Bottlenecks to Learning Evidence-Based Practice: Recommendations for Nursing Faculty.

BACKGROUND: Evidence-based practice (EBP) competency is an expected outcome of baccalaureate education; however, research indicates nursing graduates enter practice with competency gaps. PURPOSE: The purpose of this study was to explore the challenges accelerated baccalaureate students experience when learning the steps of EBP. METHODS: A qualitative, descriptive design was used to identify bottlenecks to student learning. RESULTS: Learning the steps of EBP in an accelerated format was challenging for students. Data analysis revealed 3 types of bottlenecks that stalled learning: cognitive, procedural, and emotional. CONCLUSIONS: Faculty build EBP competency by making explicit the steps that help students progress. Scaffolded learning, collaborative partnerships, and reflective practices are recommended to support student learning in accelerated formats.

The Disruption of Patient Ambulation Care Processes by COVID-19: Revealing the Value of Visitor Assistance.

OBJECTIVE: To explore the impact of COVID-19 on care processes and ambulation outcomes. BACKGROUND: COVID-19 forced hospital leaders to make systems-level changes that disrupted patient ambulation. The impact of these changes on the ambulation of hospitalized patients was unknown. The Systems Engineering Initiative for Patient Safety model was used to explore ambulation from a systems perspective. METHODS: A single-case study research design was used to investigate patient ambulation in a major medical center. Data from 12 interviews with interdisciplinary leaders were analyzed. RESULTS: Staff shortages and visitor restrictions were identified as the main work system barriers to ambulation. These barriers disrupted usual ambulation processes and supported the value of visitor assistance with ambulation. CONCLUSIONS: This study provides a systems-level perspective of missed ambulation during COVID-19, which revealed the value of ambulation assistance provided by visitors. Findings may be used to support the continued and increased involvement of family members and visitors in the process of ambulation.

Application of case study research and ethnography methods: Lessons learned.

While case studies can offer an in-depth investigation of a particular issue in healthcare, cultural context may be overlooked. Researchers may want to consider adding a cultural component to the design aimed at identifying and/or explaining values, beliefs, or traditions influencing the case. The addition of focused ethnography as a supplemental component to the research design is one strategy to examine cultural content. In this article, we provide insights gained from using case study research and focused ethnography in a qualitatively-driven mixed method design. Despite a detailed research plan, there were challenges that hindered the implementation of the design. To help prevent others from experiencing similar methodological challenges, we provide the following lessons learned and recommended strategies: discussion of structured procedures for intentional observations, reflexivity to guide decision-making, and refinement of processes using a pilot study.

The Role of the School Nurse in Suicide Prevention: Implications for Equitable Care of Vulnerable Youth.

The rising rate of youth suicide in rural Eastern North Carolina reflects the national trend. Although school nurses have been regarded as the gateway professional for mental health services, their role in suicide prevention is not well understood. The purpose of this study was to explore school nursing practice regarding suicide prevention of school-aged children in one vulnerable region of the United States. Focus groups and surveys were collected from 35 school nurses in six school districts. Findings indicate that suicide protocols inclusive of the school nurse can facilitate their role in suicide prevention. Variation of school nursing practice existed between and within districts. These variations in school nursing practice highlight the need for school districts within the state and across the country to examine their policies and practices for mental health equity. Barriers such as higher caseloads, role disconnect, and lack of specialized training contributed to variations in practice.

Barriers and facilitators to nurse practitioner buprenorphine prescribing for opioid use disorder in primary care settings.

