Learning leadership: a resource for aspiring nurse leaders

Background/purpose – Nurse leaders play a key role in the growth of the nursing profession; hence the development of future leaders is essential. Despite its importance, opportunities for leadership development can be limited. The purpose of the practicum project was to develop a comprehensive, yet concise resource to assist aspiring nurse leaders in their journey towards effective leadership. Methods – The methods used to achieve the practicum objectives were: (a) explore the literature and complete a comprehensive review (b) conduct expert consultations with current nurse leaders, and (c) develop a learning resource for aspiring nurse leaders. Results – The literature review and expert consultations highlighted the importance of effectively developing aspiring nurse leaders. The information obtained allowed for the development of a comprehensive learning resource. A detailed background, leadership theory, leadership framework, leader competencies and learning activities are presented throughout the resource. Conclusion – In order to for the nursing profession to continue to advance, effective nurse leaders are of paramount importance. However, it is essential that aspiring leaders are given appropriate opportunities for development. The learning resource was developed to provide aspiring leaders with a comprehensive tool to enhance their leadership development.

The development of an online neonatal intensive care unit family education

Background: British Columbia’s Fraser Health Authority (FHA) neonatal intensive care units (NICUs) value family centered care (FCC). Nevertheless, there is limited evidence that FCC is actually incorporated into practice, as well as some concern that FHA NICU education is inaccessible, inconsistent, or disorganized. Purpose: The mission of this project is to support the principles of FCC throughout the development of an FHA online NICU family education guide by reflecting upon the needs of families throughout their NICU journey. Methods: A needs assessment was initially completed and included literature reviews, consultations, and an environmental scan. This data informed development of an online NICU family education guide which plots current education materials along key stages of the NICU journey: prenatal, admission, early days, growing and developing, discharge and at home. For the purposes of this practicum, only the prenatal stage was fully developed and will serve as a template for other stages following a formative evaluation. A pamphlet and revised FHA Neonatal Checkpoint will also be developed to augment teaching by health care professionals. Implementation and evaluation plans were adapted from the Center for Disease Control Framework for Program Evaluation in Public Health. Results: The needs assessment validates and directs the development, implementation, and evaluation of the online guide illustrating an FCC approach. The online guide centralizes and organizes education by selecting education topics that relate to each stage of the NICU journey. This family-directed design enables families’ access to consistent and reliable information and offers them an opportunity to learn at their own pace. Conclusion: The process of creating, implementing, and evaluating an online family education program for FHA NICUs elucidates the intricacies and the advantages of integrating FCC into NICU practice.

Development of an education resource for families and clients navigating through end-of-life care with at-home palliation

Background: Community health nurses (CHNs) play a pivotal role in providing end-of-life care to clients diagnosed with a life-threatening illness. Providing quality end-of-life care is an ethical obligation. Eastern Health’s palliative end-of-life care program (PEOLC) offers nursing care, equipment, services, and support. However, the caregiver’s need for practical information about end-of-life issues is not addressed. Purpose: To develop an educational resource to assist clients and families during end-of-life and to provide a framework for new CHNs in home palliation. Methods: An informal Needs Assessment, a literature review, an environmental scan, and consultations with four CHNs involved with home palliation. Results: An educational resource was developed to address the practical end-of-life issues identified in the literature review and consultations. Conclusion: An improved delivery of care for at-home palliation in the community for clients and families, and a framework for new CHNs.

Development of a learning resource manual for nurses new to thoracic surgery

Background: Patients with lung and esophageal cancer often have surgery as a means of treatment. In Newfoundland and Labrador, patients with lung and esophageal issues are cared for on Six East, the General/Thoracic Surgery unit at St. Clare’s Mercy Hospital. These patients frequently require chest tubes, which are managed and assessed by Registered Nurses (RNs) on the unit. For nurses new to thoracic surgery, fulfilling their new role and caring for chest tube systems can be daunting. Purpose: The purpose of this practicum project was to develop a learning resource manual for nurses who are new to thoracic surgery. Via self-directed learning, the manual can increase the knowledge and self-efficacy of nurses who are caring for thoracic surgery clients and assessing chest tube systems. Methods: An informal needs assessment, integrated literature review, and several consultations via in-person interviews were conducted. Results: Based on the findings from these methodologies, Knowles’ Adult Learning Theory, and Benner’s Novice to Expert Model, a learning resource manual was created. The manual was divided into chapters covering various aspects of patient and chest tube system care and assessment. Conclusion: For the purpose of this practicum project, no evaluation was conducted. However, a plan for future evaluation of the learning resource manual has been developed to determine if the manual assisted with increasing the knowledge and self-efficacy of nurses new to thoracic surgery. “Test Your Knowledge” questions were included at the end of each chapter in the manual as well as case study scenarios to allow for participant self-evaluation.

