Evidence-based Quality Improvement Project Research Articles

Fostering Resilience and Well-Being Among New Graduate Nurses.

Nearly one third of the U.S. nursing workforce is considering leaving their current job, with millennials new to the role most likely to leave. Newly licensed registered nurses (NLRNs) often feel unprepared and overwhelmed, contributing to the risk of turnover in this workforce segment and amplifying unstable healthcare environments. This evidence-based quality improvement project integrated a resilience and well-being program into a nurse residency program, improving resilience and well-being in NLRNs transitioning to professional practice.

Expansion of the Fertility Preservation Program to All Newly Diagnosed Prepubertal Patients with Cancer at a Pediatric Hospital.

Background: As the majority of pediatric patients with cancer survive their disease, generating a population of over 500,000 childhood cancer survivors in the United States, it is imperative to minimize the lifelong consequences of treatment, which include temporary or permanent infertility caused by certain cancer treatments. A fertility consultation at diagnosis can provide patients and families with the opportunity to be informed regarding the likelihood of gonadal dysfunction and to consider fertility preservation. Method: After our pediatric hospital started to offer tissue cryopreservation, we initiated this evidence-based interventional quality improvement project. Our primary aim was to ensure that all newly diagnosed prepubertal patients with cancer who met the criteria for fertility tissue preservation were correctly identified and offered an educational consultation and preservation. Results: Between July 15, 2022 and October 30, 2022, 54 patients' treatment plans were evaluated to determine treatment-related infertility risk using the Oncofertility Consortium Pediatric Initiative Network's Risk Assessment tool. Fifteen patients were at a high level of significantly increased risk and 13 were eligible for consultation. Seven (46%) patients and their families received a consultation. Initiation of treatment before referral was the primary reason for lack of consultation. Six of seven patients receiving consultation (86%) elected to undergo preservation. Preservation procedures did not cause a delay in starting treatment for those patients. Discussion: A fertility preservation program with established policies and processes can increase the likelihood that prepubertal patients at high risk for infertility are correctly identified, educated, and offered preservation.

The Effect of Teach-Back on Readmission Rates in Rehabilitation Patients.

Thirty-day readmissions often occur in rehabilitation patients and can happen for many reasons. One of those reasons is when patients do not fully understand how to effectively manage their health after discharge. The purpose of this evidence-based quality improvement project was to determine if implementing the teach-back intervention from the Agency for Healthcare Research and Quality's (AHRQ) Health Literacy Universal Precautions Toolkit would impact 30-day readmission rates among adult rehabilitation patients. Data were collected from the electronic health record of rehabilitation patients. The comparative group included all rehabilitation admissions for 8 weeks prior to the intervention. The implementation group was composed of the rehabilitation admissions for 8 weeks post-implementation. All patients were then followed for 30 days postdischarge to capture readmissions. The total sample size was 79 ( n = 43 in the comparative group, n = 36 in the implementation group). There was a 45% decrease in the mean percentage of the 30-day readmission rate in the implementation group as compared with the comparative group. Based on the results, using the teach-back intervention from AHRQ's Health Literacy Universal Precautions Toolkit may impact 30-day readmission rates.

Implementing mobile text messaging on glycemic control in patients with diabetes mellitus.

Uncontrolled blood glucose may lead to serious complications in patients with type two diabetes mellitus (T2DM). Patients may not have the support, motivation, or encouragement to adhere to the lifestyle changes necessary to control their T2DM. More than 75% of the primary care clinic's patients are diagnosed with T2DM, with most patients at the practice site having an average hemoglobin A1c (HbA1c) level of 8.5%. The primary care clinic did not use text messaging to disseminate diabetes self-management education and support (DSMES) as outlined in Standard 4 of the American Diabetic Association's (ADA) clinical practice guideline. This evidence-based quality improvement project was conducted in a rural outpatient primary care clinic to determine whether implementing the ADA's 2022 National Standards for DSMES using text messaging would affect HbA1C levels among adult patients with T2DM. Patients were sent weekly text messages over a 12-week period. Text messages contained information promoting self-care, tips about healthy diet, exercise reminders, instructions about proper blood glucose monitoring, and reminders about medication adherence. A total of 160 patients were included. A paired-sample t-test showed a reduction in HbA1c levels after the intervention from baseline (M = 7.53, SD = 1.72) to postimplementation (M = 6.91, SD = 0.89), t (159) = 11.88, p = .001. Based on the results, implementing the ADA's National Standards for DSMES Standard 4 may affect HbA1c levels in this population.

