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THE FLORIDA STATE UNIVERSITY SCHOOL OF NURSING FLIGHT NURSES' AND NONFLIGHT CRITICAL CARE NURSES' KNOWLEDGE OF THE PULMONARY ARTERY CATHETER: A COMPARISON STUDY

By KAREN C. BIDDY

A thesis submitted to the School of Nursing in partial fulfillment of the requirements for the degree of Master of Science

Degree Awarded: Summer Semester, 2004

The members of the Committee approve the thesis of Karen C. Biddy defended on April 28, 2004.

_________________________ Jeanne Flannery Professor Directing Thesis _________________________ Denise A. Tucker Committee Member _________________________ Don Workman Committee Member

Approved: ____________________________________ Jeanne Flannery, Director, School of Nursing Graduate Program ____________________________________ Katherine P. Mason, Dean, School of Nursing

The Office of Graduate Studies has verified and approved the above named committee members.

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I would like to dedicate this manuscript to my family and Rex Harrison. Without their love, support, and perseverance, it would have been a very difficult task to complete. Jim, my husband, soul mate, and best friend, was behind me the whole way (a very long journey). Alex, my daughter, spent many hours in the library with me, keeping me company, and keeping my spirits up. Eli, my son, kept me focused with his sense of humor with the facts and the figures, statistically speaking. Rex, a special person that touched so many, thank you for being our friend and part of the family. To our God above, I thank you for giving me the strength to endure this project along with everything else that has come my way.

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ACKNOWLEDGEMENTS Dr. Jeanne Flannery, the lady with a vision, and the know-how to achieve it. You are one of a kind. Your kindness, wisdom, and gentle way have guided many of us through this jungle of academic confusion. Thank you for your support, patience and determination to keep me focused until this job was done. Dr. Don Workman, your passion for education, teaching, and student advocacy are rare and special attributes. What a gift you were when you graciously agreed to assist me in this endeavor. Dr. Denise Tucker, your passion for teaching, your expertise with cyber space, and critical care were all necessary to assist with this on-line adventure. Don Spells, mentor and friend. I could not have completed data collection, general computer skills 101 if it had not been for your patience and computer know-how. Diana Smith, secretary and mentor for the entire graduate department, kept me organized, answered questions before they were asked, and in general, kept me functioning within the university's policies and procedures. Eddie Page, thank you for keeping me in school and updated when it was needed. Jamie Marsh, computer whiz extraordinaire, who was always available for the computer crisis. Your patience and expertise are invaluable. I would like to thank Dr. Andrew B. Leibowitz and the Pulmonary Artery Study Group for the provision of the questionnaire used in this study. I would like to thank Ms. Barbara Tranbarger for her assistance in granting me the use of the Multicenter Pulmonary Artery Catheter Questionnaire, copyright 1994, in Progress in Anesthesiology, August, 1994, Volume viii, number 6, for my study. Without it, I would not have been able to complete this project. I would like to thank Ms. Marie Wayne for her assistance in granting me the use of the illustration of the pulmonary artery catheter in Nursing81, January, 1981, Volume 11, pp. 42-47; the actual illustration was on page 43. iv

TABLE OF CONTENTS

List of Tables ................................................................................ vii List of Figures ............................................................................... viii Abstract ....................................................................................... ix Chapter One ­ Introduction ............................................................... 1 Statement of Problem ........................................................... 4 Significance of Problem ........................................................ 5 Statement of Purpose ............................................................ 6 Operational Definitions ......................................................... 7 Research Questions .............................................................. 8 Hypothesis ......................................................................... 9 Conceptual Framework ......................................................... 10 Assumptions ...................................................................... 14 Limitations ........................................................................ 14 Summary ........................................................................... 15 Chapter Two ­ Review of Literature .................................................... Theory ............................................................................ Benner's From Novice to Expert ............................................. Knowles' Theory of the Adult Learner ...................................... The Pulmonary Artery (P A) Catheter ....................................... Research .......................................................................... Summary ......................................................................... 16 16 16 25 28 32 42

Chapter Three ­ Methodology ............................................................ 44 Population, Sample, and Setting .............................................. 44 Sampling Plan ................................................................... 45 Variables ......................................................................... 46 Instruments ...................................................................... 47 Demographic Data Sheet .............................................. 47 Multicenter Pulmonary Artery Catheter Questionnaire ............ 47 Protection of Human Subjects ................................................. 49 Procedure ......................................................................... 50 Data Analysis .....................................................................50 Summary .......................................................................... 54

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Chapter Four - Results ...................................................................... 56 Demographic Profile of Participants .......................................... 56 Descriptives for Flight/Nonflight Samples .................................... 58 P A Catheter Knowledge and Flight/Nonflight Samples .................... 60 Knowledge Comparison Flight/Nonflight Samples with the Literature ................................................... 62 Demographic and Professional Characteristic Variables .................... 62 Predictors of P A Catheter Knowledge ........................................ 64 Evaluation of P A Catheter Knowledge ......................................... 65 Conclusion ......................................................................... 67 Summary ...........................................................................69 Chapter Five ­ Discussion .................................................................. 71 Conceptual Framework .......................................................... 71 Synthesis of Study ................................................................ 76 Limitations ......................................................................... 80 Implications for Nursing ......................................................... 80 Recommendations for Future Research ........................................ 82 Summary ........................................................................... 83 Appendices ..................................................................................... 84 References ..................................................................................... 109 Biographical Sketch .......................................................................... 114

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LIST OF TABLES 4.1 Demographics ......................................................................... 58 .......................................................... 59

4.2 Professional Characteristics

4.3 Specialty Certifications ................................................................ 60 4.4 t ­ Test for equality of means 4.5 One sample t ­ Test ....................................................... 61

..................................................................... 62

4.6 Correlation matrix ..................................................................... 63 4.7 Self-staging .............................................................................. 65 4.8 Profile of the seven individuals ........................................................ 67

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LIST OF FIGURES 1. Diagram of the P A Catheter .......................................................... 30 2. Diagram of P A Catheter Knowledge Model ....................................... 75

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ABSTRACT Historically, several studies about knowledge of the P A catheter were done. Critical care nurses and physicians were tested for their level of knowledge of the P A catheter and its use on critically ill individuals. Unfortunately, each study revealed that a knowledge deficit among this group of professionals did exist. The purpose of this study was again to test critical care nurses, but also to include flight nurses. Their patient care arena is recognized as a critical care area, too. In order to evaluate the knowledge of the P A catheter of these two groups, flight nurses and nonflight critical care nurses, the Multicenter Pulmonary Artery Catheter Questionnaire developed by Iberti and Associates (1990), was used to sample these two groups by way of the World Wide Web. The 27-item, multiple-choice questionnaire was placed on the Internet along with a 17-item demographic data sheet to include variables such as age, gender, nursing experience (general and specific), specialty certification, P A catheter education, and educational background. These variables were chosen to replicate the ones used in prior studies and again to see if they affected the participants' scores. The questionnaire was available on the web site for 4 months. During this time, continuous effort was made by the investigator to make known the existence of the questionnaire. This was done by email, communications through nurse chat and discussion groups online, telephone calls, and follow-up links, made available through communications with professional organizations (AACN and ASTNA). The mean knowledge score for the two groups was 47.37 (n = 35), the flight nurse sample had a mean score of 59.75 (n = 8), and the nonflight critical care nurse sample had a mean score of 43.7 (n = 27). Comparing the two samples' outcomes with the mean score from the previous two studies, the flight nurse sample scores were more in line with the previous studies' scores than the scores of the nonflight nurse sample. The sample size was too small to declare that the two groups were comparable with their knowledge of the P A catheter, but from a clinical view, the difference of the two mean scores does

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make the flight nurse sample more knowledgeable of P A catheters than the nonflight nurse sample. Further research is recommended with a larger population to determine if flight nurse knowledge of the P A catheter is greater than that of the nonflight critical care nurse. It is also recommended that a new tool be developed to focus on today's changing bedside nursing and the technologies that assist in the care of the critically ill patients.

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CHAPTER 1 INTRODUCTION The pulmonary artery (P A) catheter was introduced to the medical world in 1970 (Iberti et al., 1990). In the beginning, it was utilized as a research tool for physiological study of patients with a recent myocardial infarction (Swan, 1991). Thereafter, it gained rapid, general usage as a valuable clinical tool in surgery, anesthesiology, and critical care, especially cardiology, providing valuable information on the hemodynamic state of the patient. This information has impacted diagnostics and therapy necessary for patients with a wide variety of clinical conditions (Swan, 1991). Its rapid incorporation, however, into clinical practice occurred without the usual close scrutiny that many new diagnostic tools undergo (Iberti et al., 1990). Much of the information, relative to the catheter's efficacy, provided by preliminary research and clinical trials, is now available as a result of continued use in the clinical setting. This catheter has now become a standard of care for the critical care patient in and out of the hospital. To date, there have been no universally published guidelines that address the education or practical skill necessary to provide safe and competent care for the patient with the P A catheter (Ahrens, 1997; Bridges, 2000; Burns et al., 1996; Iberti et al., 1990 & 1994). Burns (1996), Iberti (1990 & 1994), and Trottier & Taylor (1997) all recognized the need for development and continuation of educational, credentialing, and ongoing quality improvement policies involving the P A catheter. Furthermore, regionalization of health care, increased patient acuity, and the need to transport to a tertiary care facility have expanded the environment where the P A catheter is utilized (Kovacs et al., 1990).

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Since the early 1980s, at least eight studies have been done to assess P A catheter knowledge and dynamics of use. With the completion of these studies, a common theme emerged. A knowledge deficit was found in each group of participants which included acute care physicians and nonflight critical care nurses (Bridges, 2000). The same recommendations were included in each implication for study section - a need for universal development of general P A catheter guidelines, verification of skills, and a standardized approach to the education and competency of health care providers that work with patients who need a P A catheter (Ahrens, 1997; Bridges, 2000; Burns et al., 1996; Iberti et al., 1990 & 1994; Trottier & Taylor, 1997). Iberti et al. (1990) developed the multicenter questionnaire that included items concerning the P A catheter application, data acquisition and interpretation, and patient treatment. This questionnaire was administered three more times, sequentially, over a period of 6 years by Iberti et al., (1994); Burns et al., (1996), and Trottier and Taylor (1997). All four of these studies supported the same outcome of a knowledge deficit among the health care providers caring for patients with the P A catheter and other hemodynamic monitoring needs. Despite the availability of numerous articles and textbooks related to P A catheter usage, insufficient knowledge continued to be demonstrated by nonflight critical care nurses (Bridges, 2000). The questionnaire from Iberti's 1990 study was the tool utilized for the studies done after 1990 (Bridges, 2000). To support these earlier studies, it was recommended that more information be gathered to address the indications of the low levels of knowledge regarding the P A catheter (Burns et al., 1996). Essential items were identified to insure a minimum level of skill and safety when utilizing the P A catheter (Dunn, 1992). They include level of training and expertise, frequency of use, certification (Certified Critical Care Registered Nurse [CCRN] certification for the nonflight critical care nurse and Certified Flight Registered Nurse [CFRN] certification for the flight nurse), or a credentialing program that includes the correct reading of P A catheter data and the clinical interpretation of these data (Burns et al., 1996; Iberti et al., 1990 & 1994). Since this revelation, many educational programs have been developed to assure this minimum level of skill and knowledge. Programs with hemodynamic monitoring that included the P A catheter were developed. P A catheter topics have covered safe guidelines for insertion, accurate gathering and

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interpretation of hemodynamic measurements, correlation of monitoring information with clinical and laboratory data, and an algorithm for the integration of the information to assist diagnostics and therapeutics for the patient (Ahrens, 1997; Roizen et al., 1993). These programs all contain the same content with some variations in the presentation, depending on the sponsorship. Professional education corporations, specialty organizations like the American Association of Critical Care Nurses (AACN), and individual institutions have differed in their presentations but still offered the basic concepts previously mentioned. The lengths of educational programs have varied from one 50-minute presentation to a full 1-2 day session (Darovic & Franklin, 1999). Updates on this subject have been offered in the form of a continuing education program or some inservice programs offered by the critical care unit staff. Once the initial training has been completed, attendance in a follow up P A catheter class has generally not been a formal requirement (Toth, 1994). As the earlier studies suggested, guidelines, credentialing, certification, ongoing education, and skills review needed to be developed to assure a minimum skill level for catheter use (Roizen et al., 1993). A check list was proposed to document the competency requirements that are needed to function safely and render quality care for the critically ill individual, whether in the hospital setting or outside of the hospital in the transport environment (Dunn, 1992; Scribante et al., 1996). Today, the nonflight critical care nurse's role in the care and treatment of the patient has expanded. They are more involved in the data interpretation and application of therapeutic treatments in relation to the clinical condition of the patient with the P A catheter. The nonflight critical care nurse's role is further expanded to include the transport nurse, which is a specialty of critical care outside of the hospital environment. This specialty includes the flight nurse (air) and the ground transport nurse (mobile intensive care & ambulance; Koschel, 2000). It is necessary for these nurses to acquire the same skill and knowledge base that the nonflight critical care nurse needs to render safe, quality care. In addition, they must be informed of the influences that their transport environment will have on the P A catheter (Koschel, 2000). The indications from the

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studies of Iberti et al., 1990 & 1994, and Burns et al., 1996, of the knowledge deficit that exists in the use of the P A catheter suggest the need for the inclusion of the flight nurse in these studies. Statement of the Problem To date, the research data that are available in reference to the knowledge deficit of the P A catheter is scarce. The last noted studies were at least 6 years ago. With an inadequate knowledge base and skill acquisition, the clinician can be detrimental to a patient that requires a P A catheter. To date, no national guidelines have been developed to monitor the quality of hemodynamic nursing education or related clinical expertise with the P A catheter. AACN is the only professional organization that has set forth written programs that assist with this need. The use of the P A catheter has become standard in the care of the critically ill patient. Common utilization of the P A catheter has overflowed from the hospital critical care setting into the air transport critical care environment (Dunn, 1992). A knowledge deficit was documented among nurses and physicians caring for patients with P A catheters by Burns et al., 1996; Iberti et al., 1990 & 1994; and Trottier et al., 1997. To assure that a qualitative standard of care is rendered by flight and nonflight critical care nurses, minimum competent skill and knowledge criteria need to be determined. The flight nurse is considered a critical care nurse in the air medical environment outside of the hospital. Since the critical care patient with the P A catheter may require transportation to another facility for a level of care that is not available at the referring facility, the flight nurse, who is responsible for this patient during transport, should have a broad base of knowledge and clinical skill in emergency and critical care nursing (Scribante et al., 1996). The flight nurse and the nonflight critical care nurse need to be included in the evaluation of their knowledge of the P A catheter. Unfortunately, minimal literature exists that addresses the necessary level of knowledge and skills that the nonflight critical care nurse should have to work with the patient that has a P A catheter. There have been no formal studies to date that include the flight nurse. The problem, then, needs to be addressed with both nursing specialties' being the focus (Ahrens, 1997).

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Significance of the Problem Questions have been raised regarding the quality of care, patient safety when applying the data collected and modes of therapy that are indicated, and the effectiveness of P A catheter use for the critical patient. With the increase in the number of patients that require the use of a P A catheter, the need to address this knowledge deficit is of vital importance. For example, the number of patients with chest pain and cardiac-related events admitted to the hospital every year number greater than 2 million (Miller, 2000 & NCHS, 2003). In 2000, the number of open heart related procedures performed were about 700,000 (NCHS, 2003). This staggering number of patients is among the many that will require a PA catheter while hospitalized. Most undergraduate curricula do not include in depth text on hemodynamic monitoring and P A catheter use. Professional organizations such as the American Association of Critical Care Nurses (AACN) and the Air and Surface Transport Nurses Association (ASTNA) or the individual nurse and the place of employment have been responsible for establishing and maintaining minimal competencies and skill for this (Bridges, 2000; Burns et al., 1996). Also, evaluating the knowledge of the advanced practice nurse could provide a direction of responsibility for setting guidelines for personnel who will care for the patient with a P A catheter. The advanced practice nurse, along with the nurse educator, should be responsible for the education, the skill development, and determining competency of each nonflight critical care nurse and flight nurse in this specialty area (Burns et al., 1996; Holleran, 1996). The essentials of a P A catheter program include the following topics: anatomy and physiology of the cardiopulmonary system, indications for the insertion of a P A catheter, equipment needed to set up and monitor the P A catheter, complications of the catheter, clinical situations indicated for the P A catheter, and the controversy that surrounds patient outcomes from use of the P A catheter, including discourse on safety and competency of the staff (Burns et al., 1996). Routinely, knowledge and skill are not tested at the end of a program or refresher course. Courses and their content being presented should be evaluated by testing and practical application. Retention of information being taught should be checked for quality and safety for patient care (Ahrens, 1997; Bridges, 2000; Burns et al., 1996).

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Certification status has been linked with higher scores on the knowledge assessment instrument in the previous studies (Ahrens, 1997; Bridges, 2000; Burns et al., 1996; Iberti et al., 1990 & 1994; Trottier & Taylor, 1997). The requirements for certification in nonflight critical care and flight nursing enhance the level of knowledge and skill in caring for the patient with the P A catheter. Performance improves with training along with problem solving that evolves from life experiences (Toth, 1994). Of the four studies cited that utilized the assessment instrument developed by Iberti et al., (1990), the critical care nurses that were CCRN certified had higher scores than the noncertified nurses (Burns et al., 1996; Iberti et al., 1994). It has previously been established that a P A catheter knowledge deficit exists among the nonflight critical care nurses. It is unknown if this same deficit exists among the flight nurses. Due to the widespread variance in this knowledge and skill, it is critical to address the need for developing a standardized educational and competency-based program that would include guidelines for improved and safe patient care that required a P A catheter. The role of the Advanced Practice Nurse could assist with this challenge. As a natural leader, researcher, educator, case manager, and caregiver, the Advanced Practice Nurse could provide the opportunity to ensure that knowledge and skill were achieved by the professional that cares for the patient with a P A catheter. Statement of Purpose Comparing the flight nurses' and the nonflight critical care nurses' knowledge of the P A catheter is the purpose of this study. Also, a comparison was done with the results from this study and the past studies to determine if an improvement has been accomplished in the levels of knowledge. Guidelines, educational competencies, and certification in flight and critical care have been supported as positive indicators for increased knowledge and skill with the P A catheter. Each hospital has its own method of teaching the fundamentals of hemodynamic monitoring and P A catheter use to its staff (Ahren, 1997). To date, no national guidelines have been developed to monitor the quality of hemodynamic nursing education or related clinical expertise with the P A catheter. The Joint Commission on the Accreditation of Health Care Organizations (JCAHCO) is the closest body of regulation for qualifying nurse preparation in the

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clinical area and hemodynamic monitoring, which would include the P A catheter, but such specificity is not included in their regulation (Ahrens, 1997). The information provided by this study has, therefore, added to a growing body of literature attempting to illuminate the scope of an existing problem, which is knowledge deficit in the usage of the P A catheter. Operational Definitions In order to define and clarify terms used in the study, several pertinent operational definitions were included. 1. Nonflight critical care nurse: a nurse who spends 100% of his/her time on the job in clinical patient-related duties in the critical care unit. This variable was operationalized by an answer to question 10 on the Demographic Data Sheet. The nonflight critical care nurse was designated with a categorical score system of 0 or 1. 2. Flight nurse: a nurse who spends at least 100% of his/her time on the job in flight-related patient care and duties related to the aviation environment ( rotor or fixed wing aircraft). This variable was operationalized by the answer to question 10 on the Demographic Data Sheet. The flight nurse was designated with a categorical score system of 0 or 1. 3. Knowledge of the P A Catheter: information required for providing safe, accurate, and quality nursing to a patient with a P A catheter and all that is necessary to provide accurate use of data collected and the change in treatment that may result because of the data produced. This variable was measured by the greatest percentage of correct items of the total correct for full scale and four subscale categories using The Multicenter Pulmonary Artery Catheter Questionnaire (Leibowitz & Oropello, 1994). 4. Knowledge sufficient to maintain quality standards: for the purposes of this study, "knowledge sufficient" to maintain quality standards of safety and reasonable patient care was inferred from the results of previous administrations of The Multicenter Pulmonary Artery Catheter Questionnaire (Leibowitz & Oropello, 1994). Since the previous studies utilized smaller groups to test and no large, national random samples were performed, the mean results from these studies were compared to the average outcomes from the present study. If the scores from the present study mirrored the scores from the prior studies, the outcomes have reasonably revealed that the knowledge of P A catheter use and

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monitoring is insufficient. A knowledge sufficient score of 80% is established as acceptable to function. 5. Number of years of experience: the sum of the total years of experience, as answered on the Demographic Data Sheet, for nonflight critical care nurses and for flight nurses, answers to questions 7, 8, and 9. 6. Frequency of use of the P A catheter: the sum of total number of times the catheter is used within a month's time, as answered to question 15 on the Demographic Data Sheet. 7. Attendance at a P A catheter class and length of class : this variable revealed whether or not the participant attended a P A catheter class, when the class was attended, and the length of time spent in class, as answered to questions 11 and 12 on the Demographic Data Sheet. 8. Certification in specialty: this variable was categorical with four levels: certified as CCRN, CFRN, both, or none, as answered to questions 5 and 6 on the Demographic Data Sheet. Research Questions Polit and Hungler (1995) stated that the research question helps to formulate the development of the study if correctly stated. The following research questions will direct this study. 1. What are the demographic characteristics of the flight and the nonflight critical care nurses sampled for this study? 2. How does P A catheter knowledge for flight nurses compare with that of nonflight critical care nurses? 3. How does P A catheter knowledge of flight and nonflight critical care nurses compare with P A catheter knowledge of critical care nurses previously reported in the literature? 4. What is the nature of the relationship between selected demographic variables and professional characteristic variables and the cumulative knowledge scores obtained from the administration of The Multicenter Pulmonary Artery Catheter Questionnaire (Lebowitz & Oropello, 1994)? 5. What proportion of information will selected independent variables provide toward the perfect prediction of P A catheter knowledge?

