Chrystal Leigh Lewis

All Publications

• Registered Nurse-Led Visits in Ambulatory Specialty Care Clinic: Implementation Process Review. Nursing administration quarterly Lewis, C. L., Bell-Stephens, T., Vavao, J., Platon, C. G., Steinberg, G. K. 2025; 49 (4): 304-312

  Abstract

  Registered Nurse (RN)-led visits are increasingly utilized in ambulatory care. However, little information is available about implementation and sustainability for RN-led visits. Patients experienced difficulties accessing care in an ambulatory neurosurgery specialty care clinic. This article presents the implementation process and sustained success of RN-led visits over more than a 25-year time span in this neurosurgery specialty ambulatory care clinic. The number of operating room (OR) cases by a single neurosurgeon was increased by an average of 95 cases per year over a 5-year implementation time frame, growing from an average of 211 cases per year (2000-2004) to 306 (2005-2009), and sustained at this average with 309 cases in the 2020-2024 period. The sustained increased OR caseload over a 20-year time-period suggests RN-led visits can be an effective strategy to promote the entire ambulatory care team working at the top of their scope of practice. Further research is needed on economic impacts of RN-led visits, patient access wait times, and team satisfaction.

  View details for DOI 10.1097/NAQ.0000000000000707

  View details for PubMedID 40876051

• ANEW LENSfor Addressing Workplace Violence: Trauma Informed Care as an Approach to Management. Journal of the American Psychiatric Nurses Association Brewer, K. C., Lewis, C. L. 2025: 10783903251346891

  Abstract

  OBJECTIVE: To explore an innovative model for nursing administration practice in which a trauma-informed care approach is applied to staff and personnel management. This model is applicable especially for preventing workplace violence and managing its aftermath in psychiatric care facilities.METHODS: This discussion article presents a conceptual model for practice called NEW LENS (Nurses who Experience Workplace violence, Leadership to meet Expectations and NeedS), which is based on the BITTEN trauma-informed care framework. A model case exemplar is used to illustrate current nursing administration practices and to contrast them with a trauma-informed care approach to staff and personnel management.RESULTS: The model case exemplar highlights how the implementation of a trauma-informed care approach for nurses and staff could potentially impact the psychiatric work environment. Additionally, the model case exemplar suggests current administrative approaches may not adequately address the cumulative effects of workplace and personal trauma on staff responses to violence.CONCLUSIONS: There is a need for further research on trauma-informed care in psychiatric nursing. Specifically, systematic exploration is required to understand how trauma-informed care strategies in nursing administration can address the intersection of workplace and personal trauma and improve staff resilience and safety.

  View details for DOI 10.1177/10783903251346891

  View details for PubMedID 40515457

• Young adults' expectations for healthcare following institutional betrayal. Journal of trauma & dissociation : the official journal of the International Society for the Study of Dissociation (ISSD) Gigler, M. E., Lathan, E. C., Cardarelli, O., Lewis, C. L., McCabe, S., Langhinrichsen-Rohling, J. 2024; 25 (3): 299-314

  Abstract

  Healthcare-related institutional betrayal has been used to examine how patients' previous negative healthcare experiences influence their current provider-level trust and future interactions with the healthcare system. However, healthcare-related institutional betrayal has rarely been considered among emerging independent users of the healthcare system: college students. Moreover, it is unknown whether healthcare-related institutional betrayal is associated with future healthcare expectations among this population. Using a trauma-informed framework, this study examined the relations among self-reported experiences of healthcare-related institutional betrayal, trust in healthcare providers, and subsequent expectations for healthcare among college students (n = 967). Analyses considered whether greater past healthcare-related institutional betrayal during one's worst healthcare experience predicts i) lower current trust in healthcare providers and ii) greater negative expectations for future healthcare above and beyond trauma symptoms and the perceived severity of participants' worst healthcare experiences. Sixty-nine percent of participants endorsed having experienced at least one act of institutional betrayal, the most common being the institution not taking proactive steps to prevent unpleasant healthcare experiences (28.5%). As predicted theoretically, greater experiences of institutional betrayal accounted for 16% of the variance in current trust in healthcare providers, even after accounting for trauma symptoms and the severity of the worst healthcare experience. Greater endorsement of institutional betrayal experiences were also significantly associated with negative expectations for future healthcare. Given the youthfulness of the sample, it is noteworthy that 41.4% of participants endorsed at least one negative expectation for future healthcare. Future research should examine how negative expectations are related to healthcare avoidance behaviors.