BACKGROUND: Increasing access to opioid use disorder (OUD) treatment is critical to curbing the opioid epidemic, particularly for rural residents who experience numerous health and health care disparities, including higher overdose death rates and limited OUD treatment access compared with urban dwellers. Buprenorphine-naloxone is an evidence-based treatment for OUD that is well suited for rural areas. However, providers must have a specialized federal waiver to prescribe the medication. Despite the acceleration of the opioid epidemic in rural areas and the recent liberalization of federal buprenorphine-naloxone prescribing laws, few providers hold buprenorphine-naloxone prescribing waivers and even fewer prescribe the medication. PURPOSE: This study explores barriers and facilitators to buprenorphine-naloxone prescribing among nurse practitioners (NPs) working in primary care settings in eastern North Carolina. METHODOLOGY: Individual interviews were conducted with 13 NPs working in primary care settings in eastern North Carolina. Qualitative thematic analysis was used to identify perceived barriers and facilitators to buprenorphine-naloxone prescribing. RESULTS: Analysis found prescribing barriers related to OUD stigma, perceived knowledge, federal and state regulation, and prescribing resources and found facilitators related to adopting a person-centered approach, developing prescriber skills, and access to prescribing resources. CONCLUSIONS: The barriers and facilitators that NPs experience related to buprenorphine prescribing for OUD are similar to those faced by physicians, although the barriers arguably more profound. Future research should consider how to mitigate these prescribing barriers to facilitate NP buprenorphine prescribing for OUD. IMPLICATIONS: To our knowledge, this is the first qualitative study of NP buprenorphine-naloxone prescribing in rural areas. Given the prominence of OUD in rural regions and the key role NPs play in primary care provision, this study lays import groundwork for developing interventions to support buprenorphine-naloxone prescribing by NPs practicing in rural regions.

Integrative Review of Mental Health and Feeding Styles in Parents of Bottle-Fed Infants.

OBJECTIVE: To review the literature regarding the relationship between symptoms of anxiety and depression and feeding styles in parents of bottle-fed infants. DATA SOURCES: We conducted literature searches in PubMed, CINAHL, Scopus, and PsycINFO. STUDY SELECTION: We used Covidence systematic review management software during the selection process to allow for full blinding of decisions by team members. Articles were eligible for inclusion if they were reports of primary research, written in English, and focused on the relationship between symptoms of anxiety or depression and feeding styles in parents of term, bottle-fed infants younger than 12 months of age. We placed no restriction on date of publication because of the sparse amount of published literature on this topic. We identified a total of 1,882 articles. After removing duplicates, we screened 988 articles and retained six articles that met criteria for our review. DATA EXTRACTION: We used Whittemore and Knafl's integrative review methodology to guide data extraction and reporting. We extracted relevant data from all primary data sources and compiled the data into a matrix. We used the Joanna Briggs Institute Checklist for Analytical Cross Sectional Studies to assess the quality of the studies. DATA SYNTHESIS: Using an a priori coding scheme, we summarized the data using categorization of established parental feeding styles in infancy applicable to bottle-feeding. We synthesized the data into two broad categories: responsive and nonresponsive feeding styles. CONCLUSION: Although research on the topic is limited, our findings suggest that symptoms of postpartum depression may be associated with nonresponsive feeding styles in parents of bottle-fed infants. We suggest several areas for future research and recommend increased emotional and feeding support in practice for parents of bottle-feeding infants.

Student safety in middle school: Implications for school nurse and teacher collaboration.

OBJECTIVE: Adolescent suicide is a public health crisis. School connectedness, a protective factor, may be especially important in low-income rural schools, with fewer resources and higher rates of suicide as compared to urban schools. The purpose of this study was to explore teacher perceptions of safety and school connectedness in a low-income, rural middle school, and implications for collaborative practice between school nurses and teachers. DESIGN AND SAMPLE: A qualitative secondary data analysis was used. Data were taken from transcripts from four focus groups comprised of middle school teachers (n = 20). MEASUREMENT: An inductive approach to content analysis was conducted using in vivo Coding and Venn diagrams. RESULTS: Three themes were identified: (1) defiant and aggressive student behaviors were safety concerns, as teachers perceived they may be obscuring mental health needs; (2) teachers were sometimes placed in a position to assist students with safety management strategies; and (3) managing safety concerns was an obstacle to building connectedness, as reflected in safety and school connectedness. CONCLUSION: Collaborative strategies between school nurses and teachers are essential to identify student behaviors that may be masking mental health needs. Strategies have the potential to enhance school connectedness and support student safety.

