Doctor of Nursing Practice (DNP) Final Projects

The human papillomavirus (HPV) is a sexually transmitted infection (STI) that is associated with several types of cancer and genital warts. No cure exists for those currently infected with HPV, but a vaccine is available that can prevent the virus and development of cancers associated with HPV. Military servicemembers are at a high risk for contracting HPV; it is one of the most common STIs among active duty service members. The health consequences of HPV can impact a servicemember’s military readiness. The HPV vaccine is not required for military servicemembers, but it is offered free of charge. HPV vaccination rates among military service members remain relatively low.

The purpose of this evidence-based project was to increase the level of knowledge about HPV, improve health beliefs regarding HPV, increase HPV vaccine intention, recommendation, and uptake. Using the Health Belief Model as an organizing framework, a population targeted eight-minute education video on HPV and HPV vaccination was developed. It was implemented at an outpatient military treatment facility located in the southwest United States over a 6-week period, to newly reported service members. Participants included 116 military service members aged 18 to 45. A pretest and posttest questionnaire were used to assess the impact of the intervention. HPV level of knowledge increased significantly from pretest to posttest mean scores were 3.00 to 4.39 respectively (p < .001). HPV vaccine intention increased from 62% to 66% (p = .739). HPV vaccine recommendation increased from 62% to 85% (p < .001).

Purpose: Assess provider perceptions on care coordination, collaboration, teamwork, and shared decision-making practices pre and post a brief educational intervention on interprofessional collaboration (IPC).

Background and significance: A lack of care coordination and active follow up in the outpatient setting of individuals living with mental illness places this population at high risk for developing various comorbidities. Care coordination across care providers and patients in a IPC, patient-centered treatment model of care is an intervention that can reduce this barrier to care.

Methods: At a behavioral health clinic in the southwestern United States (U.S.) twenty-two participants were assessed via the Collaborative Practice Assessment Tool (CPAT), before and after an educational presentation on IPC care. The CPAT is a tool that was developed to assess collaborative practice within teams and help identify needs for professional development.

Results: Statistical significance was found from pretest to posttest scores (t(21) = -1.936, p = .066). Statistical significance was found in two of the eight domains; mission, meaningful purpose, and goals (p = .009) and decision-making and conflict management (p = .058). Increases in posttest scores were seen in all eight domains.

Conclusions: Training behavioral health professionals in IPC practice and teambuilding may facilitate improved clinical team experiences and communication. Behavioral health professionals treating individuals living with serious mental illness (SMI), IPC training could prepare providers to work more effectively and efficiently in the delivery of patient-centered care in this population with complex health care needs.

The human papillomavirus (HPV) is the most commonly spread sexually transmitted infection in the United States. Although the HPV vaccine protects against transmission of the most common strains of HPV that cause genital warts and numerous urogenital cancers, uptake in the United States remains suboptimal. Failure to vaccinate leaves individuals vulnerable to the virus and subsequent complications of transmission. The evidence demonstrates that provider recommendation alone increases rates of vaccine uptake. The literature does not suggest a specific method for provider recommendation delivery; however, best practice alerts (BPAs) were correlated with increased vaccination rates.

These findings have directed a proposed project that includes an electronic health record (EHR) change prompting internal medicine, family practice and women’s health providers to educate and recommend the HPV vaccine at a Federally Qualified Health Center (FQHC) in the Southwest United States. The project demonstrates that after the implementation of a practice change of a HPV BPA in the EHR, HPV vaccination rates increased. Practice settings pre and post were similar, making the increase clinically significant.

The strengths of this project include an increase in HPV vaccination rates, a sustainable intervention, and an intervention that can easily be replicated into other health maintenance tasks. There were some limitations including the BPA alert only catching the HPV 9 vaccine series and the BPA did not always capturing historical data. Despite these technical barriers the HPV BPA delivered an increase in the HPV vaccine to protect more individuals from the HPV virus, increased provider adherence to national guidelines, and provides a platform for BPAs to be utilized for other vaccines.