  View details for DOI 10.1080/15299732.2022.2120151

  View details for PubMedID 36073011

• Health equity: A concept analysis. Nursing outlook Lewis, C. L., Yan, A., Williams, M. Y., Apen, L. V., Crawford, C. L., Morse, L., Valdez, A. M., Alexander, G. R., Grant, E., Valderama-Wallace, C., Beatty, D. 2023; 71 (5): 102032

  Abstract

  Although health equity is critically important for healthcare delivery, there are inconsistencies in its definitions or lack of definitions.Develop a comprehensive understanding of health equity to guide nursing practice and healthcare policy.Walker and Avant's concept analysis method was used to establish defining attributes, antecedents, consequences, and empirical referents of health equity.Health equity defining attributes are grounded in ethical principles, the absence of unfair and avoidable differences, and fair and just opportunities to attain a person's full health potential. Health equity antecedents are categorized into environmental; financial or economic; law, politics, and policy; societal and structural; research; and digital and technology.Health equity's antecedents are useful to distinguish health disparities from health outcomes resulting from individual preferences. To achieve health equity, organizations need to focus on addressing the antecedents.

  View details for DOI 10.1016/j.outlook.2023.102032

  View details for PubMedID 37683597

• They've been BITTEN: reports of institutional and provider betrayal and links with Ehlers-Danlos Syndrome patients' current symptoms, unmet needs and healthcare expectations. Therapeutic advances in rare disease Langhinrichsen-Rohling, J., Lewis, C. L., McCabe, S., Lathan, E. C., Agnew, G. A., Selwyn, C. N., Gigler, M. E. 2021; 2: 26330040211022033

  Abstract

  Patients with rare and/or care-intensive conditions, such as Ehlers-Danlos Syndrome (EDS), can pose challenges to their healthcare providers (HCPs). The current study used the BITTEN framework1 to code EDS patients' open-ended written responses to a needs survey to determine their self-reported prevalence of healthcare institutional betrayal and its link with their expressed symptoms, provider perceptions, unmet needs, and on-going healthcare-related expectations.Patients with EDS (n = 234) were recruited via a rare disease electronic mailing list and snowball sampling. A total of one-hundred and six respondents (45.3%) endorsed having unmet healthcare-related needs; of these, 104 (99%) completed an open-ended prompt about these needs. Responses were coded for components of BITTEN, a framework designed to link patients' past, current, and future healthcare-related experiences in a trauma informed manner.Many respondents with ongoing needs endorsed experiencing past institutional and provider betrayal (43%; n = 45), current mental health symptoms (91.4%; n = 95), negative expectations for future healthcare (40.4%; n = 62), and a lack of trust in their healthcare provider (22.1%; n = 23). There were no significant differences in post-traumatic stress disorder (PTSD)/anxiety, depression/sadness, or isolative symptoms between respondents coded for institutional betrayal (n = 45) compared with those not (n = 59). However, EDS respondents reporting institutional betrayal were significantly more likely to self-report anger and irritability symptoms, a lack of trust in their HCPs, and more negative expectations for future healthcare than those not reporting institutional betrayal.The frequent spontaneous reporting of past healthcare betrayals among patients with EDS implies the need for trauma-informed care and provider education. Given that experiences of institutional betrayal are associated with increased anger and irritability, as well as with negative expectations for future healthcare interactions, efforts to repair healthcare provider and system-wide relationship ruptures might have positive healthcare consequences.Reports of Institutional and Provider Betrayal and Links with Ehlers-Danlos Syndrome Patients' Current Symptoms, Unmet Needs and Future Healthcare Expectations What is EDS? Ehlers-Danlos Syndrome (EDS) refers to a group of rare genetic connective tissue disorders that are primarily characterized by skin hyperelasticity, joint hypermobility, and tissue fragility. Connective tissue is largely responsible for the structural integrity of our bodies, and there are several EDS subtypes which each describe a specific connective tissue problem. In addition, there is significant overlap between EDS types and other kinds of connective tissue disorders. As a result, recognizing, diagnosing, and treating EDS is often challenging. What is Institutional betrayal? Institutional Betrayal here refers to a harmful action (i.e. commission) or lack of action (i.e. omission) on the part of a healthcare institution, individual provider/healthcare team, or insurance company. When a patient trusts that the healthcare system will act in their best interest, and trust is violated, institutional betrayal occurs. What is BITTEN? BITTEN is an acronym for Betrayal, Indicator, Trauma symptoms, Trust, Expectations, and Needs. It is a framework meant to capture previous problematic healthcare-related experiences in EDS patients, then to consider how those experiences influence a patient's current symptoms, provider trust, future expectations in healthcare encounters, and on-going needs. Why was this done? EDS, like many rare diseases, is hard to recognize and manage. We aim to:Give voice to EDS patients and their common unmet needs and healthcare-related expectations.Highlight how healthcare providers can apply BITTEN to improve care practices in rare disease patient encounters. What did we do? Using a newly articulated applied model of healthcare, BITTEN, we analyzed the open-ended responses of EDS patients describing their unmet emotional and mental health needs. What did we find? Nearly half of EDS patients who indicated they had unmet needs reported experiencing institutional betrayal.EDS patients who reported institutional betrayal also expressed anger, a lack of trust in healthcare providers, negative expectations for future healthcare, and more unmet needs more frequently than EDS patients who did not report institutional betrayal. What does this mean? The EDS patients in this sample were not directly asked if they had experienced institutional betrayal, so the exact prevalence is not known. Furthermore, responses were obtained voluntarily via the internet, so caution should be taken when generalizing these findings.However, results indicate that too many patients with EDS have experienced healthcare betrayals; these experiences are associated with current anger and negative expectations for future healthcare interactions.The prevalence of past negative healthcare experiences, along with current unmet needs and future negative healthcare expectations in EDS patients who have experienced institutional betrayal, highlights the need for healthcare providers to tend to these experiences, mend patient-provider barriers, and provide higher quality healthcare.

