Doctor of Nursing Practice (DNP) Final Projects
The Doctor of Nursing Practice Final Projects collection contains the completed works of students from the DNP Program at Arizona State University's College of Nursing and Health Innovation. These projects are the culminating product of the curricula and demonstrate clinical scholarship.
Filtering by
- All Subjects: Patient Readmission
- All Subjects: Physical Activity
- All Subjects: Emergency Rooms
Advanced Practice Registered Nurse Led Transitional Care Program in an Accountable Care Organization
Background: Hospital readmissions place a heavy financial burden on patients, families, and health care systems. Readmissions can be reduced or prevented by providing a safe transition through care coordination and enhanced communication. Research demonstrates implementation of APRN led home visits (HV) along with telephonic follow-up are cost effective and can be utilized for reducing readmissions among HF patients.
Methods: A program was designed with an ACO and carried out in a family practice clinic with a group of seven HF patients older than 50 years who were at risk of readmission. Interventions included weekly HV with supplemental telephonic calls by the APRN student along with a physician assistant for 12 weeks. Readmission data was collected. QOL and SCB were measured using “Minnesota Living with Heart Failure Questionnaire” (MLHFQ) and “European Heart Failure Self-Care Behavior Scale” respectively. Data was analyzed using descriptive statistics and the Friedman Test.
Outcomes: There were no hospital readmissions at 30 days and the interventions demonstrated a positive effect on QOL, self-care management and satisfaction (χ2 = 30.35, p=.000). The intervention had a large effect on the outcome variables resulting in an increase in QOL and SCB scores post-intervention (ES= -1.4 and -2 respectively).
Conclusions: TCP designed with an ACO, carried out in a primary care setting has a positive effect on reducing hospital readmissions and improving QOL, SCBs, and patient satisfaction among HF patients. TCPs are not revenue generating at outset due to reimbursement issues, however future considerations of a multidisciplinary team approach with convenient workflow may be explored for long-term feasibility and sustainability.
Funding Source: American Association of Colleges of Nursing and the Centers for Disease Control and Prevention with support of the Academic Partners to Improve Health.
Findings suggest that stigma associated with mental health may be as strong in healthcare providers as it is in the general public. Research involving non-behavioral health nurses, and medical and nursing students, sought to identify bias and negative attitudes directed towards psychiatric patients in a non-psychiatric setting. Studies were reviewed to determine the effects of educational interventions to teach empathy and increase knowledge related to the pathology of, and treatment modalities for, psychiatric patients. Several scales were used to measure bias and rate interventions to minimize it.
Studies found that healthcare personnel, including nurses, are considered by mental health consumers to be primary contributors to stigma and discrimination against those with mental illness. The studies also discovered that participation in an educational intervention to learn empathy and acquire knowledge about psychiatric patients directly decreased bias. The project utilized the evidence-based practice PRECEDE-PROCEED model (PPM) supported by Bandura’s Social Cognitive Theory (SCT). Combining the PPM with the SCT is supported in the literature as they both rely on learned behavior.
Moving forward, the presentation was completed and participation sought. It was at this point the project shifted its perspective. Out of 80 nurses asked to attend 1 of the 2 presentations, a total of 3 nurses participated. The search for statistical significance was not possible. We were left to formulate descriptive statistics to interpret the outcomes and reflect on their meaning.
Hospital readmissions for palliative care patients are costly for patients, families, insurance providers, and palliative care organizations. The evidence shows that integrating virtual visits into palliative care is an innovative way to reduce hospital readmissions, preserve costs, and reduce geographical barriers. The purpose of this article is to evaluate how well transitional care virtual visits reduce future hospital readmissions for palliative care patients when compared to usual care of in-home nurse visits. Palliative care patients from a large palliative company in Arizona, who received a transitional care, post hospital discharge, virtual visit with traditional model care (intervention) were compared to randomly selected traditional model care patients (control).