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6. Is the level of knowledge demonstrated by flight and nonflight critical care nurses for this study sufficient to maintain quality standards of safety and reasonable patient care? Hypotheses The early studies performed by Iberti et al. (1990 & 1994) and Burns et al. (1996) established a foundation for this study. The first research question is descriptive in nature. This question was answered descriptively without hypotheses. Research question two was concerned with a comparison of P A catheter knowledge for flight and nonflight critical care nurses. It was hypothesized that the mean P A catheter knowledge for flight nurses would be less than the mean P A catheter knowledge for the nonflight critical care nurses. The reason for this directional hypothesis is related to frequency of use, level of knowledge, and educational opportunities involving the P A catheter. Research question three compared the P A catheter knowledge of flight and nonflight critical care nurses with the P A catheter knowledge of the critical care nurses previously reported in the literature. It was hypothesized that the alternate hypothesis of this question is nondirectional. These hypotheses were proposed because no evidence exists of other interventions' having been designed to address the knowledge deficit reported by previous studies. Research question four was correlational in nature. It was hypothesized that P A catheter knowledge for flight and nonflight critical care nurses correlated positively with a) the number of years of experience, b) frequency of use of the P A catheter, c) recent attendance in a P A catheter class, and d) certification in specialty (CCRN and CFRN). Research question five had to do with the squared correlations (proportion of information) between specific independent variables and the dependent variable: P A catheter knowledge. This question was also descriptive in nature and no hypothesis was proposed. Research question six was evaluative in nature and it was hypothesized that the mean P A catheter knowledge for both flight and nonflight critical care nurses was insufficient to maintain quality standards of safety and reasonable patient care.

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Conceptual Framework Because of the rapidly expanding use of specialized advanced technologies, as pulmonary artery catheters with hemodynamic monitoring, advanced ventilatory equipment, complex laboratory tests, advanced and complex pharmacological interventions at the bedside, advanced technology and skills acquisition have made the care of the critically ill patient an overwhelming event for the novice clinician (Dunn, 1992). The integration of high level cognitive, psychomotor, and decision-making skills for this type of skilled nursing must be mastered from an abundance of theory, advanced technology, and critical thinking for decision-making at a moment's notice from all acquired data (Dunn, 1992). To provide competent nursing care, risks are taken for the patient and the nurse; skilled competence in nursing requires well-planned educational programs. Experienced-based skill refinement becomes easier and more proficient with a solid educational and experiential background. The combination of Knowles' adult learning theory (1980) and Benner's (1984) application of the Dreyfus Model to nursing will provide the theoretical foundation and direction for this study. Benner's Novice to Expert Model The Dreyfus Model of skill acquisition and skill development was perceived by Stuart Dreyfus and Hubert Dreyfus in the early 1980's. This model was based on a study of airline pilots and chess players (Alexander, 1991; Benner, 1984). The model described the route that a student travels through five levels of proficiency in order to gain the skills acquisition at each level. These levels are novice, advanced beginner, competent, proficient, and expert (Benner, 1984). These levels reflect changes in three stages of skilled performance. They are movement from reliance on abstract principles to past experience; the next one is a noticeable change in the student's perception of the demand situation which sees the situation as a complete whole and not as parts with certain parts as relevant; and the third stage moves the participant from detached observer to participant engaged in the situation (Benner, 1984). Patricia Benner (1984) successfully applied this model to nursing. Nursing skills and skilled practices are learned in the clinical setting (Benner, 1984). Experiences can be referenced as the passage of time, refinement of preconceived notions, and theory by encounters of practical situations that add dimensions to the skill.

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Skills acquisition, applied knowledge, clinical experience, and nursing skills are all results from theory development (Benner, 1984). Alexander (1991), Benner (1984), and Wesley (1995) fully described the five stages and the requirements for each, in order to move on to the next level. Novice is the first stage in which no background experience or exposure to the situation has been acquired. This correlates well with the beginner's exposure to the pulmonary catheter. The novice will function well with theory, abstract principle, and formal models (Benner, 1984). These tools will guide the novice efficiently through the learning process with concrete experience. There is no time line here since exposure to the P A catheter is part of the novice orientation and introduction into critical care nursing or flight nursing. It is all very new; no past experience is evident to assist the novice (Benner, 1984). The advanced beginner's stage is acquired through the ability to demonstrate minimal performance with a grasp of the key components of the situation (Benner, 1984). At this stage, the advanced beginner will begin to cope with a plethora of situations in order to recognize the pattern of recurring events. Accumulated experience will assist the novice in his or her transition to the next stage of advanced beginner. The parts of the whole are treated as equally important at this stage. The ability to prioritize is seen in the later stages. A timeline for this stage could be from 6 months to 2 years, depending on the individual's ability to make the transition. A new graduate in critical care nursing or flight nursing is representative of this stage. In order to reach this stage, beginning orientation with certain competencies have to be learned and experience is needed to apply the guidelines to individual situations and patients (Benner, 1984). The competent stage of skill acquisition is achieved by the actual practice and the follow-up action of others. In this stage the learner begins to see the organization and mastery of the specialty environment but lacks the speed and the flexibility of the seasoned veteran. Conscious and deliberate planning is characteristic of this level and it helps achieve efficiency and organization in day-to-day activities (Benner, 1984). Two to three years in the hospital critical care area or the air medical environment aid in the completion of this stage (Darovic & Franklin, 1999; Holleran et al., 1996). Experience is very important in completing this stage. The clinician can begin to integrate the use of the P A catheter in patient care, skilled interpretation of the data generated, and begin to

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understand its significance in guiding the plan of care for the patient (Dunn, 1992). Proficiency is based on perception of the situation in terms of the whole of the situation and not the parts. Perception is a very important component for this stage. It is based on experience and recent events (Benner, 1984). Since this stage is experience driven, the flight nurse and the critical care nurse learn what to expect in given situations and how to plan for this from past experience. The time line for this stage of development is variable depending on the individual and how quickly he or she can demonstrate knowledge and skill acquisition sufficient to transition to expert, probably within 3 years (Benner, 1984; Darovic & Franklin, 1999; Holleran et al., 1996). Some independence is present to work with the P A catheter with guidelines. Consultation is safe. The final stage of this model is the expert. This stage is achieved when intuition is second nature; identification of the changes are immediate; and the correct response is initiated intuitively. Experts with the enormous background of experience in their area of specialty are able to make the correct and quick holistic decisions (Benner, 1984). Data collection from a P A catheter, correct interpretation of these data, application of these data to the patient's condition, and prompt action to treat the clinical situation with the proper therapeutic interventions without having to consult the physician exemplify the role of the expert (Benner, 1984; Dunn, 1992). The expert operates from a deeper understanding of the total situation. Dreyfus and Dreyfus (Benner, 1984) noted that with mastery the blind person feels no pressure from the cane in the palm of the hand; the cane has become an extension of the body, such as the expert nurse clinician's tools (Benner, 1984). Veterans of 4 years or more in a specialty of flight nursing and critical care nursing have mastered the skill, and the transformation of the clinician's skill becomes a perceptual certainty-recognition ability (Benner, 1984). Intuition is enhanced by highly developed analytical abilities. Documentation of experiences and clinical performances, consultation for coworkers, and performance and patient outcomes are qualitative and quantitative measurements for achievement of this stage (Benner, 1984). Certification in one's area of specialty (CFRN for flight nursing or CCRN for critical care nursing) is one way to recognize the acquisition of knowledge. Nurses are encouraged to be certified but the certification is not always mandatory. In order to take

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either of the certification exams, it is highly recommended to have 2 years of experience in the specialty area but not mandatory. To be hired as a flight nurse, the majority of the industry will not hire without 2 years of documented critical care or emergency care experience. The development of the skill accompanying the knowledge acquisition is demonstrated in the clinical practice setting. These stages of knowledge development and skills acquisition in clinical development support the stages of growth and development in nursing and parallel the maturation in critical care nursing and flight nursing - from competent to expert (Benner, 1984). The clinician should be able to care in a holistic manner for the patient that has a pulmonary artery catheter on a transport and not exhibit any deficits in the overall process (Dunn, 1992). Knowles' Theory of Adult Learning Knowles' Theory (1980) of the adult learner was utilized also in the conceptual framework for this study. He took the concept of andragogy that had previously been developed in Europe and applied it to the learning situation for adults. In the past, education had been defined as a process that transmitted what one knew. With time, research, and cultural change, it is now defined as a lifelong process of continued inquiry with the need to learn how to learn and develop the skills of self-directed study. In essence, as a person grows and develops, he/she accumulates reservoirs of experience on which to build his/her learning. As more meaning can be attached to learning from experience, a person will be ready to learn when the experience presents a need (Knowles, 1980). . This also works well with the critical care nurse and the flight nurse. They have experiences to build on, a need to learn when the experience dictates it, and a willingness to do so. This theoretical framework of Knowles (1980) lends support to Benner's theory (1984) for this study. The principles of andragogy as defined by Knowles (1980) involve the following steps to complete the level of application: (a) the establishment of a climate conducive to adult learning, (b) the creation of an organizational structure for participative planning, (c) the diagnosis of needs of learning, (d) the formulation of directions of learning, (e) the development of a design of activities, (f) the operation of the activities, and (g) the rediagnosis of needs for learning and evaluation (Knowles, 1980). The foundation principle of adult learning put forth by Knowles (1980) requires that

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the learners be active in an inquiring process and begin to build on their background of experiences. Knowles (1980) theorized that experience and involvement could be acquired more quickly if the learner could relate such events to personal situations. Benner's theory of novice to expert (1984) and Knowles' theory of adult learning (1980) acted synergistically to support the development and implementation of this study. The flight critical care nurse and the nonflight critical care nurse are dynamic in their practices, strive to provide high quality care, and continue to be on the cutting edge with learning and skills updates. These two theories provide the framework to integrate these two specialties and support the importance of this study for both. Assumptions An assumption according to Powers and Knapp (1995) is a notion that is true, consistent with the views of the world and reality, supports different approaches to theorizing and conducting research, and may be based on accepted knowledge or personal beliefs and values. Polit and Hungler (1995) defined assumptions as basic principles accepted as truth without verification or proof. The following assumptions underlay this study: 1. The populations of flight and nonflight critical care nurses who have access to the Internet are of sufficient size to render adequate samples. 2. Respondents to the instrument have answered questions honestly. Resources were not used to assist in answering the questions. 3. Respondents had sufficient time and comfort to answer the questions from the instrument. 4. Respondents were who they said they were. Limitations The first limitation was the fact that not all flight nurses and critical care nurses may have access to the Internet. The participants were volunteers and have varied backgrounds. The second limitation is that the investigator had control over the conditions under which the participants completed the questionnaire. Despite the efforts on the part of the researcher to make the instrument accessible as well as user friendly, a

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third limitation is conceivable that a participant may not have had the computer literacy to access the web site and complete the questionnaire as instructed.

Summary The P A catheter was developed over three decades ago and has proven to be a very useful diagnostic tool for critical care patients (Swan, 1991). The usual testing of a new diagnostic tool was not done and the data needed to prove its worth were collected from the frequency of its use in the clinical setting (Dunn, 1992; Toth, 1994). The care of the critical care patient is now being done in the transport environment by the flight nurse (Holleran et al., 1996; Kovacs et al., 1990). Three earlier studies validated the same results: an alarmingly low knowledge of the PA catheter was documented from the questionnaire results administered to the critical care nurses and the acute care physicians (Burns et al., 1996; Iberti et al., 1990 & 1994). The purpose of this proposed study was to broaden the scope of such investigations to include the population of the flight nurse with the critical care nurse and compare their level of knowledge of the P A catheter. To assure that competent nursing care is provided, no risks were taken that would have affected the nurse and the patient. Skilled competence in nursing requires well planned educational programs. Experienced-based skill refinement becomes easier with solid education and experiences (Dunn, 1992; Scribante et al., 1996). The combination of Benner's (1984) application of the Dreyfus Model to nursing and Knowles' (1980) adult learning theory will provide the theoretical foundation and direction for this study (Alexander, 1991; Benner, 1984; Knowles, 1980; Wesley, 1995). In Chapter 2, the literature review has provided an expansion of Benner's and Knowles' theories and how they are integrated within this study, along with the research data that are currently available to support the study.

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CHAPTER 2 REVIEW OF LITERATURE This chapter is divided into 2 sections: theory and research. A theoretical review of Patricia Benner's (1984) From Novice to Expert, Malcolm Knowles (1980) theory of Adult Learning, and the dynamics of the pulmonary artery catheter are presented. Research studies that utilized Benner's and Knowles' works as well as the usage of the pulmonary artery catheter have been detailed. Benner's theoretical work has been explored regarding the five stages and their relationship with the developing proficiency of the P A catheter. Research utilizing her theory has been presented. Knowles' adult theory of learning has been tied in with the staging and learning needs of the adult professional - the flight nurse and the nonflight critical care nurse. The pulmonary artery catheter has been described along with diagrams to give a pictorial view to support the text that is presented. A physiological section has also been included to give the reader a perspective on the use of this diagnostic tool in the clinical setting. The combination of these theories and literature review of the research that surround them should enable the reader to understand the wide variation in the use of the pulmonary artery catheter and the vacillating level of knowledge that exists among the users of this diagnostic tool. Theory Benner's Novice to Expert Model Due to the rapidly expanding use of specialized advanced technologies as the P A catheter with hemodynamic monitoring, advanced ventilatory equipment, complex laboratory tests, complex pharmacological interventions at the bedside, advanced technology, and skills acquisition have made the care of the critically ill patient an overwhelming event for the novice clinician (Dunn, 1992). An integration of high-level cognitive, psychomotor, and decision-making skills must be mastered for this type of

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nursing. It will take an abundance of theory, advanced technology, and critical thinking to acquire the ability for split second decision-making often necessary in this environment (Dunn, 1992). Nursing, as a complex social practice, requires the attentive caring relationships with patients and family, a professional commitment in order to gain practical knowledge, developing collaborative relationships with other health care professionals, and the ability to make decisive, clinical judgments when needed (Benner, 1984). The novice to expert model demonstrates the intent for acknowledging and rewarding advancement of clinical practice and assists in the validation of reliability of nursing practice in the clinical setting (Haag-Heitman, 1999). The Dreyfus Model of skill acquisition and skill development was perceived by Stuart Dreyfus and Hubert Dreyfus in the early 1980's. This model was based on a study of airline pilots and chess players (Alexander, 1991; Benner, 1984). According to Dreyfus & Dreyfus in 1980, to acquire and develop a skill, one must pass through five stages. These stages are novice, advanced beginner, competent, proficient, and expert (Benner, 1984). These stages represent three areas of skilled performance. They are movement from reliance on abstract principles to the use of past solid experiences; the next one is a noticeable change in the student's perception of the demand situation which sees the situation as a complete whole instead of parts with more relevance than another part; the third and last area moves the participant from detached observer to participant engaged in the situation (Benner, 1984). Benner (1984) successfully took this model and systematically applied it to nursing. Nursing skills and skilled practices are learned in the clinical setting (Benner, 1984). Experiences are referenced as the passage of time, refinement of preconceived notions, and theory by encounters of practical situations that add dimensions to the learned skill. Skills acquisition, applied knowledge, clinical experience, and nursing skills are all results from theory development (Benner, 1984). The method of adaptation of this model to nursing was done in a systematic process. Interviews were set up with a core of nurses, beginners and experts. They were paired to learn how these extremes viewed the same clinical situations, the level of skill and knowledge that each possessed, and each was then placed in a level of practice according to their skill and knowledge. This was accomplished over a period of time. A series of

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four-2 hour interviews performed in small groups were conducted. A group of 51 nurses were chosen to go through this process. Along with the interviews, instructions to prepare written descriptions of experiences were given to the participants before the interviews were conducted. A panel of researchers had been chosen to do the interviews and conduct this study. Interpretation strategies were based on Heideegerian phenomenology from Heideeger in 1962 (Benner, 1984). The intent in this strategy was to present content and identify meanings (Benner, 1984). As described earlier, the same clinical situations were described by the beginner and the expert. The difference in the approach and grasp of the problem were evident in both scenarios. The expert talked fluently of the situation and what was happening without any extra details; the beginner had many extra details to add. With these data, the Dreyfus model was transformed into a working nursing model with descriptions of performance characteristics for each level of development and the teaching and learning behaviors needed (Benner, 1984). With the advancement of medicine from the 1960s to today, the lives of many have been extended and the establishment of critical care units was the result of so many critically ill individuals (Kondrat, 1994). With hemodynamic monitoring becoming a routine event in the care of these patients, the pulmonary artery catheter that had been introduced into the diagnostic arena also became a routine instrument of care used to manage these patients (Burns et al., 1996; Dunn, 1992; Kondrat, 1994). The nurse is responsible for the set up of the P A catheter and its necessary components, gathering the measurement data, interpretation of these data, and instituting treatment if the data dictate the need (Ahrens, 1997; Burns et al., 1996; Dunn, 1992). The stage is set for the utilization of Benner's model to help place the nurse in the proper position to learn to care for these patients safely and effectively. Novice is the first stage in which no background experience or exposure of the situation has been acquired. This correlates well with the beginner's exposure to the P A catheter. It is all very new; no past experience is evident to assist the novice (Benner, 1984). There are insufficient numbers of flight and nonflight critical care nurses educated and trained to provide optimal care for the rapidly expanding population of these clients (Dunn, 1992). According to Dunn (1992), a survey was conducted by Gottschall and his colleagues in 1983 of 28 hospitals and it was found that 58% of the

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nurses hired had no critical care experience. The novice stage has no timeline; it is the beginning of a timeline into critical care or flight nursing. For a new graduate nurse to acquire the general concepts to assist his or her in the transition to the next stage of advanced beginner, it should take about 6 months to conceptualize and demonstrate the ability and skill (Dunn, 1992). The advanced beginner's stage is acquired through the ability to demonstrate minimal performance with a grasp of the key components of the situation (Benner, 1984). A new graduate in critical care nursing or flight nursing is representative of this stage. In order to reach this stage, certain competencies have to be learned and experience is needed to apply the guidelines to individual situations and patients (Benner, 1984). The AACN core curriculum is utilized many times as the basis of orientation for critical care, therefore, this information would benefit the novice and the advanced beginner. Dunn (1992) noted that the study done by Gottschall and his colleagues (1983) found that 54% of the hospitals surveyed utilized the AACN core curriculum for their critical care orientation. The timeline for this stage can be anywhere from 6 months to 2 years, depending upon the individual and how quickly he or she can pass through this stage. There are four components that are part of an effective orientation to help the novice begin the transition through the stages of this nursing model. They are the format that includes the teaming of an experienced staff member with the inexperienced staff member that will provide on-the-job training along with theory. The format will be individualized to each person's needs. The setting needs to be in the unit to be worked, role to be taken by the new employee addressed, and the level of practice is decided with the assistance of the preceptor. The method of orientation will be tailored to the novice's needs. It should include lectures, observation of procedures, role play, learning contracts, group critiquing, case management, and hands-on skills experience. The fourth and last component deals with the development of a program that will bring the novice through the transitions to each level and with a positive outcome of a safe, independent nurse (Dunn, 1992). The competent stage of skill acquisition is achieved by the actual practice and the follow-up action of others. In this stage the learner begins to see the organization and

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mastery of the specialty environment but lacks the speed and the flexibility of the seasoned veteran. Conscious and deliberate planning is characteristic of this stage. It helps achieve efficiency and organization in day-to-day events (Benner, 1984). Guidelines published by the American Heart Association Task Force on Clinical Privileges in Cardiology (2000) defining competence would be appropriate to integrate at this time in the knowledge and skill evaluation of the proficient nurse. They include data interpretation and patient outcomes, recognition of anatomical landmarks as associated with the P A catheter, P A catheter waveform analysis, pathophysiological indices, assessment of lab values, and the ability to communicate effectively with the medical team and the family. The time required to transition from this stage to the next one depends on the individual and his or her ability to grasp the concepts and demonstrate the knowledge and skill necessary to transition to the next stage. Two to 3 years in the hospital critical care area or the air medical environment aid in the completion of this stage (Darovic & Franklin, 1999; Holleran et al., 1996). Experience is very important in completing this stage. The clinician can begin to integrate the use of the P A catheter in patient care, skilled interpretation of the data generated, and begin to understand its significance in guiding the plan of care of the patient (Dunn, 1992). The flight and nonflight critical care nurse require vast quantities of knowledge and technical skills along with the confidence to function effectively in their environment (Dunn, 1992). Proficiency is based on perception of the situation in terms of the whole situation and not the part. Perception is a very important component for this stage. It is based on experience and recent events (Benner, 1984). Since this stage is experience driven, the flight and nonflight critical care nurse learn what to expect in given situations and how to plan for this from past experience (Benner, 1984; Darovic & Franklin, 1999; Holleran et al., 1996). The timeline for this stage of development is variable and depends on the individual's knowledge acquisition and skill performance (Benner, 1984; Darovic & Franklin, 1999; Holleran et al., 1996). An individual can become proficient within 3 years in either of these specialties; experience and frequency of exposure to the environment will aid in this transition. Some independence is present; to work with the P A catheter with guidelines and consultation is safe.

