Doctor of Nursing Practice (DNP) Final Projects

Current obesity statistics exceed national goals with Hispanics disproportionately affected. Evidence suggests a family centered methodology focusing on culture can positively improve weight loss, client satisfaction and participation. This project will evaluate use of culturally tailored resources for primary care providers to educate Hispanics on weight loss. Eight providers in a small practice in the Southwestern US were recruited to complete a pre- and postEBPAS tool after an educational session. A BMI form tracked provider use of the fotonovela intervention against preferred methods.

Feedback on time spent educating and overall perception were collected. Four providers completed the pre-EBPAS, three completed the post-, one participated in the intervention, and six contributed project feedback. Descriptive statistics revealed an aggregate provider decrease of five-points post-educational session for attitude toward adopting EBP. The BMI documentation form demonstrated a 53% (n = 8) use of the fotonovela. However, there were five undocumented fotonovelas taken/given out postintervention. Key themes noted by providers included poor timing of the project, satisfaction with workflow and resources, and overall discontent for the fotonovela. Future implications include re-evaluating the project in a practice not undergoing significant changes with specific focus on timing of the intervention.

Maintaining good oral health during pregnancy is a significant contributor to healthy pregnancy outcomes. The physiological changes that happen during pregnancy can adversely affect women’s oral health and place her at risk for pregnancy outcomes such as miscarriage and preeclampsia. The unborn child’s health can also be affected by premature birth and low birth weight. Although professional organizations have evidence-based practice guidelines for both prenatal and dental providers, the evidence shows a gap between recommendations and practice. An oral health promotion project for pregnant women was implemented in a federally qualified community health center where there was a lack of adherence to the guidelines.

The purpose of this project was to implement established oral health screening guidelines for pregnant women and to increase dental visits among pregnant women. For this project, a two-item maternal oral health-screening tool (MOS) for the prenatal providers was added into the electronic health record to standardize and document oral health screening for pregnant women at their first prenatal visit. After three months of implementation, there was a significant increase in maternal oral health screening and referral. This project may be replicated at any prenatal setting to improve oral health during pregnancy.

Background: 
Approximately 1 in 5 U.S. school-aged children are obese. There are many known health complications associated with obesity including premature death. Family-based obesity interventions that promote healthy lifestyle habits are effective at enabling children to make changes needed to avoid long-term health complications associated with obesity. The purpose of this evidence-based practice intervention was to evaluate the effectiveness of a family-based obesity intervention on familial lifestyle behaviors related to nutrition, physical activity, and screen time.

Methods:
Two overweight-obese children (according to CDC criteria) ages 8-12 years old visiting a pediatric primary care clinic in a suburban neighborhood located in the southwest region were recruited to participate in this evidence-based practice intervention based on inclusion and exclusion criteria. Familial lifestyle behaviors were assessed using the Family Health Behavior Scale (FHBS) prior to receiving an educational intervention addressing nutritional, physical activity, and screen time recommendations and again after following these recommendation for 6-weeks. Additionally, scheduled follow-up phone calls were made every 3 or 6-weeks addressing any parental questions that surfaced. Data was insufficient for statistical analysis, however, anecdotal recommendations for future implementation of this intervention resulted.

Results:
Of the two patients who participated, pre- and post-intervention data was only attainable from one patient. That patient did have improved scores within each of the 4 FHBS subscales (parent behaviors, physical activity, mealtime routines, and child behaviors). Overall, 11 of the 27 behaviors assessed improved, 12 behaviors resulted in no change, and 4 behaviors worsened. Recommendations related to a more successful implementation of this intervention in the future include improved provider participation (buy-in), utilization of broader inclusion criteria, consideration of the implementation time-frame, and application of the Health Belief Model for addressing existing barriers for each patient prior to implementing the intervention.

Conclusions:
In order to determine the effectiveness of this intervention a larger sample size and completed post-intervention data are needed. The small sample size and lack of post-intervention data inhibits proper data analyzation and significance from being determined.