Application of the Threshold Concept Framework in Nursing: An Integrative Review.

BACKGROUND: The shift to concept-based curricula requires nurse educators to be selective with disciplinary content to avoid overburdening curricula. Although educators strive to make these concepts explicit, some learners find them troublesome. These troublesome concepts are often threshold concepts, which are critical to understanding disciplinary knowledge. PURPOSE: The purpose of this integrative review was to examine how the threshold concepts framework has been applied within nursing to facilitate student learning of troublesome knowledge. METHOD: Whittemore and Knafl's integrative literature review methodology was used. RESULTS: Twenty articles were included representing a diverse selection of literature. Data analysis resulted in 3 themes: framing difficult knowledge, developing pedagogical strategies, and designing nursing curricula. CONCLUSION: The threshold concepts framework aids in redesigning pedagogy to engage students at critical points in the learning process, helping them successfully navigate encounters with troublesome knowledge. The framework also provides guidance for identifying and sequencing concepts critical to the discipline to avoid overcrowded curricula.

Troublesome knowledge for entry-level PhD nursing students: Threshold concepts essential for the research-focused doctorate.

BACKGROUND: Evidence supports that PhD doctoral students experience conceptually difficult knowledge, or troublesome knowledge, during their studies. These areas of troublesome knowledge are often associated with threshold concepts, those ideas specific to a discipline that must be understood to advance ways of thinking and making knowledge in the discipline. PURPOSE: To examine troublesome knowledge identified by a group of PhD nursing students during an introductory course and to consider threshold concepts related to that knowledge. METHOD: Design: Case study research methodology. SAMPLE: 18 entry-level PhD nursing students recruited with convenience sampling. DATA COLLECTION: Content analysis was used to analyze data collected from student reflective learning journals. Journal data was triangulated with formative and summative faculty assessments of student learning. RESULTS: Three essential threshold concepts for entry-level PhD nursing students were identified: developing new ways of knowing, constructing researcher and writer identity, and positioning within the nursing research community. Analysis indicates that entry-level students found the threshold concept of constructing researcher and writer identity most troublesome. CONCLUSION: A PhD introductory nursing course which includes metacognitive activities, scaffolding of assignments, and early positioning within the research community can assist students with mastery of threshold concepts for the research-focused doctorate.

An integrative review of threshold concepts in doctoral education: Implications for PhD nursing programs.

OBJECTIVE: To critically analyze published research addressing threshold concepts in doctoral education, explore factors affecting conceptual threshold crossing by doctoral students, and consider the application of these findings in doctoral nursing education. BACKGROUND: Mastery of concepts specific to the research-focused doctorate is critical in order for doctoral students to become independent researchers. These threshold concepts can be challenging, or troublesome, and students may find themselves 'stuck' during the learning journey. Engaging with troublesome concepts may place a student in a state of liminality, a transitory space of uncertainty. DESIGN: An integrative approach was adopted for this review. DATA SOURCES: A combination of keywords was used to search PubMed, CINAHL Plus, PsycINFO, ProQuest Search, Education Research Complete, Scopus, and Science Direct for literature published through July 2019. REVIEW METHODS: Integrative review methods described by Whittemore and Knafl (2005) were used to review and analyze a total of 20 qualitative studies identified based upon specific inclusion criteria. RESULTS: The majority of identified threshold concepts emerge during the development stage of research, indicating a need for strategies to support students with navigation of the liminal spaces encountered early in the doctoral journey. Factors affecting conceptual threshold crossing include student writing development, presence of community, and faculty influences. CONCLUSION: Doctoral program strategies are needed to support how to both teach and learn threshold concepts within safe spaces. Recommendations for strategies to develop student writing, support community building, and cultivate faculty-student relationships in doctoral nursing programs are provided. More intentionally incorporating threshold concept strategies into doctoral level nursing education has the potential to support both graduation rates and successful career transition to maintain a steady pipeline of nurse scientists.

The Role of the School Nurse in Suicide Interventions: An Integrative Review.

