Doctor of Nursing Practice (DNP) Final Projects

Background and Purpose: Over 30 million people in the United States (U.S.) have diabetes mellitus, which comprises about 9% of the population, and about 90% of individuals with diabetes have type 2 diabetes (Centers for Disease Control and Prevention [CDC], 2017). Adults with type 2 diabetes at a local internal medicine clinic were consistently having high glycated hemoglobin (HbA1C) levels, demonstrated by data collected from the electronic health record (EHR), and there was no ordering process for referring patients to diabetes management education and support (DSMES) services. The purpose of this project was to improve glycemic control, demonstrated by lower HbA1C levels, and reach a diabetes education attendance rate of 62.5% at an internal medicine clinic in Chandler, Arizona.

Methods: An electronic health record (EHR) template was created and brief staff training was completed to connect patients with diabetes in the community to a local formal diabetes education program. HbA1C levels were measured before and three months after adults with education program. HbA1C levels were measured before and three months after adults with type 2 diabetes mellitus (T2DM) received physicians’ orders for a DSMES program, and rates of attendance to the program were calculated. Data was collected through the EHR and through feedback from the DSMES program. Descriptive statistics were used in data analysis.

Outcomes: The participants’ results did not demonstrate significant differences in pre-referral and post-referral HbA1C results after they were ordered DSMES services (p = .506). The proportion of education attendance (30%) was lower than the project goal of 62.5%, but increased from the clinic baseline.

Conclusions: EHR template implementation for referral to DSMES may increase rates of formal diabetes education and improve glycemic control. Larger sample sizes, longer project periods, alternative methods of communication, and increased follow-up of participants may be required to produce significant results.

Women in recovery from substance use disorders (SUD) face significant barriers to achieving reproductive well-being (RWB) and disproportionately experience unintended pregnancy. Unintended pregnancy can have serious consequences in this population. Equity-informed approaches promote the integration of reproductive health care (RHC) with recovery programs to improve both access to and quality of RHC. Arizona’s largest SUD recovery program, Crossroads, Inc. recently opened an on-site, integrated primary clinic offering RHC. A one-month pilot demonstration of One Key Question (OKQ), a pregnancy desire screening tool, was implemented with fidelity at Crossroads to identify clients with RHC needs and offer care.

IRB exempt status was obtained through Arizona State University. All female-bodied clients aged 18-49 were screened following routine admission assessments. The Institute for Healthcare Improvement Triple Aim model based on Self-Determination Theory and Motivational Interviewing was used to prioritize client autonomy. The client experience of care was measured using an adapted Interpersonal Quality of Family Planning scale. The magnitude of needs and desires were summarized with descriptive statistics. Sixty-three clients were screened with OKQ. Needs were identified in 97% of clients. Of those clients, 98% accepted referrals. Ninety percent of items measuring the client experience of care were rated as “excellent.” OKQ provided an efficient structure for person-centered screening and referral conversations to integrate RHC in a large SUD recovery program with excellent care experiences reported by clients.

Purpose: This project examined the effectiveness of an online educational module on basic Motivational Interviewing (MI) techniques for Nurse Practitioners (NPs) providing obesity management to middle-aged women.

Background: Middle-aged women experience distinct physiological and psychosocial factors that contribute to weight gain and make obesity management especially challenging. The evidence supports the use of motivational interviewing (MI) interventions as a highly effective approach to obesity management in combination with standard medical weight loss programs. Educating NPs that provide medical weight loss on basic MI counseling techniques is necessary to facilitate the use of this intervention.

Methods: NP providers at a group of seven medical weight loss clinics in the southwestern United States completed an online MI educational module that was developed for this project. The module content covered basic MI counseling techniques. MI knowledge was assessed using a 6-item pre/post-test. Participants completed an 8-item course evaluation to provide additional feedback.

Results: Ten of the 13 NPs eligible participated in the project. The overall response to the project was positive as demonstrated by high scores on the course evaluation. The average post-test knowledge scores increased after completion of the module, however no statistical significance was noted.