Pregnancy is a specific time in a woman’s life filled with complex changes in health, including the oral cavity. During this time, dental and perinatal care teams can be influential in helping women initiate and maintain essential habits to improve health and prevent adverse outcomes. There is research evidence that dental providers are reluctant to treat dental problems during pregnancy. Barriers to practice identified by dentists include lack of education, time, financial constraints, and concern for the safety treating pregnant women. Factors that facilitate dental care for pregnant women include purposeful assessment, referrals from prenatal providers, and continuing education for dental team members.

Multiple organizations recommend the treatment of oral health conditions during pregnancy to promote health and prevent pregnancy complications. In order to promote community-based partnerships in a healthcare system, dentists are encouraged to develop an intentional plan to increase collaboration with other members of the women’s healthcare team. Prior to developing a system wide intervention to improve access to dental care during pregnancy, dental team members were surveyed to identify barriers and facilitators which promote or hinder care in their practice. The data acquired will be used to inform the design and implementation of an intervention to specifically meet the needs of patients and providers in that system.

Homeless individuals encounter barriers such as lack of health insurance, increased cost of care and unavailability of resources. They have increased risk of comorbid physical disease and poor mental health. Depression is a prevalent mental health disorder in the US linked to increased risk of mortality. Literature suggests depression screening can identify high-risk individuals with using the patient health questionnaire (PHQ-9).

The objective of this project is to determine if screening identifies depression in the homeless and how it impacts healthcare access. Setting is a local organization in Phoenix offering shelter to homeless individuals. An evidence-based project was implemented over two months in 2019 using convenience sampling. Intervention included depression screening using the PHQ-9, referring to primary care and tracking appointment times. IRB approval obtained from Arizona State University, privacy discussed, and consent obtained prior to data collection. Participants were assigned a random number to protect privacy.

A chart audit tool was used to obtain sociodemographics and insurance status. Descriptive statistics used and analyzed using Intellectus. Sample size was (n = 18), age (M = 35) most were White-non-Hispanic, 44% had a high school diploma and 78% were insured. Mean score was 7.72, three were previously diagnosed and not referred. Three were referred with a turnaround appointment time of one, two and seven days respectively. No significant correlation found between age and depression severity. A significant correlation found between previous diagnosis and depression severity. Attention to PHQ-9 varied among providers and not always addressed. Future projects should focus on improving collaboration between this facility and providers, increasing screening and ensuring adequate follow up and treatment.

The chronic nature of substance use disorder requires continuity of care after residential treatment. Only a small proportion of patients, however, adhere to aftercare follow-up plans and the relapse rates remain between 40- 80% within a year post-discharge. Synthesis of evidence showed that facilitated referral (FR) significantly increased follow- up adherence and resulted to positive outcomes. The study aimed to examine the effectiveness of FR in improving access, follow-up adherence and engagement to aftercare services, and relapse rate after a month post- discharge.

After the Institutional Review Board approval, 30 participants were recruited in two residential treatment facilities. Questionnaires, the Assessment of Warning Signs of Relapse and Health leads surveys were utilized to collect data. Data were analyzed using descriptive statistics, McNemar, and Wilcoxon signed rank tests. Results showed that FR significantly increased access to many community aftercare services (p<.05). A significant reduction in relapse risk post-intervention was also noted (Z= -3.180, p= .001). Additionally, most participants discharged with scheduled appointments followed-up and had continued engagement with aftercare services. Eight participants maintained sobriety and 18 were lost to follow-up a month post-discharge, while four relapsed in the facility.

Overall, FR increased access to needed aftercare services and significantly decreased the relapse percentage risk post-discharge. FR is a promising intervention that can be implemented for practice. Future research is recommended to further examine the correlation with follow-up adherence and continuous engagement to aftercare services, and relapse rate at 30 days after discharge.