Palliative Extubation in Pediatric Patients in the Intensive Care Unit and at Home: A Scoping Review.

This scoping review is aimed at systematically mapping the evidence on palliative extubation in the pediatric intensive care unit. MEDLINE, EBSCO, and Cochrane databases were searched for articles published between January 2018 and December 2022, in English. Critical appraisal of sources of evidence was done using the Joanna Briggs Institute tools. PRISMA guidelines for scoping reviews were followed. Six studies were included, with 366 patients, from the USA (n = 4), Brazil (n = 1), and Germany (n = 1). Three were high-quality studies, two were moderate, and one was a low-quality study. Most studies were retrospective analysis; two were narrative approaches; two were evidence-based recommendation and quality improvement project; one study was a prospective intervention. Symptom control is crucial pre- and postextubation. A checklist (symptom management and family support) and a postdebriefing template improve team communication and staff support postextubation. Critical care transports from the hospital are feasible to provide extubation at home. A framework addressing common planning challenges and resource management is recommended for extubation at home. The provision of pediatric palliative extubation is necessary since futile measures and prolongation of suffering violate the principle of nonmaleficence. Future research on this subject will result in more benefits for patients, parents, and professionals.

Assessing medication self-management challenges and self-efficacy during emergency department medication reconciliation: An evidence-based quality improvement project

Assessing medication self-management challenges and self-efficacy during emergency department medication reconciliation: An evidence-based quality improvement project

Quality Improvement: Increasing SANE Utilization of Evidence-Based Practice.

Background: Varying protocols among sexual assault nurse examiner (SANE) programs lead to inconsistent patient care and indicate that evidence-based recommendations are not being utilized. To address this problem, an evidence-based treatment protocol designed to improve care provided to patients who have experienced sexual assault was implemented at an outpatient rape crisis center (RCC). In addition to implementing the new protocol, a SANE education program was provided. Methods: Retrospective chart reviews were conducted. A total of 21 protocol components were examined pre- and post-implementation of the quality improvement project. Additionally, a knowledge quiz and self-efficacy tool were administered before, immediately after, and 3 months after the SANE education program. Results: Before implementation, the overall compliance with the 21 protocol components was 42.1% for RCC exams and 17.9% for hospital exams. After implementation, the overall compliance increased to 85.3% for RCC exams and 56% for hospital exams. When examining protocol components individually, compliance varied dramatically. There was an improvement in SANE knowledge and self-efficacy when comparing pre- and post-scores; however, the results were not statistically significant and were found to have unequal variances. Conclusion: Nurses are ideally positioned to instigate protocol changes that will positively impact patient outcomes. Other nursing professionals can utilize the quality improvement project content, steps, lessons learned, and results to create similar evidence-based practice quality improvement projects to address gaps in practice.

Interprofessional Telerounds in a Pediatric Intensive Care Unit: A Quality Improvement Project.

Family-centered rounds are standard practice in pediatrics. However, some parents of children in the pediatric intensive care unit cannot attend rounds. A 36-bed academic, tertiary care pediatric hospital implemented telerounds during the COVID-19 pandemic. After visiting restrictions were lifted, nurses were interested in continuing telerounds for families who could not attend daily rounds. The aim of this evidence-based quality improvement project was to develop a standardized, family-centered telerounding process that satisfied parents, nurses, and physicians. Nurses offered telerounds to pediatric intensive care unit family members who could not attend rounds. Families received a unique link to telerounds using a secure connection. Nurses completed electronic satisfaction surveys after each session; physicians completed surveys at the end of their weeklong pediatric intensive care unit rotation; families received surveys at the end of the pediatric intensive care unit stay. Twenty families qualified for telerounds; 16 families completed sessions. Enrolled patients and families participated in 93 telerounding events. Nine family members (56%) returned satisfaction surveys revealing an overall satisfaction level of 9.9 out of 10. Thirty nurses reported an overall satisfaction level of 8.8 out of 10. Eleven physicians reported a mean satisfaction level of 8.8 out of 10. This project demonstrated that a standardized process of secure telerounding was feasible in a pediatric intensive care unit. Families, nurses, and physicians reported satisfaction with the process. Telerounds can be implemented without considerable inconvenience to staff and enable continuation of family-centered care when parents are absent from the hospital.

