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: Advance Directives
- All Subjects: Human trafficking
Disease burden is higher in the United States than in comparable countries. The Patient Self Determination Act of 1990 requires healthcare facilities to provide Advance Care Planning (ACP) information to all Medicare patients. The healthcare staffs’ (n=7) commitment to 3-days of ACP training increase ACP rates in the primary care setting. The Medicare Incentive Program is the platform for this initiative. This quantitative project used a valid and reliable pre and posttest design that consisted of 27 items on a Likert-scale. A 3.5-month chart audit (n=91) was conducted to assess the completion rate. Descriptive statistics was used to describe the demographic data.
The results of the two-tailed Wilcoxon signed rank test were significant based on an alpha value of 0.05, V = 0.00, z = -2.37, p = .018. There was a significant increase in the post-readiness to change average scores. A Mann Whitney test was used to analyze the statistically significant difference between the averages in two ACP types and electronic health record documentation (EHR). Staff did not always code (Mdn = 0.00) but they documented in the EHR (Mdn =1.00; 512.00, p = 0.003). ACP discussion was performed 63% of the time during Annual Wellness Visits (AWV), and there was a 49% increase in the EHR documentation. Trained staff are key stakeholders in guiding ACP conversations. They understand the barriers, impact, and consequences related to the lack of advance directives.
Background and Significance: National regulations mandate that patients are provided information about advance directives in the healthcare setting, but completion rates are not monitored and continue to be low. ACP is now a billable service for healthcare providers, but it has not provided enough incentive to increase completion rates. Barriers for healthcare providers in the outpatient setting include lack of time, protocols, and lack of education on how to initiate and foster advance care planning discussions.
Methods: Healthcare providers in a primary care office attended a 15-minute structured educational session with and a toolkit was provided on the importance of ACP, how to initiate conversations with patients, and bill for the service. Participants completed a portion of the Knowledge, Attitudinal, and Experiential Survey on Advance Directives (KAESAD) survey assessing their confidence in ACP before and three months post intervention. Participant confidence (N = 6) in ACP was analyzed using the Wilcoxin test and descriptive statistics. The number of billed ACP services for the office was collected for four months post intervention and compared to the previous four months. Outcomes: A significant increase in provider confidence after participating in a multimodality education program was found in the results (Z = -2.21, p = .03). There was a 42.1% increase in the number of billed ACP discussions for the office in the four months post intervention.
Conclusion: The future desired state is that ACP discussions become standard practice in primary care leading to the completion of advance directives. This can be accomplished through formalized education sessions and resources for providers in order to increase their confidence in initiating ACP discussions with patients. The ultimate goal is to decrease unnecessary spending at end-of-life while improving patient and family satisfaction with the quality of care received at end-of-life.
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.
The project used a mixed method design. Participants were recruited from a primary care practice. Descriptive statistics described the sample and outcome variable. An independent t- test measured if there were significant changes in the participant responses for the ACP survey.
The average age (standard deviation) of the chart review sample was 72.22 (SD=9.47). The ages ranged from 60 to 100 years of age. Most of the sample in the chart audit were female with 105 (53%) participants and 95 (48%) were male. Most of the sample, 183 (92.5%) reported having a chronic health condition and 17 (7.5%) of the sample reported having no chronic condition. Overall, the results were inclined towards a significant difference in participants who did the ACP discussions and those who did not when comparing completed AD forms.
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.
Purpose: The purpose of this project was to examine if a relationship existed between the changes in attitude and knowledge of a mental health care provider, before and after an educational intervention was given on how to identify sex trafficking victims.
Background: According to the National Trafficking Hotline (2017), last year there were over 5,000 cases of sex trafficking reported. Lederer & Wetzel (2014) discuss that more than 88% of victims interact with a health care provider while being trafficked at least once. A majority of cases, mental health care providers were informed that their patient was a sex trafficking victim through collaboration of other services. Without this collaboration, many providers would have never
known that they had interacted with a victim (Domoney, Howard, Abas, Broadben, & Oram, 2015).
Methods: The participant population consisted of psychiatrists, psychiatric nurse practitioners and psychologists working in acute and out patient settings.
A pre survey was given to identify the participant’s knowledge of sex trafficking and their awareness of available resources and tools to help screen as well as treat victims of sex trafficking. After completion, the participants viewed an educational voice over presentation that educated them on how to identify current sex trafficking victims, what screening tools are available, the mental health risk factors and how to protect both the victim and provider from potential danger from the alleged trafficker. A post survey was then given to assess their knowledge after the presentation intervention, how much they retained and their confidence in being able to assess and treat sex trafficking victims. All surveys and the presentation were available online for participant convenience via a private link.
Results: The knowledge posttest score was higher than the pretest (Z=-2.694, p<0.007).
The confidence score on treating sex trafficking victims was higher posttest (Z=-2.251, p<0.024) No significant change in attitudes for advocating for sex trafficking victim care. All providers agreed that this high-risk vulnerable population needs advocates (Z=4.67, p<0.707).
Conclusion: All providers agreed for the need to advocate for victim care prior to the educational intervention. The results suggest that mental health providers are more knowledgeable posttest about risk factors, have a higher level of confidence in treating sex trafficking victims and have a higher confidence in their ability to protect victims and provide adequate care.
