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.

Skin and soft tissue infections (SSTI’s) are a significant health concern with serious potential implications. Evidence suggests the importance of implementing a severity stratification tool to improve early identification of SSTI’s. The aim of this evidence based project is to examine if educating healthcare staff on the use of a severity stratification tool would increase staff knowledge of SSTI's. The sample consisted of 18 participants, 12 healthcare providers and 6 healthcare staff at a correctional facility in the Southwestern United States. A pre-and posttest design, including an educational session was implemented.

A 14-item multiple choice self-developed questionnaire was used to evaluate participants’ knowledge of identifying and ranking SSTI’s using the CREST tool. A one tail paired t-test was performed to compare the pre-and post-test case study scores for the healthcare provider group. A significant increase from pre-test to post-test case study scores was found (t(13)= -6.19, p < 0.00). Of the healthcare providers, 57% found the tool “moderately helpful.” Of the non-provider sample, 50% found the tool “extremely helpful” and plan to use the tool “all of the time.” The findings of this study suggest that implementing an educational session on a wound severity stratification tool improves staff knowledge and increases the likelihood of the tool being used in practice. Recommendations for future research include larger sample sizes across a variety of regional correctional facilities to further explore the use and knowledge of the tool in practice.

Background and Purpose: Readmission rates for those with chronic conditions are exceeding benchmarks and driving up healthcare spending; there is a need to improve care coordination and outcomes. This project was done to evaluate and offer evidence-based suggestions for improvement to a multidisciplinary care coordination team in an Accountable Care Organization (ACO). Internal data suggests the team is underutilized within the ACO and that the ACO is underperforming. Conscious workflow design has been shown to improve the efficiency of existing work processes.

Methods: The care coordination team (N=6), licensed practical nurses and social workers, were the project participants. Following Institutional Review Board approval, a presentation was given on current ACO performance data and project goals. Team members were invited to participate by filling out a survey. The 31-item Team Development Measure (Cronbach’s α) assessed team functioning to identify where gaps exist in the team’s processes. Further knowledge about workflow was gained via quality improvement methods of direct observation and informal conversational interviews with team members, the ACO team manager, and various providers within the ACO and their staff. Field notes were analyzed and confirmed with the ACO team manager. Rasch analysis was performed on survey data to convert ordinal numeric results from the Likert scale into an interval score from 0 to 100, which correlates with elements of team development.

Results: Rasch analysis revealed a mean score of 54.17 (SD=8.06). Based on this score, the team has cohesiveness and communication in place but has not yet established role and goal clarity. Analysis of notes and impressions revealed a lack of adherence to date deadlines, inconsistent processes among team members, and use of non-evidence based patient care interventions such as minimal to no home visits and a lack of standardized patient education. Team analysis results, workflow observations, and current evidence on transitional care were integrated into an executive report containing realistic prioritized changes that maximize team member’s skill sets and clarify roles and goals of the team which was provided to the ACO administration along with recommendations for evidence-based process improvements.

Conclusion: This project can serve as a model for analyzing team functioning and workflow to inform agencies where gaps in their processes are affecting performance. The analysis can then be used to recommend evidence based practice changes. Implementation of the suggested workflow should improve existing efforts in trying to meet benchmark quality measures for the ACO as well as improve team functioning.

People who inject drugs (PWID) are at high risk for disease transmission and bacterial invasion of the blood and/or skin. PWID are a marginalized population who often delay medical treatment or substitute self-care treatment due to increased fear, barriers, or stigmatization in traditional healthcare settings. These delays often create multifaceted complications that eventually cost the healthcare system billions of dollars. This leads to poorer health outcomes in PWID. There is evidence that community-based interventions are effective in reaching this population of people in order to promote better health outcomes.

To address this gap in care, an evidenced based project centered on increasing the confidence levels of community lay workers when providing general wound education to PWID was conducted. The project was implemented at a rural harm reduction agency site in Northern Arizona. Utilizing the theoretical framework of the Adult Learning Theory, a convenience sample of 22 participants received a general wound education intervention consisting of a PowerPoint presentation with a written brochure over multiple sessions.

Adapted questions from the new general self-efficacy (NGSE) scale, which has demonstrated valid internal consistency, were utilized to measure confidence levels of participants and a scored checklist was used to measure teaching performance. Confidence levels significantly increased from baseline to week four (p = .001). Teach-back performance scores also increased from baseline to week two and four. Providing a general wound education intervention to community lay workers improved confidence levels and teaching performance which can promote better health outcomes in PWID.