Seclusion and restraint (SR) continue to be used in psychiatric settings when a patient is a harm to self or others despite growing concern and calls to eliminate the practice due to its harmful, potentially life-threatening effects on patients. The purpose of this evidence-based project was to assist a hospital in the southwestern United States decrease their seclusion and restraint rates among their adolescent patients. Trauma-informed care approaches have been shown to significantly reduce the incidence of SR in inpatient settings.

The nurses and behavioral health technicians (BHTs) received a two-hour trauma-informed care training in November of 2019. SR rates three months pre-training and post-training were compared. In the three months prior to the training, SR rates averaged 23.4 events per 1000 patient days. Comparatively, the three months after the training SR rates averaged 19.5 events per 1000 patient days. This shows a clinically significant decrease in SR rates after the TIC training. This evidence-based project (EBP) highlights the need to address this problem and gives an intervention option that can reduce harm for patients and address the needs of healthcare organizations seeking to improve patient care.

Human papillomavirus (HPV) is a prevalent sexually transmitted infection that affects many adolescents and adults worldwide. The consequences of contracting HPV have proven to be devastating, potentially leading to a variety of life-threatening genitourinary and oral cancers. As such, prevention via vaccination is critical. HPV vaccination is recommended for all adolescents beginning at 11 years of age. Although the immunization has proven to be safe and effective, HPV vaccination rates are substantially below target goals worldwide.

A literature review of evidence from the last five years was conducted to examine barriers and facilitators to HPV vaccine uptake. The most commonly cited barriers to vaccination included lack of knowledge about the vaccine and inadequate provider recommendation. Current evidence regarding interventions to increase HPV vaccine uptake reveal that best practices are multi-factorial and should include a combination of provider education and recommendation training. These findings led to the proposal of an evidence-based intervention aimed to increase adolescent HPV vaccination rates.

A one-hour educational program was conducted at a local pediatric primary care facility. Five healthcare providers participated in the program, which consisted of a PowerPoint presentation outlining the benefits of HPV vaccination and use of an interactive application from the CDC. The app taught participants how to offer a strong recommendation for the vaccine through active participation. Pre and posttests were administered to determine the providers’ intent to vaccinate and vaccination rates were monitored. Analysis of the data collected revealed a statistically significant rise in vaccination rates. These results reveal that provider education can improve recommendation techniques and therefore increase vaccine coverage. Further research is needed to see if one-time education is sustainable.

Introduction: Despite depression affecting one of every ten adolescents, primary care providers struggle to detect depression in affected individuals. Unmanaged early onset adolescent mood disorders have an increased potential to result in suicide, the second leading cause of death in adolescents. Referring all patients with a positive depression screen to a mental health specialist creates treatment delay and burdens already limited community resources.

Objective: The objective of this primary care practice transformation was to improve pediatric primary care provider confidence and behavior to support and deliver evidence-based behavioral healthcare for adolescents with mild to moderate depression.

Methods: An evidence-based adolescent depression education program was delivered to pediatric primary care providers in a small community setting. The program’s components included measures to identify and manage mild to moderate depression. Outcome measures included: 1. Provider knowledge, beliefs, and confidence measured pre- and post-intervention; and 2. Electronic health record documentation of provider adherence to guideline recommendations one, two, and three months post-intervention.

Results: Four providers participated in the intervention. The mean total score for the provider beliefs and knowledge from a 5-point Likert scale demonstrated a positive increase after the intervention (14.75 vs. 23.25, p = .068). The mean total provider confidence score achieved near significance as well (12.25 vs. 21.75, p = .066). Resultant behavior change in the providers did not reach statistical significance when the electronic health records of all adolescent well visits over a three-month period were assessed. Screening for depression at adolescent well visits
Adolescent Depression 3 increased from 0% to 84-90% post-intervention. Setting treatment goals upon detection of depression increased from 0% to 41% (p = .089). Providers appropriately administered active support 67% of the time when a patient was identified with mild depressive symptomology post-intervention. Providers complied with guideline recommendations with identified cases of moderate and severe depression (n = 2).