Caring for the autistic child: a resource manual for health care providers

Background: Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder that affects approximately 1 in 68 children (CDC, 2014). Comorbid medical conditions and psychiatric disorders increase the likelihood that these children will require acute care services more often than their neurotypical peers (McDermott, Zhou, & Mann, 2008; Simonoff et al., 2008). The evidence suggests that most health care providers are unprepared for the complexity of the interactions with these children during an acute care episode (McGongile, Migyanka, et al., 2014; McGongile, Venkat, et al., 2014; Muskat et al., 2015). Currently, there are no formalized training programs for acute health care workers in Regina Qu’Appelle Health Region (RQHR). Purpose: The purpose of this practicum project was to use the best available evidence on the care needs of children with Autism Spectrum Disorder (ASD) and effective interaction strategies to guide development of a resource manual for acute care health workers, especially registered nurses (RNs), working in the RQHR. Methods: Initial steps involved planning for and conducting a needs assessment. The resulting database emerged from a critical review of relevant literature, an environmental scan of resources within RQHR, and informal consultations with parents and caregivers of children with ASD, acute care nurses and nurse managers and experts in the field of ASD. Following analysis and collation of all data into major themes, a draft blueprint guided development of a resource manual for health care providers interacting with and providing care to children with ASD. Results: The needs assessment data informed development of an educational resource manual appropriate for all health care providers who encounter children with ASD and their parents and/or caregivers within acute care environments. The Caring for the Autistic Child: A Guide for Health Care Providers in Acute Care provides insightful information on the disorder and associated comorbid conditions, as well as effective approaches to care delivery with this priority population. Implementation and evaluation plans will guide distribution of the resource manual within the RQHR. Conclusion: The sequential and interdependent steps taken in this practicum project led to the development of a resource manual comprised of simple, easy to implement strategies capable of assisting nurses and all healthcare providers in providing care tailored to the autistic child’s unique needs and challenges.

The development of a learning module for youth care counsellors working with incarcerated youth

Background: A shift toward a rehabilitative model of care has prompted the Newfoundland and Labrador Youth Centre to institute a policy restricting seclusion and restraint as a means of behavioural management. This policy has been received with skepticism by youth counsellors who use these methods to contain disruptive behaviours. Insufficient training in mental health has precipitated feelings of inadequacy as they feel ill-equipped to do their jobs. Purpose: The purpose of my practicum is to develop a mental health learning module for youth counsellors to reduce seclusion and restraint in youth corrections. Methods: A literature search illustrated what is known on the topic of seclusion and restraint in youth corrections. Consultation with stakeholders revealed staff attitudes regarding the policy and its operational impact. An environmental scan revealed the availability of other resources intended to address disruptive behaviours. Conclusion: The learning module is focused on mental illnesses to increase youth counsellors’ competency in managing disruptive behaviours while minimizing the use of seclusion and restraint.

CAUTI prevention bundles: improving best practices within Western Health for continued success

Background: Persons in acute care settings who have indwelling urethral catheters are at higher risk of acquiring a urinary tract infection (UTI). Other complications related to prolonged indwelling urinary catheters include decreased mobility, damage to the meatus and/or urethra, increase use of antibiotics, increased length of stay, and pain. UTIs in acute care settings account for 30 to 40% of all health care associated infections (HAIs). Of these, 80% are catheter associated UTIs (CAUTIs). Purpose: To utilized the CDC (2009) bundle approach for CAUTI prevention and create a program which supports a multimodal method to improving urinary catheter use, maintenance, and removal, including a continuing competency program where role expansion is anticipated. Methods: A comprehensive review of the literature was conducted. Physicians were consulted through a power point presentation followed by a letter explaining the project, a questionnaire, and two selections of relevant literature. Nursing staff and allied health professionals from the target units of 3A and 3B medicine attended one of two lunch and learns. They were presented the project via a power point presentation and the same questionnaire as distributed to physicians. Results: Five e-learning modules, a revised policy, and clinical pathway have been developed to support staff with best practice knowledge transfer. Conclusion: Behaviour changes need to be approached with a framework, extensive consultation, and education. Sustainability of any practice change cannot occur without having completed the background work to ensure staff have access to tools to support the change.

