Taxonomy development and knowledge representation of nurses' personal cognitive artifacts.

Nurses prepare knowledge representations, or summaries of patient clinical data, each shift. These knowledge representations serve multiple purposes, including support of working memory, workload organization and prioritization, critical thinking, and reflection. This summary is integral to internal knowledge representations, working memory, and decision-making. Study of this nurse knowledge representation resulted in development of a taxonomy of knowledge representations necessary to nursing practice.This paper describes the methods used to elicit the knowledge representations and structures necessary for the work of clinical nurses, described the development of a taxonomy of this knowledge representation, and discusses translation of this methodology to the cognitive artifacts of other disciplines. Understanding the development and purpose of practitioner's knowledge representations provides important direction to informaticists seeking to create information technology alternatives. The outcome of this paper is to suggest a process template for transition of cognitive artifacts to an information system.

Certified nurse midwives effects on catecholamine levels and maternal anxiety during labor

Studies of nurse midwifery care in the last twenty one years have reported excellent birth outcomes (Levy, Wilkenson and Marine, 1971; Platt et al. 1985; Stone et al. 1976). These outcomes are frequently attributed to the special support offered during labor and delivery by nurse midwives. This supportive style is thought to decrease catecholamine levels by reducing maternal anxiety. This prospective observational study evaluated catecholamine levels, anxiety levels, in-hospital costs, obstetrical practices and outcomes between low risk, term, labor and delivery primigravida patients managed by obstetrical residents (n = 55) or by certified nurse-midwives CNM (n = 59). The two groups were similar with regard to obstetrical risk factors present at admission. Each group was selected over the same period of time between March 23, 1994 and November 2, 1994. Specific catecholamines evaluated were epinephrine and norepinephrine. Obstetrical and newborn characteristics were also compared. This study did not prove that there is a decreased level in stress as indicated by lower levels of epinephrine and norepinephrine in nurse-midwife patients compared to obstetrical resident patients after adjusting for the use of epidural anesthesia. There was also no difference found in the perceived anxiety levels between the two groups. This study did confirm that nurse-midwives and obstetrical residents have different practice styles. Nurse-midwife patients had fewer augmented deliveries, fewer operative deliveries, less blood loss, fewer episiotomies and fewer third and fourth degree lacerations. The physician's choice to utilize more interventions such as continuous fetal monitoring and epidural anesthesia did not improve outcomes. The hospital cost of the nurse-midwife patients in this study was 35 percent lower than the physician patients. ^

General practitioner teachers’ job satisfaction and their medical students' wish to join the field – a correlational study

Background There will be increasing competition for young physicians worldwide as more and more physicians retire. While enthusiasm towards GP work is important for GP teachers as role models, satisfaction within the profession has declined. This study aims to determine if medical students’ desire to become GPs is related to the job satisfaction of their teaching GPs and explore the factors tied to this job satisfaction. Methods In this cross-sectional, correlational study, teaching GPs of the University of Bern and the fourth year medical students completing internships with them filled in separate questionnaires. Results Whether or not the GP teacher is perceived by a student to be satisfied with her/his job is correlated to that student’s satisfaction with the internship, which in turn, is correlated with student’s wish to be a GP after the internship. Results show which factors are most related to GP job satisfaction and the effect of working hours and their composition. Conclusions Medical students’ perception of their GP teachers’ job satisfaction positively affect their wish to become GPs, and their satisfaction with their internships adds to this. Enhancing the positive aspects of GP work, such as recognition, and improving negative ones, such as administrative duties, are necessary to attract medical students into the GP field.