Conclusions: The basic MI education module was beneficial for NPs providing obesity management and future research should focus on developing standardized MI weight loss interventions.

Stress of transitioning to parenthood, hormonal fluctuations as well as physical changes, and complications during postpartum could be addressed at the routine postpartum follow-up visit to avoid long-term adverse effects. While emphasis on preconception and prenatal care has increased nationwide, attendance at this important visit is on the decline. The purpose of this project was to investigate how enhanced prenatal education and concurrent scheduling of a well-baby visit at four weeks, instead of the traditional six weeks, could increase adherence to recommended follow-up care at a federally qualified health clinic in the Southwestern United States.

The Theory of Reasoned Action guided the intervention while Rosswurum and Larrabee’s evidence-based practice model was used to develop the project. The pre-existing weekly prenatal education program was enhanced with information regarding the importance of a four-week postpartum follow-up visit. Front desk schedulers were educated to offer same day appointments for the postpartum care visit and one-month well-baby appointment. Data collection took place for three months after implementation of the project and was compared to adherence rates during the three months prior to the intervention. Providers and scheduling staff members participated in a short post-intervention interview. Prenatal education and convenience of concurrent scheduling increased the percentage of adherence to follow-up visits over a three-month period. Providers and clinic staff recommend continuing with the process changes to increase patient’s access to family centered care.

Purpose/Aims: The purpose of this project was to evaluate how patient education can improve medication adherence.

Background and Significance: An exhaustive literature search was conducted with critical appraisal and evidence synthesis to evaluate the effectiveness of patient education on medication adherence. The search concluded that adherence is crucial to chronic disease processes. However, there was no one intervention that emerged as being superior for improving medication
adherence. Working with patients individually to address needs through a variety of methods appeared was the best way to improve medication non-adherence.

Methods: A project to improve medication adherence in an outpatient mental health clinic incorporated electronic medical record (EMR) technology with patient education materials. The project evaluated provider satisfaction with the EMR handout system and evaluated providers’ perceptions of improved medication adherence. Providers (n=9) were followed for eight weeks once system was live. Appraisal was conducted on the providers and pre-test, mid project test, and an eight week post-test were administered. The instrument used was the Technology Acceptance Model-2 (TAM-2).

Outcomes: Friedman Test was conducted. Results obtained showed no significant difference between the three tests (χ2 (2) =2.889, p>0.05). The pretest had a standard deviation of 14.24. The posttest standard deviation was 23.75.

Conclusion: Providers educate patients about a variety of topics such as chronic conditions and wellness. It is beneficial to focus on education more broadly, instead of only medication adherence.

Keywords: patient education, medication adherence, physician perceptions

Diabetes is a leading cause of morbidity in the world. About 42 million people worldwide have
diabetes. Poorly managed diabetes leads to long term complications and mortality. Diabetes self-management education (DSME) has been effective in preventing or delaying complications.The purpose of this project is to implement a diabetes self-management education (DSME)
program in primary care and to evaluate its impact on glycemic control and diabetes knowledge in a selected group of adults 18 years or older in a community-based practice.

Purpose:
The purpose was to implement a self-management program to decrease pain and disability and improve self-efficacy among low-income, Latino individuals diagnosed with arthritis.

Background:
All arthritis pain has the potential to impair mobility. Arthritis is the leading cause of disability among American adults, with over 50 million individuals affected. The Latino population experiences a disproportionate incidence of disability attributable to arthritis compared to other populations. Evidence supports self-management education incorporating physical activity as a promising intervention for arthritis.

Methods:
The intervention included a curriculum developed by the Arthritis Association, three teaching sessions, and a pre/post-test. Anticipated outcomes included decreased pain measured by the Pain Visual Numeric, decreased report of disability measured by the Stanford HAQ, and increased self-efficacy measured by the Arthritis Self-Efficacy Scale. The setting was a faith-based medical clinic that services the uninsured population located within Southwest Arizona. Participants included Spanish and English speaking adults diagnosed with arthritis.

