Doctor of Nursing Practice (DNP) Final Projects

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.

Children with congenital heart disease (CHD) are at increased risk for psychosocial issues (PSI), decreased quality of life (QOL), and decreased resilience. The purpose of this project was to implement a screening protocol for PSI, QOL, and resilience, with appropriate psychosocial referral for children with CHD.

A pilot protocol was implemented to screen children with CHD, aged 8-17 years, and parents, for resilience, QOL, and PSI. Referrals for psychosocial services were made for 84.2% of children screened (n = 16) based on scoring outcomes. Statistically significant differences in the parents and children’s resilience mean scores were noted. Higher parental scores may indicate that parents believe their children are more resilient than the children perceive themselves to be.
Early identification of concerns regarding QOL, resilience, and PSI in children with CHD can provide ongoing surveillance, while affording opportunities for improved communication between providers, parents, and children. Routine screening and longitudinal follow-up is recommended.

Diabetes mellitus (DM) is a detrimental disease that afflicts approximately 23.6 million Americans and costs $176 billion dollars annually in direct medical expenses (American Diabetes Association [ADA], 2015). Approximately 208,000 children and adolescents with diabetes are under the age of 20 years (ADA, 105; CDC, 2014). Currently, the standard of medical practice in school-aged children and adolescents with type 1 diabetes is to administer insulin after the child or teen has eaten. The most current evidence has demonstrated a decrease hemoglobin A1C (HbA1c) and preference for pre-prandial insulin administration (Cobry et al., 2010; Danne et al., 2003; DePalma et al., 2011; Enander et al., 2012; Luijf et al., 2010; Scaramuzza et al., 2010).

This Doctor of Nursing Practice (DNP) project delivered an educational program for parents of school age children and adolescents with type 1 diabetes and instituted pre-prandial insulin administration as the standard of care in an outpatient pediatric endocrine clinic. Education was delivered in both verbal and written formats. Data collection included weekly blood glucose reports and HbA1c at initial and follow-up sessions. Descriptive statistics were utilized to analyze the data. No post intervention data was able to be collected due to participant drop out. Future directions to promote this practice change are discussed.

Approximately 15,270 children were diagnosed with cancer last year and a common treatment includes daily radiation therapy. Children must remain immobilized for the planning and treatment to ensure the radiation beam precisely delivers radiation to the tumor and reduces exposure to the normal surrounding tissue. Radiation therapy may last several weeks, which requires children to be put under daily anesthesia for an extended length of time to ensure immobilization. The risks for anesthesia include airway obstruction, broncho/laryngospasm, oxygen desaturation, apnea, nausea/vomiting, hypothermia, hypotension, hypoxia, cardiac arrest, sepsis due to central line access, and death. The relationship between daily anesthesia administration and neurotoxicity is currently unclear.

The purpose of audiovisual distraction (AVD) during radiation therapy was to decrease anesthesia exposure, improve quality of life, and decrease anxiety of patients and families. A plan to implement an AVD device at the time of radiation planning and during daily treatments was conducted in a large pediatric radiation oncology practice in Arizona. Inclusion criteria were children needing radiation, between the ages of 5 and 15, who do not have history or complaint of visual impairment, who have the ability to follow directions for AVD, and were deemed candidates by the Radiation Oncologist and Child Life Specialist through physical and mental assessment. Data collection included anesthesia requirements, heart rate, PedsQL Tool, and time in treatment room gathered at the planning session and at the end of treatment. Microsoft SPSS was used for data analysis. Descriptive statistics were used to describe the sample and outcome variables.

The aggregated data was analyzed to ascertain if the number of children in the inclusion age range had a decreased need for anesthesia, decreased anxiety, and increased quality of life. The primary outcome for the AVD was: all four children who participated were able to undergo radiation therapy without the need for anesthesia . The children were able to remain awake for treatment could attend school, as permissible, eat before treatment, and spend significantly less time at the treatment facility. The concern of repetitive anesthesia and neurotoxicity will not be a factor in the child’s long term late effects of treatment. The reduction of need on anesthesia staff and nursing staff was estimated to save over 500,000 dollars for the 89 treatments the four children underwent with the AVD. The benefits of the intervention not only provided a better treatment experience for all children, but it allowed the facility to utilize the treatment machine more efficiently, providing radiation therapy as an option to even more patients.

Introduction: More than 1.2 million children in military families face long separations from a parent due to deployment or extended assignment, which can lead to significant family dysfunction as well as behavioral, emotional, and scholastic problems for the child. The purpose of From Caring 2 Coping is to identify and provide healthcare providers of military children tools to recognize and address maladaptive and externalizing behaviors of these children, while also assisting the nondeployed parent or caregiver to provide their children with the necessary support to reduce stress and increase their own coping skills.

Materials and Methods: After approval from Arizona State University IRB, children aged 4-11 years who are currently or forecasted to be separated from a military parent due to a deployment or extended assignment, were recruited from a military pediatric clinic along with their primary caregiver. An intervention was adapted from Bowen and Martin’s (2011) Resiliency Model of Role Performance for Service Members, Veterans, and their Families to identify and improve individual assets and family communication skills, find support through social connections, and prepare for potential stressors by constructing a Roadmap of Life. The Parental Stress Scale (PSS) and Pediatric Symptom Checklist (PSC-17) were completed before and after the 4-week intervention along with a final caregiver survey to evaluate the caregiver’s perceptions of From Caring 2 Coping.

Results: Four mothers and eight children completed the program for which Wilcoxon matched-pairs signed-rank test compared results from pre- and post PSC-17 surveys from the children showing significant improvement post-intervention (p = 0.017). The post PSC-17 results were compared to post PSS results with Spearman Correlation Coefficient, r = 0.949, that is statistically significant (p = 0.05). From Caring 2 Coping is rated as an effective program by parents in a postintervention survey that is easy to incorporate into daily activities. Parents ranked highest satisfaction through use of the Family Communication Plan and Family Timeline.

Conclusions: From Caring 2 Coping intervention tools improved family communication, use of individual assets and Roadmap of Life coping skills, thereby improving child and caregiver coping response as evidenced by improved PSC-17 and PSS scores. Basing the intervention on the Resiliency Model of Role Performance which has proven successful in the military population, improves the chances for success in this target population. However, the small sample size of four families requires further study with more families at all levels of the deployment cycle in order to refine the intervention.

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.