PURPOSE: Nurse practitioners (NPs) have reported aspects of their jobs that they are more and less satisfied with. However, few studies have examined the factors that predict overall job satisfaction. This study uses a large national sample to examine the extent to which autonomy and work setting predict job satisfaction. DATA SOURCES: The 2012 National Sample Survey of Nurse Practitioners (n = 8311) was used to examine bivariate and multivariate relationships between work setting and three autonomy variables (independent billing practices, having one's NP skills fully utilized, and relationship with physician), and job satisfaction. CONCLUSIONS: NPs working in primary care reported the highest levels of autonomy across all three autonomy measures, while those working in hospital surgical settings reported the lowest levels. Autonomy, specifically feeling one's NP skills were fully utilized, was the factor most predictive of satisfaction. In multivariate analyses, those who strongly agreed their skills were being fully utilized had satisfaction scores almost one point higher than those who strongly disagreed. Work setting was only marginally related to job satisfaction. IMPLICATIONS FOR PRACTICE: In order to attract and retain NPs in the future, healthcare organizations should ensure that NPs' skills are being fully utilized.

Does Prior RN Clinical Experience Predict Academic Success in Graduate Nurse Practitioner Programs?

BACKGROUND: There is limited evidence on whether prior RN clinical experience is predictive of academic success in graduate nurse practitioner (NP) programs. The purpose of this study was to explore whether the frequently held assumption that more prior clinical experience is associated with better academic success in The George Washington University online NP programs. METHOD: Applications (n = 106) for clinical NP students entering from 2008-2010 were examined along with data on academic performance. RESULTS: No relationship was found between years of prior RN clinical experience and three educational outcome variables (cumulative grade point average [GPA], clinical course GPA, and having failed any courses or been put on probation). However, students with the most prior RN clinical experience were less likely to graduate in 4 years, compared with those with the least experience. CONCLUSION: These findings serve as a building block of empirical evidence for admissions committees as they consider entry requirements for NP programs.

Fatigue and depression in patients with lymphoma undergoing autologous peripheral blood stem cell transplantation.

PURPOSE/OBJECTIVES: To describe the patterns of depression and fatigue, including its dimensions, and the relationship between these two variables in patients with lymphoma undergoing autologous peripheral blood stem cell transplantation (PBSCT). DESIGN: Prospective, descriptive, correlational, repeated measures. SETTING: Midwestern university National Cancer Institute-designated clinical cancer center. SAMPLE: 27 patients with lymphoma aged 19 to 71 undergoing autologous PBSCT. METHODS: The revised Piper Fatigue Scale was used to measure fatigue and its dimensions. The Center for Epidemiologic Studies' Depression Scale was used to measure depression on selected days at baseline and during chemotherapy and recovery. MAIN RESEARCH VARIABLES: Fatigue and its four dimensions (behavioral/severity, sensory, cognitive/mood, and affective meaning) and depression. FINDINGS: Total fatigue, fatigues four dimension scores, and depression scores changed significantly over time, with the highest scores at day + 7 after transplant. Total fatigue and the four dimension scores were highly and positively correlated with depression, with the highest correlation reported between the affective fatigue dimension and depression. CONCLUSIONS: The findings support the importance of assessing fatigue and depression in patients undergoing autologous PBSCT at baseline, during chemotherapy, and throughout recovery. IMPLICATIONS FOR NURSING: Routine clinical assessment with close observation around day +7 after transplant and patient education about the patterns of fatigue and depression will help the healthcare team to intervene at the appropriate time and may help patients to better manage these symptoms.

An exploratory study of multicomponent treatment intervention for tobacco dependency.

PURPOSE: To conduct an exploratory study of two interventions to help smokers abstain over a period of 3 months. The specific aims were to describe the outcomes, test feasibility of the study design, and evaluate effect size. DESIGN AND METHODS: A randomized experimental design was used in a sample of 42 patients who received multicomponent treatment intervention (MTI) or standard care (SC) in a midwestern city in the United States. Variables were behavioral (quit rate, self-efficacy, motivation), psychosocial (depression, partner interaction), and symptom management (use of nicotine replacement therapy [NRT]). Data analysis included descriptive statistics and repeated measures ANOVA. RESULTS: The typical participant was Caucasian, middle aged, nicotine dependent, married or partnered, and employed, and had a high school education. Participants in the MTI group were more likely to use NRT and to have higher self-reported quit rates at follow-up. Statistically significant differences were found between groups over time for self-efficacy and positive to negative behavior ratio. Barriers to quitting were relapse, stress, weight gain, lack of support, and depression that were more frequent in the SC group. For effect size (0.25), probability level (.05), and power (.80), a sample size of 140 patients was calculated. CONCLUSIONS: The MTI group had higher quit rates, more NRT, higher self-efficacy, and more positive behavioral interactions. Limitations of the study included self-report of tobacco use, small sample, and attrition. The investigators suggest a future study with a larger sample to test whether multicomponent interventions with telephone calls after discharge are more effective than is standard care in helping patients to quit and continue to abstain from smoking.