Improving safety of nursing staff: challenges and solutions regarding safety for nursing staff in acute care psychiatric settings

Workplace violence is defined as an act of abuse, threatening behaviour, intimidation, or assault on a person in his or her place of employment. Unfortunately, such violence is a reality for nurses. These take the form of physical, verbal, and threating behaviours, and harassment. Violence, particularly verbal abuse, is so prevalent that it is often considered “part of the job” and can contribute to many negative professional and personal effects for nurses. Therefore, it is important to understand what influences an individual to become violent in order to suggest and support initiatives to decrease it. A literature review and consultations with key stakeholders were conducted to gather relevant information regarding violence committed by patients and others visiting mental health care settings. Through data analysis, two relevant themes were revealed: reporting and interventions. Reporting incidents of workplace violence is important to track and quantify aggressive episodes, thus emphasizing its seriousness. Nurses may differ in the perception of what constitutes violence, underreport incidents, and feel a sense of futility when reported violence continues. In addition, cumbersome methods of reporting can be a hindrance to the reporting process. Six areas of potential interventions were identified to increase safety for nurses. These are staffing, de-escalation training, environmental considerations, addictions services, organizational support, and consequences. All findings were summarized in a document to be presented to the leadership of the Mental Health and Addictions program within the local health care authority. The goal is to offer recommendations to lead to a decrease in workplace aggression and increased safety for nurses in the acute care psychiatric setting.

The development of a self-directed learning module for rural emergency nurses on pediatric diabetic ketoacidosis

Background: Newfoundland and Labrador has a high incidence of type 1 diabetes and diabetic ketoacidosis (DKA) is a complication of type 1 diabetes. A clinical practice guideline was developed for the treatment of pediatric diabetic ketoacidosis (DKA) to standardize care in all Emergency Departments and improve patient outcomes. Rural emergency nurses are requires to maintain their competency and acquire new knowledge as stated by the Association of Registered Nurses of Newfoundland and Labrador (ARNNL). Purpose: The purpose of this practicum was to develop a self-learning module for rural emergency nurses to increase their knowledge and understanding of the clinical practise guideline to assess, treat, and prevent pediatric ketoacidosis. Methods: Two methodologies were used in this practicum. A review of the literature and consultations with key stakeholders were completed. Results: The self-learning module created was composed of three units and focused on the learning needs of rural emergency nurses in the areas of assessment, treatment, and prevention of pediatric DKA. Conclusion: The goal of the practicum was to increase rural emergency nurses’ knowledge and implementation of the clinical practice guideline when assessing and treating children and families experiencing DKA to improve patient outcomes. A planned evaluation of the self-learning module will be conducted following dissemination of the module throughout the rural Emergency Departments.

The transition experience for registered nurses new to case management in the community

Case management is increasingly being used within today‟s healthcare system in an effort to reduce healthcare costs while meeting the complex needs of populations within the community. Registered nurses (RNs) are often recruited for the role of case managers in the community because of their specific skill set and ability to navigate the healthcare system. There is a vast amount of literature related to the client and system benefits of case management, the roles and responsibilities of RN case managers, and job satisfaction among RN case managers. However, there is a literature gap noted in relation to the transition experience for RNs new to case management in the community setting. This research study used grounded theory methodology, guided by Glaser and Strauss (1967) to explore the process of RNs transitioning to case management in the community setting. Eleven RNs new to case management in the community were interviewed using semi-structured interviews. Data analysis was carried out using the constant comparative method. Three stages of adjusting to case management in the community were identified: slugging it out, seeing the job as it is, and finding the way. By gaining an understanding of this transition experience, recommendations for nursing practice and administration, education, and research that are based on the evidence from this study can be implemented to improve the transition experience for RNs new to case management in the community setting