Data was collected through a retrospective chart review at 30 and 60 days post hospital discharge to evaluate for hospital readmissions and avoided readmissions. The Fishers Exact test was used to compare the results of the two groups to each other. There was no significant difference between the two groups. Virtual visits have an added cost to the agency without decreasing the risk of readmission. Implications for practice are to continue offering transitional care in-home nurse visits. Future research should evaluate if using virtual visits justify the increased costs of use.
Purpose/Aims: The purpose of this project was to increase the rate of depression screening for patients with chronic musculoskeletal disorders in the physical therapy setting.
Methods: The institutional review board at Arizona State University approved this study with exempt status.
Depression screening with a Patient Health Questionnaire (PHQ-9) was completed by adult clients in three outpatient physical therapy clinics in the Midwest and Southwest United States (n=165). Degree of depression and patient response rates were measured and analyzed using descriptive statistics.
Staff were surveyed prior to and post project completion regarding their viewpoints on IPC and depression in this patient population. Staff demographics were analyzed and they were evaluated on their change in perception of the problem and their likelihood of sustainability with a Wilcoxin Signed Ranks Test.
Outcomes: Patient response rate was 91.5% (n=165) exposing a mean PHQ-9 score of 5.01 (mild depression). More notably, patients whom had an existing diagnosis of depression had a mean PHQ-9 score 10.47 (moderate depression) indicating poorly controlled symptoms.
After an educational session to increase knowledge, staff perception of the problem did not significantly change, with a mean score of 2.25 out of 5 predicting “somewhat” likelihood of project sustainability.
Conclusion: Implementing a PHQ-2 rather than PHQ-9 depression screening into patient’s electronic medical records would resolve staff and patient concerns of time consumption while simultaneously improving the rates of depression screening and management in patients with chronic musculoskeletal disorders.
Gestational diabetes mellitus (GDM) is a well-established predictor for the development of type II diabetes mellitus (T2DM) later in life. The incidence of GDM has been on the rise over the past 30 years and is the leading co-morbidity during pregnancy (Ferrara, 2007). Physical activity (PA) in combination with nutritional therapy has been shown to achieve glycemic control in women with GDM and is therefore first line therapy for management (American College of Obstetrics and Gynecology [ACOG], 2017; Center for Disease Control and Prevent [CDC], 2018).
Recommendations for PA in pregnancy include 150 minutes of moderate intensity exercise most days of the week (ACOG 2015; U.S. Department of Health & Human Services, 2018). Because of this, an innovative project was created to determine the feasibility of adding a walking plan into GDM care. Participants in the project received verbal and written instruction on an unsupervised structured walking plan set up for a beginner to gradually increase PA to the recommended time of 150 minutes per week for a total of four weeks. Eight women were interested, recruited, and enrolled in the project.
Results show that overall, participant PA increased. One hundred percent agreed that the walking plan was useful and increased their awareness about PA. The addition of a walking plan in GDM teaching is an effective strategy to lower serum blood glucose (SBG) levels and for meeting PA recommendations during pregnancy.
Purpose: The purpose of this project was to implement health promotion education for overweight and obese adults with endocrine disorders. The overarching goal was to change dietary intake and improve exercise to reduce the incidence, prevalence, and impact of comorbidities associated with obesity.
Background/Synthesis: Obesity is a significant epidemic facing the nation today with multiple impacts on the national healthcare system. There is often an association between obesity and endocrine disorders such as type 2 diabetes and prediabetes. Both obesity and diabetes cost the nation billions of dollars annually in healthcare costs. Evidence shows that lifestyle modifications related to nutrition and physical activity are effective in weight reduction and prevention of chronic disease, especially when given by a healthcare provider.
Methods: Fifteen adult patients at an endocrinology office in Arizona received individual counseling using the teach-back method focusing on health promotion behaviors through nutrition and exercise with a two-week follow-up phone call. Short-term outcomes measured in this project included changes in dietary intake and exercise behaviors through a pre- and post-test adapted from an obesity-screening tool developed by Greenwood et al. (2008).
Outcomes/Results: Participants were primarily Caucasian and Hispanic, married, female, average age of 50 years, average BMI of 34.5, and some college education. There was a statistically significant increase in health promoting behavior on posttest scores (M=66, SD=6.23, range=58-76) compared to pretest scores (M=61, SD=4.72, range=50-66), t(14)=-2.55, p=0.023.