Suicide rates among children and adolescents have continued to rise over the past decade indicating the need for school-based suicide prevention programs. School nurses (SNs) are well positioned to assist in assessment, early identification, and intervention of at-risk students. This integrative review aimed to (1) critically examine the role of the SN in school-based suicide interventions, (2) explore potential barriers preventing the SN from participating in suicide interventions, and (3) recommend strategies to build capacity for principles of school nursing practice in suicide intervention. The National Association of School Nurses' Framework for 21st Century School Nursing Practice was used to categorize interventions and outcomes related to suicide prevention. Findings demonstrate a lack of reported nursing interventions directly linked to student outcomes and suggest obscurity in the role of the SN. Recommendations for future research and strategies to build capacity for principles of school nursing practice are provided.

Mutual Benefits of a Service-Learning Community-Academic Partnership.

BACKGROUND: Service-learning community-academic partnerships provide opportunities for nursing student development. Although mutual benefit has been identified as a critical element for the success of these partnerships, research indicates a lack of attention to this element during the collaborative process. METHOD: This single case study aimed to identify benefits of an innovative service-learning community-academic partnership between a college of nursing and an elementary school. Data were collected and analyzed from four sources of evidence: interviews, artifacts, documents, and fieldwork. RESULTS: Findings suggest that both the college of nursing and elementary school mutually benefitted from the partnership. Mutual benefits were categorized into three categories: (a) student service leadership development, (b) service-learning curricula enrichment, and (c) enhanced partner service initiatives. CONCLUSION: To increase capacity for sustainability of service-learning partnerships, the following strategies are recommended: initiation of a formal contract between partners, use of a guiding framework to identify outcomes, and faculty support for service initiatives. [J Nurs Educ. 2020;59(2):93-96.].

Fostering scholarship in doctoral education: Using a social capital framework to support PhD student writing groups.

The shortage of nurse scientists in the United States complicates nursing's ability to sustain research-intensive environments, build knowledge for translation, and advance nursing science. More emphasis is needed on the preparation of PhD doctoral students to better equip them for a career of scholarship. Four recent PhD graduates participating in a writing group, examined the influence of social capital on their ability to develop capacity for scholarship. They found that a strong social factor supported their efforts to engage as scholars, be accountable for their writing, and make contributions to the research community. Although the writing group provided a space to practice scholarly writing and increased scholarly productivity, the experience was transformative in building capacity for scholarship. This article includes recommendations for academic leaders to both create and support writing groups within doctoral nursing programs using a social capital framework. Strategies are provided using the three dimensions of social capital: structural, relational, and cognitive. Investing in strategies that build social capital within a community can directly impact the advancement of science by elevating capacity for scholarship.

Changing New Graduate Nurse Profiles and Retention Recommendations for Nurse Leaders.

OBJECTIVE: This study compares and contrasts new graduate nurse attributes and perceptions using findings from a 2010 study and a recent analysis of new graduate nurses participating in the same residency program. BACKGROUND: As millennials saturate the healthcare work environment, their unique views and needs will influence the evolution of new graduate nurse residencies. METHODS: This study used previously reported data on new graduate nurses between 1999 and 2009 and compared it with a secondary analysis of data collected on new graduate nurses between 2011 and 2016. RESULTS: This study provides evidence that millennial new graduate nurses' levels of commitment and satisfaction do not moderate turnover intentions in the 1st 2 years of practice as they did in the previous group of new graduate nurses. CONCLUSIONS: Job embeddedness, a construct that measures the likelihood of whether a person is going to stay, may be a better measurement among new graduate nurses than commitment or satisfaction because millennials, a generation that is predominant in current new graduate nurses, are more engaged than loyal.

Threshold Concepts in Doctoral Education: A Framework for Writing Development in Novice Nurse Scientists.

Pedagogical practices for writing development in doctoral programs are often the by-product of completing dissertation research and may lack deliberate strategies to assist students with complex genres of writing. This article proposes a framework for doctoral education to assist students with mastery of threshold concepts in writing. Threshold concepts in writing are examined for their applicability to the evolution of writing in PhD nursing students as they begin to think and write like nurse scientists.