Supporting the Safe Use of the Dorsogluteal Intramuscular Injection Site: An Evidence-Based Quality Improvement Project.

Administering intramuscular (IM) injections is common in the adult mental health patient care setting, using the deltoid, vastus lateralis, ventrogluteal, or dorsogluteal site. Mental health nurses frequently use the dorsogluteal site to administer short and long-acting IM injections as specified in the drug package insert or because of patient agitation. However, the site is often not recommended due to the potential risk of nerve injury. Aims of this evidence-based quality improvement project were to (1) determine the best evidence for supporting the safe use of the dorsogluteal site for short and long-acting IM injections and (2) implement this evidence through nurse education. This project had two phases: Determining best evidence through an integrative literature review and implementing the recommendations to use the dorsogluteal site when directed by the drug package insert, clinical need, nursing judgment, or patient preference. Implementation followed the Plan-Do-Study-Act quality improvement process and involved written resources and simulation. Evidence supported the use of the dorsogluteal site in four instances and the importance of education. Nurses were highly satisfied with the education and opportunity to practice their skills with feedback during return demonstration. After studying nurses' follow-up survey results, a refresher simulation and medical center guideline were completed. There were no reports of IM injection patient injuries after 2 years and approximately 768 dorsogluteal and ventrogluteal IM injections in the academic medical center. Pursuing recent and possibly overlooked evidence provided guidance in supporting the safe use of the dorsogluteal site for IM injections.

Expansion of the fertility preservation program to all newly diagnosed prepubertal oncology patients at a pediatric hospital.

10064 Background: As the majority of pediatric oncology patients survive their disease, generating a population of over 500,000 survivors in the United States, it is imperative to minimize the lifelong consequences of treatment, which includes temporary or permanent infertility caused by certain cancer treatments. Fertility preservation (FP), the opportunity to preserve one’s ability to have genetically-related children prior to damaging the reproductive system, is a young but rapidly expanding field and recent scientific advances have led to an expansion of options for prepubertal patients. A fertility consultation at diagnosis can provide patients and families with the opportunity to be informed regarding likelihood of gonadal dysfunction and to consider FP. Methods: After our pediatric hospital started to offer tissue cryopreservation, we initiated this evidence-based interventional quality improvement project. Our primary aim was to ensure that all newly diagnosed prepubertal oncology patients who met criteria for FP were correctly identified and offered an educational consultation and preservation. Inpatient admission lists and provider schedules were reviewed daily to identify patients. Treatment plans were discussed with providers to calculate infertility risk. All procedures were to be completed at the time of another procedure to increase likelihood of insurance coverage and minimize delays. Results: Between 07/15/22 and 11/30/22, 54 newly diagnosed prepubertal patients’ treatment plans were evaluated to determine treatment-related infertility risk using the Oncofertility Consortium Pediatric Initiative Network’s Risk Assessment tool. 15 patients were at a high level of significantly increased risk and were therefore eligible for consultation. 7 patients and their families received an educational consultation and 6 elected to undergo FP (3 TTCs; 3 OTCs). FP procedures did not cause a delay in starting treatment for any of these patients. 8 patients did not receive consultations. Reasons included the provider electing to proceed with treatment without consultation (4), the patient’s comorbidities (1), the inability to bundle FP with another procedure (1), and the family decision to decline consultation (1). Conclusions: Of the patients at high risk of infertility, only 46% received consultation with lack of referral prior to initiating treatment as the primary reason. Of the patients offered preservation methods, 86% elected to preserve their fertility, illustrating patient and family interest. Providers must acknowledge changes in practice and be informed on the impact that high-risk treatment protocols can have on fertility. An FP program with established policies processes can increase the likelihood that prepubertal patients at high risk for infertility are correctly identified, educated, and offered preservation.