  View details for DOI 10.1177/26330040211022033

  View details for PubMedID 37181101

  View details for PubMedCentralID PMC10032464

• BITTEN at the Bedside: An Application Guide for Nurse Practitioners JNP-JOURNAL FOR NURSE PRACTITIONERS Lewis, C. L., Lathan, E. C., Selwyn, C. N., Agnew, G. A., McCabe, S. D., Gigler, M. E., Langhinrichsen-Rohling, J. 2021; 17 (6): 691-696

  View details for DOI 10.1016/j.nurpra.2020.12.006

  View details for Web of Science ID 000660121400014

• Dealing with "Difficult" Patients and Families: Making a Case for Trauma-informed Care in the Intensive Care Unit. Annals of the American Thoracic Society Ashana, D. C., Lewis, C., Hart, J. L. 2020; 17 (5): 541-544

  View details for DOI 10.1513/AnnalsATS.201909-700IP

  View details for PubMedID 31944818

  View details for PubMedCentralID PMC7193814

• Emergency care: Operationalizing the practice through a concept analysis. Journal of the American Association of Nurse Practitioners Davis, W. D., Dowling Evans, D., Fiebig, W., Lewis, C. L. 2020; 32 (5): 359-366

  Abstract

  Current uses of emergency care are ambiguous and lack clarity, leading to imprecise use of the term in nursing practice. An explicit definition of emergency care is necessary to build and advance the field. An empirically driven definition of emergency care is lacking in the refereed literature. The purpose of this article was to present an in-depth inquiry of emergency care that contributes to the advancement of knowledge and to articulate a defensible definition of emergency care.This concept analysis was performed using the eight-step approach of Walker and Avant. A database search within the disciplines of nursing, medicine, education, and social sciences was conducted using the keyword emergency care. Databases of refereed literature were reviewed. Additional searches of nonrefereed literature, such as dictionaries and thesauri, were also examined.Based on this concept analysis, the attributes of emergency care include the immediate evaluation and treatment of an unexpected illness or injury. Emergency care is not specific to a setting or location. Antecedents to emergency care consist of a precipitating event, recognition that medical help is required, and access to emergency care. A model, borderline, related, and contrary cases of emergency care are presented.The identification of emergency care attributes in this concept analysis contributes to the body of knowledge in emergency care and clarifies the ambiguity of the concept to prompt developments in practice, theory, and research with implications for emergency nurse practitioner clinical education, and scope of practice regulation.

  View details for DOI 10.1097/JXX.0000000000000229

  View details for PubMedID 31274679

• Using Team-Based Learning to Teach Human Subjects Research Ethics. Medical science educator Lewis, C. L., Estis, J. M. 2020; 30 (1): 617-620

  Abstract

  For health sciences students, understanding human subjects research ethics is essential for providing equitable healthcare. Active learning approaches were needed to engage students with the content and support transfer of knowledge to clinical practice.A team-based learning (TBL) module was developed and implemented in an evidence-based practice undergraduate nursing course across 3 semesters with 169 students to promote understanding and application of research ethics principles.Thematic analysis of student reflections showed five themes: change in attitude, learning/understanding, application of ethical principles, specific terminology, and specific examples. Faculty facilitators reported increased engagement, understanding, and application.

