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: Heart failure
- All Subjects: Nurse practitioners
There is an estimated 6.2 million people Americans over the age of 20 suffering from Heart Failure (HF) (Bejamin et. al., 2019). It is essential that HF patients have sufficient knowledge about the disease and self-management (Abbasi, Ghezeljeh, & Farahani, 2018; Dinh, Bonner, Ramsbotham & Clark, 2018). Lack of self-management is largely to blame for many HF exacerbations. Current evidence supports utilizing both verbal and written education with an emphasis on self-care and education delivered in a group setting or individual setting showed equal impact on self-care and HF knowledge ( Hoover, et. al., 2017; Ross et. al., 2015; Tawalbeh, 2018).
An outpatient VA clinic located in a suburb of the large metropolitan identified there was no consistency on how a HF patient was educated, managed, or tracked and the registered nurses (RNs) lacked knowledge of HF. As a results of these findings this Evidence Based Project (EBP) was implemented. RNs were educated on HF and completed a self-assessment questionnaire evaluating their knowledge pre and post education. The RNs, as part of a multidisciplinary team, educated HF patients on signs and symptoms of HF as well as on how to manage the disease. Patients completed, the Kansas City Cardiomyopathy Questionnaire (KCCQ) to assess quality of life and the Self Care Heart Failure Index (SCHFI) to assess knowledge of HF and self-management skills.
These questionnaires were completed initially and at 30 and 60 day intervals. The RNs self-assessment of their knowledge and ability to educate patients increased in all areas. The patient’s KCCQ and SCHFI score improved at 30 days and 60 days when compared to their initial score. Larger EBPs are needed over a longer period of time to assess the impact on hospital readmissions and same day clinic visits for HF exhibitions.
While the COVID-19 pandemic continues to evolve, America’s nursing work force continue to work in the most challenging of circumstances. While expected to hold the fort and continue on, deep inside, they bury an unprecedented level of acute stress, anxiety and depression. Peer support groups have been posed as a possible coping behavior. This cross-sectional designed project was developed to assess the worth and feasibility of a virtual peer support group with a focus on healthcare provider wellness during a period of surge of the COVID-19 pandemic. Overwhelmed staff, technology/documentation changes and challenges, competing clinical demands, short-staffing and Zoom fatigue were identified as the limiting factors for this project’s completion within its given timeframe. These findings informed of current barriers, providing a basis for future program development to mitigate the impact of psychological distress among healthcare providers. Evolving literature on this topic supports recommendations for further study and action by individual health care providers, organizations and at the state and national levels.
New graduate nurse practitioners and physician assistants, also known as advanced practice providers (APPs), face a significant number of challenges when entering professional practice. If the new graduate does not receive sufficient guidance and support during this transition to practice (TTP), they will likely experience significant psychological stress and anxiety. If an organization does not implement measures to address TTP, the new graduate is much more likely to leave the current position within the first two years of practice.
An extensive literature review was conducted investigating the effects, and necessary components of an orientation program which supports the new graduate through TTP. Using Van Maanen & Schein’s (1979) Theory of Organizational Socialization, a comprehensive new graduate orientation program was designed and implemented in large multi-specialty practice. Initial results suggest that this program improves both the perceived organizational support felt by the new graduate, as well as the new graduates’ affective commitment to the organization. Improvements in both these dimensions have been shown to decrease turnover intention and increase retention of the employee.
Heart failure affects millions of Americans each year. Treatment of advanced heart failure with reduced ejection fraction and left ventricular failure is sometimes treated with implantation of a left-ventricular assist device. While living with this life-sustaining machine, anticoagulation with Coumadin is necessary. Many of these patients are readmitted within 30-days of being discharged for pump clots, gastro-intestinal bleeds and even strokes. Patients are often discharged without adequate education on Coumadin management, which promotes inadequate self-care and medication non-adherence.
In current practice, healthcare providers lecture information in a quick manner without the evaluation of patients’ comprehension. Research suggests implementing the teach-back method during education sessions to assess for comprehension of material to improve medication adherence. Healthcare providers should implement Coumadin teach-back education to heart failure patients with left-ventricular assist devices to improve quality of life, increase medication adherence and decrease 30-day hospital readmission rates.
The mentor role can help support the experienced nurse practitioner (NP) enhance a sense of belonging and commitment to the organization; however, NPs identify barriers of time, dedication, and lack of knowledge about mentoring. Current mentoring programs in Arizona are sporadic and formal training for the mentor is even more limited. In this project, an online training intervention to develop mentorship skills was provided for experienced NPs who viewed three video sessions of 20-25 minutes each. The topics (Open Communication & Accessibility; Mutual Respect & Trust; Independence & Collaboration) focused on developing key mentoring competencies identified from the literature. Participants did not report a significant increase in their mentoring skills after the video sessions, but they identified useful individual outcomes. Participants identified the need to formalize the experience with objectives for both the mentee and mentor and recommended seeking out the novice NP to build a mentoring relationship.
