Doctor of Nursing Practice (DNP) Final Projects

As Baby Boomers age, the number of older homeless patients facing end of life is increasing. Homeless individuals die of the same diseases as their domiciled counterparts, but they have distinct barriers to equitable end-of-life care, such as lack of regular medical care, a higher likelihood of comorbid serious mental illness and substance abuse, alienation from potential healthcare proxies, and specific fears related to dying. Completion of an advance directive (AD) would address many of these barriers, as well as national goals of reducing medical costs associated with end of life care. A review of the literature indicates that homeless individuals, once educated on the purpose and significance of ADs, complete them at a higher rate than non-homeless people. Further, racial and ethnic disparities in document completion are minimized with educational interventions about an AD’s purpose.

King’s Theory of Goal Attainment provides the theoretical basis for the application of such an intervention in the setting of a medical respite center and a day resource center that both serve the homeless. Thirty-seven clients of the two sites and 14 staff members were administered a pre-and post-test measuring attitudes and knowledge relating to ADs on a Likert scale, resulting in an increase in knowledge about one of the two documents that traditionally comprise an AD, while not significantly affecting attitudes. Implications for practice include an inexpensive intervention that does not require a medically trained individual to deliver, enabling a broad application to a variety of settings with the goal of empowering a traditionally disenfranchised population to make health decisions related to the most vulnerable of life passages.

Background and Purpose: The lack of an advance directive (AD) can predispose a person to an aggressive course of treatment despite their wishes. When AD’s are incomplete, the chances of unwanted procedures, such as tube feedings and repeated transitioning between nursing homes and hospitals often result in the risk of increased mortality and morbidity, especially for older adults. Making end-of-life decisions can improve the quality of death by allowing individuals to make decisions to die in a dignified manner. The purpose of this project was to improve AD completion rates by implementing “Five Wishes” (FW) into the admission process in a long-term care facility (LTCF).

Methods: The project took place on the skilled nursing units at a LTCF in Southwestern Arizona over a 2-month period of time. Twenty random charts were assessed before the start of the project to determine the residents AD status. Those 20 were then informed about FW’s and encouraged to complete one, along with all newly admitted residents to the skilled nursing units. Logs were used for data collection and each participating resident signed a HIPPA document. Descriptive statistics were used to describe the sample and outcome variables.
Outcomes Of the 20 current residents included in the quantitative chart assessment, 6 (30%) residents completed a FW’s document. Fifty residents were admitted during the project span and 21 (42%) of them completed FW’s.

Conclusions: The FW’s completion rates were lower than expected. None of the residents had an AD more detailed than a basic full code or do not resuscitate (DNR) status before being informed of FW’s. It is recommended that the facility social workers would have implemented the intervention to increase the likelihood of adherence.

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.

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.