The Impact of New Graduate Nurse Transition Programs on Competency Development and Patient Safety: An Integrative Review.

Stronger evidence on the value of new graduate nurse transition programs is needed to justify the cost and warrant expansion of these programs to more health systems. The aim of this integrative review was to critically analyze published research on the relationship between new graduate nurse transition programs and patient safety outcomes. Limited evidence was found on actual safety improvement; rather, transition programs have predominately measured the development of competency as a process outcome variable for improving patient safety. A systems model is proposed to guide future research examining structure, process, and outcome variables, linking transition programs with patient outcomes.

Factors Facilitating Publication by Clinical Nurses in a Magnet® Hospital.

OBJECTIVE: This study examined the cognitive, behavioral, and environmental factors that facilitate publication by clinical nurses in Magnet® hospitals. BACKGROUND: The culture promoted by the Magnet Recognition Program® promotes nurses practicing in those settings to use, generate, and disseminate best practices. Successful and promising models of care and nursing practice are rarely disseminated beyond the organization where they are practiced. The questions persist: what barriers to writing for publication exist for clinical nurses, and how do we overcome them to advance emergent evidence? METHODS: A focused ethnographic, multiple-case study design examined 5 well-published nurses with high levels of dissemination occurring outside the Magnet organization where they were employed. RESULTS: Nurses in this study most often credited cognitive and behavioral factors for promoting publication. Although the organization encouraged peer-reviewed publication, there were limited environmental efforts to support efforts to publish in peer-reviewed journals by clinical nurses. CONCLUSIONS: The results of this case study call for more research on the multifaceted factors that promote publication by clinical nurses in the practice environment. Publication of research in peer-reviewed journals was supported by environmental influences of time to write, collaborative writing opportunities, and supportive and accurate guidance from editors.

Writing Development in Associate Degree in Nursing-to-Baccalaureate Degree in Nursing Students: Moving Out of the Comfort Zone.

BACKGROUND: The nursing profession has made several unsuccessful attempts to differentiate practice between nurses with associate degrees and baccalaureate degrees entering the workforce. Writing competency has been identified as one potential area of differentiation. METHOD: A descriptive, qualitative research design was used to explore Associate Degree in Nursing-to-Baccalaureate Degree in Nursing (ADN-to-BSN) graduates' perceptions of scholarly writing development in their baccalaureate studies. Nine recent graduates from a public college of nursing participated in semistructured interviews. RESULTS: Findings from content analysis revealed three phases of awareness in development of a scholarly writer: being a scholarly writer, assessing writing abilities, and connecting to practice. CONCLUSION: The study findings provide insight into competencies that could differentiate practice between ADN and BSN nurses entering the workforce. Although this study aimed to find out how ADN-to-BSN students are shaped as writers, findings suggest that the experience of learning to write may also be shaping students as professional nurses. [J Nurs Educ. 2017;56(3):182-185.].

Changing the Publication Culture From "Nice to Do" to "Need to Do": Implications for Nurse Leaders in Acute Care Settings.

PROBLEM: Nurses in clinical settings often generate innovative practice ideas to inform their practice and improve patient outcomes. Yet, few publish and share these innovations with a wider audience. Barriers impeding clinical nurses from writing for publication include discomfort with writing, lack of time, and scarce resources. METHODS: A qualitative study was designed to determine obstacles and facilitators to writing for publication. Interviews were conducted with five clinical nurses who had recently published in peer-reviewed journals. FINDINGS: Three themes emerged from the data: culture of "nice to do," personal motivation, and writing experiences. Findings from the study offer implications for nurse leaders to help increase publication efforts by clinical nurses in acute care settings. CONCLUSION: Nurse leaders can promote publication by clinical nurses through three main strategies: create a culture that supports publication, offer incentives to motivate nurses to publish and reward those who do publish, and provide writing experiences that facilitate writing for publication.