Conclusions and Implications: Overall, patient health promotion behaviors increased with this educational intervention. Clinical implications include a potential decrease in patient comorbidities related to overweight and obesity. Implications for the greater healthcare system include decreased comorbidities, utilization of healthcare resources, and costs associated with overweight and obesity. Future recommendations would include determining weight and BMI changes over a longer period of time for even better outcome measures.
Keywords: obesity, obese, overweight, health promotion, health education, diet, exercise, nutrition
The World Health Organization (2010) reports the nursing shortage is a global issue. With the impact of the shortage causing concern for nurse leaders, retaining Registered Nurses (RNs) is an effective strategy. The emergency department (ED) work environment provides an additional challenge to keep nurses as the ED is a fast-paced, critical care setting where RNs are providing care to multiple patients with a wide range of needs every shift. This paper will examine current literature addressing factors impacting and strategies for improving ED RN retention.
A systematic review of the literature showed relationship-focused/transformational leadership practices have a positive influence on job satisfaction and organizational commitment which translates to higher RN retention. The literature also indicated complexity leadership is needed in today’s changing health care environment. An evidence-based practice project was designed to assist the ED leaders evaluate and improve their leadership behaviors. A combination of education and coaching was provided, utilizing the Multifactor Leadership Questionnaire to assess the participants’ self- and rater evaluations before and after the intervention.
Although the results were not statically significant, feedback from participants and observations by the coach identified the education and coaching did have an impact on individuals that actively participated in the project. Those that embraced the concepts and followed through on their action plans have continued to practice, further developing innovative leadership behaviors after the project timeframe was completed
Methods: Analysis of a subset of questions from a larger survey was used to evaluate wearable device attitudes and behavior changes over time. Convenience sample (n=10), ages >18, required enrollment in a clinic-based weight and wellness program (WWP) to participate. The survey questions assessed effectiveness of wearable device on a 0-10 motivation scale to increase physical activity and a self- assessment of behavioral changes at specific intervals over a 6-month period. Descriptive statistics and non-parametric, two-tailed tests will be used to analyze the data. Due to the necessity of detecting minute differences with the small sample size, the significance level will be tested at the p<0.10.
Results: Participants >18 years of age, enrolled in a WWP (n=10) included 20% male and 80% female. Although a 12.3% increase in the mean score was found from week-1 to 6-months, the results were not statistically conclusive to the effectiveness of self-motivation to increase activity by participants wearing an activity tracking device; however, results are statistically significant for participants to increase activity with behavior changes based on device dashboard.
Conclusions: It is recommended for primary care providers to encourage the use of an activity tracking wearable device for behavior change to increase activity.
According to the National Institute on Drug Abuse (NIDA), tobacco, alcohol, and illicit drugs accounted for 820 billion dollars in costs related to crime, lost work productivity, and health care services. Nearly 20 million Americans suffer from substance misuse, but only 3.7 million received treatment. Of those who receive treatment, the risk of relapse is high, ranging from 40-60% within a year of treatment. Improvement in the treatment of substance use disorders (SUD) is necessary to improve the health of our society.
Current literature demonstrates that individualized recovery plans and follow-up care are effective in reducing relapse and readmission. Costs to the individual, institution, and healthcare system can be reduced. This project aimed to decrease the risk for relapse and readmission with recovery plan reviews at 72hrs, and two-weeks, post-discharge. The risk of relapse was measured by the Time-To-Relapse questionnaire and the UCLA loneliness scale. The project took place in a residential treatment facility in Phoenix, Arizona. There were five participants initially; two were lost at the two-week follow-up. Pre and post-test results were compared to measure potential predictability of relapse. The two-tailed paired samples t-test was performed to compare the means of the scores but yielded insignificant results.
All participants maintained sobriety. Qualitative data via interview showed positive results demonstrated by statements from the participants. Recovery plan review with follow-up care is a promising evidence-based practice that can be implemented to help individuals maintain sobriety. Additional research is recommended to examine further the impact on the maintenance of sobriety over time.
