Doctor of Nursing Practice (DNP) Final Projects

As the incidence of acute and chronic wound conditions rises and wound dressing protocols become more complex, uninsured patients lacking access to specialty wound care are challenged to manage their own wounds. Understanding multistep dressing change protocols may be inhibited by low health literacy. Low health literacy is associated with reduced disease knowledge and self-care. Little evidence of health literacy effects on wound patients is available nor are literacy-sensitive educational interventions that address wound knowledge and self-care. Improved outcomes occur in all health literacy levels in other diseases with the use of literacy-sensitive educational interventions that incorporate more than one literacy strategy over multiple sessions. To examine the effectiveness of a literacy-sensitive wound education intervention on wound knowledge and self-care, an evidence-based pilot project was conducted in an urban wound clinic.

A convenience sample of 21 patients received a literacy-sensitive wound education intervention consisting of spoken and written communication over several sessions. Instruments measured health literacy level, wound knowledge, dressing performance, and wound healing status. There was a significant increase in wound knowledge scores in all literacy groups from baseline to visit two (p < .01) and four (p < .01). Dressing performance scores remained consistently high through visit four in all literacy levels. All participant’s wounds progressed toward wound healing significantly from baseline to visit two (p < .01) and four (p < .01). Incorporation of a literacy-sensitive education intervention with supportive literacy aids over several sessions supports improved wound knowledge and dressing self-care and can affect healing in patients of all health literacy levels.

Interprofessional collaboration (IP) is an approach used by healthcare organizations to improve the quality of care. Studies examining effects of IP with patients with type 2 diabetes mellitus (T2DM) have shown improvement in A1C, blood pressure, lipids, self-efficacy and overall greater knowledge of disease process and management. The purpose of this project was to evaluate the impact of IP with attention to identifying and addressing social needs of patients with T2DM. Participants at least 18 years of age with an A1C >6.5% were identified; Spanish speaking patients were included in this project. The intervention included administration of Health Leads questionnaire to assess social needs. Monthly in person or phone meetings were conducted during a 3-month period.

The patient had the option to meet with the doctor of nursing practice (DNP) student as well as other members of the team including the clinical pharmacist and social work intern. Baseline A1C levels were extracted from chart at 1st monthly meeting. Post A1C levels were drawn at the 3 month follow up with their primary care provider. Study outcomes include the difference in A1C goal attainment, mean A1C and patient satisfaction. Pre A1C levels in participants ranged from 7.1% to 9.8% with a mean of 8.3%. Post A1C levels ranged from 6.9% to 8.6% with a mean of 7.7%. Two cases were excluded as they did not respond to the intervention. A paired-samples t test was calculated to compare the mean pre A1C level to the post A1C level. The mean pre A1C level was 8.24 (sd .879), and the post A1C level was 7.69 (sd .631). A significant decrease from pre to post A1C levels was found (t (6) = 2.82, p<.05).

The prevalence of Type 2 Diabetes is on the rise, as are the costs. This nation’s healthcare system must promote interprofessional collaboration and do a better job of addressing SDOH to more effectively engage patients in the management of their disease.

Cancer survivorship has been identified as separate stage in cancer treatment posing unique issues that arise from the diagnosis of cancer, as well as late effects associated with treatments. Evidence shows that cancer survivors demonstrate suboptimal follow-up care, and report high levels of unmet needs related to their cancer experience. To improve care for the increasing number of cancer survivors in the United States, survivorship care plans (SCPs) have been proposed as way to strengthen care coordination and improve patient outcomes.

Research suggests that SCPs have favorable impact on patient satisfaction and quality of life, however little research to date investigates the utility of SCPs in improving patient outcomes, adherence to follow-up recommendations, or patients’ confidence in self-care management. To further understand the role of SCPs in survivorship care, a pilot implementation of SCPs in colon cancer patients was implemented to gather data on the identified gaps.

The purpose of this project is to look at the relationship between education about Autism Spectrum Disorder (ASD) and knowledge, attitudes and beliefs in adult primary care providers. The project addresses the transition challenges adults with ASD have in finding a primary care provider who is comfortable and competent with ASD. Education was provided to adult primary care providers in a multi-site primary care clinic in a large metropolitan city in the Southwestern United States. The Modified Knowledge/Attitudes/Belief instrument was used. A pre-test was administered prior to the education session, then a post-test and a one-month post-test were given afterward.

The results of the education program showed that attitudes and beliefs increased after the education and continued to increase more in the month following. Knowledge improved after the education session but declined after a month although scores were not back to the pre-education level. Primary care providers who receive education about ASD may be more comfortable in caring for this population and more likely to welcome adults with ASD into their practice. Education for primary care providers is key to improving health outcomes for adults with ASD.

The reactionary nature of the current healthcare delivery system in the United States has led to increased healthcare spending from acute exacerbations of chronic disease and unnecessary hospitalizations. Those who suffer from chronic diseases are particularly at risk. The dynamics of health care must include grappling with the complexities of where and how people live and attempt to manage their health and disease. Team-based care may offer a solution due to its interdisciplinary focus on proactive, preventative care delivered in outpatient primary care.

Studies examining the effects of team-based care have shown improvement in; HbA1c, blood pressure, lipids, healthcare team morale, patient satisfaction rates, quality of care, and patient empowerment. In an effort to improve type 2 diabetes health outcomes and patient satisfaction a team based care project was implemented. The setting was an outpatient primary care clinic where the patients are known to have limited social resources. The healthcare team was comprised of a DNP Student, Master of Social Work Student, Clinical Pharmacist, and Primary Care Physician, who discussed patient specifics during informal meetings and referral processes.

Adult patients whose HbA1c level was greater than 6.5% were eligible to participate, 183 were identified and invited. Fourteen (14) agreed to participate and seven (7) completed the initial screening with a mean HbA1c of 9.7%. Significant social needs were identified using the Health Leads Questionnaire. The diabetes and social needs were addressed by members of the team who met individually with patients monthly over the course of three months. Of those who completed the initial evaluation only two (2) returned for a follow-up and had a repeat HbA1c. Both participants had important improvements in their A1C with a decrease of 2.3%, and 3.4%. The others were lost to follow up for unknown reasons. Despite the small numbers of participants this project suggests that patients can benefit when an interdisciplinary team addresses their needs and this could improve health outcomes.

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.