Conclusions: Pediatric primary care providers demonstrated some positive behavioral changes towards integrating behavioral healthcare into their practice after an educational session on the guidelines for adolescent depression.

Aim: To determine the change in provider’s compassion fatigue after implementing an education-based intervention in behavioral health.

Materials and Methods: A four-part education-based intervention for compassion fatigue was implemented over the course of 16 weeks. The Professional Quality of Life instrument was used to measure compassion fatigue and compassion satisfaction.

Results: Although not statistically significant, mean compassion fatigue scores decreased in the sample.

Conclusion: Based on these results, further exploration into the causative factors of compassion fatigue in behavioral health are recommended.

Background: The cost of substance use (SU) in the United States (U.S.) is estimated at $1.25 trillion annually. SU is a worldwide health concern, impacting physical and psychological health of those who use substances, their friends, family members, communities and nations. Screening, Brief Intervention (BI) and Referral to Treatment (SBIRT) provides an evidence-based (EB) framework to detect and treat SU. Evidence shows that mental health (MH) providers are not providing EB SU management. Federally grant-funded SBIRT demonstrated evidence of decreased SU and prevention of full disorders. Implementation outcomes in smaller-scale projects have included increased clinician knowledge, documentation and interdisciplinary teamwork.

Objective: To improve quality of care (QOC) for adolescents who use substances in the inpatient psychiatric setting by implementing EB SBIRT practices.

Methods: Research questions focused on whether the number of SBIRT notes documented (N=170 charts) increased and whether training of the interdisciplinary team (N=26 clinicians) increased SBIRT knowledge. Individualized interventions used existing processes, training and a new SBIRT Note template. An SBIRT knowledge survey was adapted from a similar study. A pre-and post-chart audit was conducted to show increase in SBIRT documentation. The rationale for the latter was not only for compliance, but also so that all team members can know the status of SBIRT services. Thus, increased interdisciplinary teamwork was an intentional, though indirect, outcome.

Results: A paired-samples t-test indicated clinician SBIRT knowledge significantly increased, with a large effect size. The results suggest that a short, 45-60-minute tailored education module can significantly increase clinician SBIRT knowledge. Auditing screening & BI notes both before and after the study period yielded important patient SU information and which types of SBIRT documentation increased post-implementation. The CRAFFT scores of the patients were quite high from a SU perspective, averaging over 3/6 both pre- and post-implementation, revealing over an 80% chance that the adolescent patient had a SU disorder. Most patients were positive for at least one substance (pre- = 47.1%; post- = 65.2%), with cannabis and alcohol being the most commonly used substances. Completed CRAFFT screenings increased from 62.5% to 72.7% of audited patients. Post-implementation, there were two types of BI notes: the preexisting Progress Note BI (PN BI) and the new Auto-Text BI (AT BI), part of the new SBIRT Note template introduced during implementation. The PN BIs not completed despite a positive screen increased from 79.6% to 83.7%. PN BIs increased 1%. The option for AT BI notes ameliorated this effect. Total BI notes completed for a patient positive for a substance increased from 20.4% to 32.6%, with 67.4% not receiving a documented BI. Total BIs completed for all patients was 21.2% post-implementation.

Conclusion: This project is scalable throughout the U.S. in MH settings and will provide crucial knowledge about positive and negative drivers in small-scale SBIRT implementations. The role of registered nurses (RNs), social workers and psychiatrists in providing SBIRT services as an interdisciplinary team will be enhanced. Likely conclusions are that short trainings can significantly increase clinician knowledge about SBIRT and compliance with standards. Consistent with prior evidence, significant management involvement, SBIRT champions, thought leaders and other consistent emphasis is necessary to continue improving SBIRT practice in the target setting.

Keywords: adolescents, teenagers, youth, alcohol, behavioral health, cannabis, crisis, documentation, drug use, epidemic, high-risk use, illicit drugs, implementation, mental health, opiates, opioid, pilot study, psychiatric inpatient hospital, quality improvement, SBIRT, Screening, Brief Intervention and Referral to Treatment, substance use, unhealthy alcohol use, use disorders