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The final stage of this model is the expert. This stage is achieved when intuition is second nature; identification of the changes are immediate; and the correct response is initiated intuitively. Experts with the enormous background of experience in their area of specialty are able to make the correct and quick holistic decisions (Benner, 1984). Data collection from a PA catheter, correct interpretation of these data, application of these data to the patient's condition, and prompt action to treat the clinical situation with the proper therapeutic interventions without having to consult the physician exemplify the role of the expert (Benner, 1984; Dunn, 1992). The expert operates from a deeper understanding of the total situation. Dreyfus and Dreyfus (Benner, 1984) noted that with mastery the blind person feels no pressure in the palm of the hand; the cane has become an extension of the body, such as the expert clinician's tools (Benner, 1984). Veterans of 4 years or more in a specialty of flight or critical care nursing have mastered the skill, and the transformation of the clinician's skill becomes a perceptual certainty-recognitional ability (Benner, 1984). Intuition is enhanced by highly developed analytical abilities. Documentation of experiences and clinical performances, consultation for coworkers, and performance and patient outcomes are qualitative and quantitative measurements for achievement of this stage (Benner, 1984). In order to transport effectively a critically ill patient either intra-hospital or inter-hospital, appropriate hemodynamic stabilization and monitoring are necessary. This type of patient would do well with the expert clinician (Ehrenwerth et al., 1986). Advanced practice nurse clinician fits very nicely in this stage. For the novice nurse to begin in flight or critical care nursing, a time line begins with the entry into the specialty, and, depending on the ability of the individual, it may take up to 6 months to acquire the necessary skill and knowledge to transition to the advanced beginner stage. The advanced beginner will probably require about 6 months to 2 years to be ready to transition to the competent stage. The proficient and expert stages will follow at the rate the individual can gain the knowledge and skill to transition. In about 4 years from the time the individual begins his or her journey in flight or critical care nursing, he or she should be at the expert stage. Flight Nurse (CFRN) Expertise Certification is a process where a nongovernmental agency supports, based upon predetermined guidelines, an individual nurse's qualification and knowledge for practice

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in a defined function or clinical area of nursing (AACN, 2002; ASTNA, 2002). Certification in one's area of specialty (CFRN for flight nursing or CCRN for critical care nursing) is one way to recognize the acquisition of knowledge. Nurses are encouraged to be certified but certification is not always mandatory. The scope of flight nursing is multidimensional; its diverse characteristics utilize the multitasking capabilities that seem to accompany this nursing specialty. The many dimensions include the dedication to provide quality care to all patients (holistic in nature to meet the perceived, actual, or potential needs), the development of training standards, standards of care and quality assurance for flight nursing, sharing of knowledge and assistance to the area that is served by each flight program, and the development and promotion of safety and competence during transport (Holleran, 1996 & 2003). It is a unique specialty which has taken nursing to new heights along with a diverse and dynamic operational environment hospital and prehospital. For this practice, knowledge in many areas of medicine is necessary: critical care, emergency care, pediatric, neonatal, obstetric, orthopedic, geriatric, and prehospital care. This multidimensional practice promotes collaboration with these specialties to enhance patient care (Holleran et al., 1996 & 2003). The scope of practice for a flight nurse is influenced by internal and external systems. The scope is determined by state licensure requirements, national organization guidelines, guidelines of employment influenced by governmental agencies such as OSHA (Office of Safety and Health Administration), FAA (Federal Aviation Administration), and CAAMS (The Commission on Accreditation of Air Medical Services) (Holleran et al., 1996 & 2003). Before taking the CFRN exam, it recommended but not required to have at least 2 years of flight experience. It is a rare situation that a nurse without at least 2 years of critical care or emergency care experience is hired as a flight nurse. It is not a requirement to be certified when hired as a flight nurse, but it is highly recommended and becomes a part of the job requirement within a year of hiring. Length of certification is 4 years with the option to recertify with continuing education or retaking the exam. In order to qualify for this exam, one must be a registered nurse. CFRN is recognized throughout the world, but the exam is based on flight nursing practice in the United

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States. The number of nurses that took the CFRN exam in 2001 was 262. Of that number only 44% passed and obtained their CFRN (ASTNA, 2002). The flight nurse must demonstrate competency and expertise for ensured continuity of safety and adequate care for the patient. This is achieved through the acquisition and maintenance of knowledge and skills necessary for competency for this specialty. The comprehensive scope of care is quite expansive. The flight nurse must be competent in hemodynamic monitoring (including the P A catheter) and many other components. The uniqueness of this specialty demands frequent educational and skills updates along with the collaboration with other health care providers, and participation in safety and survival programs. Excellence in this specialty is recognized by the Air and Surface Transport Nurses Association in the form of certification, CFRN. It is looked on as a measure of advanced competence in flight nursing - an attainment and application of knowledge and skills to function expertly and independently (Online: www.astna.org, 2002). Benefits of certification for the individual, the employer, and the patient are reputation, accountability, achievement, and assurance. It is a strong statement when the flight service can show that their staff are certified; insurance carriers are offering financial incentives to employers for a certain quota of certified staff; certification equals high achievers; The Pew Commission on behalf of the public have requested certification in nursing staff to support competency. The benefits for the individual include selfsatisfaction, pride, growth, employment opportunities, and financial rewards (Online: www.astna.org, 2002). Critical Care Nurse (CCRN) Expertise Certification in critical care (CCRN) is an achievement of excellence, a measure of competency, and maintenance of knowledge and skill up-dates in care of the critically ill that the individual nurse can have (AACN, 2002). The critical care nurse is a licensed professional who is responsible for ensuring safe and appropriate care with positive outcomes for the critically ill individual. AACN developed guidelines that support the maintenance of skills and knowledge of the critical care nurse. In this specialty, the nurse must be able to make split-second decisions, collaborate with the health care team when making ethical and other problem-oriented decisions, to actively seek out educational opportunities that maintain expertise in this area. The critical care nurse is recognized by

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AACN as functioning at a competent and expert level when CCRN is obtained. This certification is a measurement and application of a defined body of critical care knowledge that is necessary to function competently in this area of nursing. To earn this certification, one must be employed in critical care for a 2-year period and have performed 1,750 hours of bedside care of critically ill patients with 875 hours in the most recent year. In 2001, 1200 nurses applied to take the CCRN exam and 55% passed. Like the CFRN exam, self-satisfaction, financial reward, employment possibilities, pride, and growth with one's professional career. Employer benefits include advertisement of credentials of staff, insurance breaks, and accountability within the organization (AACN, 2002). Certification is for 3 years. To renew, one must retake the exam or satisfy several categories through education, on the job work hours, publishing, and community projects. The development of the skill accompanying the knowledge acquisition is demonstrated in the clinical practice setting. These stages of knowledge development and skills acquisition in clinical development support the stages of growth and development in nursing and parallel the maturation in critical care nursing and flight nursing - an expert clinician (Benner, 1984). The clinician should be able to care in a holistic manner for the patient that has a P A catheter on a transport or in the clinical setting and not exhibit any deficits in the overall process (Dunn, 1992). Gatley (1992) described the curriculum development for a diploma for District Nursing at the University of Liverpool to be based on Benner (1984). It was relevant that the nurses be self-reliant, self-directed adult learners with a life-long learning habit to absorb the wide base of knowledge. While many of the theorists from North America would have a difficult time transitioning into the United Kingdom, Benner's work has gained international recognition. The combination of skills acquisition and clinical expertise offered a workable solution for that which was needed for this program. The criticisms were hopefully expected to be resolved and the practice of nursing would be united in theory and practice. Benner's (1984) model was used to develop a study that was supported with federal funding for seven participating nursing schools in the San Francisco area. It was a grant to develop methods of evaluation of ways to perceive the ideal and real performance expectations of nursing in the clinical area and the actual nurse educators' perception of

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that which is needed to assist the development of the student to graduate. The title of the project was Achieving Methods of Intra-professional Consensus, Assessment, and Evaluation (AMICARE) (Benner, 1984). Another model that used Benner (1984) was the staff at St. Luke's Medical Center in Milwaukee, Wisconsin. It was chosen because it satisfied the intent for acknowledgment and rewards for advancing clinical practice. It was felt that it presented a reliable measurement for nursing practice. This was used to develop the new nursing model of Clinical Practice Development Model. It was used to make the clinical judgment, caring, and collaborative work of the nurse visible (Haag-Heitman, 1999). Benner and Wrubel (1982) referred to clinical knowledge as the knowledge that is embedded in the practice of nursing. The authors have taken the strategies for clinical knowledge development, for documenting, conserving, and enhancing the unique and intuitive knowledge of the experienced clinician and presented them as a means of job enrichment and retention opportunities of the experienced nurse. The difference of practical and theoretical knowledge and the implications for enhancing the practical knowledge gained from clinical experience were examined. Knowles' Theory of Adult Learning Knowles' Theory of the adult learner was developed from the European concept of andragogy, which evolved from the model of pedagogy. Pedagogy means the art and science of teaching children (Knowles, 1980). Knowles (1980) defined andragogy simply as the art and science that helped the adult to learn. In the past, education had been defined as a process that transmitted what one knew. With time, research, and cultural change, it is now defined as a lifelong process of continued inquiry with the need to learn how to learn and develop the skills of self-directed study (Knowles, 1980). In essence, as a person grows and develops, he/she accumulates reservoirs of experience on which to build his/her learning. As more meaning can be attached to learning from experience, a person will be ready to learn when the experience presents a need. This also works well with the flight and the nonflight critical care nurse. They have experiences to build on, a need to learn when the experience dictates it, and a willingness to do so (Dunn, 1992; Holleran et al., 1996 & 2003). The assumptions of learning can easily relate with Benner's model of skills

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acquisition. The environment that is conducive to adult learning can be paralleled with the same kind of environment that the nurse will need to absorb the knowledge and practice the skill that is necessary for this career. Diagnosis of needs reflects the adult's concept of self drive despite what the teacher might think is appropriate to learn. A selfdiagnosis of needs for learning can be looked at in three phases: one must develop a model of the competencies needed to achieve a goal of performance. This requires a plan to please the teacher, self, and the institution. This can be related to the stages of learning from novice to expert. There are different expectations and needs at each level that must be completed. As each stage is completed, the experiences can help one assess his/her present level of competency by performance, learning tools, and feed-back sessions (Knowles, 1980). The andragogical model portrays the same idea of processes to help one figure out his/her area of competency and weakness. This is done by critical incident processes, socio-drama, computerized games, simulation exercises, and the feedback session for objectivity in learning one's strengths and weaknesses. This can be defined as motivation to learn with the experience of self-induced dissatisfaction with present deficiencies added to the clear sense of direction that one can develop for self improvement (Knowles, 1980). The critical care nurse and the flight nurse have a strong motivation to learn, assess weakness, develop one's strength, and strive for self-improvement. This is shown in one's commitment to excellence in patient care and safety. The planning process can be a negative or positive experience. It can create resentment if everything is planned by the teacher for the adult learner without his/her input. On the other hand, the involvement of the adult student in planning for educational opportunities utilizes the teacher as a guide and a resource. This participation can have a positive affect on the student. The staging process of novice to expert is similar to this idea of the learner's taking control of the planning process (the novice, the expert nurse, and the teacher plan the practical and the theoretical material to be used in the staging transition; Benner, 1984; Knowles, 1980). The Knowles' (1980) andragogical learning process can be a single course, a training program, or small group meetings within a conference networking to learn, Benner's novice to expert is group oriented, motivational, small meeting with each staged

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transition, and they are all helping each other to learn. The self evaluation process assists the teacher in helping the adult learner to realize the progress being made in reaching his/her goals. The strengths and the weaknesses must be addressed in the program; has it motivated the student or inhibited his/her progress? This same type of evaluation is done with Benner's staging with the novice to expert. This is done before each level is achieved (Benner, 1984; Knowles, 1980). The principles of andragogy involve the following steps to complete the levels of application. 1. The establishment of a climate conducive to adult learning (Knowles, 1980). The nurse has to have this in critical care/flight nursing to be able to relax and concentrate on learning the skill and knowledge to function. 2. The creation of an organizational structure for participative planning (Knowles, 1980). This is seen in the structure needed for orientation to bring the novice along to eventually attain the expert level over much time. 3. The diagnosis of needs for learning (Knowles, 1980). The diagnosis is within each stage of development in Benner's model. It requires meeting certain requirements before the next stage can be considered. 4. The formulation of directions of learning (Knowles, 1980). This is already laid out with the needs of each stage and what must be learned before going on to the next level. 5. The development of a design of activities (Knowles, 1980). This is planned with the theory to be learned within each stage. Certain skills of application must be performed to accompany the theory for that objective. 6. The operation of the activities (Knowles, 1980). The process of performing the skills when the theory has been presented reflects this one. 7. The re-diagnosis of needs for learning (evaluation) (Knowles, 1980). This is done at the end of each level of competency. Have they satisfied each objective and skill and have they been able to do it successfully with a motivational preceptor and stimulating environment for learning? The foundation principle of adult learning put forth by Knowles (1980) requires that the learners be active in an inquiring process; the learners will need to begin to build on their background of experiences, needs, interests, problems, and concerns of fellow

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participants. Knowles (1980) felt that this experience and involvement can be done more quickly if the learner can relate the events to personal situations, retain the information and experience longer, and self-direct this learning experience into their sense of personal competence. Oddi (1987) studied the perspective on self-directed learning. It is incorrect to consider it as a process of self-instruction. This cannot apply to those adult learners that cannot organize their own learning environment and experiences. An added dimension to this would be to look at the personality traits of individuals and how they can initiate and persist in the learning process. Warren (1989) investigated the legacy of N. F. S. Grundtvig, a Danish philosopher in the mid 1800s. His ideals of life-long learning; students' progressing at their natural pace; subjects chosen on personal choice and need; reciprocal teaching/learning as a dynamic process; and learning as an enlightenment of life, correlate closely with the works of Lindeman's in 1926 and Knowles' assumptions of andragogy in 1980. This is acknowledged by both authors in a very limited way. Caffarella and O'Donnell (1987) sought to provide an analysis of self-directed learning and suggested future research directions. Knowles (1980) wrote that the adult oriented to learning is focused; experience acts as a learning resource, and becomes selfdirected in the learning process as a natural step. It was found that nurses use informal sessions with their co-workers for information sharing and learning resources. Research parameters were defined; self-directed study methods were questioned; the planning process for self-directed learning was outlined; learning resources were identified. Knowles in 1975 and Tough in 1971 were used as a resource for the competencies needed for self-directed learning by an adult. Deficiencies were found with understanding how adults plan and organize their learning, trying to find a pattern of collaboration among independent adult learners, and seeking to understand how the selfdirected process increases the effectiveness and acquisition of information for the adult learner. The Pulmonary Artery (P A) Catheter The pulmonary artery (P A) catheter is a multilumen (usually 4-5 ports), flowdirected, balloon-tipped catheter that is percutaneously introduced into the vascular

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system at the bedside through the antecubital, femoral, subclavian, and internal and external jugular veins (Swan, 1991). It allows for hemodynamic monitoring of the critically ill person continuously (Swan, 1991). The catheter is radiopaque and made of polyvinyl chloride. It is marked with black rings at 10 cm intervals from the tip and is 110 cm long. The distal lumen terminates at the tip; the right atrial lumen opens approximately 30 cm proximal to the tip; the venous port is 1 cm proximal to the right atrial lumen. A wire connects a themistor lead, whose lumen is about 3.7 cm from the tip, to an external connector that plugs into a cardiac output computer at the bedside. A latex balloon (inflation capacity 1.0-1.5 cc of air) is located near the tip to facilitate passage of the catheter through the circulatory system, into the right atrium, through the tricuspid valve, into the right ventricle, and on out into the pulmonary artery after passing through the pulmonic valve. The inflated balloon facilitates this passage and minimizes the risks of endocardial contact and arrhythmias (Swan, 1991; Visalli and Evans, 1981). The catheter is hooked up to a pressure monitoring unit. There are several reliable models available. A pressure monitor is usually available with a digital display attached to the oscilloscope for viewing the electrocardiogram and pulmonary arterial waveforms. It usually has printout capabilities and alarms. A transducer cable is attached to the catheter and monitoring system. This optical cable converts electrical energy into mechanical energy that is viewed as waveforms on the oscilloscope. This system is made up of a pressure bag that keeps the catheter lumen patent, assists with fluid therapy if needed and saline bag of fluid (Visalli and Evans, 1981). See Figure 1. The inflated balloon assists the catheter's flotation in the circulatory system as it passes into the right atrium. The venous blood can also be measured for the oxygensaturation determinations. The shortest lumen is positioned in the right atrium and measures the central venous pressure equivalent to right heart function and infuse intravenous solutions It passes through the tricuspid valve into the right ventricle on its way to the pulmonary artery circulation after passing through the pulmonic valve. It will measure the pulmonary artery pressure (PAP). It will then occlude this branch and give reflective readings of the left ventricle, left atrium, and left end-diastole. This is recorded as the Pulmonary Capillary Wedge Pressure or PCWP (Swan, 1991; Visalli & Evans, 1981).

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Figure 1. This is a sketch of a #7-French 110-cm (44-inch) four-lumen Swan-Ganz thermo-dilation catheter. The cross section illustrates two insulated wires. These run the thermistor lumen's length from its port to its opening 3.7 cm (1.5 inches) from the catheter tip. The inflation lumen port is used to inflate and deflate the 1.5 ml capacity balloon. The distal port lumen ends at the tip of the catheter. Chamber pressures, P A pressures, P A wedge pressures, and blood samples can be accessed through this port. The distal lumen has its opening in the pulmonary artery. The proximal lumen terminates 30 cm from the catheter tip, which places it in the right atrium. The solution that is needed for cardiac output computation is injected here. Other solutions can also use this access. When the proper pressure transducer is connected to this port, the right atrial pressure can be monitored. The thermistor port houses the electrical leads for the thermistor. The balloon assists with the passing of the catheter through the heart chambers when inflated. This is due to the dynamics of the fluid drag on the balloon. When the balloon is fully inflated, it distributes the tip force over a larger area and reduces the possibilities of premature ventricular contractions that are caused by the catheter irritation to the endocardium ( ( (with permission: Visalli & Evans, 1981, Nursing81, p. 43)(see Appendix A).

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The basics of cardiac circulation will help clarify the physiology of the pulmonary capillary wedge pressure. In diastole, the heart is relaxed and filling with blood from the pulmonary veins, the pulmonary vascular system, the left atrium, and ventricle. This acts like a single chamber with equal and identical pressures. The catheter does not enter the left side of the heart (Swan, 1991; Visalli & Evans, 1981). While the P A catheter has been around since 1970 (Swan, 1991), the model and purpose have not changed. It is used to diagnose right and left ventricular failure, specific cardiac and pulmonary disorders, monitor fluid replacement therapies, and effect of vasopressors and other medications. It can also measure cardiac output by using the thermistor. Major complications include infection, arrhythmias, thrombosis, and pulmonary infarction (Swan, 1991). With the development of cardiac catheterization by Courmand in 1938, cardiovascular physiology and its relationship to clinical practice was established. Notable milestones were developed, enhancing the conceptualization of cardiology, cardiac catheterization, and the instrumentation that was technically needed. While studies were being conducted in surgery, the research and usage of this catheter increased dramatically to include bedside treatment. Broader application of this catheter in surgery, anesthesia, critical care, cardiology, and transport has a considerable collection of hemodynamic data that have had a major influence on patient diagnosis and treatment. The development of the P A catheter and hemodynamic monitoring proved to be a natural extension of the application of physiologic principles to medical practice at the bedside (Swan, 1991). In order to utilize effectively the P A catheter in the clinical setting, the practitioner must have a basic understanding of hemodynamics, along with a working knowledge of how to apply the data that are generated, knowledge of the monitoring equipment, and understanding of the appropriate therapies. A measure of competency is required to assure proper management of the P A catheter; to assure sufficient knowledge to perform safe and competent patient care; to perform proper interpretation of hemodynamic data; and to recognize complications (Swan, 1991). The hemodynamic state of the critically ill patient can be assessed by the use of the P A catheter when it cannot be done clinically or noninvasively. Measurement of the

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cardiac output, systemic, pulmonary artery and venous pressure readings can be done through the use of this catheter and proper treatment designed from the data gathered (Waxman & Matthay, 2001). For example, the central venous pressure (CVP) can be obtained from the right atrium. The normal readings are 1-7 mm Hg. The CVP correlates with the right ventricular function. It is elevated in conditions like right ventricular failure, tricuspid valve disease, pericardial tamponade, and fluid overload. It is decreased in conditions like hypovolemia and vasodilation. Pulmonary artery pressures evaluate cardiac function and can detect problems that are primary to the pulmonary vasculature. Normal range of pressures is 20-30/10-15 mm Hg. The pulmonary artery wedge pressure reflects left ventricular function. Normal ranges are from 8 to 15 mm Hg. High pressures reflect left ventricular, septal defects, and mitral valve insufficiency. A low pressure can be indicative of hypovolemia. Cardiac outputs and cardiac indices are also valuable parameters to gather with this diagnostic tool. A normal cardiac output ranges from 4-8L / min. and even more diagnostic and individualized for treatment is the cardiac index.. The range for this is 2.4-4L / min. To utilize these data to the best advantage of patient care, trends are noticed, treatments are dictated to be used if certain parameters are documented, and follow up is necessary after each assessment change and treatment change. When using the P A catheter to treat a patient, it is important to remember to treat the complete patient (Dvorak-King, 1997). Complications that can result from P A catheter use are transient arrhythmias like ventricular tachycardia or ventricular fibrillation, infection at the insertion site or catheter related sepsis, mural thrombus, pulmonary infarction, rupture of the pulmonary artery, catheter migration that can cause infarction or rupture, and catheter knotting. These are among the more common problems that are encountered with the use of this catheter. If the clinician utilizes this catheter frequently and has a well developed knowledge base and skilled technique in its usage, these problems will be observed and intercepted quickly (Waxman & Matthay, 2001). Research Benner's Novice to Expert Model Nursing is a complex social practice that requires the attentive, caring relationships

