COMMUNICATING NURSING RESEARCH Volume 51 TRANSFORMING HEALTH THROUGH ADVANCES IN NURSING RESEARCH, PRACTICE, AND EDUCATION

COMMUNICATING NURSING RESEARCH Volume 51 TRANSFORMING HEALTH THROUGH ADVANCES IN NURSING RESEARCH, PRACTICE, AND EDUCATION An annual publication of the Western Institute of Nursing containing the proceedings of the Communicating Nursing Research Conference and WIN Assembly held April 11-14, 2018 at the Davenport Grand Hotel in Spokane, Washington. WESTERN INSTITUTE OF NURSING SN-4S 3455 SW US VETERANS HOSPITAL ROAD PORTLAND, OR An Affirmative Action/Equal Opportunity Employer Spring 2018 1 COMMUNICATING NURSING RESEARCH issues previously published: Volume 1: The Research Critique Volume 2: Problem Identification and the Research Design Volume 3: Methodological Issues in Research Volume 4: Is the Gap Being Bridged? Volume 5: The Many Sources of Nursing Knowledge Volume 6: Collaboration and Competition in Nursing Research Volume 7: Critical Issues in Access to Data Volume 8: Nursing Research Priorities: Choice or Chance Volume 9: Nursing Research in the Bicentennial Year Volume 10: Optimizing Environments for Health: Nursing’s Unique Perspective Volume 11: New Approaches to Communicating Nursing Research Volume 12: Credibility in Nursing Science Volume 13: Directions for the 1980’s Volume 14: Health Policy and Research Volume 15: Nursing Science in Perspective Volume 16: The Image of Nursing Research: Issues and Strategies Volume 17: Advancing Nursing Science: Qualitative and Quantitative Approaches Volume 18: Influencing the Future of Nursing Research through Power and Politics Volume 19: The Winds of Change: New Frontiers in Nursing Research Volume 20: Collaboration in Nursing Research: Advancing the Science of Human Care Volume 21: Nursing: A Socially Responsible Profession Volume 22: Choices within Challenges Volume 23: Nursing Research: Transcending the 20th Century Volume 24: Partnerships: Putting It All Together Volume 25: Silver Threads: 25 Years of Nursing Excellence Volume 26: Scholarship in Practice Volume 27: Research, Practice, and Education within the Health Care Agenda Volume 28: Innovation and Collaboration: Responses to Health Care Needs Volume 29: Advancing Nursing through Research, Practice, and Education Volume 30: Nursing: Changing the Environment Volume 31: Quality Research for Quality Practice Volume 32: Nursing Research: For the Health of Our Nation Volume 33: Building on a Legacy of Excellence in Nursing Research Volume 34: Health Care Challenges Beyond 2001: Mapping the Journey for Research and Practice Volume 35: Health Disparities: Meeting the Challenge Volume 36: Responding to Societal Imperatives through Discovery and Innovation Volume 37: Hallmarks of Quality: Generating and Using Knowledge Volume 38: Looking Ahead: Innovations in Nursing Science, Practice, and Education Volume 39: Building Knowledge for Practice Volume 40: 50 Years of Advancing Nursing in the West 1957 – 2007 Volume 41: The Circle of Nursing Knowledge: Education, Practice and Research Volume 42: Networks in Nursing Science: Creating our Future Volume 43: Nursing Science: Informing Practice and Driving Policy Volume 44: Transitions: Unifying Practice, Education, and Research to Improve Health Volume 45: Advancing Scientific Innovations in Nursing Volume 46: Creating a Shared Future of Nursing: Research, Practice, and Education Volume 47: Taking It Global: Research, Practice, and Education in Nursing Volume 48: Equity and Access: Nursing Research, Practice, and Education Volume 49: Innovations in Engagement through Research, Practice, and Education Volume 50: 50 Years of Leadership: Continuing the Vision The Cumulative Index of the Communicating Nursing Research Conference Proceedings, Volumes 1 to 25, () was published in 1992. COMMUNICATING NURSING RESEARCH has been published annually by the Western Institute of Nursing. Each volume contains the addresses and abstracts of papers presented at the annual Communicating Nursing Research Conference. 