Outcomes and cost effectiveness of treating type 2 diabetes with a nurse case manager following treatment algorithms versus primary care physicians

Background. Diabetes places a significant burden on the health care system. Reduction in blood glucose levels (HbA1c) reduces the risk of complications; however, little is known about the impact of disease management programs on medical costs for patients with diabetes. In 2001, economic costs associated with diabetes totaled $100 billion, and indirect costs totaled $54 billion. ^ Objective. To compare outcomes of nurse case management by treatment algorithms with conventional primary care for glycemic control and cardiovascular risk factors in type 2 diabetic patients in a low-income Mexican American community-based setting, and to compare the cost effectiveness of the two programs. Patient compliance was also assessed. ^ Research design and methods. An observational group-comparison to evaluate a treatment intervention for type 2 diabetes management was implemented at three out-patient health facilities in San Antonio, Texas. All eligible type 2 diabetic patients attending the clinics during 1994–1996 became part of the study. Data were obtained from the study database, medical records, hospital accounting, and pharmacy cost lists, and entered into a computerized database. Three groups were compared: a Community Clinic Nurse Case Manager (CC-TA) following treatment algorithms, a University Clinic Nurse Case Manager (UC-TA) following treatment algorithms, and Primary Care Physicians (PCP) following conventional care practices at a Family Practice Clinic. The algorithms provided a disease management model specifically for hyperglycemia, dyslipidemia, hypertension, and microalbuminuria that progressively moved the patient toward ideal goals through adjustments in medication, self-monitoring of blood glucose, meal planning, and reinforcement of diet and exercise. Cost effectiveness of hemoglobin AI, final endpoints was compared. ^ Results. There were 358 patients analyzed: 106 patients in CC-TA, 170 patients in UC-TA, and 82 patients in PCP groups. Change in hemoglobin A1c (HbA1c) was the primary outcome measured. HbA1c results were presented at baseline, 6 and 12 months for CC-TA (10.4%, 7.1%, 7.3%), UC-TA (10.5%, 7.1%, 7.2%), and PCP (10.0%, 8.5%, 8.7%). Mean patient compliance was 81%. Levels of cost effectiveness were significantly different between clinics. ^ Conclusion. Nurse case management with treatment algorithms significantly improved glycemic control in patients with type 2 diabetes, and was more cost effective. ^

Psychiatrists' and Psychiatric APRNs' Views of the Adolescent Mental Health Nurse's Role In the Inpatient Setting

Current perceptions about nurses’ roles and responsibilities are examined in this study, specifically relating to adolescent inpatient MHNs. Psychiatrists and psychiatric advanced practice registered nurses (APRNs), who work with MHNs and have also published scholarly psychiatric articles, were contacted to request their participation in an anonymous survey hosted by SurveyMonkey.com. This research was conducted to examine the stereotypes that exist against nurses within the health care profession itself, as compared to the pre-existing stereotypes displayed by the media’s view of nurses. Due to investigator time constraints, only six subjects participated in the study. Analysis of survey responses revealed four overarching themes. First, MHNs are a critical component of the health care team, emerging as rigorous, independent leaders, although still classified as female and sociable. Second, MHNs complete a wide range of daily activities, many of which go unnoticed by observers, often resulting in mixed feelings regarding whether MHNs are given the respect and recognition deserved. Third, MHNs treat each patient as a person with unique thoughts, feelings, and physical make-up. Fourth, MHNs act as a coordinator of care between various health professionals to provide the patient with a holistic approach to healing.

Evaluation of the LBJ Hospital Ask Your Nurse Advice Line

This retrospective, case-control study investigated the effectiveness of the Houston, Texas Ask Your Nurse Advice Line (AYN) in diverting callers with non-emergent medical conditions away from the emergency department (ED). After asking callers a series of questions, AYN nurses evaluate the medical condition and make recommendations for appropriate care, e.g., home care, see a clinic physician, or visit the ED. To evaluate the AYN, the rate of caller ED visits before accessing the AYN for the first time was compared to the caller ED visit rate afterwards. The pre-post rate change was compared to that of a control group of similar caller age, race, gender, and insurance status drawn from a Harris County Hospital District HCHD database. ^ The treatment group (AYN caller) had a 66% reduction in ED visits after the first AYN call compared to an 18% drop in ED visits among control group subjects during the same time period. Study results were presented to HCHD staff on August 30th, 2007 and recommendations were made for future studies that would provide a basis for policy development. ^