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with patients and family. A professional commitment is begun in order to gain practical knowledge, development of collaborative relationships with other health care professionals, and the intuitive ability to make decisive, clinical judgments when the need is presented (Benner, 1984). Benner's theoretical proposals have gained international recognition and much research continues to be based on her works. Daley (1999) looked at the learning processes that are used by novices and experts. Ten novice and 10 expert nurses were used for this study. They were recruited while at a continuing education program. Semi-structured interviews and clinical narratives produced the data. Three components were used to designate novice or expert status. They were use of abstract principles and past experience, understanding the clinical situation as a discrete part, or as an integrated whole, and acting as a detached observer or as an involved performer. Novices also had from 6 months to 1 1/2 years experience. Experts were described as having a range of 5-34 years of experience. Age range was 23 to 62 years of age. The findings indicated that the novice nurse used formal, structured programs, policy and procedure manuals, attendance of classes, and reading of journal articles. The expert was more informal in the learning process. These included consultation with their peers, research, and personal experiences. The nurses were taught how to continue to learn in their practice. The study of professional expertise has developed from the understanding of serial problem-solving; to include the development of career motivated self-directed studies, and understanding the link between learning and expertise (Daley, 1999). Moore (1998) took the opportunity to use case study analysis to explore nursing events that might use reflective learning to link theory to practice. The students used their practice experiences as a basis for reflection. The literature reviewed looked at aspects of reflections, the use of critical incidents and the recording of these in a journal. Benner (1984) has written of the wealth of knowledge that practitioners possess from personal experiences, and how this can be shared if it is recorded. Reflection has varying levels that occur at different times and in different ways for people. They are reflectivity, affective reflectivity, and judgmental reflectivity. There are others, but these were simplified for this study. In order for the student to engage in

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reflection at any level, he or she must have certain skills. This could be a motivational, open mind (Moore, 1998). The Case Study, according to Yin (1984), can be used to investigate and understand complex social questions. Within this case study, real life situations were critiqued and explored. The participants were randomly picked from a Diploma-in-Nursing course. A total of four were selected. The instructor acted as tutor for this group. The age and backgrounds were mixed (both social and academic). Common aspects were that they all were seeking a 3 year diploma and the tutor was common to each of them. The study was undertaken in the first 18 months of the nursing program. The students were active in class and clinical. They were asked to keep a reflective journal of their personal experiences. Analysis of the data was completed by a method in which the transcripts were coded into themes. The data were categorized and coded by identifying themes and issues taken from the journals. The analysis process was restricted to the critical learning process of the student. It was easy to pick out the ways of knowing, but the levels of reflection were difficult to identify. The students did grasp the ability of reflectivity and affective reflection, but the judgmental reflectivity was not yet developed (Yin, 1984). Hegedus (1999) discussed the development and testing of a scale that is designed to look closely at nurses' caring behaviors. According to Benner & Wrubel (1989), caring is viewed as the central focus of nursing practice. A pilot study was done with the assistance of a convenience sample (N=81) of 42 nurses (providers) and 39 patients (consumers). Two community hospitals were the setting in the New England area. The 20-item survey was administered two times, to the providers and the consumers. The participants assigned the items of nursing care behaviors a rank. The mean spread was 3.5 to 16.7. The Wilcoxon two-sample rank-sum test was used to test the difference with the rank of the 20 items between the providers and the consumers. The consumers ranked five of the items much higher than the providers. They valued the behaviors that focused on them as individuals and the behaviors that assisted them with change. The providers ranked four items higher than the consumers and these were behaviors that were geared to nurse-patient relationship of caring and confidence. The results show that the consumers and providers agreed on

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nursing behaviors that were seen as most caring, average caring, and least caring. Nurses placed greater value on the behaviors that enhance the patients to explore and discuss their feelings. Finally, patients placed greater value on the nursing behaviors that supported their individual needs and those of their families. It was recognized that the scale needed further testing and minor revisions (Hegedus, 1999). Benner's work is referenced in numerous articles, research studies, and textbooks. Benner and Tanner (1987) wrote an article about the expert nurse's intuition. Intuition is seen as an understanding without a rationale. It is this type of judgment that separates the expert from the beginner. A pilot study was done to identify the nature and role of intuition in expert clinical judgment. Twenty-one nurses with at least 5 years of experience were interviewed three or more times. They had been identified as experts by their peers. The information gained from the interviews and the narrative accounts provided rich examples of the nurses' intuitive skill and judgment. Six aspects of intuitive judgment were evident in all of the narratives. These key aspects of intuitive judgment were from the works of Dreyfus and Dreyfus in 1985. They are pattern recognition, similarity recognition, commonsense understanding, skilled know-how, sense of salience, and deliberative rationality. Each one was explored and presented with a personal account (Benner & Tanner, 1987). Knowles' Theory of Adult Learning Knowles' (1980) adult learner concepts have been utilized by many in their research, articles of essence, and textbook references. Self-directed study is a dynamic characteristic seen in the specialty nurses. It is a life-long need to learn and experience. Caffarella and Caffarella (1986) investigated the idea of using learning contracts in higher education along with the question of these contracts, also enhancing the adult learning process toward competencies for self-directed learning. They recruited 163 students who were enrolled in six different universities in graduate courses in adult education. Learning contracts were part of these courses, pre-and post-tests were given to measure any significant gain in their competencies for self-directed learning. Two instruments were used: the Self-Directed Learning Readiness Scale (SDLRS) and the Self-Directed Learning Competencies Self Appraisal Form (SDLCSAF). For data analysis, a pretest-treatment-posttest research design was used. For the data analysis, 83

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matched sets of pre-and post-administrations of the SDLRS (51% of the original sample), and 130 matched sets of the SDLSCAF (80% of the original sample) were able to be used. Variables that were uncontrollable were the unmatched response rate and the lack of control groups. A series of non-directional t-tests were used for data analysis. The first major finding included no significant change in a student's readiness for selfdirected learning as measured by the SDLRS. The mean scores were very high on both the pretest (241) and the posttest (243); the mean for the normal population was 214.4 (SD = 25.6). The mean score for this study was about 1 SD above the norm with the students' approaching the maximum score for the SDLRS (ranges of score from 141 to 285). The second major finding was that of a significant increase of 3 of the 12 competencies measured on the SDLCSAF. The competencies that increased were the translation of learning needs into learning objectives, differentiation of human and learning resources, and utilization of specific strategies to enhance the use of learning resources. In conclusion, the use of learning contracts did not enhance self-directed learning readiness, and 3 of the 12 competencies were improved. Oddi (1986) investigated the personality characteristics of the self-directed continuing learners. The development of an instrument was done to assist in identifying the category of learner. Prepilot and pilot results provided the data for redoing the 24item questionnaire. After testing the validity of the instrument, a sample study was done. The Oddi Continuing Learning Inventory (OCLI) was developed and tested. It is an instrument that was tested and showed reliability and stability. The correlation of the scores with other instruments supports this. Four instruments of known reliability and validity were used to provide external validity of the OCLI. They were: a) The Leisuri Activity Survey (LAS) (Litchfield, 1965-66), a measure of the extent that adults participate in educational activities; b) The Internal-External Scale (I-E Scale) (Rotter, 1966), a measure of individual differences in a locus of control and was selected for the convergent validity of the cold dimension; c) Four subscales of the Adjective Check List (ACL) (Gough & Heilbrum, 1983), a selfreport instrument describing personality characteristics; d) The Shipley Institute of Living Scale (Shipley, 1982), an estimation of adult intelligence (Oddi, 1986). The findings for the total group (N = 271) in graduate law, nursing, and adult

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education that were tested with a demographic survey along with one of the instruments selected to provide either a measure of discriminant or convergent validity tested out with a mean of 123.627, a SD of 19.026, and a median of 126. The skew value of -.802 was significant at the .01 level (Oddi, 1986). The subgroups had similar findings: law students (n = 110) exhibited a mean of 119, and a median of 119. The nursing students (n = 78) had a mean of 126.231, and a median of 130. Adult education (n = 83) tested out with a mean of 125.434, and a median of 129 (Oddi, 1986). Two demographic variables also correlated significantly with the total OCLI scores. They were sex (r = .228, p < .0001), and age (r = .250, p < .0001). No other significant correlations were noted from the demographics (Oddi, 1986). Scores on the LAS and OCLI correlated positively (r = .363, p = .004). The ACL subscales (r = .551, p < .0001) also correlated positively with the LAS and OCLI. They both provided convergent validity of the OCLI. A discriminant validity was exhibited with the OCLI when it did not correlate with the Shipley scores (r = .040, p = .754) (Oddi, 1986). The research provided the findings as an instrument of satisfactory reliability and stability for the OCLI. The conclusions are that the OCLI is a valid instrument for identifying self-directed learners (Oddi, 1986). Conti (1985) explored the suggestion that the teacher affects student achievement. The instrument used to test the suggestion was the Principles of Adult Learning Scale (PALS). It examined the adult education theory base, the teacher's practice, and how it affected the student's academic achievement. This sample study involved 29 teachers and 837 students that were enrolled in an adult education course. Teaching style and academic achievement by the student were significantly related. The 44-item PALS test score mean was 130.05. This was 0.8 of a SD below the mean norm of 146. It placed the group at the 21st percentile ranking. The teachers' scores ranged from 111.5 to 155. Three teachers scored above the mean (146). Teaching style of this sample did not match with the adult education nor was the distribution similar with the larger groups tested with PALS. In order to compare the teachers' score with the students' achievement, PALS scores

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were standardized by ½ of a SD. The SD was 20 so each category had a range of 10. Analysis of covariance was utilized to compare the independent variable of teaching style with the dependent variable of student achievement (p < .001). The greatest gain was among the group of students whose teachers scored 1.5-2.0 SD below the PALS mean. The next highest gain was seen with the students whose teachers had the highest PALS scores in the study. The study results were affected when the attendance hours were factored in. Analysis provided a significant difference (F = 4.93, df = 4/805, p = .001) with the teaching style and student academic achievement when the student attendance was included. These results were reversed. Thus, a relationship did exist between teaching style and student achievement in adult education. The time required to build this relationship helps to explain the increased achievement seen with the increase in hours of attendance (Conti, 1985). The Pulmonary Artery (P A) Catheter Pulmonary Artery (P A) catheters are one of the most commonly used monitoring devices in the management of the critically ill patient (Papadabos, et al., 1997). Many physicians and critical care nurses are responsible for the insertion, calibration, data interpretation, and treatment associated with the P A catheter. Few studies exist that evaluate the P A catheter knowledge and skills of the physicians and critical care nurses. The research that has been done will be reviewed along with some other studies that support the need for the knowledge level evaluation and proposals to help correct the knowledge deficit. Trottier and Taylor (1997) administered a 51-item questionnaire by mail to the membership of the U. S. Society of Critical Care Medicine. The survey was to be returned in one month. It consisted of two parts: the first 20 questions focused on the physicians' attitudes and the last 31 questions were concerned with the P A catheter. Five thousand surveys were mailed out and 1095 were returned (22% return rate). The mean test score was 25.6 (82.6%) with a SD of +/- 3.46 and a range of 3 to 31 (10% to 100%). A significant finding was revealed (p < 0.001) with the variables of specialty, practice pattern, number of P A catheter insertions per month, training, and certification in critical care medicine. The results compared very closely to those of the prior studies done with the original group of physicians. These current physicians had more specialty

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training and experience than the prior group. A general consensus was reached that some kind of development and maintenance of education, credentialing, and constant skill competency assessment be required (Trottier & Taylor, 1997). Burns et al., (1996) evaluated a group of critical care nurses for their level of knowledge of the P A catheter. The questionnaire developed by Iberti et al., (1990) was used. It was a two-part multiple choice test with 14 demographic questions and 31 multiple choice questions about the P A catheter. It was administered to 168 critical care nurses in urban southern California. They were from several different hospitals. The investigators traveled to the different institutions to explain and administer the questionnaire. The mean score was 16.4 of 29 questions (56 % correct) with a SD of 3.74, correct score ranges of 8 to 25. Two questions were deleted since it was decided that they were physician specific. Variables that correlated with the higher scores were CCRN certification, recent attendance in a P A class, number of years of critical care nurse experience, and frequency of use of P A catheter. Outcomes were reflective of an earlier study of critical care nurses. Again, the knowledge level was alarmingly low. The question was posed, "What will determine a safe measure to qualify a critical care nurse to offer safe and optimal care for this type of patient?" (Burns et al., 1996). Iberti et al., (1994) utilized the Multicenter P A catheter questionnaire to test the knowledge level of a group of critical care nurses at the AACN National Teaching Institute (NTI) in New Orleans in 1992. There were 37 multiple choice questions testing the knowledge level of the P A catheter. It was administered to 216 nurses. The mean score was 16.5 with a +/- SD of 5.7 (48.5 % correct). The scores were notably improved with CCRN certification, number of years in critical care nursing, frequency of use of the P A catheter, and recent attendance of a P A catheter class. A wide range of knowledge and understanding exists. The need for re-evaluation of the teaching practices and specific competency policies are indicated. Iberti et al., (1990) administered the original Multicenter P A Catheter Questionnaire to 496 physicians who practiced at 13 different facilities in the United States and Canada. This was done to document the knowledge and understanding when the P A catheter was going to be used in patient care. The mean score was 20.7 (67% correct) with a SD of 5.4

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and a range of 6 to 31 (19% to 100%). Higher scores correlated with training, frequency of use, frequency of insertion, and experience in critical care medicine. This original study brought the existing knowledge deficit to the attention of the medical community. At the time of the study, credentialing policies were being considered, along with the consideration of restricting the P A catheter use to individuals with documented competency which had yet to be defined. More research is available to support the need for developing universal guidelines and training protocols in the critical care arena for standardization of care and safety. A few of these studies follow. Grap et al., (1997) surveyed 1000 members of AACN to determine current practices of hemodynamic monitoring and patient position and any barriers to current research that could be used to improve this. The survey was mailed out. Items of concern were procedures related to patient position, number of times for cardiac output measurement, technique used to determine bed position, use of iced versus room-temperature injectate, use of printed or digital information, nurses' input into written procedures, and barriers to research utilization. Results showed that 24.1% always kept the bed flat when measuring P A pressures, 55.0% elevated the head of the bed 30 degrees or less, 80.7% always had patients supine for measurements, and 13.3% placed patients in lateral or other positions. Unit policy dictated the flat position in 25.8%. The research data generated proved to be relevant and helpful. It was shown that barriers could be overcome. Lundstedt (1997) set out to compare three methods for measuring P A pressures during mechanical ventilation and regular breathing in cardiovascular surgical patients with stable hemodynamics. These measurements were done on 53 patients while they were being ventilated after surgery and 37 were studied again when they were extubated. Three monitoring methods were compared: graphic strip recording, monitor screen freezing, and digital-display. Outcomes with the comparisons showed the differences to be at least +/- 3mm Hg with the three methods. When the ventilator was in place, the digital and graphic methods of measure of systolic pressure varied greatly (57% [30/53]) of the comparisons had at least +/- 3 mm Hg difference. The cursor and graphic methods of measurement of diastolic pressures varied least often (12% to 37%). The difference between digital and graphic for systolic measurements was 3mm Hg or more (30%

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[11/37]) of the time and the difference between cursor and graphic measurements was 3 mm Hg or more (53% [17/32]) of the time. These findings supported the use of the graphic method, as the digital and cursor varied too much and were not so reliable. Koschel (2000) reviewed the current practices of hemodynamic monitoring in the air. The air medical transport industry took the guidelines for patient care and the use of hemodynamic monitoring and adapted it to the aviation environment. A recent survey was sent to 57 programs. The survey had eight open ended questions which focused on hemodynamic monitoring practices. Standards of care with invasive lines, continuous monitoring, versus capping the lines, and leaving the pressurized system in place, and other options were items of inclusion. Type of monitoring system, monitoring protocols as it applied to patient care, percentage of flights that used hemodynamic monitoring and the time in flight, any special precautions for P A catheters or arterial lines, and training/competency requirements were also included on the survey. Thirty five programs responded that they transported with this type of invasive lines. Twelve of the respondents did not monitor during flight but capped off the transducer port. Of these 12 respondents, only 10% of these flights required this type of monitoring. Documentation of pressures and waveforms before and after the transport was common practice. No one performed pulmonary artery wedge pressure readings while in flight. Initial training requirements and ongoing competency training varied at the program's discretion. Some variations were yearly competency, quarterly updates, and bimonthly review. Included in these sessions were hands on experiences, setting up the equipment, zero balancing, monitoring, precautions, and complications. AACN has a set of published guidelines suggesting that this type of patient should receive the same physiologic monitoring in transport that is being performed while in the ICU. Since this survey reflected a variety of practices among the 57 respondents, universal guidelines and safety protocols are indicated (AACN, 2002; Boggs et al., 1993). Kovacs et al., (1990) reviewed the literature and did a telephone survey with 50 rotor wing transport programs to evaluate the procedures and safety protocols in place for helicopter transport of patients with indwelling P A catheters. A comprehensive literature review revealed little information. A telephone survey of the 50 air medical programs contained the same questions: each program's monitoring capability,

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maintenance of the P A catheter lines in flight (4% monitored on a case-by-case assessment and 84% did not monitor the pressure waveform). Three methods were used to maintain the PA catheter while in flight. These results were that 36.4% maintained the pressure system but disconnected the transducer, 27.3% disconnected everything from the catheter and flushed intermittently with a heparin solution, and both methods were used in 36.4% of the respondents. No complications were documented of the 25 patients analyzed. Reasons given for the minimal use of monitoring was cost for equipment, space, and weight. A larger more random study needs to be done before guidelines are developed. The common denominator in all of these studies is the knowledge and skill that the nonflight critical care nurse and the flight nurse must possess to perform safe and optimal care for the patient that has a P A catheter. These studies support the need for ongoing assessment and evaluation of the competency of these providers. Summary Benner's (1984) model, From Novice to Expert, is based on the Dreyfus (1980) model of skills acquisition. It provides a language needed to describe effectively a nurse's real talent at the bedside. Many references are noted in the literature in the form of resource or research. Benner and Tanner (1987), Benner and Wrubel (1982), Gatley (1992), Daley (1999), and Moore (1998) all reference the Novice to Expert model in the individual works cited. Many find it very difficult to describe their expertise in patient care. The evaluation system lacks the language to describe this nurse's uniqueness, experience, and competency. This model was explored and interfaces well with the role of the flight and nonflight critical care nurse. Studies support the different stages of experience, skill, and knowledge. Bridges (1994 & 2000), Burns et al., (1996), Iberti et al., (1990 & 1994), and Trottier and Taylor (1997) all described the evaluation of knowledge of the P A catheter of critical care nurses and physicians. The results revealed a knowledge deficit. The higher scores were obtained through consistent criteria of experience, exposure, credentialing, and frequency of use. This correlates well with the novice to expert

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staging. The least experienced had the lower scores and the more experienced scored higher. Other studies were related to this model that revealed that experience, skill, and knowledge were necessary to perform the job of caregiver safely and with optimum outcome (Benner, 1984; Bridges, 1994 & 2000; Burns et al., 1996; Holleran et al., 1996 & 2003; Iberti et al., 1990 & 1994). Knowles' (1980) theory of adult learning integrates well with this group of professionals. The self-directed learning is a characteristic of the medical professional. He/she strives for more information to enhance his/her bank of knowledge. This drive to keep learning is a life long commitment. It helps keep the skills and knowledge updated and current. Research for this model included the works of Caffarella and O'Donnell (1987), Conti (1985), and Oddi (1986). Chapter 3 will discuss the method of obtaining data for this study. The study design, setting, instruments, population, procedure, sampling plan, data collection, and analysis along with the discussion of human subject considerations are discussed. Assumptions of the study for descriptive and inferential techniques are included.