2 FOREWORD With my retirement planned later this year, this is the last Foreword I will write for the Communicating Nursing Research Conference proceedings. I will complete 22 years as the Executive Director of the Western Institute of Nursing (WIN). I have been so honored to stand on the “shoulders of the giants” who served before me, Jo Eleanor Elliott and Jeanne Kearns. Looking back over 22 years, the advancements the organization have made are striking. I became the Executive Director during a time of rapid technology growth. During that time, we have moved from a paper operation to an electronic operation. We initiated the first WIN webpage and upgraded it several times, most recently for use on various electronic devices; developed a database to facilitate the work of staff and members; instituted social media channels to better communicate with members; and started the use of a conference application (app). We initiated the “Nursing Education Xchange: NEXus” by which doctoral students in one of the consortium member school may take distance education classes from another member school. In 2017, we celebrated the 60th Anniversary of WIN and the 50th Communicating Nursing Research Conference, both a testimony to the work of our members and the longevity of the mission and vision of the organization. While these advances happened on my “shift”, I have used the term “we” deliberately. It certainly takes a strong and committed team to enact all these changes. I have been extremely fortunate to have partnered with Presidents, Board members, and Committee members, all of whom are wholeheartedly dedicated to the WIN vision and the tasks to move the organization forward. The Program Committees over the past 22 years have worked diligently to create conference programs that stimulate and educate with a gentle Western welcome to all who attend. The staff team over the years has not only made the work of the Board and Committees easier, but staff members have contributed skill and advancements to their respective jobs. The WIN staff works very hard, and none of the advances noted above could have happened without their commitment. To echo Jeanne Kearns’ final Foreword, each has certainly made my professional life an exceptional experience. This organization has extraordinary members who are dedicated to their careers in research, practice, and education, and accomplished students who are engaged in educational programs to enhance their contributions to nursing science. My wish for all members is that you continue to facilitate the growth of WIN and to remain committed to the 60-year WIN vision of excellence in research, practice, and education. WIN has been greatly enriched through its partnership with the Oregon Health & Science University School of Nursing. The School and its deans, Carol Lindeman, Kate Potempa, Michael Bleich, and now Susan Bakewell-Sachs, have been supportive and nourishing in the relationship between the school and the western regional nursing organization. We owe them a debt of gratitude. I close with my appreciation and fondness to each and every one, within and outside the organization, who has made my tenure here such an amazing experience. I will miss you all. Paula A. McNeil, RN, MS Executive Director Western Institute of Nursing April 2018 3 PREFACE The 51st Annual Communicating Nursing Research Conference, “Transforming Health through Advances in Nursing Research, Practice, and Education,” was held April 11-14, 2018 at the Davenport Grand Hotel in Spokane, Washington. The keynote address was delivered by Bobbie Berkowitz, PhD, RN, NEA-BC, FAAN, Dean and Mary O’Neil Mundinger Professor, Columbia University School of Nursing and Senior Vice President, Columbia University Medical Center, New York, NY. State of the Science presentations were delivered by: Eileen Cody, BSN, RN, Representative of the 34th Legislative District, Washington State Legislature and Neuro-Rehab Nurse, Group Health Cooperative, Seattle, WA; Usha Menon, PhD, RN, FAAN, Professor and Associate Dean for Research & Global Advances, College of Nursing, The University of Arizona, Tucson, AZ; and Carolyn Montoya, PhD, CPNP, FAANP, FAAN, Interim Dean, College of Nursing, University of New Mexico, Albuquerque, NM. Two award papers were presented: Distinguished Research Lectureship Award: Patricia Butterfield, PhD, RN, FAAN, Professor and Associate Dean for Research, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA; and Carol A. Lindeman Award for a New Researcher: Daniel T. Linnen, MS, RN-BC, PhD Candidate, School of Nursing, University of California, San Francisco and Health Systems Research Resident, Kaiser Permanente Northern California, Oakland, CA. The Proceedings include the abstracts of symposium, podium, and poster presentations. One hundred and fifty-seven papers were presented in podium sessions on a wide variety of topics, including completed research, theoretical papers, and projects. Fifty papers were presented in eleven symposia, and one hundred and seven papers were organized in twentyfive other sessions. Four hundred and twenty-one posters were displayed over four poster sessions, representing projects and research, completed or in progress. A total of two hundred and thirteen posters were submitted from member institutions for the Research & Information Exchange. Awards were given