NO BUGS: Nosocomial operative best-practices for unplanned infections in gynecologic surgery: A 6-month retrospective.

e18765 Background: An estimated 94,000 women have newly diagnosed gynecologic cancer (ovarian, uterine, cervical, and vulvovaginal) annually–with rates increasing over the last 20 years. Surgical site infections (SSIs) complicate up to 4% of all hysterectomies in the United States. Other surgical sequelae, such as operative length, estimated blood loss, wound dehiscence, and 30-day readmission, further complicate the post-surgical course of this vulnerable population. Methods: A quality improvement initiative was conducted in a large academic health system between January to June 2022 to investigate whether implementing an SSI bundle, defined as a set of 11 evidence-based practices performed collaboratively, can reduce intraoperative and postoperative complications. The study population included women who received gynecologic oncologic surgery. To evaluate trends following the implementation of an SSI prevention bundle, we studied two time periods: 1/1/22-3/31/22 and 4/1/22-6/30/22. Trends were analyzed using chi-squared and a two-sample t-test. Results: Over our six-month study period, 233 patients underwent primary gynecologic oncologic surgery. Robotic-assisted hysterectomies were the most common (27.89%, n = 65), followed by total abdominal hysterectomies (21%, n = 49), laparoscopic hysterectomies (7.72%, n = 18), and supracervical hysterectomies (3%, n = 7). An invasive, abdominal approach was needed for less than half of the surgeries for whom intraoperative and postoperative outcomes were measured (46.35%, n = 108). Following the implementation of our SSI bundle, there was a rise in estimated blood loss (134.49 to 252.67 mL), operative length (199.24 to 227.23 min), and length of stay (1.58 to 2.20 days). Yet, there was a decline in the SSI rate from 4.62% to 3.7% (p = 0.97) and 30-day all-cause readmission from 12.96% to 7.4% (p < 0.05). The overall incidence of 30-day wound dehiscence also declined over six months from 3.7% to 1.85% (p = 0.74). Upon intersectional analysis, patients with SSI were older (55.93 vs. 62, p = 0.39) and were more likely to be obese (BMI 27.04 vs. 31.06, p < 0.05). Individuals with functional status limitations, ECOG score > 2, had longer lengths of stays (4.7 vs. 1.76 days, p < 0.05), estimated blood loss (230 vs. 185.9 mL, p = 0.12), and operative length (374 vs. 205.2 min, p < 0.001). Those with a supracervical hysterectomy also had a longer length of stays (4 days, p < 0.05), blood loss (921.43 mL, p < 0.001), and operative lengths (315.14 min, p < 0.001). Conclusions: Following the implementation of an evidence-based SSI quality improvement project, cancer patients had fewer SSI, hospital readmissions, and wound dehiscence. High ECOG scores, supracervical hysterectomies, and obesity were all associated with worse postoperative outcomes. Prospective studies on postoperative surgical quality are needed to improve care for our most vulnerable patients.

Standardized Venous Access Assessment and Safe Chemotherapy Administration to Reduce Adverse Venous Events.

Staff of the ambulatory infusion clinic at a Magnet-designated academic medical center observed the rates of adverse venous events, including infiltration and extravasation. An evidence-based quality improvement project was d.

Impact Evaluation of a Resident-Driven Research Training Workshop in Idaho: A Feasibility Study.

Engagement in research activities is a critical component of clinical residency training. It is vital to build research capacity of residents to help interpret evidence-based medicine and design quality improvement projects. A mixed methods study was conducted to assess the impact of a 1-day research training workshop conducted at Eastern Idaho Regional Medical Centre, Idaho in May 2022. The workshop was targeted to improve the research knowledge of current clinical residents of Internal Medicine and Family Medicine. Workshop comprised of expert presentations, with assessment of difference in knowledge with a pretest and post-test. The sessions were organized around the core competencies of Institute of Medicine. Suggestions were also gathered from the audience. A pretest and post-test based on 13 questions was administered to the participants to assess change in research-related knowledge. Comments and suggestions of the participants were also recorded. Wilcoxon rank test was applied to determine statistical difference across each question and cumulative knowledge score. Conventional content analysis was applied to explore the comments and feedback. The mean score of participants improved across all 12 questions. Statistically significant results were observed for the questions about types of studies qualifying as qualitative research. The cumulative score of participants increased in the post-test from 8.57 to 9.35. The participants gained new knowledge (94.3%), and felt more comfortable in application of research methods (74.3%). Encouraging feedback was obtained from the audience. They stated that they had benefited from the workshop and felt more prepared and motivated to indulge in scholarly activities. The study shows improvement in research-related knowledge of clinical residents attending a 1-day training workshop. We recommend inclusion of such workshops in the curriculum of residents for skill building and enhanced indulgence in research activities in order to prepare them as future leaders in quality improvement, health policy, and hospital administration.