Understanding the role of transforming growth factor beta signalling and epigenomics in osteoarthritis

Osteoarthritis (OA) is the most common form of arthritis with a high socioeconomic burden, with an incompletely understood etiology. Evidence suggests a role for the transforming growth factor beta (TGF-ß) signalling pathway and epigenomics in OA. The aim of this thesis was to understand the involvement of the TGF-ß pathway in OA and to determine the DNA methylation patterns of OA-affected cartilage as compared to the OA-free cartilage. First, I found that a common SNP in the BMP2 gene, a ligand in the Bone morphogenetic protein (BMP) subunit of TGF-ß pathway, was associated with OA in the Newfoundland population. I also showed a genetic association between SMAD3 - a signal transducer in the TGF-ß subunit of the TGF-ß signalling pathway - and the total radiographic burden of OA. I further demonstrated that SMAD3 is over-expressed in OA cartilage, suggesting an over activation of the TGF-ß signalling in OA. Next, I examined the connection of these genes in the regulation of matrix metallopeptidase 13 (MMP13) - an enzyme known to destroy extracellular matrix in OA cartilage - in the context of the TGF-ß signalling. The analyses showed that TGF-ß, MMP13, and SMAD3 were overexpressed in OA cartilage, whereas the expression of BMP2 was significantly reduced. The expression of TGF-ß was positively correlated with that of SMAD3 and MMP13, suggesting that TGF-ß signalling is involved in up-regulation of MMP13. This regulation, however, appears not to be controlled by SMAD3 signals, possibly due to the involvement of collateral signalling, and to be suppressed by BMP regulation in healthy cartilage, whose levels were reduced in end-stage OA. In a genome-wide DNA methylation analysis, I reported CpG sites differentially methylated in OA and showed that the cartilage methylome has a potential to distinguish between OA-affected and non-OA cartilage. Functional clustering analysis of the genes harbouring differentially methylated loci revealed that they are enriched in the skeletal system morphogenesis pathway, which could be a potential candidate for further OA studies. Overall, the findings from the present thesis provide evidence that the TGF-ß signalling pathway is associated with the development of OA, and epigenomics might be involved as a potential mechanism in OA.

An application of evolutionary algorithms for WAG optimisation in the Norne Field

Water-alternating-gas (WAG) is an enhanced oil recovery method combining the improved macroscopic sweep of water flooding with the improved microscopic displacement of gas injection. The optimal design of the WAG parameters is usually based on numerical reservoir simulation via trial and error, limited by the reservoir engineer’s availability. Employing optimisation techniques can guide the simulation runs and reduce the number of function evaluations. In this study, robust evolutionary algorithms are utilized to optimise hydrocarbon WAG performance in the E-segment of the Norne field. The first objective function is selected to be the net present value (NPV) and two global semi-random search strategies, a genetic algorithm (GA) and particle swarm optimisation (PSO) are tested on different case studies with different numbers of controlling variables which are sampled from the set of water and gas injection rates, bottom-hole pressures of the oil production wells, cycle ratio, cycle time, the composition of the injected hydrocarbon gas (miscible/immiscible WAG) and the total WAG period. In progressive experiments, the number of decision-making variables is increased, increasing the problem complexity while potentially improving the efficacy of the WAG process. The second objective function is selected to be the incremental recovery factor (IRF) within a fixed total WAG simulation time and it is optimised using the same optimisation algorithms. The results from the two optimisation techniques are analyzed and their performance, convergence speed and the quality of the optimal solutions found by the algorithms in multiple trials are compared for each experiment. The distinctions between the optimal WAG parameters resulting from NPV and oil recovery optimisation are also examined. This is the first known work optimising over this complete set of WAG variables. The first use of PSO to optimise a WAG project at the field scale is also illustrated. Compared to the reference cases, the best overall values of the objective functions found by GA and PSO were 13.8% and 14.2% higher, respectively, if NPV is optimised over all the above variables, and 14.2% and 16.2% higher, respectively, if IRF is optimised.