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CHAPTER 3 METHODOLOGY This chapter includes a discussion of the study design, setting, instruments, population of interest, procedure, the sampling plan, analytical tools to be employed for data analysis, and human subject considerations. A discussion of assumptions necessary for all descriptive and inferential techniques will be included. This study was non-experimental and comparative in nature utilizing crosssectional data. It also included correlational and predictive analyses. One of the purposes of this study was to assess current P A catheter knowledge of flight and nonflight critical care nurses. A comparison of these samples and the relationships between specific demographic variables and the dependent variable, knowledge, was also included. This study examined flight and nonflight critical care nurses' knowledge of the P A catheter using the Multicenter Pulmonary Artery Catheter Questionnaire, originally developed by Iberti et al., 1990. Various descriptive statistics and analytical techniques were employed to describe not only the demographic and professional characteristics of the study samples, but also, the predictive ability of selected independent variables toward the perfect prediction of P A catheter knowledge. The mean knowledge scores obtained for the two nursing specialties was compared with each other, as well as combined and compared with the results of previous studies using this instrument. Based on the results of these comparisons, a determination was offered as to the degree to which such knowledge is sufficient to provide safe and reasonable patient care. Population, Sample, and Setting The populations to be sampled for this study included: a) the nonflight critical care nurses who work in the hospital setting and b) the flight critical care nurses who

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provide critical care during the air transport of patients from one location to another. An additional inclusion criterion for this study was that all subjects to be considered must have Internet access for completion of the demographic data sheet and the study questionnaire. According to the American Association of Critical Care Nurses (2002), there are approximately 65,000 members. According to the Air and Surface Transport Nursing Association (2002), there are approximately 1800 members. The samples of flight and nonflight critical care nurse data to be subjected to analysis for this study were obtained randomly from the online questionnaire submissions completed by qualified participants. A minimally adequate sample size was determined by consideration of alpha (two-tailed = .10), Power (.90), and an effect size equal to 10 percentage points on the knowledge questionnaire. Effect size is a subjective opinion on the part of the researcher, which expresses the degree of difference of knowledge between the flight nurses, and the nonflight critical care nurses which would be of practical importance. Effect size will say that if a difference in knowledge exists between the flight nurses and the nonflight critical care nurses, how big a difference would have to exist as minimal for the researcher to call the difference "important". No literature search has found any evidence of comparing flight nursing and nonflight critical care nursing knowledge of the P A catheter, so a purely subjective setting of effect size is warranted. The 10 percentage points came from review of previous studies that had used this instrument. Consultation of Cohen's (1990) sample size tables revealed, with these a priori determinants, a minimally adequate sample to be 173 subjects per specialty group. Sampling Plan The questionnaires to be completed by potential candidates were posted to a web page designed for this study. The web page address was submitted to individual nonflight and flight critical care nurses via numerous nursing groups and nursing organizations, which have a presence on the World Wide Web. Notices were posted on the Internet with nursing discussion groups. Word of mouth, telephone follow-up, and contacts in local hospital critical care units and flight programs were utilized. Computers with access to the Internet have revolutionized the ability to collect data and enhance research projects (Fawcett & Buhle, 1995). The use of the electronic survey

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enabled the collection of data worldwide. According to a study done by Scarborough Research, a profile of personal computer (P C ) ownership resembles the typical American family (married couple, children at home, ownership of own home; Haskins, 2000). This study revealed that an average of 70 % of US households was in possession of a personal computer with Internet access. The survey also found that 20 % of the homes without a personal computer planned to purchase one in the near future (Haskins, 2000). Ownership of personal computers (PC) is soaring among United States consumers (Bowman, 1999). Two studies released by Market Research Info Beads noted that more than half of all homes in the U.S. have at least one PC (Bowman, 1999). Because of the increase in the number of professional nurses who have access to and use of the Internet, participants for this study were recruited from the Internet. With the continued expansion of Internet capabilities, this new venue for survey research has promoted greater efficiency and expanded opportunities to reach larger audiences for participation (Turner & Turner, 1998). Security efforts have been advanced for increased anonymous interaction, data retrieval, and recommendation for online design (Turner & Turner, 1999). Subsequent to completion of the survey, the randomly selected results were compiled electronically using data base software. These results were subjected to the appropriate analyses. Variables The dependent variable of primary interest for this study was P A catheter knowledge and was measured by the Multicenter Pulmonary Artery Catheter Questionnaire (1994; Appendix B). This dependent variable is comprised of four subscales: a) Recognition and Resolution of Complications, b) Physiology, c) Interpretation, and d) Application to Patient Management. Demographic variables and professional characteristics that were believed to relate to the dependent variable were considered independent variables for this study. A detailed list of these variables as well as their nature and scale of measurement for the purposes of this study, are included in the data analysis section of this chapter.

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Instruments Demographic Data Sheet The basic descriptive information collected was taken from the Demographic Data Sheet (Appendix C). The information that this instrument provided is similar to the data collected and utilized in the earlier studies (Burns et al., 1996; Iberti et al., 1990 & 1994). This information sheet includes age, gender, level of education, state of licensure, years of experience (total), with a subcategory of number of years as a flight nurse or hospital critical care nurse, specialty certification (CFRN or CCRN), attendance of P A catheter class, with the length of class included, frequency of use of the PA catheter in past 6 months, if he/she, as the nurse, was responsible for interpretation of data, personal level of knowledge and ability to utilize information related to P A catheter data, and minimum criteria for job description of flight nurse or hospital critical care nurse. Multicenter Pulmonary Artery Catheter Questionnaire The original questionnaire was developed in 1990 by Iberti et al. It consisted of 31 questions that were divided into the following categories: insertion technique, complication recognition and management, cardiac physiology, waveform interpretation, pressure-volume relationships, and data application (Burns et al., 1996). The original questionnaire was developed to assess the level of knowledge of the physicians that was involved in the care of patients that required the PA catheter. This questionnaire was also administered to the critical care nurses. For the study that was performed by Burns et al., 1996, four items were removed from the original questionnaire. The items removed were related to the PA insertion technique and were felt to be unrelated to nurse practice. No other items have been changed and the comparison of the results of this study will be made with the Iberti studies of 1990 and 1994 (see Appendix B). This questionnaire was administered on the Internet. It consisted of 44 questions (inclusive of the Demographic Data Sheet and the Multicenter Questionnaire). Four questions that pertained to the insertion technique of the P A catheter were removed as suggested in the prior studies (Burns et al., 1996; Iberti et al., 1990 & 1994). This minimally revised version was utilized. This investigator felt that this reflected better the knowledge specific to the nonflight critical care nurse and the flight nurse. Items on the questionnaire include recognition and resolution of complications, cardiac physiology,

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data interpretation, and clinical data management. Since this tool has never been tested over the Internet, the reliability and validity will be reported from the previous uses of this instrument. The reliability will be determined for this study using Chronbach's alpha for internal consistency. In four previous administrations of this instrument, reliability and validity have been established through the usage first by Iberti et al., 1990 and 1994. The first application of this instrument was reported as a pilot study given to 121 physician subjects in 1990 by Iberti et al. Validity was established from six expert physicians. Their mean test score was 93%. The final version was administered to 375 physicians with a score of 67% with a significant score variability among the tested physicians. This same instrument with a little variation in the questions was given to 215 critical care nurses at the National Teaching Institute sponsored by AACN in New Orleans, LA, in May, 1992, (results reported in 1994). The results were again disturbing at a mean score of 48.5% with significant score variability among the tested critical care nurses. Burns et al. (1996) were responsible for the third administration of this instrument. The instrument was administered 10 times to a total of 168 participants. Critical care nurse specialists with more than 30 years combined experience collaborated on the minimally revised version that had deleted four questions from the insertion and technique section that were felt not to be pertinent to nursing practice. The mean score was 56.8% with significant score variability. A fourth administration of this instrument was to a group of critical care physicians (about 5,000 with a 1095 return). Trottier and Taylor (1997) reported a mean score of 82.6% with significant score variability. The results of these outcomes reflect the then current existence of a knowledge deficit. All of the studies are supportive of the original study that set the reliability and validity of the Multicenter Questionnaire Instrument. The only tested method of the instrument with statistical data documented was in the original study. Validity was established with the assistance of a study of six expert physicians. Their mean score after taking the test was 93%. Reliability was established through item analysis and the KuderRichardson Formula 20 reliability estimate which was .71 (Burns et al., 1996).

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Permission to use the instrument was obtained from the original authors, Iberti et al., 1990 (Appendix D). Permission was also obtained from the editor of Progress in Anesthesiology, Barbara Tranbarger, which is owned by Dannemiller Memorial Education Foundation (Appendix E). Protection of Human Subjects In accordance with the guidelines and requirements for a thesis published at Florida State University, approval to conduct the research was obtained from the Institutional Review Board at Florida State University. Participation in this study was completely on a voluntary basis. A guarantee of anonymity was given to each participant in the cover letter (Appendix F) accompanying the questionnaire. This letter informed each participant that there were no data collected which could identify the participant and each questionnaire was deleted after the data were collected. Only those 18 years of age or older were asked to participate. No cookie (cookies are short pieces of data used by web servers to help identify web users) were installed on the participant's computer. Viewing the questionnaire page source code confirmed this. This could be done at any time. Pressing the view button and bringing this page up easily accessed the source code. It had everything on it that related to the web page with the cover letter, demographic data sheet, and questionnaire. This page showed all identifiable information related to this study. Nothing was saved that could identify the participant. This ensured each participant's anonymity. Participants with questions or concerns were encouraged to contact Dr. Jeanne Flannery, the Institutional Review Board at Florida State University, or Karen Biddy at the telephone numbers included in the cover letter. All responses were deleted as soon as the data were processed and the survey was completed. If any participant felt anxious or uncomfortable while taking part in this study, it was recommended that the process be discontinued. There were no risks or health hazards involved while participating in this study. Informed consent was given by completing and submitting this questionnaire. All of the processed data will be kept in a locked box for 5 years after completion of the study and then shredded by December, 2008. This locked box has been placed in a locked

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file cabinet in the researcher's home and the only people with access to this information were the investigator's committee and the investigator. Procedure Approval (Appendix G) was requested and granted from the Institutional Review Board. Permission was obtained from the original authors, Dr. Iberti and Dr. Leibowitz at Mount Sinai School of Medicine, New York, N Y, to use the Multicenter P A Catheter Questionnaire (Appendix B). Permission was also requested and granted from the owners of the publication, Barbara Tranbarger, Editor, Progress in Anesthesiology,San Antonio, Texas (Appendix E). Once this permission was granted, the Multicenter P A Catheter Questionnaire was formatted for Internet use. The original format was utilized minus the four questions that were omitted that referenced insertion technique of the P A catheter. The questionnaire was contained within a web page located on the World Wide Web and was in the form similar to those contained in Appendices A, B, E, & G. The web page contained an introduction and 44 questions with pull down menus for selection of appropriate answers. Once the participants used the submit button at the end of the questionnaire, these results were sent anonymously by E-mail back to an E-mail address for data collection and analysis. Only those questionnaires that were completed correctly were analyzed for this study. The web page questionnaire was posted on the Internet following approval from the Institutional Review Board of Florida State University and was available for access for four months. The web page address was placed online with the professional nursing organizations of AACN and ASTNA, nursing discussion groups, information letter sent to flight programs and hospital critical care units, and telephone calls to flight programs and critical care units. Locally, advertisement information was available to flight programs and hospital critical care units (see Appendix H). Data Analysis This section of the chapter identified the specific analytical tools employed for the purpose of answering this investigator's research questions. For the reader's

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convenience, those questions are restated below. 1. What are the demographic characteristics of the flight and the nonflight critical care nurses sampled for this study? 2. How does P A catheter knowledge for flight nurses compare with that of nonflight critical care nurses? 3. How does P A catheter knowledge of flight and nonflight critical care nurses compare with the knowledge of critical care nurses previously reported in the literature? 4. What is the nature of the relationship between selected demographic variables and professional characteristics and the cumulative knowledge scores obtained from the administration of The Multicenter Pulmonary Artery Catheter Questionnaire (Lebowitz & Oropello, 1994)? 5. What proportion of information will selected independent variables provide toward the perfect prediction of P A catheter knowledge? 6. Is the level of knowledge demonstrated by flight and nonflight critical care nurses for this study sufficient to maintain quality standards of safety and reasonable patient care? Research Question One Research question one inquired about the demographic characteristics of the flight and nonflight critical care nurses sampled for this study. Specific demographic variables, their nature and scale of measurement for the purposes of this study are: 1. Age - this variable was considered as continuous and scored on an interval scale. 2. Gender - this discrete variable was scored on a nominal scale with the value "1" designating female and the value "0" designating male. 3. Level of Education - this discrete variable likewise was measured on an ordinal scale with five categories (Diploma, ADN, BSN, MSN, Ph.D or other doctorate). 4. Geographical Location of Licensure - this discrete variable was measured on a nominal scale with four geographical descriptors (Northeast, Southeast, Northwest, and Southwest). 5. Specialty Certification - this discrete variable included only the categories of CFRN and CCRN. 6. Experience - this continuous variable was measured on an interval scale. 7. P A catheter education with designated length of P A catheter education

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experience - this is a continuous variable that was scored on an interval scale with "hours" used as the unit of measurement. 8. Recent date of P A catheter education-this is a continuous variable that was scored on an interval scale with "months" used as the unit of measurement. 9. Frequency of P A catheter experience - this continuous variable was considered categorical with five discrete categories which was scored on an interval scale with "number of catheter utilizations per month" used as the unit of measurement. The interval-scaled variables mentioned previously were described as per central location, dispersion, and other characteristics such as skew. Central location was described using the arithmetic mean, median, and when informative, the mode. Dispersion of these variables was described using variance and standard deviation. Distribution characteristics were described statistically using skew and, graphically, using frequency displays. The categorical variables were described using frequencies, percentages, and cumulative percentages. Cross tabulations were also used to describe joint relationships between the discrete variables. Research Question Two Research question two was comparative in nature and inquired about the differences in P A catheter knowledge for flight and nonflight critical care nurses. It was hypothesized that mean P A catheter knowledge for flight nurses would be less than the mean P A catheter knowledge for nonflight critical care nurses. The reason for this directional hypothesis is related to frequency of use, level of knowledge, and educational opportunities involving the P A catheter. This question was answered using two analytical tools. The first is the traditional, parametric, two-independent samples t - test. The second is the non-parametric analog to the t - test: Permutation test for two independent samples. The assumptions required for the defensive use of the t-test are: 1. the two populations being sampled are normally distributed 2. the variances of these two presumed normal populations are equal in value (Homogeneity of Variance assumption) 3. the observations both within and between the samples must be presumed to be independent 4. the samples must be selected at random

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5. the scores on the dependent variable must be presumed interval in scale While it is impossible to know whether or not a population is normally distributed, this investigator is reasonably comfortable with the first assumption because of the outcome of the knowledge scores. These scores are the result of a summing process and the Central Limit Theorem can be used (Brewer & Workman, 2002). With regard to the second assumption, the Levene's Test for the equality of variances was conducted to give the reader a measure of comfort with the Homogeneity of Variance assumption. With regard to the intra-sample and the inter-sample independence assumption, the researcher made a reasonable effort to insure that these assumptions were not violated. Similarly, this investigator is reasonably comfortable with the scale of measurement required for this test. Finally, after determining a minimally adequate sample size using Cohen's Tables (1990), the investigator randomly selected observations from both populations. The Permutation Test makes the same assumptions as the t-test previously discussed but without the normality assumption. An advantage of the Permutation Test is that it offers the researcher an exact p value as opposed to the approximate p provided by the traditional t-test (Statexact, Version 4, 1999). Another advantage of the Permutation Test is that it has a Power Efficiency of 1.0 with the t-test (Siegel & Castellan, 1988). Research Question Three Research question three compared P A catheter knowledge of flight and nonflight critical care nurses with the P A catheter knowledge of critical care nurses previously reported in the literature. It was hypothesized that the alternate hypothesis of this question was nondirectional. Rather than a flight/nonflight critical care nurse comparison on the dependent variable, knowledge, this question required comparison of the mean knowledge for each of the two groups with the mean P A catheter knowledge previously published in the literature. This question was answered using a one-sample t-test as well as its nonparametric analog (Siegel & Castellan, 1988). The assumptions for this t-test included all but number 2 discussed previously for the independent samples t-test. This test also has a smaller sample size requirement than for the two independent samples t test so the n = 173, determined for the two independent samples t - test is adequate for this one.

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Research Question Four Research question four was correlational in nature. It was hypothesized that P A catheter knowledge for flight and nonflight critical care nurses correlated positively with number years experience, frequency of use of the P A catheter, recent attendance of a P A catheter class, and certification in speciality (CCRN or CFRN). As previously mentioned, this question was answered descriptively using statistical tools appropriate for the nature of the variables considered. Research Question Five Research question five required for its answer that the demographic variables and professional characteristics that were shown to correlate well with P A catheter knowledge (dependent variable) were selected as independent variables in a regression equation to predict P A catheter knowledge. This was a descriptive process and no inferential tools were employed. Research Question Six An answer for research question six required that an evaluative conclusion be made subsequent to the analyses conducted for research question three. Given that the test value used for these analyses, and derived from the literature, has previously been judged as inadequate by critical care experts, the mean knowledge values obtained from the study samples were similarly judged. A score of 80 % on the questionnaire was the researcher's opinion of sufficient knowledge. Summary The purpose of this study was to examine the level of knowledge of the P A catheter that the flight nurse and the nonflight critical care nurse have. A comparison was made with the information collected from this study and the other studies that were completed prior to this one. It also helped to determine if this level of knowledge is sufficient to perform safe and qualitative nursing care of the patient with a P A catheter. A demographic tool and the Multicenter P A catheter questionnaire were used to collect the data for this study. The study was non-experimental and comparative in nature and relationships between specific independent variables and the dependent variable, knowledge, were explored. Population, sample, and setting were described. The

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protection of human subjects has been adequately addressed. The world wide web was used for the implementation of the questionnaire and the data collected were analyzed through various methods described in the chapter. In chapter 4, the results collected from the instrument and demographic data sheet will be presented. The overall results will be reviewed and each demographic and professional characteristic item that had an impact on the outcome of the survey will be discussed in detail.

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CHAPTER 4 RESULTS This non-experimental, comparative study utilized data obtained from flight and nonflight critical care nurses from a cover letter, demographic data sheet, and Multicenter Pulmonary Artery Catheter Questionnaire (Iberti et al., 1990) that were all placed on the World Wide Web. The results were generated from utilizing data from the 35 (9%) participants that completed the demographic data sheet and the survey from a total number of 366 visits to the web site. The survey was online for 4 months. An effort to increase awareness of the survey's presence on the World Wide Web was accomplished by way of online discussion groups, email links, and telephone calls utilizing a brief script describing the study and how to access the online site. This was done frequently throughout the time the survey was available online. The findings of this study will be presented with reference to each of the research questions stated in Chapter 1.

Demographic and Professional Profile of the Participants Research question one inquired of the demographic characteristics of the flight and the nonflight critical care nurses sampled for this study. Demographic variables included age, gender, level of education, and geographical location of licensure. The professional characteristics were specialty certification, experience, P A catheter education with designated length of P A catheter education experience, recent date of P A catheter education, and frequency of P A catheter experience. The total sample of flight/nonflight critical care nurses ranged in age from 23-55 years with a mean age of 39.7 years (median = 41) and more than a third of the sample at 44 years of age and older. There were 8 (22.9%) male participants and 27 (77.1%) female participants. Fifteen (42.9%) of the participants had earned a

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baccalaureate degree in nursing, 10 (28%) of the participants had an associate degree and 2 (6%) had earned a diploma in nursing. There were seven (20%) participants with a master's degree in nursing and one participant had earned his /her doctorate degree. Twenty-five (61.7%) of the participants were licensed in states geographically located in the Southeastern area (AL, FL, GA, KY, LA, MS, NC) of the United States. Thirteen (37%) respondents from this group were CCRN certified and there were 8 (24%) respondents of this group that were CFRN certified. Fourteen of the 35 respondents had neither of the specialty certifications. Thirty-five answered the CCRN certification question; only 33 of the 35 respondents answered the CFRN specialty question. The total sample had a mean of 14.7 years employed as a nurse (median = 14, mode = 19) with a SD of 8.3 years. The mean number of years employed in flight nursing for the 15 participants answering this question was 9.6 years (median = 12 years, mode = 12 years) with a SD of 6.9 years. The mean number of years employed in critical care for the 32 participants answering this question was 10.8 years (median = 10 years, mode = 1 year) with a SD of 8.2 years (see Table 4.1). Fifteen of 32 (47%) respondents indicated that they had recently attended a P A catheter class. Eleven (31%) respondents indicated no P A catheter class attendance. Three (9%) of the respondents attended a P A catheter class less than 1 month ago. Five (14 %) attended a P A catheter class within the last 2-3 months. Three (9%) attended a P A catheter class within the last 4-6 months. Thirteen (37%) had attended a P A catheter class at a time period of greater than 6 months. The length of the class that was attended had various responses. Fifteen (43%) of the 35 respondents attended P A catheter class for less than 2 hours. Eight (23%) of the 35 respondents indicated that the class lasted 2 - 5 hours. Seven (20%) of the 35 respondents attended a class that was 6 -10 hours in length. Lastly, three (9%) of the 35 respondents indicated that the class time for them was greater than 10 hours in length. Twenty-four (75%) of the 32 respondents that answered this question indicated they had a responsibility for data interpretation from PA catheter utilization. Frequency of P A catheter use in the clinical setting was measured in times of catheter use per month in patient care. Eight (23%) of the 35 respondents indicated no use in a month's time. Eight (23%) of the 35 respondents indicated a frequency of less than two P A catheters used. Five (14%) of the 35 respondents had

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Table 4.1 Demographics Age 23-33 34-44 > 45 Gender Female Male Level of Education Diploma Associate BSN MSN PhD Geographical Location Northeast Southeast Southwest N 8 14 12 27 8 2 10 15 7 1 3 25 6 % 23 40 37 77 23 6 28 43 20 3 9 74 17

used the catheter 2-5 times in a month. Five (14%) of the 35 respondents indicated a usage of 6-10 P A catheters per month. Finally, nine (26%) of the 35 respondents indicated that the use of the P A catheter was more than 10 times a month (see Table 4.2). Descriptives for Flight/Nonflight Samples The reader will recall the operational definitions that are in Chapter 1; for the purposes of this study the flight nurse was defined as one who spent 100% of his/her patient care time in flight-related duties. Two (5.7%) of the sample related that 100% of their time on the job was spent with flight-related duties. Because the primary purpose of this study was to compare flight and nonflight critical care nurses' knowledge of the P A catheter, the definition was modified to be inclusive of those respondents who indicated that 75% or more of their time was spent in flight-related patient care responsibilities.