  View details for DOI 10.1007/s40670-019-00846-7

  View details for PubMedID 34457713

  View details for PubMedCentralID PMC8368337

• Once BITTEN, Twice Shy: An Applied Trauma-Informed Healthcare Model. Nursing science quarterly Lewis, C. L., Langhinrichsen-Rohling, J., Selwyn, C. N., Lathan, E. C. 2019; 32 (4): 291-298

  Abstract

  Nurses need a pragmatic theory to understand and respond to the impact of vulnerable patients' previous healthcare experiences, as these are likely to influence response and adherence to treatment plans. The authors of this paper present the new BITTEN (Betrayal history by health-related institutions, Indicator for healthcare engagement, Traumas related to healthcare, Trust in healthcare providers, patient Expectations and Needs) Model of Trauma-Informed Healthcare. BITTEN identifies patients' current healthcare expectations and needs as a function of their previous betrayal by healthcare systems, which operates in conjunction with their current health indicators to potentially trigger trauma symptoms and impact trust in healthcare providers.

  View details for DOI 10.1177/0894318419864344

  View details for PubMedID 31514618

• GROWTH: A Strategy for Nursing Student Retention. The Journal of nursing education Lewis, C. L., Swanzy, D. M., Lynch, C. M., Dearmon, V. A. 2019; 58 (3): 173-177

  Abstract

  Faculty focused on student success may look for opportunities to facilitate nursing student retention. Students commonly struggle with study skills, time management, and critical thinking in the nursing curriculum. This article presents the GROWTH (Growth, Readiness, Opportunity, Work, Time management, and Habits) form, an open-ended question form aimed at the identification of affective, environment, and psychosocial variables known to impede nursing student success.Faculty used the GROWTH form when meeting with students in the beginning of the prelicensure program.Using the GROWTH form facilitates structured, focused faculty-student meetings and individualized action plans for students who are not achieving their desired level of academic performance. The GROWTH form also encourages students to take ownership of their own learning.Using the GROWTH form facilitates faculty-student meetings and encourages student self-reflection. Future research should investigate whether use of the GROWTH form has further implications for program progression and retention. [J Nurs Educ. 2019;58(3):173-177.].

  View details for DOI 10.3928/01484834-20190221-09

  View details for PubMedID 30835806

• The Shared Emotional Themes of Illness and Anaphylaxis: An Application With Relevance for Medical Family Therapy FAMILY JOURNAL Taylor, J. Z., Lewis, C. L. 2018; 26 (2): 208-216

  View details for DOI 10.1177/1066480718777410

  View details for Web of Science ID 000439113800011

• Impact of prior ICU experience on ICU patient family members' psychological distress: A descriptive study. Intensive & critical care nursing Lewis, C. L., Taylor, J. Z. 2017; 43: 129-135

  Abstract

  To determine if current levels of anxiety, depression and acute stress disorder symptoms differ significantly among family members of intensive-care-unit patients depending upon previous intensive-care experience.This study used a prospective, descriptive study design.Family members (N=127) from patients admitted within a 72-hour timeframe to the medical, surgical, cardiac and neurological intensive care units were recruited from waiting rooms at a medium-sized community hospital in the Southeastern United States.Participants completed the Hospital Anxiety and Depression Scale, the Impact of Events Scale-Revised, the Acute Stress Disorder Scale and a demographic questionnaire.A multivariate analysis revealed that family members of intensive-care-unit patients with a prior intensive-care experience within the past two years (n=56) were significantly more likely to report anxiety, depression and acute stress symptoms, Λ=0.92, F [4122]=2.70, p=0.034, partial η2=0.08, observed power=0.74.Results of this study show that family members' psychological distress is higher with previous familial or personal intensive-care experience. Nurses need to assess for psychological distress in ICU family members and identify those who could benefit from additional support services provided in collaboration with multidisciplinary support professionals.

  View details for DOI 10.1016/j.iccn.2017.09.008

  View details for PubMedID 29033252

• Implementing an Alcohol Withdrawal Protocol: A Quality Improvement Project. Journal of nursing care quality Holt, C., Dearmon, V., Lawrence, S. M., Lewis, C. L., Skotzko, C. E. 2017; 32 (3): 234-241

  Abstract

  This quality improvement project evaluates the effectiveness of implementing an evidence-based alcohol withdrawal protocol in an acute care setting. Patient outcomes, length of stay, and nurses' knowledge and satisfaction with care are compared pre- and postimplementation. Implementation resulted in significant reduction of restraint use, transfers to critical care, 1:1 observation, and length of stay, whereas no reduction was seen in rapid response calls. Nurses' knowledge post-alcohol withdrawal protocol education increased and satisfaction with patient care improved.

  View details for DOI 10.1097/NCQ.0000000000000231

  View details for PubMedID 27787460