to numerous WIN individual members during the 2018 conference. Please consult the Table of Contents for the location of the aforementioned papers, the list of awardees honored by WIN, and the name and subject indexes. The conference was planned and organized by the WIN Program Committee, and we extend our gratitude to the Program Committee members: Anthony McGuire, Chair, ME; Judith Berg, AZ; Katreena Collette-Merrill, UT; Mary Ellen Dellefield, CA; Linda Edelman, UT; Bronwyn Fields, CA; Bonnie Gance-Cleveland, CO; Lori Hendrickx, SD; Kathryn Lee, CA; Judy Liesveld, NM; Kristin Lutz, OR; Paula Meek, CO; Usha Menon, AZ; Annette Nasr, CA; Joanne Noone, OR; Jennifer Peterson, CA; Kristine Qureshi, HI; Roberta Rehm, CA; Sharon Ruyak, NM; Hilaire Thompson, WA; and Catherine Van Son, WA. We thank all of the nurse researchers who submitted papers and participated in the 2018 conference. Charlene A. Winters, PhD, RN President, Western Institute of Nursing Anthony W. McGuire, PhD, CCRN-K, ACNP-BC, FAHA Chair, Program Committee, Western Institute of Nursing 4 State of the Science Paper WHAT WOULD FLORENCE DO? SURVEY RESULTS OF SELECTED NURSING PROGRAMS IN WESTERN STATES: IMPLICATION FOR THE FUTURE OF NURSING EDUCATION Carolyn Montoya, PhD, PNP, FAAN, FAANP Robert Wood Johnson Fellow Associate Professor and Interim Dean College of Nursing University of New Mexico Albuquerque, NM 5 WHAT WOULD FLORENCE DO? SURVEY RESULTS OF SELECTED NURSING PROGRAMS IN WESTERN STATES: IMPLICATION FOR THE FUTURE OF NURSING EDUCATION Carolyn Montoya, PhD, PNP, FAAN, FAANP Robert Wood Johnson Fellow Associate Professor and Interim Dean College of Nursing University of New Mexico Albuquerque, NM In 2017, the Western Institute of Nursing (WIN) celebrated 60 years of advancing nursing science, education, and practice to improve health outcomes. As is the tradition at the WIN annual conferences, state of the science papers on nursing research, education, and practice were presented with a focus on the future of nursing in each of these areas. The 2017 state of the science presentation on nursing education identified the following three areas expected to influence the future of nursing education: student traits and major trends in both health care and higher education. (Young, 2017). Young’s literature review provided compelling evidence regarding the challenges that face nursing education including the greying of the nursing workforce, the aging of the U.S. population, the diversity of our culture, declining state support for higher education resulting in ever increasing tuition and fees, the transformation of education due to advances in technology, and the diversity of student learning preferences. The literature on challenges facing nursing education continues to grow. Fang and Kesten (2017) used American Association of Colleges of Nursing (AACN) full-time faculty data from the AACN Annual Survey of Baccalaureate and Graduate Programs in Nursing to estimate faculty retirements in and the impact of these retirements on the nursing faculty workforce. They projected that one-third of U.S. nursing faculty active in 2015 would retire between 2016 and 2025. Concerns about a shortage of nursing faculty extend beyond the United States. Nardi and Gyurko (2013), in their review of the global nursing faculty shortage, described several challenges including aging faculty, poor salaries, lack of funding, faculty dissatisfaction with the role, and a decreasing number of full-time equivalent faculty positions. Among the most intriguing possible challenges facing nursing education are disruptive innovations. The concept of a disruptive innovation was originally developed in the business sector to describe the process of a smaller company displacing an established company by providing a service or product to a segment of the customers whose needs were either overlooked or not deemed significantly important by the established company (Christensen, Raynor, & McDonald, 2015). True disruptors generally start by engaging clients who are either not currently served or are at the low-end of the market and then evolve to include more mainstream consumers. Christensen et al. (2015) noted that disruptive innovations are initially considered inferior by mainstream consumers. Rather than trying the new “product” because it is less expensive, mainstream consumers wait until the quality of the new product improves. The concept of disruptive innovation has been discussed within the context of higher education and in health care delivery. Christensen, Horn, Caldera, and Soares (2011), in a report for the Center for American Progress, cited the use of online learning as an enabler for