Context: This project was completed at a federally qualified primary healthcare clinic in Phoenix, Arizona that served patients of all age groups, but primarily cared for the Hispanic population providing primary care, preventative services, family planning, two lab technicians, one promoter, two medical assistant supervisors, five front desk staff, one chief administrative officer, one chief financial officer, two medical directoers who were also providers at the clinic.
Problem and Analysis Assessment: During my clinical rotations, I saw the burden a missed patient appointment had not only on the patients themselves, but also on the clinic, providers, and the staff. It caused delay in treatment for patients, and it did not allow other patients that wanted to be seen to be seen. It also increased unnecessary costs and wasted provider time. Thereafter, I met with some of the leadership team and one of the medical directors to determine a solution to reduce the number of missed appointments that were occurring. An educational session was kept to discuss the findings of this problem to the providers and the staff and when surveys were handed out to the patients, providers, and staff to assess their satisfaction with the old scheduling system versus the new scheduling system, they were also provided with a cover letter discussing the project.
Intervention: In order for improvements in care to occur, a system process change including the way patients are scheduled must occur. In this case, an open-access scheduling system (OAS) was implemented. OAS allows a patient to schedule an appointment on the 'same-day' or the 'next-day' to be seen. One provider at each of the clinics, each day of the week was available for 'same-day' appointments from 1300-1600. The providers were still available for scheduled appointments using the previous scheduling method. Walk-ins were still accepted, and were scheduled based on patient provider preference; however, if an appointment was not available for their preferred provider, they were typically seen with the provider that was the 'same-day' provider for that day.
Strategy for change: Since patients were only allowed to schedule appointments one month in advance, only one month was needed to implement this process change. A recommendation for the future would be to clearly identify the patient encounter type, and label it as a same-day appointment, as this would be helpful when gathering and extracting data for this type of patient group specifically.
Measurement of Improvement: Over a three-month period, a data collection plan was used to determine the number of Mas over a three-month period before and after implementation of this change. Satisfaction scores were measured using likert scales for patients, provider, and staff, and a dichotomous scale was used to determine the likelihood of emergency room or urgent care use. A comparison was done to measure revenue during the same time frame. During the three months, a clinically significant decrease in MAs was seen (<0.52%), with an increase in revenue by 41%. Additionally, a statistically significant increase in patient, provider and staff satisfaction was also noted when compared to the old scheduling system, as >68% of all patients, providers and staff reported feeling either very satisfied or extremely satisfied with the new scheduling system. Additionally, patients also reported that they were less likely to visit an emergency room(88%) or urgent care (90%) since they were able to be seen the same-day or the next-day by a provider.
Effects of changes: An incidental finding occurred during this study - where 877 more patients were seen in the three months during the implementation of this project, compared to the three months prior; which likely resulted in a 41% increase in revenue. Additionally this project, allowed patients that wanted to be seen on the same day, to be seen, and it decreased unnecessary costs associated with emergency room or urgent care visits. Some of the limitations involved included the current political environment, appointment slots that were previously 15 minutes in length (in 2016), increased to 20 minutes in length (in 2017), a language barrier was noted for the patient surveys since English was not the first language for many of the patients who completed the survey (although documents were translated), and the surveys used were not reliable instrument given that a reliable instrument in previous studies could not be found.
Lessons learnt: In order to have accuracy of the survey results, it is best for the author of the study to hand out and provide scripture for the survey so that complete data is received from the surveyors.
Messages for others: Begin by making a small process change where only one provider allows for the open-access scheduling so that the entire office is not affected by it, and if results begin to look promising then it can be expanded. Additionally, correct labeling of patients as 'same-day' is also important so that additional data can be gathered when needed regarding the 'same-day' patients.
Patient/Family/Guardian Involvement: Patients who benefited from the new scheduling system (open-access scheduling) were asked to fill out a survey that asked them to disclose some demographic data and asked them to determine their satisfaction with the new vs old scheduling system and their likelihood of visiting an emergency room or urgent care.
Ethics Approval: Arizona State University Institutional Review Board (IRB) Received: September 2017