Strategies for successfully completing a DNP final project.

Completion of a final project is an essential component of Doctor of Nursing Practice programs. Strategies for successful project planning, implementation, and evaluation are outlined, from identifying an evidence-based practice or quality improvement project, advisor, and practice mentor through completion, presentation, and dissemination of your work.

An Evidence-Based Industry-Standard Departmental Quality Improvement Project to Improve Customer Service – the Net Promoter Score

<h3>Purpose/Objective(s)</h3> In 2003, an article in the Harvard Business Review by Reichheld, et al, identified a simple single investigative question – "How likely is it that you would recommend [company X] to a friend or colleague?" – that best represented customer loyalty and would predict company growth. With a renewed interest in patient satisfaction, this survey has been adapted in the healthcare community, but there are no known publications describing its use in a radiation oncology clinic. <h3>Materials/Methods</h3> From April of 2019 through February of 2022, hard-copy forms were given to patients after CT simulation and at completion of therapy in a private room onsite. The question read, "How likely are you to refer patients who are friends or family to [Institution] Radiation Oncology?" If he or she agreed to answer the survey, the respondent used a Likert scale from 0 to 10 (least to most likely) and added comments in a free-text section. Responses with a 0 to 10 score were logged with no identifying information and were classified as "promoters" (9 to 10) or "detractors" (0 to 6); a monthly Net Promoter Score was calculated by dividing the number of "promoters" by the sum of "promoters" and "detractors." Comments, if available, were additionally transcribed. The scores and comments were shared with the department once weekly in morning huddle. <h3>Results</h3> Patients filled out 1318 forms (62%). Monthly Net Promoter scores ranged from 94.44 to 100. The average response was 9.74 with marks of 9.76, 9.74, 9.75, and 10.00 for 2019, 2020, 2021, and 2022, respectively. In 2019 and 2020, replies were separated by timepoints of CT simulation (9.73 and 9.71) and after radiotherapy (9.75 and 9.78). During this timeframe, comments were further analyzed by qualitative analysis and were classified into "staff appreciation," "patient feelings/treatment," "wait times," "respect," and "communication." <h3>Conclusion</h3> The Net Promotor Score is an available tool to get immediate feedback from patients, allowing rapid service recovery, if needed. In our department, scores were consistently favorable with little difference through the COVID-19 pandemic, and patients noted that they were appreciated, felt respected, and experienced short wait times.

Prevent postoperative urinary retention in day surgery adult patients: evidence-based quality improvement project.

Postoperative urinary retention (POUR) is a complication that often leads to adverse outcomes and prolonged hospital stay if treatment is delayed. The aim of this project was to improve the competence of nurses in the provision of preoperative POUR education and ensure all patients received preoperative POUR education, and hence reduce the incidence of POUR. The evidence-based quality improvement project utilized JBI's Practical Application of Clinical Evidence System and Getting Research into Practice module, adopting two POUR best practice recommendations and two audit criteria. The first criterion was for nurses to conduct preoperative education on POUR and the second criterion was to initiate early ambulation of postoperative patients. The project was implemented in three phases from June 2019 to August 2020 in short-stayer and day surgery wards. Criteria 1 and 2 revealed low compliance of 0 and 30%, respectively, during preimplementation audit. There were significant improvements in the first and second cycles of postimplementation audit for both criteria 1 and 2. Our results indicated that most of the patients who were ambulated early were able to void urine. However, there were a few incidents of urinary retention reported despite early ambulation. Following the audit of the third cycle of postimplementation, the compliance for both criteria were found to be satisfactory (criteria 1: 87%, criteria 2: 82%). The implementation of the evidence-based quality improvement project reduced the incidence of POUR. A standardized management would enable nurses to provide consistency in care and effective management and hence prevent the occurrence of POUR.

Increasing Awareness on Substance Use Disorder.