disruption in higher education. The proliferation of for-profit higher education businesses that offer online programs is an exemplar of disruptive innovation. While universities have adopted online courses and programs, the authors described the current model of offering research, teaching, and career preparation as overly complex for the focused purpose of educational program delivery, resulting in significant overhead expenditures. In contrast, for-profit educational businesses are able to keep their overhead lower as they focus solely on providing online educational programs. Thompson (2016a, 2016b) used the concept of disruptive innovation to advocate for embracing distance education using online delivery in graduate nursing education. While 6 state and private universities have embraced online courses, there has been resistance to move entire programs to an online format due to the concerns regarding the quality of totally online programs. Thompson advocated for “…embracing new pedagogies and technologies to improve the quality and delivery of education, and specifically those strategies shown to work well for distance education” (Thompson, 2016b, p. 238). She argued that colleges and universities need to learn to protect their market by adopting new technology and embracing distance education as the preferred means by which students obtain higher education. Hwang and Christensen (2007) argued that, unlike higher education, technology enablers in health care delivery have failed to produce any true disruptive innovations due to the challenges of fragmented care, lack of a retail market, regulatory barriers, and lower reimbursements for care. They classify general hospitals and physician practices as solution shops which “are institutions built to diagnose and solve unstructured problems” (p.1332). The authors noted: The legacy institutions of health care delivery are jumbled mixtures of multiple business models struggling to deliver value out of chaos, incorporating indecipherable systems of cost accounting, excessive overhead, pervasive crosssubsidization, and an unacceptable amount of variability and medical error. (p.1332) One example of a truly disruptive innovation in health care that can extend the reach of nurses and improve care is telehealth nursing (Grady, 2014). Telehealth encompasses telemedicine which, while originally rejected by traditional healthcare providers and consumers, now includes over 200 telemedicine networks with over 3500 service sites (American Telemedicine Association, 2017). In addition to describing potential uses of telehealth by nurses, Grady sounded a “call to action” for nurse educators to disrupt the current pedagogical methods of passive learning and include exposure to telehealth nursing. Her example of a potentially disruptive innovation in nursing education was to develop a virtual nursing unit where students could be exposed to a variety of technology that they are likely to encounter in practice. Huston, et al. (2017), further advocated for disruptive innovation in nursing education that would promote active, learner-centered education as a strategy to help bridge the academic/practice gap. One example of a teaching modality that may be considered the beginning of a disruptive innovation in nursing education is the use of a TeleECHO for advanced practice students. The Extension for Community Healthcare Outcomes (ECHO) model, developed at the University of New Mexico Health Sciences Center, was originally designed to offer best- practice care for hepatitis C infection to minorities and underserved populations in New Mexico through telemedicine and internet connections (Arora, et al., 2007). As explained by Dr. Stephen V. Roper, TeleECHO clinics are virtual grand rounds where primary care providers from multiple locations connect at regularly scheduled times with a team of specialists utilizing low cost, multi-point video conferencing (personal communication, January 5, 2018). Dr. Roper, a faculty member at the University of New Mexico College of Nursing, is currently utilizing TeleECHO in seven advanced practice courses for primary care Advanced Practice Registered Nurse (APRN) students as well as for APRN providers across the state. While truly disruptive innovation may still be in the future for nursing education and health care, the impact of technological innovation is not. Nursing has embraced technological innovation by incorporating simulation as a teaching/learning method and by offering hybrid web-based courses, courses that are entirely web-based, and entire online degree programs (Skiba, Connors, Jeffries, 2008). In order to sustain and advance technological innovation, nursing needs to increase technological competence. White, Pillay, and Huang (2016) assessed nurse leaders’ perceptions of innovation competencies and their perceived level of competence. They found participants to have significant gaps in 18 of the 19 competencies, leading them to recommend that all nursing programs include innovation competencies in their curricula. 