Assessing the impact of leadership on nurse job satisfaction and the desire for unionization in health care settings

This dissertation focuses on the leadership styles of managers, the impact these leadership styles have on the job satisfaction of staff nurses, and the proclivity of nurses to consider unionization. The aims of the dissertation include conducting a literature review on topics of leadership style, job satisfaction, and unionization; identifying and elucidating pertinent constructs with respect to shared interrelationships and how they could be measured; and developing a means of assessing if and to what extent transformational and transactional leadership styles affect nurse proclivity to unionize.^ The instrumentation selected includes the Multifactor Leadership Survey, Job Satisfaction Survey, and a newly created Union Preference Survey. Each survey instrument was evaluated as to its appropriateness to administer at a non-consultant level within a health care facility. Options other than self-administering the survey instruments include online access for participants, which provides confidentiality and encourages more responses. ^ The next part of the dissertation is a plan for health care facilities to use the survey tool by administering it themselves. The plan provides a general description of the survey tool, administering the instrument, rating the instrument, and leadership development. Integration of the three surveys is presented in a non-statistical format by coordinating the results of the three survey instrument responses. Recommendations are presented on how to improve leadership development warranted for improvement.^ The conclusions reached are that nurses’ preference for unions is influenced by the leadership style of direct report managers, as rated by staff nurses, and the nurses’ job satisfaction, which is in turn in part dependent on their managers’ leadership style. Thus, changes in leadership style can have a profound impact on nurse job satisfaction and on nurses’ preference for unionization.^

Nurse likelihood to report a pediatric medication error: Examination of the "pre-reporting" period

Each year, hospitalized patients experience 1.5 million preventable injuries from medication errors and hospitals incur an additional $3.5 billion in cost (Aspden, Wolcott, Bootman, & Cronenwatt; (2007). It is believed that error reporting is one way to learn about factors contributing to medication errors. And yet, an estimated 50% of medication errors go unreported. This period of medication error pre-reporting, with few exceptions, is underexplored. The literature focuses on error prevention and management, but lacks a description of the period of introspection and inner struggle over whether to report an error and resulting likelihood to report. Reporting makes a nurse vulnerable to reprimand, legal liability, and even threat to licensure. For some nurses this state may invoke a disparity between a person‘s belief about him or herself as a healer and the undeniable fact of the error.^ This study explored the medication error reporting experience. Its purpose was to inform nurses, educators, organizational leaders, and policy-makers about the medication error pre-reporting period, and to contribute to a framework for further investigation. From a better understanding of factors that contribute to or detract from the likelihood of an individual to report an error, interventions can be identified to help the nurse come to a psychologically healthy resolution and help increase reporting of error in order to learn from error and reduce the possibility of future similar error.^ The research question was: "What factors contribute to a nurse's likelihood to report an error?" The specific aims of the study were to: (1) describe participant nurses' perceptions of medication error reporting; (2) describe participant explanations of the emotional, cognitive, and physical reactions to making a medication error; (3) identify pre-reporting conditions that make it less likely for a nurse to report a medication error; and (4) identify pre-reporting conditions that make it more likely for a nurse to report a medication error.^ A qualitative research study was conducted to explore the medication error experience and in particular the pre-reporting period from the perspective of the nurse. A total of 54 registered nurses from a large private free-standing not-for-profit children's hospital in the southwestern United States participated in group interviews. The results describe the experience of the nurse as well as the physical, emotional, and cognitive responses to the realization of the commission of a medication error. The results also reveal factors that make it more and less likely to report a medication error.^ It is clear from this study that upon realization that he or she has made a medication error, a nurse's foremost concern is for the safety of the patient. Fear was also described by each group of nurses. The nurses described a fear of several things including physician reaction, manager reaction, peer reaction, as well as family reaction and possible lack of trust as a result. Another universal response was the description of a struggle with guilt, shame, imperfection, blaming oneself, and questioning one's competence.^