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Table 4.2 Professional characteristics Most recent P A catheter class None < 1 month 2-3 months 4-6 months > 6 months Length of P A catheter class None < 2 hours 2-5 hours 6-10 hours > 10 hours Responsible for data Interpretation Yes No Frequency of use None < 2 month 2-5 month 6-10 month > 10 month N 11 3 5 3 13 2 15 8 7 3 % 31 9 14 9 37 6 43 23 20 9

24 11 8 8 5 5 9

69 31 23 23 14 14 26

Eight of the 23 respondents who answered the question met this criterion. Likewise, 15 (65%) of the 23 respondents spent 25-50% of their time in flight-related duties. It was assumed that the 12 (34%) respondents that did not answer the flight-related questions considered themselves nonflight critical care nurses. The mean age for the flight nurse group respondents (n = 8) was 42.6 (median = 45) years. The mean age for the nonflight critical care nurse respondents (n = 27) was 38.8 (median = 44) years. There were 2 (25%) male and 6 (75%) female flight respondents. For the nonflight critical care nurse respondents, there were 8 (22.2%) male and 21 (77.8%) female participants for this sample. The greatest number of responses indicated that the associate degree (n = 3, 37.5%) and the baccalaureate degree (n = 3, 37.5%) were the highest level of education that the flight nurses' sample had achieved. One of the

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respondents had earned a master's degree and one had earned a doctorate degree in nursing. The nonflight critical care nurse respondents had a predominance of the baccalaureate degree (n = 12, 44.4%) prepared individuals along with 7 (25.9%) who had an associate degree and 6 (22.2%) had their master's degree. Four (50%) of the flight nurses sampled were from Florida and 8 (27%) of the nonflight critical care nurses were also from this state. The variables in Table 4.3 are representative of the certification specialties of the entire sample. Of the flight nurse sample, 5 of the 8 respondents had both CCRN and CFRN certification. Three of the 13 certified nonflight nurse sample were dually certified. Table 4.3 Specialty certifications N CFRN CCRN None 8 13 14 % 23 37 40 Total 33 35 35

The mean number of years of experience for the flight nurse sample was 12.6 (median = 12) years with a mean number of 16.7 (median = 17.5) total years experience in nursing. The nonflight critical care nurse sample yielded a mean number of 11.7 (median = 10) years of critical care experience with a mean of 14 (median = 12) total years experience in the nursing profession. Of the flight nurse sample, the recency of P A catheter attendance most common was the 4-6 month interval. The nonflight critical care nurse sample revealed that the recency of P A class attendance was the 2-3 month interval. Both the flight and nonflight nurse samples indicated that the most common class length was less than 2 hours. Fifty percent of both of the flight and nonflight nurse samples indicated responsibility for data interpretation and a frequency of use of the P A catheter at least 5-10 times per month.

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A Comparison of Flight and Nonflight Nurses on P A Catheter Knowledge Research question two was answered using the traditional, parametric, twoindependent samples t-test. It inquired about the differences in P A catheter knowledge for flight and nonflight critical care nurses. This test compared the mean P A catheter knowledge scores for the flight (n = 8) and the nonflight (n = 27) participants. The mean knowledge score for those designated as flight nurses was 59.75 (SD = 34.02) and the mean knowledge score for those designated as nonflight critical care nurses was 43.7 (SD = 25.28). The Levene's Test (F = 3.09, p = .088) for the equality of variances was used for the Homogeneity of Variance assumption required for the t-test. This test was not significant for an alpha = .05. The t-test (See Table 4.4) for the equality of knowledge means for the two groups, likewise, was not significant (t = 1.46, df = 33, p = .155) for the designated two-tailed alpha = .10. Despite this non-statistically significant finding, the difference in means (16.05) exceeded the a priori 10 percentage points designated for effect size. This finding was of practical importance to the researcher.

Table 4.4 t ­ Test for equality of means t Percent correct Df p (2-tailed) 0.155 Mean diff 16.05 Std error difference 11.02

1.46 33

The reader should be reminded that for maximum power, sample sizes for the two groups should be equal. For the present study, not only were the two sample sizes unequal (flight n = 8, nonflight n = 27); neither of the two sample sizes achieved the researcher's a priori definition of a minimally adequate sample size. While it is inevitable that there was a net reduction in power due to the poor response rate from nonflight and flight nurses, the exact amount of such a reduction cannot be analytically

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determined. In Chapter 3, it was indicated that the Permutation Test would also be used to answer this question; the necessary software to conduct this test was not available for use. A Comparison of Flight/Nonflight Knowledge with the Literature Research question 3 used a one sample t-test to test the mean P A catheter knowledge for the flight and nonflight populations with that reported previously in the literature. The flight nurses' mean value of 59.75 did not significantly differ (t = .611, df = 7, p = .56) from the mean value of 52.4 previously discussed in the literature (Burns et al., 1996; Iberti et al, 1990 & 1994). The nonflight nurses did differ significantly from the mean test value of 52.4 with a mean of 43.70 (t = -1.79, df = 26, p = .086). The reader is once again reminded of the limitations of these results due to inadequate sample sizes (See Table 4.5). Table 4.5 One sample t - Test Flight Nonflight t Df 0.611 7 -1.79 26 p (2-tailed) 0.56 0.086 mean diff std error diff 7.35 12.02 -8.7 4.86

Demographic and Professional Characteristic Variable Associations with P A Catheter Knowledge Research question 4 was answered by describing the relationship between knowledge, the dependent variable, and the demographic (age, gender, geographic location ) and professional characteristic variables(level of education, certification specialty, experience, P A catheter education with class time defined, recent date of PA catheter education, frequency of use of P A catheter and data interpretation) already discussed at length for research question 1 (Table 4.6). The variables were analyzed by using frequencies, correlations, and cross tabulations. The independent professional characteristic variables that appeared to correlate with knowledge of the P A catheter were a) percentage of time employed as a

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flight nurse, b) recent attendance of a P A catheter class, c) frequency of use of a P A catheter, and d) certification in one's specialty.

Table 4.6 Correlation matrix of demographic and professional characteristic variables Yrs employed as a flight nurse 1 Yrs employed as a critical care nurse Total number of yrs in nursing Percent correct

Yrs employed as a flight nurse Yrs employed as a critical care nurse Total number of yrs in nsg Percent correct

0.621

0.565

0.595

1

0.716 -0.011

0.788 0.369

0.766 0.113

1 0.128 1

For the total sample, years employed as a flight nurse (n = 15, r = .37), years employed as a nonflight critical care nurse (n = 32, r = .11), and total number years employed as a nurse (n = 35, r =.13) all show a positive correlation. Whereas age (r = .01) correlated with several of the other continuous variables, it did not appear to be associated with P A catheter knowledge. The ordinal scale outcomes with P A catheter knowledge were that the highest nursing degree did not associate (rs = -.03) with this dependent variable. Likewise, recency of a P A catheter class showed little (rs = .16) correlation with P A catheter knowledge. The only ordinal scale variable showing any correlation worthy of discussion was the percentage of time spent in flight-related duties (rs = .35). The length of the most recent P A catheter class did correlate (rs = .24), but this variable did not have a strong correlation. The recency of P A catheter use negatively correlated (rs = .-10) with P A catheter knowledge.

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The association between the discrete variables and P A catheter knowledge was described using descriptives of the discrete variables for each of the categories. Gender revealed the following information: the males scored higher (mean = 69, median = 85) with a SD = 33 than the females (mean = 42, median = 43) with a SD = 26. The mean score for the master's degree category was 51.8 (median = 59), the baccalaureate level (mean = 47.5, median = 47.3) was lower than the associate level (mean = 50.7, median = 46.5). The scores (mean = 62, median = 58) of the nurses who were CCRN certified were higher than those of the non certified CCRN nurses (mean= 39.3, median = 37); the CFRN nurses had a mean score of 70.3 (median = 81), while the non CFRN nurses had a mean score of 40.52 (median = 41). The recent attendance of a P A class revealed a mean of 50.8 (median = 53.5) for those who had attended and a mean of 46.5 (median = 44) for those that had not attended. Individuals who were responsible for the interpretation of P A catheter data showed scores with a mean of 48 (median = 52) and those who were not responsible for P A catheter data interpretation scored with a mean of 47 (median = 45). A Model for Predicting P A Catheter Knowledge Research question 5 requires for its answer, the selection of demographic variables and professional characteristics to predict P A catheter knowledge. The independent variables considered were years employed as a flight nurse (r = .369), percentage of time spent in flight related duties (r = .325), and length of most recent P A catheter class (r = .337). Approximately twenty percent of the information needed to predict perfectly P A catheter knowledge was provided by these three independent variables (r2 = .193). Certification in the flight nurse specialty (CFRN) was also found to be a positive predictor of P A catheter knowledge (part corr = .588). By including CFRN certification into the regression equation, the proportion of information for perfectly predicting P A catheter knowledge was increased to .61 (r2 = .617). The squared part correlation for each independent variable's influence on P A catheter knowledge is as follows: years employed as a flight nurse (.02), percentage of time in flight related duties (.309), length of most recent P A class (.499), and CFRN certification (.346).

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An Evaluation of P A Catheter Knowledge Research question 6 requires an evaluative, but subjective conclusion to be made by the researcher for sufficient knowledge, as defined by the results of this study and compared to the previously published studies in the literature. The mean score for the two groups sampled was 47.37 (n = 35). The mean score of the flight nurse sample was 59.75 with 50% (n = 4) scoring at 80% or above, thus classifying them as capable to practice safe and effective patient care for a patient with a P A catheter according to the researcher's subjective opinion. The mean score for the nonflight critical care nurse was 43.70 with 10% (n = 7) of this sample scoring at the 80% or higher score classifying them as capable to practice safe and effective patient care for a patient with a P A catheter according to the researcher's subjective opinion. The mean of the two previously published studies by Burns et al., (1996) and Iberti et al., (1994) was 52.4. The flight nurse mean scores were more aligned with the previously published studies than were the nonflight critical care nurse mean scores. Sixteen percent of the total sample (n = 35) did score at the 80% score or above that which this researcher felt was sufficient to function as a capable nurse clinician. The respondents were asked to assess their own level P A catheter knowledge and place themselves within the Benner model. The variables in Table 4.7 illustrate the entire self-staging responses for the total sample and the staging of the two sub-samples. Thirty-four of the 35 participants were included in this response. No one staged him/herself in the competent category for the flight sample. Table 4.7 Self-staging within Benner model Flight n Novice Advanced beginner Competent Proficient Expert 2 2 0 2 2 % 25 25 0 25 25 Nonflight n 5 3 7 7 4 % 19 12 27 27 15 Total N 7 5 7 9 6 % 21 14 21 26 18 Mean % correct 42.4 34.6 38.8 65 56.2 SD 19.8 38.2 34.8 23.7 27.8

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According to Benner (1984), the staging and transition that takes place with the acquisition of knowledge and skill, takes less time than was represented with the self staging of the participants of this study. As referenced in Chapter 2, the Benner model associates nursing skills and skilled practices as acquired in the clinical setting. Experiences are referenced with the passage of time; theory development assists with skills acquisition and applied knowledge in the clinical area. Timelines for the stages are shorter than represented by the participants in this study. Novice has no accrued time line. Everything is new and correlates well with exposure. The time suggested to transition through this stage is about 6 months. The participants who staged themselves as novice in this study were seasoned nurses who had at least 5 years of experience to build on. The participants who staged themselves as advanced beginner were expected to transition from about 6 months to 2 years. The participants in this study have about 6-8 years to their credit. The competent stage is achieved in 3 years whereas the competent in the critical care staging (7-9 years overlapping with the advanced beginner) with this study was well beyond that. The flight nurse sample did not have a competent staging. The proficient and expert staging with Benner move through each stage in 3-5 years respectively. The nurses that staged themselves as proficient or expert had practiced well beyond that (average of 9-10 years). This more mature group was later and older to stage according to Benner's model (1984) than suggested timelines in Chapter 2. The scores of these self-staged individuals do not correspond with the criterion for each stage. They scored well below the expected 80th percentile. Of this total sample, only 7 (16%) of the respondents that completed the questionnaire scored at or above the suggested minimum of 80%. Table 4.8 profiles the 7 individuals. Scores for the seven respondents were as follows: 81% (n = 2, associate degree [1]; BSN [1]); 85% (n = 1, BSN); 89% (n = 1, BSN); 93% (n = 1, MSN); and 96% (n = 2, associate degree [1]; BSN [1]). The respondent that scored 96% with an associate degree was a flight nurse and had self-staged at the advanced beginner's level. Six of the seven had an accurate perception for self-staging. The respondent with the doctorate is a flight nurse and scored below the 80th percentile on the questionnaire.

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Finally, the independent variables that were notable from this study for predicting P A catheter knowledge were acknowledged in the profile of these seven respondents. As noted earlier, they are all dually certified; five of the seven participants had recently attended a P A catheter class within the last 6 months with varying class length (< 2 hours to > 10 hours). Ten to twelve years employed as a flight nurse with 75% of their time involved in flight related duties also supports the independent variables that assist in predicting P A catheter knowledge. Table 4.8 Profile of the seven individuals Age 34 44 45 51 Level of education Associate BSN MSN Job specialty Flight Non Flight Certification CFRN CCRN Self-staging Advanced Beginner Competent Proficient Expert Male 1 1 2 0 0 2 2 2 2 4 4 0 0 2 2 Female 1 0 1 1 2 1 0 2 1 3 3 1 1 1 0 Conclusions A knowledge deficit of P A catheters exists. This deficit was revealed in the four studies that were completed utilizing the Multicenter P A Catheter Questionnaire that was developed by Iberti and associates in 1990. The present study went one step further and included another group of critical care nurses, not located in the hospital environment

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proper, but in the air medical environment - the flight nurse. In addition, the researcher compared results of the present study with the outcomes of the two previous studies. PA catheter knowledge is influenced by many variables. The independent variables that were identified to enhance the score were years of experience, certification in one's specialty, recent attendance in a P A catheter class, frequency of use of the P A catheter, and the length of the P A catheter class. The same variables were identified from the studies of Burns et al., (1996) and Iberti et al., (1994) as enhancers of higher scores on the questionnaire. The studies completed by Burns et al., (1996) and Iberti et al., (1994) were focused on the knowledge of critical care nurses only. The flight nurses scored (mean = 59.75) higher on the Multicenter P A Catheter Questionnaire than the nonflight critical care nurses (mean = 43.7). Certification in one's specialty correlated with higher scores on the questionnaire. The demographic profile for the flight nurse sample revealed a more mature age group along with a higher mean total number of years employed in nursing than the nonflight critical care nurse sample. Fifty percent (n = 4) of the flight nurse sample performed well with the scored outcomes that were equal to or greater than the 80% that the researcher had defined as adequate to perform safe and optimal patient care with the P A catheter. Ten percent (n = 3) of the nonflight critical care nurse sample scored at or above the 80% score needed for the safe and optimal category for patient care with a P A catheter as defined by the researcher. The outcomes of this study follow Benner's (1984) model with the 16% that scored at or over the 80th percentile set by the researcher to provide safe and optimal patient care that involves the use of the P A catheter. The seven that were profiled integrate into their personal practice influences of Benner and Knowles. Self-motivation to achieve competence in their practice and maintain it is evident by the years of employment in practice, class attendance, and certification (Benner, 1984). The need to achieve could be an innate feeling of inadequacy with the necessity to learn to maintain their level of competence (Knowles, 1980). The self-motivated adult learner with the skills and experience to support the knowledge that is accumulated over the span of a career is exemplified by these "magnificent" seven. For the participant to have scored at or over the 80%, he/she would have to have the drive within him/herself to attain this level of proficiency or expertise over time. The

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self- motivation to continue to learn and acquire skill and knowledge throughout one's lifespan or career reflect the essence of both Benner (1984) and Knowles (1980). This was reflected with the need to achieve specialty certification, recent attendance and length of P A class, along with the amount of time employed in the specialty. Two (5.8%) had a score within the 70-75 percentile on the questionnaire. With some incentive, they could achieve the 80% or better. The 78% that scored below the 80%, set as minimal to function safely within the clinical arena of the critical care patient with a P A catheter, are well below the proficient or expert stage that the majority should have attained by this time in their career. What was perceived by the participant as a knowledge level and the actual knowledge level scored was different.

Summary Demographics were gathered to profile the flight and nonflight critical care nurses. The comparison of both samples was done. Their results were then compared with two prior studies completed by Burns et al., (1996) and Iberti et al., (1994) which focused on the critical care nurse. Independent variables were identified to assist in predicting P A catheter knowledge. The conceptual frameworks of Benner (1984) and Knowles (1980) were used to guide this study. The Multicenter P A Catheter Questionnaire, developed by Iberti and associates (1990), and the Demographic Data Sheet were formatted for Internet use and placed on the World Wide Web for 4 months. A small sample (n = 35) was obtained and the data generated were analyzed. Age, gender, geographic area of licensure, level of education, P A catheter education within a designated time interval, and frequency of P A catheter use with data interpretation were independent variables studied that did not influence the outcome of the questionnaire scores. The independent variables of CFRN certification (n = 5, 62.5%), time in flight-related duties (75% or greater), length of P A catheter class (the greater length of time), and the number of years employed as a flight nurse (mean = 8.8) all contributed significantly to the better scores on the Multicenter P A Catheter Questionnaire. Certification and class attendance are reflective of the self-motivation needed in the adult learner (Knowles, 1980) and the need to continue to acquire skill and knowledge to advance in the profession is reflective of Benner (1984). 69

In Chapter 5, the outcomes of the study will be discussed in relation to the literature and conceptual framework. Also, the discussion of the findings will include significant and insignificant outcomes. Limitations will be included, as well as the relationship of the assumptions. Implications for nursing and recommendations for future research will be discussed.

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CHAPTER 5 DISCUSSION In 1970, the P A catheter was introduced to the medical world and its use as a diagnostic tool rapidly replaced its original intention as a research tool. Its value grew quickly and it became a standard of care in surgery, anesthesiology, and critical care. It began to provide valuable hemodynamic information that had not been available prior to the introduction of this tool. This information went on to have a tremendous impact on the diagnostics and therapies now available for the critically ill individual (Iberti et al., 1990; & Swan, 1991). This study was focused upon the comparison of the flight nurses' and the nonflight critical care nurses' knowledge of the P A catheter. The conceptual framework, discussion of the findings, and the limitations of the study are discussed. The implications for nursing practice and future research recommendations are discussed in this chapter. Conceptual Framework This study was guided by Benner's (1984), Novice to Expert Model, and Knowles' (1980), Model of the Adult Learner. The integration of both models guided the clinician through the stages of skills acquisition, beginning at the novice level and rapidly progressing to the competent stage where he/she transitioned beyond this stage as the experience, knowledge, and developmental skills were mastered. Because the nurse clinicians and the advanced practice nurses are the care providers in these complex environments, an abundance of theory, advanced technology, and critical thinking are required to acquire the ability to make the split-second decisions. Self-motivation is a driving force within the professional to stay abreast of any and all changes that will be

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needed in his/her practice arena. This ongoing need to learn and excel will maintain the level of knowledge and capability to work efficiently with the P A catheter. Four previous studies were done to determine the level of understanding among the critical care nurses and physicians that used the pulmonary artery catheter in the clinical setting. The results of the published studies indicated a knowledge deficit among the physicians and the critical care nurses. Two of the four studies were interested only in outcomes of the questionnaire when the target samples tested were the critical care nurses. Both studies revealed knowledge deficit of the P A catheter in the critical care setting. The results of the present study were compared with the two previous P A catheter knowledge studies that used only the critical care nurses' as the sample population (Burns et al., 1996; Iberti et al., 1994). Other sources indicated that this knowledge deficit may be in part due to the lack of formal guidelines for educational opportunities that include hemodynamic monitoring with P A catheter knowledge as part of the educational program, and the lack of studies that were focused on the knowledge factor (Dunn, 1992; Roizen et al., 1993; Scribante et al., 1996; Toth, 1994). This study investigated and compared the level of knowledge of the P A catheter in two groups of professional nurses: the flight nurse and the nonflight critical care nurse. Professional characteristics and demographic variables were gathered from the respondents. The respondents were asked to place themselves within one of the categories that Benner (1984) had proposed in her model, providing the opportunity for each participant to evaluate his/her perceived level of capability with the P A catheter. The self-staging revealed an even spread among the 34 that answered the question (one respondent did not self-stage). The statistics reveal a mature group with 14 years of experience of nursing. Because of these numbers, the self-staging was a surprise. Seven of the 34 staged themselves as novice; 5 of the 34 staged themselves as advanced beginner; 7 of the 34 staged themselves as competent; 9 of the 34 staged themselves as proficient; and 6 of the 34 staged themselves as expert. Twenty-seven scored below the 80th percentile that the researcher felt was sufficient to render safe and effective patient care. Their scores actually reflected the advanced beginner or novice stage. Sixteen percent scored at or above the 80th percentile that the researcher had proclaimed as the minimum acceptable score to provide safe, effective care for the patient with the P A

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catheter. The sixteen percent's self-staging correlated well with their knowledge of the P A catheter. The timeline that is profiled in Chapter 2 for transitioning through the stages of Benner's model are reflective of a younger and less experienced professional than is profiled in this study. The time required for the transition would be from 6 months to 2 years to move from novice to competent, then another 2-3 years to transition to expert. The profile for this study was of a more mature professional traveling through the stages at a slower rate. According to Daley (1999), personal and professional maturity contributes to the ability to put the big picture together. Enhanced knowledge gleaned from reading, research, and discussion with coworkers promoted the active and selfinitiated process of skills acquisition that assist the clinician in the air-medical or critical care environment (Daley, 1999). The critical care nurse had been employed longer than the flight nurse. It was also revealed that the flight nurse had been employed in critical care before assuming the independent and demanding role in the air-medical field. Because the profile of the Benner model differs from the mature profile of this sample, the characteristics are of interest. These same driving roles can be assumed in the transition through Benner's model, but the role of the clinician in these two specialties is more mature. He or she still is self-motivated to achieve specialty certification (CCRN, CFRN, or both). The flight nurse functions as a critical care nurse, too, utilizing skills and knowledge from both roles. The self-motivation that drives the adult learner (Knowles, 1980), along with the skills acquisition and knowledge (Benner, 1984) is embedded in the developmental process of each of the respondents. In figure 2, the model for predicting P A catheter knowledge evolved from Benner and Knowles and the results of this study. The triangle represents the stages of transition with the beginning of skill and knowledge acquisition. The circle that encloses the triangle beginning at the competent stage signifies the beginning of the influence of Knowles (1980). The professional has moved through the novice and advanced beginner with help and assistance. Upon entry into the level of competency, the individual has become more independent, looks at the whole of the situation and begins to take the initiative to learn and acquire skills independently. Self-motivation to expand his/her horizons becomes second nature. Knowledge and skills acquisition progresses through

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the next two stages. The adult learner/healthcare professional is motivated and selfdirected and has moved beyond simple task orientation into the more complex picture. Age, experience, creation of individual knowledge base, skills acquisition, and certification are parallel components of stages of the Benner model. The learning process and individual knowledge base integrates assimilated experiences, differentiation of experiences, and shared experiences. Knowledge and experience develop together and produce skills acquisition. The cycle continues and becomes more undefined with each stage of transition. From the competent stage into the proficient stage, the clinician is taking past knowledge and building on it with new learning experiences and skills that are needed. It is undefined because the expert has developed an open-mindedness with an active pursuit for fuller understanding. The expert understands how to learn and as a result has created and utilized the knowledge and skill in the context of his/her practice. A great responsibility is felt to learn in order to share this knowledge with other professionals. It stimulates the professional to search out the most current information available to ensure excellence and acquisition of P A catheter knowledge. This holistic development of knowledge and skill is demonstrated with the aide of Benner and Knowles.