The first time delivery of the first link learning series using Skype and YouTube

Introduction: This case study documented the experiences of informal and service providers who participated in the first time delivery of the First Link Learning Series from May–August 2013 in Newfoundland and Labrador. The aim of this study was to understand how informal caregivers of people with dementia experience this Internet mediated health resource, and how Skype and YouTube can be used as tools for the Alzheimer Society of Newfoundland and Labrador to effectively deliver the First Link Learning Series. Methods: Sources of data included key informant interviews (n=3), pre- study and post-study interviews with informal dementia caregivers (n=2), institutional documentation, field notes, and YouTube analytics. Framework Analysis was used to make meaning of the qualitative data, and descriptive statistics were used to report on quantitative outcomes. Findings: Between 3% and 17% of registered First Link clients attended the learning series sessions, however only two caregivers participated using Skype or YouTube. Framework Analysis revealed three shared themes: access, connection and privacy. Discussion: The themes helped to begin building theory about barriers and facilitators to Internet mediated health resources for informal dementia caregivers. Experiences of service providers using the Internet to support clients served to begin building a case for the appropriateness of these media. A modified version of Dansky et al.’s (2006) theoretical framework for evaluating E-Health research that situates the person/user in the model, helped guide discussion and propose future directions for the study of Internet based health resources for informal dementia caregivers.

Performing "Up The Shore": a stylistic analysis of Newfoundland Irish English vowels in the Ferryland dinner theatre

This study is a variationist sociolinguistic analysis of two speech styles, performance and interview, of a dinner theatre troupe in Ferryland on the Southern Shore of Newfoundland. Five actors and ten of their characters are analyzed to test if their vowels change across styles. The study adopts a variationist framework with a Community of Practice model, drawing on Bell’s audience and referee design to argue that the performers’ stage conventions and identity construction are influenced by a third person referee: the Idealized Authentic Newfoundlander (IAN). Under this view the goal of the performer is to both communicate with and entertain the audience, which requires different tactics when speaking. These tactics manifest phonetically and are discussed in a quantitative, statistical analysis of the acoustic measurements of the vowel tokens [variables FACE, KIT, LOT/PALM and GOAT lexical sets with Newfoundland Irish English (NIE) variants] and a qualitative discussion.

Morbidity and mortality following pelvic rami fractures in an elderly Newfoundland population

Introduction: Pelvic rami fractures in the elderly are associated with significant morbidity and mortality. Despite our rapidly aging population there is a paucity of literature dealing with fractures of the pelvic rami in this age group. The purpose of this study is report mortality rates following these injuries in the Eastern region of Newfoundland. Additionally, we aim to describe and quantify the important resultant morbidity in this vulnerable elderly population . Methods: A retrospective chart review was performed of all the pelvic fractures in individuals over the age of 60 between 2000 and 2005 in the Eastern Health region of Newfoundland and Labrador. From these patients, only those with the radiographic parameters consistent with low energy pattern pelvic ring injuries were included. Excluded from the study were those with concurrent fractures of the femur. Survival data, comorbidities, injury characteristics, hospital stay, ambulatory status, and place of residence were recorded from the chart. A surrogate control group was formulated from Statistics Canada survival data for use as a survival comparison group. Results: There were 80 fractures of the pelvis identified in patients over 60 years old from 2000-2005. Of these, 43 met our inclusion/exclusion criteria and were used in our analysis. The one and five year mortalities of these patients were 16.3% (95% CI; 7.80% to 30.3%) and 58.1% (95% CI; 43.3% to 71.6%), respectively. These were both significantly different from the point estimates from our constructed age and gender matched control group from the Statistics Canada data of 6.58% (one year mortality) and 31.3% (five year mortality). Morbidity was quantified by change in ambulatory status (independent, walker/cane assisted, wheelchair) and change in residential independence (independent, assisted living, nursing home). Post fracture, 36% of patients permanently required increased ambulatory aids and 21% of patients required a permanent increase in everyday level of care. Conclusion: This study suggests that there may be significantly increased mortality and morbidity following low energy pattern pelvic rami fractures in an elderly population compared to age and gender matched controls. In contrast to previous studies describing these injuries, there is greater homogeneity in this population with respect to age and mechanism of injury. This study generates several important hypotheses for future research and in particular highlights the need for larger prospective studies to identify factors predicting the highest risk for poor outcomes in this population.