Changes in 911 call volume and type during Hurricane Ike and the implementation and usefulness of the TeleHealth Nurse system for the Houston Fire Department

This study examined both changing call volume and type with resulting effect of TeleHealth Nurse, the Houston Fire Department's (HFD) telephone nurse line, on call burden during Hurricane Ike. On September 13, 2008, Hurricane Ike made landfall in the Galveston area and continued north through Houston resulting in catastrophic damages in infrastructure and posing a public health threat. The overall goal of this study looked at data from Houston Fire Department to obtain a better understanding of the needs of citizens before, during, and after a hurricane. This study looked at four aspects of emergency response from HFD. The first section looked at call volumes surrounding the time of Hurricane Ike in 2008 compared to the same time period in 2007. The data showed a 12% increase in calls surrounding Hurricane Ike compared to previous years with a p value <.001. Next, the study evaluated the types of calls prevalent during Hurricane Ike compared to the same time period in 2007. The data showed a statistically significant increase in chronic health problems such as diabetes and cardiac events, Obstetric calls and an increase in breathing problems, falls, and lacerations during the days following Hurricane Ike. There was also a statistically significant increase in auto med alerts and check patients surrounding Hurricane Ike's landfall. The third section analyzed the change in call volume sent to HFD's Telephone Nurse Line during Hurricane Ike and compares this to earlier time periods while the fourth and final section looks at the types of calls sent to the nurse line during Hurricane Ike. The data showed limited use of the TeleHealth Nurse line before Hurricane Ike, but when the winds were at their strongest and ambulances were unable to leave the station, the nurse line was the only functioning medical help some people were able to receive. These studies bring a better understanding to the number and types of calls that a city might experience during a natural disaster, such as a hurricane. This study also shows the usefulness of an EMS Telephone Nurse Line during a natural disaster.^

Relationship between nurse leader emotional intelligence and registered nurse job satisfaction

Aim: To determine the relationship between nurse leader emotional intelligence and registered nurse job satisfaction. ^ Background: Nurse leaders influence the work environments of nurses working at the bedside. Nursing leadership plays an important role in fostering work environments that attract and retain nurses. ^ Methods: A non-experimental, predictive design study conducted in 5 hospitals evaluated relationships between 31 nurse leaders and 799 registered nurses. The nurse leaders were administered the MSCEIT and MBTI. The registered nurses participated in the 2010 NDNQI RN Job Satisfaction Survey. ^ Measurements and Results: The sample population completed two online instruments, the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT) and the Myers Brigg Trait Inventory (MBTI). Nurse leader demographic data was collected consisting of age, sex, race, educational level, certification status and years in the profession of nursing. The relationships among characteristics of the nurse leader and staff nurses were examined using regression analysis and stepwise deletion. The results from the MBTI were obtained electronically from CPP. Inc. and the results of MSCEIT were obtained electronically from MHS, Inc. The nurse leader response rate was 46% and the NDNQI RN Job Satisfaction response rate was 62%. The sample of 31 nurse leaders were 65 percent female and 67.7% were White, 12.9% Black, and 19.4% Hispanic. The most prevalent MBTI type was ESTJ (19.35%), followed by ENFJ and ISFJ (9.68% each). The nurse leader sample was primarily extroverts (n=20), sensing (n=18), thinking (n=16) and judging (n=19). The nurse leaders' overall MSCEIT scores ranged from 69 to 111 (implying a range from those who should consider development to competent) with a mean score of 89.84 (consider improvement). The nurse leaders scored highest in the MSCEIT Facilitating subscale with scores ranging from 69 to 121 (consider development to strength) and a mean score of 95.19 (low average score). The overall mean MSCEIT mean scores for the entire sample ranged from 89.90 to 95.19 (consider emotional intelligence improvement to low average score) Overall, staff nurse participants in the NDNQI RN Job Satisfaction Survey were moderately satisfied with the nurse leaders as noted by a mean t score of 55.03 of 60 and this score was consistent with the comparison hospitals that participated in the 2010 NDNQI RN Job Satisfaction Survey (American Nurses Association, 2010). Staff nurses gave nurse leaders a mean score of 4.50 for patient assignments appropriate, and rated a mean score of 4.35 and moderately agreeing to recommend the hospital to a friend. ^ Conclusions: Future research is needed to determine if there is a relationship between nurse leader emotional intelligence ability and registered nurse job satisfaction. Additional research is also needed to determine what to measure in regards to nurse leader emotional intelligence, ability or behavior. Another issue that emerged in the examination of EI is the moderating relationship between the nurse leaders span of control and staff nurse satisfaction on the NDNQI. ^