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Figure 2: Model of Predicting PA Catheter Knowledge

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Synthesis of Study The overall response rate for this study was 9% (N = 35) of the 366 visitors to the web site. This was partially due to the difficulty of the questionnaire, according to the comments that were submitted by visitors to the web site. Another reason that was given by the visitors was a time factor and the inability to recall the equations needed to answer some of the patient assessment questions. The potential participants that submitted these comments did not utilize these equations as much, because the computer technology in their work place performed the computations for them. Another possibility for the poor response was intimidation and the feeling of inadequacy on the part of potential participants. The clinician that works as a flight nurse or critical care nurse would view him/herself as highly skilled, independently capable of working out the difficult patient oriented challenges, knowledgeable in his/her area of expertise, and confident of personal skills. With the increased capabilities of computer technology, the independence of the flight/nonflight critical care nurse clinician has been diminished by the subtle dependence that develops from all of the features that the computer performs. This was evident from the feedback of potential respondents with regards to the questionnaire and the difficulty of the questions that required the computations for answers. The decreased independence could affect the self-esteem of the professional and make him/her feel vulnerable in the work place. Demographic Variables and Professional Characteristics of the Flight/Nonflight Samples The independent variables that described this sample revealed a mature group of educated flight/nonflight critical care nurses. Their expectations would require excellence in their work performance. They were a mix of male and female individuals that were highly motivated to maintain their expertise with experience, education, certification, and skill acquisition. The self-staging that was done by the participants supports a positive self-esteem among the group. This profile was similar to the data generated from the studies of Burns et al., (1996) and Iberti et al., (1994). The professional was well educated, was CCRN certified, selfmotivated, and would seek educational outlets to maintain high levels of expertise and

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skill (Burns et al., 1996; Iberti et al., 1994). Self-staging was similar to the self-assessed adequacy of knowledge category from the previous two studies (Burns et al., 1996; Iberti et al., 1994). Gender was also mixed. A Comparison of Flight/Nonflight Critical Care Nurse on P A Catheter Knowledge The flight nurse sample scores were better than those of the nonflight critical care nurse sample. This was unexpected until a closer look at the professional and demographic characteristic variables revealed an interesting trend. The flight nurses sample had critical care in their background prior to changing specialties. This group also had the background to pull from for their knowledge of the P A catheter. A Comparison of Flight/Nonflight Critical Care Nurse Knowledge with the Literature The flight nurse sample scores on the questionnaire were more aligned with the scores of the two previous studies that Burns et al., (1996) and Iberti et al., (1994) completed than were the nonflight critical care nurse sample. This was a surprise. Again, expectations were that the nonflight critical care nurse sample would score higher and be aligned with the prior studies. From the results of the studies of Burns et al., (1996) and Iberti et al., (1994), it was discovered that CCRN certification, years working as a critical care nurse, and frequency of use of the P A catheter all correlated with higher scores on the questionnaire. Because of these results, the researcher felt that the nonflight critical care nurse would have the higher scores. The researcher feels this again can be attributed to the combined background of critical care and flight experience. The flight nurse sample was employed longer and had the experiences of both specialties to provide increased knowledge and skill capabilities. Demographic and Professional Characteristics Associated with P A Catheter Knowledge The mature professional has had time to acquire knowledge, skill, and finesse in his/her practice. Maturity, self-motivation to achieve more than is expected, experience with time spent on the job, specialty certification, frequency of P A catheter use, and responsibility for data interpretation were all influential in higher scores on the questionnaire. The same characteristics and variables were cited in the two prior studies of Burns et al., (1996) and Iberti et al., (1994), as having the same influence with score outcomes.

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A Model for Predicting P A Catheter Knowledge The outcomes revealed for predicting P A catheter knowledge for this study were length of class time spent studying about the P A catheter, time spent in flight-related duties, number of years employed as a flight nurse, and CFRN certification. Utilizing the theory from Benner (1984) and Knowles (1980), a model to assist in the predicting P A catheter knowledge emerged. A self-motivated adult learner (professional nurse) seeks to expand his/her horizons with employment in a challenging specialty as critical care or flight nursing. To succeed, he/she must be mature enough to self-educate when the opportunity is presented, years on the job with quality time spent in job-related duties, and specialty certification contributes to the acquisition of P A catheter knowledge. Approximately 20% percent of the information needed to predict perfectly P A catheter knowledge was provided by these independent variables: years of employment as a flight nurse, percentage of time spent in flight-related duties, and length of the P A class. With the inclusion of CFRN certification, the ability to predict perfectly P A catheter knowledge was increased to 61%! According to Cohen (1990), "large effect" for a regression analysis in the Social Sciences is equal to .26 or 26% of the variance accounted for in the dependent variable from knowledge of the independent variables. The reader is reminded of the limitations imposed from the small sample size for this study. Likewise, Burns et al., (1996) demonstrated similar predictable variables for P A catheter knowledge. Years working in critical care, CCRN certification, frequency of P A catheter use, and attendance at a P A catheter course were the "predictors" of P A catheter knowledge. Evaluation of P A Catheter Knowledge The researcher concluded the evaluative nature of research question six that 16% of the total sample demonstrated that they possessed adequate knowledge of the P A catheter. The score of 80% or more on the questionnaire determined this. It was declared sufficient to perform safe and optimal care for a patient that required a P A catheter. There were 7 (16%) of the 35 that demonstrated having adequate P A catheter knowledge. Self-staging by these individuals was at the competent level or above except

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for one that staged herself as an advanced beginner. She had one of the highest scores on the questionnaire. The seven that had scored at or above the 80th percentile did especially well in the subset of patient management. The case scenarios were similar to actual situations. The respondents answered them with ease. The area of difficulty was the subset for interpretation. Waveforms, oxygenation interpretation, and catheter position in regards to the anatomical and numerical results all were problematic. The P A catheter knowledge deficit that has been consistent in the outcomes of the studies of Burns et al, (1996), and Iberti et al., (1994), and others is evident in the outcomes of the present study. The researcher does not feel that the P A catheter knowledge deficit has worsened, but that it continues to exist. A new tool specific to the flight and nonflight critical care nurse population today could be an asset for P A catheter knowledge. The outcome of this study does reveal a knowledge deficit related to the P A catheter. It is felt by the researcher that the gap is closing with the new technologies available to assist in the use of this tool and care of the patient needing it. Guidelines and programs have been developed to target the professional that will use this tool. AACN has made remarkable progress in this direction. They have interactive tutorials on line and have pioneered an orientation for critical care that must be tailored for use. It has had positive reviews (AACN, 2002). Benner's model guided this study with the theory of skill and knowledge acquisition that is necessary for each one of this sample to have in order to function at the level he/she classified him/herself on the Demographic Data Sheet. Even though outcomes were not reflective of the personal classifications for the majority of the study sample, for a small number (n = 7), it did reveal a level of competency necessary to perform safe and reasonable patient care acquired through skill and acquisition from experience. Knowles' model supported this study also with the self- motivation of the adult learner that is seen in these professionals to achieve specialty certification, to attend classes to learn more about the tools of the trade, and to continue education that is needed to maintain the skill and knowledge.

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Limitations The sample size is a major limitation. The background of the participants was varied and the geographical location was not limited. There were responses from all over the country, but the majority was located in the Southeastern United States. The difficulty of the questionnaire was a limitation in that it discouraged most of the visitors to the web site from completing the survey. Computer technology was a limitation because it generated all of the data necessary for patient care, which resulted in the decreased ability of the respondent to complete the questionnaire. Many of the would-be respondents stated that they would not do well because of the infrequent use of the equations necessary to determine the answers to the questions on the survey. Advances in technology in the form of computerized computations' doing the work for them were the reason for their inability to answer these questions independently. Implications for Nursing Nursing Profession Nursing practice will benefit from the development of guidelines that are universal for educational programs and competency checks for the utilization of the P A catheter. The knowledge deficit that exists does raise questions about the effectiveness of care delivered by professionals that exhibit this deficiency. The nonflight and flight critical care clinician and advanced practice nurse have indicated more analysis of the methods of education and training is needed. Cooperative development of an educational program curriculum should be organized by professional organizations on a national level to establish minimal criteria and competencies for the nurse clinician who cares for patients with the P A catheter Advanced Practice Nursing Many authors have utilized Benner's model and Knowles's model to study the learning process, how it is incorporated into personal and professional experiences, and factors that help direct the self-learning process (Conti, 1985; Daly, 1999; Moore, 1998; Oddi, 1986). Critical care clinicians, whether in flight or in hospital, need to have in place a universal competency-based model that would include guidelines for safe and improved patient care that required a P A catheter. The components of such a model

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should be developed in association with local, regional, and national nursing organizations for a standardized program. Since the advanced practice nurse (apn) has mastered the skill and knowledge acquisition implied in Benner's model, the advanced practice nurse can assist in the role of educator, researcher, consultant, leader, case manager, and care giver to provide the necessary opportunity for skill and knowledge acquisition of the P A catheter for the flight nurse and the nonflight critical care nurse. Administration The management of institutions that offer care for the critically ill, whether it is in the air medical environment or the hospital environment, has the ability to assist in correcting the knowledge deficit. Administrators depend on their staff to provide the educational opportunities for this competency, have the qualified staff to guarantee that the process and the protocols are in place, and are involved on a local and national level for the maintaining of requirements of such importance. Administrative services can encourage the need for specialty certification and all of the perks it offers. This shouts professionalism, excellence, and knowledge in his/her area of expertise. There can be career incentives to enhance this. Hospitals that are striving to achieve magnet status should expect specialty area professionals to achieve certification status. Online learning would be a means of enhancing professional development and be cost effective. The online tutorials that are available could be utilized at the staff's convenience. This would promote competency-based assessments and assist in monitoring actual bedside performance. Educators The professional is involved at all levels to evaluate the need for courses; to determine the effectiveness of the information being taught; to assist in evaluating the knowledge level of other educators and APNs; and to assist with the ongoing work to develop the needed standards of care for this skill. Continuing education can offer updates with uniform programs developed on a national level and disseminated among the many companies, professional organizations, and institutions of care that promote the use of the P A catheter. For example, AACN has now developed an online P A catheter tutorial. It is also included in a universal critical

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care orientation program that is being pioneered by healthcare institutions around the country. The success of such a program will be evaluated in the near future. Schools of nursing may offer an introduction to hemodynamic monitoring and P A catheter usage in areas of advanced care. This is a specialty and general nursing does not have the time or resources to focus on it. An introduction to the tool can be a beginning to build skill and knowledge. Because technological developments in the medical arena have assisted the clinician in areas of patient care like vital sign recording, assessment of body temperature, drug computations, titration suggestions, and many more, it is the responsibility of the practitioner to assure accuracy as it associates to patient care. It is acceptable to depend on the "machine's" calculations but it is also important to be able to manually calculate these outcomes and validate that the machine is indeed functioning properly. Online learning is an alternative method of offering continuing education at a cost effective and convenient schedule for most of the staff. It supports the staff needs and is educator-controlled and offers self-directed study. This method encourages a competent staff development through education and the application of the knowledge gained through on-the-job performance. Recommendations for Future Research Further research is indicated. A new tool is needed to keep up with the changes in practice and more appropriate for the new age flight and nonflight critical care nurses. The application of this tool could be done through the mail, on the World Wide Web, or personal group testing. The questions should be multiple choices with quick pick answers. It should require only a limited amount of time to complete. It should be focused on the clinical setting and patient management. Technology has changed the way computations and assessment of certain knowledge and skills acquisition is accomplished. Although the enhancement of patient care through technological advancements is important, it is just as important to be able to reach the same conclusions the old fashioned way, by the nurse's doing it his/herself. The art of observation, bedside assessments, and the skill of calculation and drug titration do not need to become a lost art. It is ironic that the computer was partially responsible for the diminished response. The World Wide Web is a good place to conduct research. The

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trend to go online and check things out is becoming more and more the norm. Access to the internet is becoming much easier. Computers are easier to operate and all ages are becoming adept in their usage. Replication of this study is indicated. A larger sample is needed. The flight nurses should be included, because they are considered critical care. Communication to increase the awareness of an online study is relatively easy to accomplish; organizations, chat groups, email, discussion groups, all make it easier to accomplish. Summary The findings of this study support the earlier studies of P A catheter knowledge deficiency. The study's outcome displayed a continued existence of this knowledge deficit. Benner's (1984) Novice to Expert Model and Knowles' (1980) Theory of the Adult Learner were appropriate models to guide this study. P A catheter knowledge, the dependent variable, and independent variables gathered from the Demographic Data Sheet were investigated. Specialty certification, length of the P A catheter class, number of years of experience in flight nursing, and time spent in job related duties all influenced the knowledge variable. Other variables had minimal influence on the knowledge variable. Since time and experience are needed to assist in the acquisition of the skill and the knowledge needed to advance from novice (beginner) to expert (accomplished) with respect to P A catheter competency, the variables that supported the ability to predict P A catheter knowledge were a surprise to this researcher. No written test or questionnaire can duplicate the clinical setting and knowledge does not always indicate one's skill. The results of the questionnaire for this study indicated that the flight nurse is more knowledgeable than the nonflight critical care nurse with respect to P A catheter knowledge. Because of these surprising results, it was assumed that the flight nurse sample (as indicated from the Demographic Data Sheet) had a strong critical care background to pull from and enhanced this skill and knowledge when changing from critical care nursing to flight nursing. The skill, knowledge, and experience that are necessary to function in the air medical environment hint at the possibility of an advanced practice role as a future consideration.

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APPENDIX A PERMISSION TO USE P A CATHETER ILLUSTRATION

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APPENDIX B THE MULTICENTER PULMONARY ARTERY CATHETER QUESTIONNAIRE

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THE MULTICENTER PULMONARY ARTERY (P A) CATHETER QUESTIONNAIRE This questionnaire is divided into four parts. It will evaluate the knowledge base of the flight nurse and the nonflight critical care nurse. Choose only one answer from each question. At the end of the questionnaire, hit the submit button to complete this survey. Comments are welcome. Calculators are allowed, if needed. Recognition and Resolution of Complications: (questions 1-2) 1. If the pulmonary artery catheter balloon ruptures and 1.5 ml of air is inadvertently injected, which of the following is MOST LIKELY to occur to the patient? Select one of the following: a. no detectable change b. transient dyspnea c. ventricular arrhythmia d. infiltrate on STAT chest x-ray e. none of the above 2. Several hours after an uneventful catheter insertion, it is noted that the volume of air needed to inflate the balloon to obtain a wedge tracing is less than previously required. The MOST LIKELY cause is: Select one of the following: a. air in the pressure tubing b. the catheter tip is occluded by the vessel wall c. balloon rupture d. distal migration of the catheter e. calibration error Physiology: (questions 3-5) 3. In a supine patient, the P A catheter generally flows to: Select one of the following: a. posterior dependent lung zones b. superior lung zones c. inferior lung zones d. anterior lung zones e. areas with high ventilation-to-perfusion ratios

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4. Ventricular compliance may be increased by: Select one of the following: a. myocardial ischemia b. cardiac shock c. right ventricular overload d. vasodilators e. pericardial effusion 5. Systemic vascular resistance: Select one of the following: a. is a measurement obtained directly from the P A catheter b. can be calculated as (MAP-PAWP/CO) x 80 c. can be calculated as (SAP-PAWP/CO) x 80 d. can be calculated as (SAP-PAWP/MAP) x 80 e. can be calculated as (MAP-CVP/CO) x 80 Interpretation: (questions 6-12) 6. Referring to the figure 1 (below) what is the wedge pressure in mm Hg of this spontaneously breathing patient?

Figure 1. Pulmonary artery waveforms obtained from a spontaneously breathing patient.

Select one of the following: a. 10 c. 30 e. 50 b. 20 d. 40 7. The pulmonary artery wedge pressure gives an accurate measure of: Select one of the following: a. left ventricular compliance b. intravascular volume c. left ventricular volume d. ventricular interdependence e. none of the above

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8. Large v-waves on the wedge pressure tracing may indicate all of the following EXCEPT: Select one of the following: a. papillary muscle rupture b. ruptured chordae tendineae c. dilated mitral annulus d. 2:1 AV block e. papillary muscle ischemia 9. Which of the following disorders is MOST likely to increase the CVP and simultaneously decrease the PAWP? Select one of the following: a. left ventricular myocardial infarction b. excessive administration IV fluids c. rupture of the mitral valve papillary muscle d. acute pulmonary embolus e. acute dissecting aneurysm with aortic regurgitation 10. A patient with Adult Respiratory Distress Syndrome is on an FiO2 of 0.6, positive -end expiratory pressure (PEEP) of 17 cm H20 with an ABG of pH 7.3, pCO2 40 mm Hg, and pO2 55 mm Hg. When estimating the PAWP the current recommendation is: Select one of the following: a. Temporarily disconnect the patient from the ventilator and measure the PAWP at end-expiration. b. Determine the pressure at end-expiration and follow the trend. c. Determine the pressure at end-expiration. d. Do not follow the PAWP, at best it will be misleading. e. a and b 11. Aspirated blood from the distal port of the P A catheter has a pO2 of 83 mm Hg (saturation 90%). Which of the following is the MOST likely cause? Select one of the following: a. High levels of supplemental O2 b. The arterial pO2 is greater than 100 mm Hg. c. The catheter is coiled in the right ventricle. d. The catheter is in the wedge position. e. The patient is septic with a high cardiac output.

