Date of Award

12-2026

Degree Type

Dissertation/Thesis

Degree Name

Doctor of Nursing Practice (DNP)

School

Leadership and Advanced Nursing Practice

Committee Chair

Dr. Douglas Allan Lovern

Committee Chair School

Leadership and Advanced Nursing Practice

Committee Member 2

Dr. Jessica Miley

Committee Member 2 School

Leadership and Advanced Nursing Practice

Abstract

High-acuity, low-occurrence (HALO) events necessitate swift and accurate intervention by Certified Registered Nurse Anesthetists (CRNAs). Limited experience with these scenarios in clinical practice may diminish confidence and compromise performance. Simulation training, which incorporates cognitive aids, provides a valuable approach to enhancing preparedness and self-efficacy.

This doctoral project evaluated whether high-fidelity simulation combined with a cognitive aid improves CRNA self-efficacy in HALO management and explored factors influencing self-efficacy and performance. Ten CRNAs participated in a simulation using a flowchart to manage Local Anesthetic Systemic Toxicity (LAST). Self-efficacy was measured before and after using the NGSE scale. Pearson’s correlations examined links among self-efficacy, performance, leadership support, prior HALO experience, and demographics. Paired t-tests and Wilcoxon tests evaluated changes in NGSE scores.

NGSE scores increased from a mean of 31.60 (SD = 7.52) pre-intervention to 36.00 (SD = 3.09) post-intervention, with significant results from a one-tailed t-test (p = .033) and Wilcoxon test (p = .035). Pre-test NGSE correlated positively with lower anxiety (r = .626, p = .026) and leadership support (r = .536, p = .055). Performance scores related to prior HALO experience (r = .557, p = .047) and leadership support (r = .583, p = .038). No link was found between NGSE scores or certainty and simulation performance.

Findings support Bandura’s (1977) theory that mastery experiences, specifically simulated HALO management with guided cognitive aid use, are powerful drivers of SE. Leadership support was identified as a key factor influencing both confidence and performance, consistent with existing literature on organizational culture and crisis intervention readiness. Although the results show immediate improvements in self-efficacy, previous research indicates these gains may diminish over time without continuous reinforcement, emphasizing the importance of ongoing, PDSA-driven refresher simulations. High-fidelity simulation with cognitive aids can improve CRNA self-efficacy in managing HALO events, particularly when paired with visible leadership support. Future research should assess the durability of these gains and test domain-specific self-efficacy measures for stronger predictive validity.

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Available for download on Thursday, December 10, 2026

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