There is a lack of substance use disorder (SUD) providers in the micropolitan Midwestern state. Individuals who live in rural areas with SUD may have a gap in treatment for their addiction. The objective of this quality improvement project was to increase the engagement, participation, and awareness of rural primary care providers in treatment of individuals with SUD. This is a quality improvement project that utilized a skip-logic standardized survey to evaluate participants who attended Project ECHO (Extension for Community Healthcare Outcomes) Addiction educational sessions. Findings included 176 participants over 14 sessions, while reaching primary care providers in 62 clinics over a 7-month period. However, it was found that only half of those participants completed the survey. A variety of topics surrounding SUD were offered. In addition, each session included a case study with feedback provided by the team. Seventy participants (79%) rated "strongly agree" and "agree" to "I will make changes to my practice." Participants provided feedback as to how they would change their practice after an educational session; responses included adapting how naltrexone is prescribed based on the recommendations made during the presentation, update treatment guidelines, screen for adverse childhood experiences, utilize motivational interviewing, feeling more confident in providing medication-assisted treatment for patients, and finally, better able to manage pain in those with SUD. Project ECHO Addiction is an evidence-based translational quality improvement project that reaches rural primary care providers to help increase awareness, engagement, and networking in treatment of patients with SUD, which in turn improves patient outcomes as they receive treatment in a timely fashion.

Impacting Outcomes in the Hospitalized Oncology Patient: Evidence-Informed Quality and Safety Project to Implement Routine Screening for Delirium

Background: Delirium can occur in cancer patients during an acute hospitalization or in the terminal stages of cancer. Iatrogenic delirium can complicate hospital stays for over 2.6 million older persons by increasing fall risk, restraint use, length of stay, postacute placement, and costs. The purpose of this evidence-based quality improvement project was to implement routine screening for delirium with a consistent instrument and adopt an interprofessional plan of care for delirium. Methods: This project was identified as an interprofessional improvement initiative. The project leader identified a deficiency in the screening for delirium, convened stakeholders, evaluated evidence, reviewed screening instruments, and developed a plan of care for delirium management. Practice changes incorporated routine delirium screening across the inpatient units. A delirium interprofessional plan of care was integrated into the electronic health record for ease of adoption and workflow modification. Results: Routine screening for delirium and early interprofessional interventions reduced length of stay by 2.27 days for patients screening positive for delirium. The percentage of inpatient falls that were linked to an episode of delirium during hospitalization reduced from 23.4% to 17%. Discussions: Routine screening and targeted interventions are a first step in prevention and identification of those inpatients at risk of developing delirium. Delirium prevention is the goal for potential associated iatrogenic conditions.

Improving Developmental Positioning in a Level III NICU Using Evidence-Based Teaching and a Standardized Tool: An Evidence-Based Quality Improvement Project.

Positioning and handling is a core measure of developmental care that has been universally difficult to implement in the technical NICU environment. Appropriate positioning has been shown to not only improve postural and musculoskeletal outcomes, but enhance sensory development, physiologic stability, thermal regulation, behavioral organization, sleep facilitation, and brain development. In order to improve the developmental positioning practices of bedside nurses in a level III neonatal intensive care unit, a quality improvement project was initiated. Guided by the Iowa Model for Evidence-Based Practice, this project included an evidence-based educational intervention and a standardized positioning assessment tool. After the intervention, there was improvement in knowledge scores, and positioning scores increased from an average of 8.81 +/- 0.19 to 10.93 +/- 0.15.

Managers' and Leaders' Perceptions of Sexual and Gender-Based Public Harassment in the Veterans Health Administration.

Managers and leaders have a critical role to play in sexual and gender-based harassment prevention within organizations. Although the Veterans Health Administration has committed to eliminating harassment through national directives and training programs, it is unclear how aware local-level managers and leaders are about public harassment at their facilities and how they perceive sexual and gender-based harassment. We examined middle managers' and leaders' views about whether harassment is perceived as a problem locally, and what policies and procedures (if any) are in place to address public harassment. We conducted 69 semistructured telephone interviews with middle managers and facility leaders before implementation of an evidence-based quality improvement project designed to improve delivery of comprehensive women's health care. Transcripts were coded using the constant comparative method and analyzed for overarching themes. Perceptions of the prevalence of sexual and gender-based public harassment varied among middle managers and leaders. A little more than one-half of respondents were unaware of facility-level policies and procedures to address public harassment between patients. To decrease patient-to-patient harassment, both groups generally supported the creation of separate clinical spaces for women. However, middle managers also stated that education was needed to change patient harassing behavior, which they tied to male military culture. Aligning divergent perspectives of what constitutes sexual and gender-based harassment and how to address it is a necessary step towards tackling harassment at the local level. Managers and leaders should continue to assess environments of care and share findings widely among employees and leadership to improve awareness and inform a unified response.