7 Reports published annually by the New Media Consortium in collaboration with EDUCAUSE Learning Initiative provide descriptions of key trends accelerating higher education technology adoption (Adams Becker, et al., 2017). These reports include considerations of both long term trends, projected to be 5 or more years in the future, and “wicked” technology-related challenges facing higher education. In the 2017 report, longterm trends included advancing both cultures of innovation and deeper learning approaches; wicked challenges included managing knowledge obsolescence and rethinking the roles of educators. Regarding timelines for technology adoption, artificial intelligence and natural user interfaces (wearable computing) were predicted to be adopted in higher education within 4 to 5 years. True innovation will mean a major shift in attitudes as most individuals resist change, academia is not particularly nimble at making changes, and there is strong aversion to the possibility of failure (Giddens, 2015). Given that nursing academic leaders will be at the forefront of managing these educational challenges, a survey was developed to assess the perception of academic nursing leaders in the 13 states served by the Western Institute of Nursing. The survey assessed perception of academic nursing leadership in these states related to: (a) current and future challenges facing nursing education; (b) implementation of innovative strategies in response to one of the identified challenges; and (c) identification of at least one potentially disruptive innovation that would possibly impact nursing education in the next 30 years. Methods All members of the research team participated in the development of the survey tool which was then reviewed by and pilot tested with five senior leaders in academic nursing. Survey feedback was reviewed and incorporated into the survey during an iterative process over a three month period in 2017. The survey contained five core, open-ended questions regarding current challenges in nursing education at their institution as well as anticipated challenges in the future. Participants were also asked to describe at least one innovative strategy that they had implemented in response to a challenge and to describe at least one potentially disruptive innovation that they thought would impact nursing education in the next 30 years. The sampling frame for this survey consisted of 116 nursing programs that are American Association of Colleges of Nursing member schools in the 13 states served by the Western Institute of Nursing. Contact information was located for a nursing leader with primary responsibility for the academic mission for 100 of these 116 programs. This survey and the methodology was approved as an exempt study by the institutional Human Research Protections Office. The REDCap platform was used to e-mail a survey to these 100 academic leaders, generating 42 responses in late fall 2017. Results The majority of responses came from public institutions, about half of responses came from minority-serving institutions, and nearly half of responses came from institutions with more than 500 nursing students enrolled. A majority (14 of 20) minority serving institutions were Hispanic-serving, having undergraduate enrollment at least 25% Hispanic and less than 25% any other minority group. A majority (29 of 42) of institutions offered some type of graduate degree program in nursing and a majority of these institutions (23 of 29) offered specialty graduate programs for nurse practitioners. Aside from the ADN, the PhD (5 of 42) was the least common degree program offered at responding institutions. An iterative process was used to classify responses to the question on the most challenging issues currently facing nursing education in to three major themes: faculty issues, resources, and changes. These themes remained the same when respondents were asked to anticipate the most challenging issues facing nursing education at their institutions in the next 10-20 years, with multiple respondents stating, “same as above.” Therefore, the responses to these two questions were combined. Survey responses under the theme of faculty issues were congruent with what has been reported in the literature regarding faculty workforce. Respondents were very concerned 8