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12. In an 18 year old woman who is 4 ft. 6 in. in height, a PAC is inserted via the right internal jugular vein and reaches a satisfactory wedge position at 35 cm. Repeated cardiac output determination varies from 2-10 liters per minute. All of the equipment is checked and found to be in good working order. Which of the following is the problem? Select one of the following: a. The cardiac output is so high that it cannot be accurately measured. b. The proximal port is not in the right heart. c. There is a large change in the cardiac output with respiration. d. The body surface area is underestimated. e. None of the above. Application to Patient Management: (questions 13-27) 13. A 74 year old patient with a history of CHF and COPD is admitted to the ICU with a BP 70/40 mm Hg, RR 35/min, rales 1/3rd of the way up both lung fields, and an ABG on FiO2 0.4 of pH 7.01, pCO2 58 mm Hg, and a pO2 50 mm Hg. The CBC, Na, K, Glucose, and BUN are all within normal limits. The EKG reveals the patient to be in atrial fibrillation with a ventricular response of 135/min. A chest x-ray has been ordered. Your first maneuver should be: Select one of the following: a. Insert a PAC from a nonsubclavian site to avoid a pneumothorax. b. Insert a PAC with the patient in the sitting position. c. Give 1 ampule of sodium bicarbonate and insert the PAC. d. Insert the PAC from any site as soon as possible prior to initiating any therapy. e. None of the above. 14. An 18 year old male is injured in a head-on collision in which he was the driver of the vehicle. At surgery, he had repair of a liver laceration and resection of his pancreas and spleen. On admission to the ICU, his BP is 60/40 mm Hg, HR 120/min, and he is mechanically ventilated. He is given 500 ml of fluid without response and a pulmonary artery catheter is inserted revealing cardiac index (CI) 2.01 L/min/M2, CVP 2 mm Hg, PAWP 1 mm Hg, and PAP 15/5 mm Hg. The most likely diagnosis is: Select one of the following: a. cardiac contusion b. hypovolemia c. over ventilation d. cardiac tamponade e. pneumothorax

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15. PAC data on a 68 year old cirrhotic patient reveal an elevated cardiac index, decreased systemic vascular resistance, normal pulmonary vascular resistance, elevated PVO2, increased oxygen delivery, and decreased arterial venous oxygen content difference. These calculations may suggest all of the following EXCEPT: Select one of the following: a. hyperdynamic picture of sepsis b. hyperdynamic picture of cirrhosis c. pulmonary embolus d. previously placed arterio-venous fistula e. none of the above 16. Which of the following interventions will cause oxygen delivery to increase the most? Select one of the following: a. increase the PaO2 from 75 mm Hg to 100 mm Hg b. increase the cardiac output by 10% c. increase the hematocrit from 20% to 25% d. interventions a, b, c, will all have an equal effect e. none of the above will raise the delivery of oxygen 17. Which of the following statements is true? Select one of the following: a. In a critically-ill patient, changes in the central venous pressure parallel changes in the pulmonary wedge pressure. b. Positive end-expiratory pressure increases the PAWP by 1 mm Hg for every 1 cm in water pressure. c. Insertion of the catheter in a patient with a left bundle branch block is contraindicated. d. Prophylactic lidocaine should be administered prior to the insertion of P A Catheters. e. None of the above. 18. In a 180 cm (5 feet 11 inches) tall, 70 kg patient with normal anatomy, at what cm length should a pulmonary artery catheter reach the wedge position if inserted via the right internal jugular approach? Select one of the following: a. 25-35 cm b. 36-44 cm c. 45-59 cm d. 60-75 cm e. more than 75 cm 19. A 76 year old patient with a history of coronary artery disease who is clinically stable and has a normal physical exam undergoes elective P A catheter insertion. The following data are obtained: HR 90/min, BP 150/75 mm Hg, CO 4.5 L/min, PAWP 6 mm Hg. Suddenly, the patient complains of severe chest pain and a 12 lead EKG shows lateral wall ischemia. New P A catheter data reveal: HR 125/min, BP 160/80 mm Hg, CO 5.0 L/min, PAWP 17 mm Hg. The change in the PAWP MOST LIKELY represents:

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Select one of the following: a. a change in total body volume b. an increase in the left ventricular volume c. intravascular volume overload d. a change in the ejection fraction e. a decrease in the left ventricular compliance 20. When determining the cardiac output, injection of less than the correct amount of volume (i.e., 9 ml instead of 10 ml) will lead to : Select one of the following: a. an underestimation of the cardiac output b. an overestimation of the cardiac output c. no change in the determined cardiac output d. an unpredictable change in the cardiac output e. the cardiac computer will read "error" 21. Which of the following are needed to calculate oxygen delivery from P A catheter data? Select one of the following: a. cardiac output, hemoglobin, arterial oxygen saturation, arterial pO2 b. stroke volume, hemoglobin, pulmonary artery pO2, arterial saturation c. arterial pO2, pulmonary artery pO2, arterial saturation, cardiac output d. pulmonary artery saturation, arterial saturation, cardiac output, oxygen consumption e. none of the above 22. All of the following may raise the pO2 of blood drawn from the distal port of a P A catheter in a patient with no cardiorespiratory pathology EXCEPT: Select one of the following: a. early sepsis b. increased cardiac output c. arterio-venous fistula d. malignant hyperthermia e. inotropic agents

23. The pulmonary artery wedge pressure must be determined: Select one of the following: a. as the mean of the diastolic pressure b. at end-expiration c. with the patient holding his/her breath d. following inflation of the balloon for at least 30 sec e. as the mean pressure given by the bedside monitor

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24. Which of the following may cause an abnormal elevation in the oxygen saturation of blood drawn from the distal port? Select one of the following: a. ventricular septal defect b. catheter in the wedge position c. peripheral arterio-venous fistula d. severe mitral regurgitation e. all of the above Questions 25-27 pertain to the following data: The following data are obtained from an ICU patient: Height: 60 inches (152 cm), Weight: 140 pounds (64 kg), Body Surface Area: 1.50 m2, Temperature: 37.5 C, HR: 114/min, MAP: 60 mm Hg, PAP: 40/20 mm Hg, PAWP: 18 mm Hg, CVP: 10 mm Hg, CO: 4 L/min, Hgb: 10.0 gm%, FiO2: 0.8, pH: 7.39, pCO2: 40 mm Hg, pO2: 70 mm Hg, Art Hgb Sat: 95%, SvO2 sat: 75%, PvO2: 28 mm Hg. Assume 1.34 ml of O2 per gm Hgb at 100% saturation. 25. The cardiac index (L/min/m2) is: Select one of the following: a. 1.8 b. 2.3 c. 2.7 d. 3.4 e. 6.8 26. The systemic vascular resistance (dynes.sec.cm-5) is: Select one of the following: a. 840 b. 1000 c. 1300 d. 1900 e. 2200 27. The arterial oxygen content (ml O2/100 ml blood) is: Select one of the following: a. 5.1 b. 8.3 c. 10.1 d. 12.9 e. 16.8 Please include any comments or concerns in the space provided.

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APPENDIX C DEMOGRAPHIC DATA SHEET

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Demographic Data Sheet Please check the appropriate box with the most accurate answer as of this date. Answer only the questions that apply to you as of this date. 1. Age (specify in years) ___ 2. Gender A. male B. female 3. Highest nursing degree held A. Diploma B. Associate C. Baccalaureate D. Master's E. Doctorate 4. State of Licensure ___ 5. CCRN certification Yes No 6. CFRN certification Yes No 7. Employed as Current job Flight nurse ____ # yrs ER nurse ____ # yrs Critical care nurse ____# yrs 8. Years employed at job prior to current position as (if applicable) Flight nurse ____ # yrs ER nurse ____ # yrs Critical care nurse ____# yrs 9. Total number of years in nursing _____

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10. Approximate percentage of time spent with flight related patient care and duties related to aviation environment (Please include all flight related duty time) A. B. C. D. 25 % 50 % 75 % 100 %

11. Recent attendance in a P A catheter class within last 12 months Yes No 12. Most recent date of P A catheter class A. >6 months B. 4-6 months C. 2-3 months D. < 1 month E. none attended 13. Average length of P A catheter class A. < 2 hours B. 2-5 hours C. 6-10 hours D. > 10 hours E. none attended 14. Are you responsible for interpreting P A catheter data A. Yes B. No 15. Frequency of P A catheter use in past 6 months A. None B. < 2 per month C. 2-5 per month D. 6-10 per month E. > 10 per month 16. Classify your personal level of knowledge and ability to utilize information generated from P A catheter data A. Novice B. Advanced beginner C. Competent D. Proficient E. Expert

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17. Minimum requirement for current nurse position: (Check all that apply) Flight Nurse: ___ Licensed as a registered nurse ___ Previous flight/ground transport experience ___ # yrs experience as flight/ground transport nurse Nonflight critical care nurse: ___ Licensed as a registered nurse ___ Previous critical care experience ___ # yrs experience as nonflight critical care nurse ___ ACLS certification ___ at least 2-3 years ER or ICU experience ___ CCRN certification ___ ACLS and PALS certifications ___ CFRN certification ___ EMT or Paramedic certification

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APPENDIX D PERMISSION TO USE QUESTIONNAIRE FROM ORIGINAL AUTHORS

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APPENDIX E PERMISSION TO USE QUESTIONNAIRE FROM MAGAZINE EDITOR

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APPENDIX F COVER LETTER AND INFORMED CONSENT

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Hello, My name is Karen Biddy. I am a graduate RN student completing the requirements for my Master's degree in the nursing program at Florida State University, conducting research for my thesis entitled, Flight Nurses' and Nonflight Critical Care Nurses' Knowledge of the Pulmonary Artery Catheter: a Comparison Study under the guidance of Dr. Jeanne Flannery. This questionnaire is part of this process. I am a hospital-based flight nurse. The questionnaire that you are about to answer will reflect the knowledge level that you, as a healthcare professional, use when caring for patients that require a pulmonary artery catheter as part of their treatment while in the hospital. The purpose of this study is to compare the nonflight critical care nurse's knowledge of the P A catheter with the flight nurse's knowledge of the P A catheter. The ICU today is dynamic: on the ground, in the hospital, or in the air; a critical care patient with a P A catheter can be in any of these environments. The nurse that is caring for this patient should be knowledgeable and proficient with this tool to offer care sufficient for patient safety and optimal outcomes. If you are an RN working in critical care nursing or flight nursing and 18 years of age, please take a few minutes and answer the questions on the following pages. This is a completely voluntary process. There are 44 questions total and it should take about 30 minutes of your time. The first section of the questionnaire has 17 questions that will give me some information about you, as a nurse. Answer the questions as accurately as possible. The next section will provide the data for this study. There are 27 questions about the use of the P A catheter. Select one answer for each question. You may use a calculator. Please do not use any resources to assist you in answering these questions. You may take as long as you like to complete these questions. Please do not stress yourself. There are no data collected which will identify you (to check this, just access the questionnaire page source code). The questionnaire is completely anonymous. No cookies will be installed on your computer. The information that is collected from each questionnaire is grouped, formatted, and sent via email to the statistician. This is done via an anonymous email address that is set up with the web page to assure your anonymity. All information is collated so no identifying data are available. The data collected will be kept for 5 years (December, 2008) in a locked box inside of a locked file cabinet in the researcher's home, and then disposed of by shredding the information. The only people having access to this information will be the thesis committee and me. Should you have any questions, you can contact me (Karen Biddy, 850-878-5947), Dr. Jeanne Flannery (850-6445626). If you have concerns about your rights as a participant, you may contact the Institutional Review Board at FSU (850-644-8633) with comments and concerns that you may have. You will be implying informed consent by completing and voluntarily submitting the questionnaire. Should you feel uncomfortable and do not want to complete this process, or become anxious for any reason, you should stop the process. You just close the page and

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you're finished without anyone's being aware of this. There are no risks or health hazards involved. The reward or benefit with this study is your satisfaction in assisting with improving outcomes for critical patients. Your concerns and comments are welcome; include them at the end of the questionnaire. Thank you in advance for your time and effort. Sincerely, Karen Biddy, RN

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APPENDIX G FLORIDA STATE UNIVERSITY INSTUTIONAL REVIEW BOARD APPROVAL LETTER

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APPENDIX H SCRIPT FOR TELEPHONE AND MAIL NOTIFICATION

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Hello, My name is Karen Biddy. I am an RN nursing student at Florida State University School of Nursing. Under the guidance of Dr. Jeanne Flannery, I am completing the requirements for my Master's degree in Nursing. A questionnaire, The Multicenter Pulmonary Artery (P A) Catheter Questionnaire, will be part of this process. It can be accessed online at http://garnet.acns.fsu.edu/~kcb2738/. Complete information and instructions can be accessed at the web address. Your participation would be greatly appreciated. It is a voluntary process and complete anonymity is guaranteed by the anonymous e-mail, the absence of cookies, and the ability to check the source code at any time to verify this. There are no risks involved and your consent is implied by completing and voluntarily submitting the questionnaire. The benefits are in your knowing that your participation will greatly enhance the probability of increasing the knowledge of pulmonary artery catheters that are used by critical care and flight nurse personnel. It will take approximately 30 minutes of your time to complete the process. There are no health hazards to be worried about. For more information, please contact Karen Biddy at 850-878-5947 or Dr. Jeanne Flannery at 850-644-5626. If you have concerns about your rights as a participant, you may contact the Institutional Review Board at FSU (850-644-8633). Thank you. Sincerely, Karen Biddy, RN (This letter will be used as telephone script and local notices for the flight programs and critical care units.)

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REFERENCES Ahrens, T. S. (1997). Is nursing education adequate for pulmonary artery catheter utilization? New Horizons 5 ( 3), 281-285. Alexander, J. E. & Keller, S. L. (1991). From novice to expert: Excellence and power in clinical nursing practice. In A. Marriner-Tomey (Ed.), Nursing Theorists and Their Work, 163-175. St. Louis, MO: Mosby Publishing. American Association of Critical Care Nurses Certification Corporation (2002). Facts about certification and aacn. Retrieved April 5, 2002, from http://www.aacn.org. Air and Surface Transport Nurses Association (2002). Facts about flight nursing and certification. Retrieved April 5, 2002, from http://www.astna.org. American Heart Association (2000). AHA task force on clinical privileges in cardiology. Retrieved July, 2001, from http://www.americanheart.org/guide.html Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley Publishing. Benner, P., & Tanner, C. (1987). Clinical judgment: How expert nurses use intuition. American Journal of Nursing 30(5), 23-34. Benner, P., & Wrubel, J. (1982). Skilled clinical knowledge: The value of perceptual awareness. Nurse Educator 7(3), 11-17. Boggs, R. L., & King, M. W. (Eds.) (1998). AACN procedure manual for critical care (3rd ed.). Philadelphia: W. B. Saunders Publishing. Bowman, L. (1999). More households than not have pcs. ZDNet tech news. Retrieved July, 1999, from http://www.webcrawler.com/computers _and_internet/tech_news/znet/?article-znews/.mp

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Brewer, J. K., & Workman, D. R., (2002). Introductory statistics for researchers (7th ed.). Edina, MN: Burgess International Group, Inc. Bridges, E. J. (2000). Monitoring pulmonary artery pressures: Just the facts. Critical Care Nurse 20 (6), 1-21. Retrieved May 5, 2002, from http://www.critical-care-nurse.org/aacn/jrnlccn.nsf/(Articles) Burns, D., Burns, D., & Shively, M. (1996). Critical care nurses' knowledge of pulmonary artery catheters. American Journal of Critical Care 5 (1), 49-54. Caffarella, R. S., & Caffarella, E.. P. (1986). Self-directedness and learning contracts in adult education. Adult Education Quarterly 36(4), 226-234. Caffarella, R. S., & O'Donnell, J. M. (1987). Self-directed adult learning: A critical paradigm revisited. Adult Education Quarterly 37(4), 199-211. Cohen, J. C. (1990). Statistical power analysis for the behavioral sciences (3rd ed.). Hillsdale, NJ: Lawrence Eilbaum Associates. Conti, G. J. (1985). The relationship between teaching style and adult student learning. Adult Education Quarterly 35(4), 220-228. Daley, B. J. (1999). Novice to expert: An exploration of how professionals learn. Adult Education Quarterly 49(4), 122-147. Darovic, G. O., & Franklin, C. M. (1999). Handbook of hemodynamic monitoring. Philadelphia: W .B. Saunders Publishing. Dunn, S. V. (1992). Orientation: The transition from novice to competent critical care nurse. Critical Care Nurse 15 (1), 69-77. Dvorak-King, C. (1997). P a catheter numbers made easy. RN 11(11), 45-49. Ehrenwerth, J., Sorbo, S., & Hackel, A. (1986). Transport of critically ill adults. Critical Care Medicine 14 (6), 543-537. Fawcett, J., & Buhle, E.L. (1995). Using the internet for data collection: An innovative electronic strategy. Computers In Nursing 13(6), 273-279. Gatley, E. P. (1992). From novice to expert: The use of intuitive knowledge as a basis for district nurse education. Nurse Education Today 12(2), 81-87. Grap, M. J., Pettrey, L., & Thornby, D. (1997). Hemodynamic monitoring: A comparison of research and practice. American Journal of Critical Care 6 (6), 452-456.

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Haag-Heitman, B. (1999). Clinical practice development using novice to expert theory. Gaithersburg, MD: Aspen Publishers. Haskins, W. (2002). Pc households. P C Magazine. Retrieved March 22, 2002, from http://www.pcmag.com. Hegedus, K. S. (1984). Providers' and consumers' perspective of nurses' caring behaviours. Journal of Advanced Nursing 30(5), 1090-1096. Holleran, R. S. (Ed.) et al. (1996). Flight nursing: Principles and practice (2nd ed.). St Louis,MO: Mosby Publishing. Holleran, R. S. (Ed.) et al. (2003). Air & surface patient transport: Principles & practice (3rd ed.). St. Louis, MO: Mosby Publishing. Iberti, T. J., Daily, E. K., Leibowitz, A. B., Schecter, C. B., Fischer, E. P., & Silverstein, J. H. (1994). Assessment of critical care nurses' knowledge of the pulmonary artery catheter. Critical Care Medicine 22 (10), 1674-1678. Iberti, T. J., Fischer, E. P., Leibowitz, A. B., Panacek, E. A., Silvestein, J. H. & Albertson, T. E. (1990). A multicenter study of physician's knowledge of the pulmonary artery catheter. JAMA 264 (22), 2928-2933. Knowles, M. S. (1980). What is andragogy? The modern practice of adult education: From pedagogy to andragogy (2nd ed.), 40-55. New York: Association Press. Kondrat, P. (1994). Critical care nurses' knowledge of pressure waveforms obtained from the pulmonary artery catheter. Doctoral dissertation, University of Washington, Seattle, WA. Koschel, M. J. (2000). Hemodynamic monitoring in the air: A look at current practices. Air Med 6 (5), 48-49. Kovacs, D. E., Frame, K. S., Gay, J., & Mayberry, R. T. (1990). Air medical transport of patients with indwelling pulmonary artery catheters. The Journal of Air Medical Transport 12 (11), 9-12. Leibowitz, A. B., & Oropello, T. (1994). Multicenter pulmonary artery catheter questionnaire. Progress in Anesthesiology 8(16), 276-289. Lundstedt, J. L. (1997). Comparison of methods of measuring pulmonary artery pressure. American Journal of Critical Care 6(4), 324-332.

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Miller, K. (2000). Safety of stress testing patients with cad. American Family Physician, January 1, 2000. Retrieved May, 12, 2002, from http://www. aafp.org/afp/20000101/tips/13.html. Moore, P. (1998). Effectiveness of reflective learning. Retrieved September 8, 2002, from http:www.wnb.org.uk/e25104.htm. National Center for Health Statistics (2003). Heart disease health facts. Retrieved July, 2003, from http://www.cdc.gov/nchs/fastats/heart.htm. Oddi, L. F. (1986). Development and validation of an instrument to identify self-directed continuing learners. Adult Education Quarterly 36(2), 97-107. Oddi, L. F. (1987). Perspectives on self-directed learning. Adult Education Quarterly 38(1), 21-31. Papdakos, P. J., & Vender, J. S. (1997). Training requirements for pulmonary artery catheter utilization in adult patients. New Horizons 5(3), 287-291. Polit, D., & Hungler, B. (1995). Nursing research (5th ed.). Philadelphia: Lippincott Publishing. Powers, B. A., & Knapp, T. R. (1995). A dictionary of nursing theory and Research (2nd ed.). London: Sage Publications. Roizen, M. F., Berger, D. L., Gabel, R. A., Gerson, J., Mark, J. B., Parks, R. I., Paulus, D. A., Smith, J. S., & Woolf, S. H. (1993). Practice guidelines for pulmonary artery catheterization: A report by the American society of anesthesiologists task force on pulmonary artery catheterization. Anesthesiology 78 (2), 380-394. Scribante, J., Muller, M. E., & Lipman, J. (1996). A guideline for competency of the critical care nurse. American Journal of Critical Care 5 (3), 217-223. Siegel, S., & Castellan, N. J. (1988). Nonparametric statistics for the behavioral sciences (2nd ed.). New York: McGraw-Hill Publishers. Stat-Xact-4 for Windows (1999). Cambridge, MA: Cytel Software. Swan, H. J. C. (1991). The pulmonary artery catheter. Disease-a-Month, 475-543.0 Toth, J. C. ( 1994). Basic knowledge assessment tool for critical care nursing, version (bkat-4): Validity, reliability, and replication. Critical Care Nurse 14 (3), 111-117.

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Trottier, S. J., & Taylor, R. W. (1997). Physicians' attitudes toward and knowledge of the pulmonary artery catheter: Society of critical care medicine membership survey. New Horizons 5 ( 3), 201-206. Turner, J. L., & Turner, D. B. (1998). Using the internet to perform survey research. Syllabus 12 (4), 58-61. Turner, J. L., & Turner, D. B. (1999). Using the internet to perform survey research. Syllabus 12 (5), 55-56. Visalli, F., & Evans, P. (1981). The swan-ganz catheter ­ a program for teaching safe, effective use. Nursing81 11(1), 42-47. Warren, C. (1989). Andragogy and n. f. s. grundtvig: A critical link. Adult Education Quarterly 39(4), 211-223. Waxman, A. B., & Matthay, M. A. (1998). Critical assessment of pulmonary artery catheter use in the icu. American College of Chest Physicians. Retrieved September 7, 2002, from http://www.chestnet.org/education. Wesley, R. L. (1995). Nursing theories and models (2nd ed.). Springhouse, MD: Springhouse Corporation.

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BIOGRAPHICAL SKETCH Karen Biddy was born on September 9, 1950, in Apalachicola, Florida. She is the daughter of Robert (Bob) and Louise (Lou) Connell. She is married to Jim Biddy and they have two children: Alex, age 20, and Eli, age 17. Karen graduated from Florida State University in March, 1972, obtaining a Bachelor of Science degree in nursing. She also achieved certifications in critical care nursing, flight nursing, and paramedic practice. In order to expand her professional capabilities, she completed her course work and other requirements for the nurse practitioner curriculum in family medicine, also at Florida State University. She received a Master's Degree in Nursing, August, 2004. This will enable her to pursue a career as an advanced practice nurse. She remains active in the local chapters and the national organizations of the American Association of Critical Care Nurses and the Air and Surface Transport Nurses Association. She assists with committee activities, outreach education, and general membership needs.

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FLIGHT NURSES' AND NONFLIGHT CRITICAL CARE NURSES' KNOWLEDGE OF THE PULMONARY ARTERY CATHETER: A COMPARISON STUDY

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