Results:
Twelve participants were consented however, only eight participants completed the entire project. Although the mean pain score decreased, indicating reduced pain, it was not statistically significant (pretest- M=5.75 SD=3.19; posttest- M=5.25 SD=2.82; z (7)=-.11, p= .92). However, there was a statistically significant increase in reports of exercise after the intervention (pretest M=.83, SD=.39; posttest- M=.43, SD=.53; z (6)=-2.0, p =.046). This was in response to an non validated question developed by the primary investigator and co-investigator of, “Do you currently exercise?”.

Conclusions:
Results include increases in reports of exercise post-intervention and decreased pain. The use of non-pharmacological interventions such as self-management to reduce pain and increase mobility in arthritic patients can help lessen the socioeconomic health disparity gaps.

Low back pain is a worldwide health problem. Preoperative education is essential to provide patients with information across the continuum of care. Gaps exist among healthcare organizations regarding deficiencies in properly educating patients about their surgical experience. The lack of proper preoperative education can negatively impact reimbursement for healthcare systems, providers, and patient outcomes. In a large metropolitan tertiary care center providing spine surgery, an evidence-based project was implemented. A self-developed pre and post intervention surveys was given assessing patients’ knowledge and surgical expectations after surgery. A tri-fold education pamphlet was given to the participants with information that included detailed information regarding expectations before and after surgery.

Descriptive statistics were used to describe the sample and outcome variable. An increase in knowledge in expectations after surgery was noted from pre-intervention (mean 1.83, SD .408) to post-intervention (mean 1.67, SD .816) with a Cohen’s D of 0.248 although this was not statistically significant. However, the change in average length of stay (LOS) was significant. The average LOS for the project participants dropped from 4.54 days to 2.833 days which is within the Centers for Medicare and Medicaid Services (CMS) guidelines of 2.92 days for this surgical population. In conclusion, an increased in patients’ knowledge regarding expectations following surgery and decreased LOS was seen for the project participants.

One in every three deaths in the United States results from cardiovascular disease (CDC, 2013). Cardiovascular Rehabilitation (CR) is a medically supervised program designed to help improve cardiovascular health for patients who have experienced heart attack, heart failure, angioplasty, or heart surgery (AHA, 2016). A hospital in the southwestern region of the United States of America reports their 2016 CR attendance rate of 79 %, which is much lower than the national average of 94% (AACVPR, 2016). Motivational interviewing (MI) is a proven method used to promote a positive behavior change for cardiac rehab patients. MI includes quality improvement activities such as peer support and cardiac rehab educational classes that have shown to increase health related quality of life measures and decreased depression symptoms (Pietrabessa et al., 2017; Pack et al., 2013).

Despite all the knowledge about CR and its benefits for health nationally, there are low attendance rates, therefore the purpose of this evidence-based project is to improve CR attendance rates using MI. Patients enrolled into CR participated in the motivational interviewing for eight classes. At the end of the class, they were given notecards to create Specific Measurable Achievable Realistic and Timely (SMART) Goals for themselves for that week. The measurement tools, the PHQ-9 and Dartmouth COOP is a simple, reliable, and valid tool for assessing functional status of cardiac patients and the current CR program utilizes this tool and is familiar with explaining this tool (Eaton, Young, Fergussion, Garrett, & Kolbe, 2005).

A Pearson correlation coefficient was calculated for the relationship between the MI classes and the CR attendance, depression scores, and quality of life. A strong positive correlation was found (r (82)= .456, p< .001) indicating a significant linear relationship between motivational interviewing and cardiac rehab attendance. A weak correlation that was not significant for depression symptoms and quality of life. The impact of this evidence-based project is to give cardiac rehab programs further evidence that the implementation of motivational interviewing can positively influence cardiac rehab attendance rates.