UNDERSTANDING NURSE CREATED COGNITIVE ARTIFACTS: PERSONALLY-CREATED-COGNITIVE-ARTIFACTS AS EXTERNAL REPRESENTATIONS OF DISTRIBUTED COGNITION

Manuscript 1: “Conceptual Analysis: Externalizing Nursing Knowledge” We use concept analysis to establish that the report tool nurses prepare, carry, reference, amend, and use as a temporary data repository are examples of cognitive artifacts. This tool, integrally woven throughout the work and practice of nurses, is important to cognition and clinical decision-making. Establishing the tool as a cognitive artifact will support new dimensions of study. Such studies can characterize how this report tool supports cognition, internal representation of knowledge and skills, and external representation of knowledge of the nurse. Manuscript 2: “Research Methods: Exploring Cognitive Work” The purpose of this paper is to describe a complex, cross-sectional, multi-method approach to study of personal cognitive artifacts in the clinical environment. The complex data arrays present in these cognitive artifacts warrant the use of multiple methods of data collection. Use of a less robust research design may result in an incomplete understanding of the meaning, value, content, and relationships between personal cognitive artifacts in the clinical environment and the cognitive work of the user. Manuscript 3: “Making the Cognitive Work of Registered Nurses Visible” Purpose: Knowledge representations and structures are created and used by registered nurses to guide patient care. Understanding is limited regarding how these knowledge representations, or cognitive artifacts, contribute to working memory, prioritization, organization, cognition, and decision-making. The purpose of this study was to identify and characterize the role a specific cognitive artifact knowledge representation and structure as it contributed to the cognitive work of the registered nurse. Methods: Data collection was completed, using qualitative research methods, by shadowing and interviewing 25 registered nurses. Data analysis employed triangulation and iterative analytic processes. Results: Nurse cognitive artifacts support recall, data evaluation, decision-making, organization, and prioritization. These cognitive artifacts demonstrated spatial, longitudinal, chronologic, visual, and personal cues to support the cognitive work of nurses. Conclusions: Nurse cognitive artifacts are an important adjunct to the cognitive work of nurses, and directly support patient care. Nurses need to be able to configure their cognitive artifact in ways that are meaningful and support their internal knowledge representations.

Climate and grazing control nurse effects in an Ecuadorian dry shrubby community

Positive plant interactions have strong effects on plant diversity at several spatial scales, expanding species distribution under stressful conditions. We evaluated the joint effect of climate and grazing on the nurse effect of Croton wagneri, by monitoring several community attributes at two spatial scales: microhabitat and plant community. Two very close locations that only differed in grazing intensity were surveyed in an Ecuadorian dry scrub ecosystem. At each location, two 30 × 30-m plots were established at four altitudinal levels (1500, 2630, 1959 and 2100 m asl) and 40 microsites were surveyed in each plot. Croton wagneri acted as community hubs, increasing species richness and plant cover at both scales. Beneath nurses mean richness and cover values were 3.4 and 21.9%, and in open areas 2.3 and 4.5%, respectively. Magnitude of nurse effect was dependent on climate and grazing conditions. In ungrazed locations, cover increased and diversity reduced with altitude, while grazed locations showed the opposite trend. In ungrazed plots the interactions shifted from positive to negative with altitude, in grazed locations interactions remained positive. We conclude that the nurse effect is a key mechanism regulating community properties not only at microsite but also at the entire community scale.