The project outcomes led to several recommendations. To support ongoing mentor relationships, organizations may need to push training out to their experienced NPs on the role of the mentor. Mentors who do not self-identify for remediation or training may need organizations to provide the training and not make it optional. Community and professional organizations like the Arizona Board of Nursing, Arizona Nurses Association and others could create training modules utilizing multiple platforms to reach NPs in rural and urban parts of the state. Finally, further projects are necessary to identify the most effective modalities when delivering training.
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.
Background and Significance: HF affects over 5.1 million people in the United States, costing $31 billion a year; $1.7 billion spent on Medicare readmissions within 30 days of discharge. Guidelines and care coordination prevent expenses related to hospital readmissions and improve quality of life for adults with HF.
Methods: Healthcare providers (HCPs) at a metropolitan hospital participated in an education session reviewing HF treatment and CMD. Thirty participants completed the single five-point Likert scale pre/post surveys evaluating their opinions of knowledge and behaviors toward implementation of guidelines and CMD. Patient outcome data was abstracted measuring pre/post education compliance for ejection fraction, ACE/ARB, beta-blocker, HF education, follow-up appointments, aldosterone antagonist, anticoagulation, hydralazine nitrate, and CMD 30-45 day’s pre/post education. Analyses included descriptive statistics of participants and pre/post surveys using a paired t-test. Percentage of compliance for quality measures was completed on patients from September through December.
Results: Providers post intervention showed improved knowledge and behaviors toward implementation of guidelines and CMD, including reconciliation of medications to statistical significance. However, the demographics showed the majority of participants were non-cardiac specialties. Improved compliance for outcome data of quality measures was insignificant over time. The non-cardiac demographic may have contributed to this result.
Conclusion: The surveys did not correlate with the patient outcome data. Recommendations would include targeting cardiac focused HCPs for future education sessions.
Heart failure (HF) is one of the most common and costly conditions for hospital readmissions in the United States (Conway, 2015). Cardiac rehabilitation (CR) programs are effective in decreasing hospital readmission rates (Koukoui, Desmoulin, Lairy, Bleinc, Boursiquot, Galinier, & Koukoui, 2015). Medicare has established new requirements for qualification into a CR program; thus, patients are at risk for readmission in the six-weeks post discharge. To reduce HF hospital readmissions and to increase enrollment into the HF program, an infrastructure was implemented beginning in January 2016. This quality improvement project employed a patient chart audit reviewing overall hospital readmission rates for HF at a large hospital in Arizona.
A comparison of readmission rates was made between the 6 months prior to, and the 6-months after the expanded utilization of the HF program. An independent-samples t test was calculated comparing the mean score of the readmission rates before and after a HF CR intervention. No significant difference was found (t(358) = .721, p > .05). The mean of the group before the intervention (m =.15, sd = .36) was not significantly different from mean in the intervention group (m = .13, sd = .33). Implications for practice cannot completely be concluded from this project findings. Continued studies focusing on the enrollment, attendance, and completion of the HF CR program could assist in determining the benefits of referring all patients with the diagnosis of HF to the HF CR program.
Rural healthcare leaders are increasingly tasked with the responsibility of providing health access to 21% of the national population with only 10% of the provider workforce (Sonenberg, Knepper, & Pulcini, 2015). Provider recruitment strategies offering loan repayment have had some success in the short term, but are less impactful at creating a long-term retention rate, unless the providers have an existing connection to either the community in which they are working or rural healthcare (Renner et al., 2010).
Responding to this data, a demonstration project has been created in Colorado to test a rural focused “grow your own” advanced practice registered nurse (APRN) model. This model is designed to recruit RNs from inside rural communities to return to school and become primary care providers within those communities upon graduation. The project offers stipend support with assistance in the school application process, educational support, clinical and job placement assistance, and monthly coaching. Additionally, communities are asked to provide matching funds to support the APRN students with a goal of creating a self-sustaining model that will build a continuous pipeline of APRN providers. This strategy avoids the costly need to recruit and relocate providers who have no ties to the community.
The initial response from rural nurses and communities around the state has been overwhelmingly successful. This success suggests that this model could serve as a new and sustainable strategy for building a rural APRN provider workforce pipeline while ensuring access to a primary care health provider for all people living in rural areas.