Doctor of Nursing Practice (DNP) Final Projects

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.

Background: Vaccine-preventable diseases significantly influence the health and academic success of college students. Despite the known negative impact of these diseases, vaccination rates routinely fall short of national goals and recommendations. Although vaccination decisions are complex, a recommendation from a health care provider is one of the key motivators for individuals receiving a vaccine. Motivational interviewing (MI), a counseling approach primarily used to address substance abuse, can be applied to other health-related behaviors.

Local Problem: Despite previous quality improvement efforts aimed at increasing vaccine rates for influenza, human papillomavirus (HPV), and meningitis B (MenB), vaccinations at large university health centers have been well below benchmarks set by Healthy People 2020.

Methods: This study was guided by the Theory of Planned Behavior and included MI training and regular reinforcement for health care providers to address vaccine hesitancy with college students.

Results: Influenza vaccination rates improved, but HPV vaccine rates remained stable and MenB vaccine rates decreased compared with the previous year. Clinicians demonstrated a significant increase in knowledge of MI techniques after a targeted educational intervention. Repeat measures indicate the potential for sustained improvement when ongoing reinforcement is provided.

Conclusion: MI can be an effective part of a strategy to increase vaccination rates.

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.

Cancer survivorship has been identified as separate stage in cancer treatment posing unique issues that arise from the diagnosis of cancer, as well as late effects associated with treatments. Evidence shows that cancer survivors demonstrate suboptimal follow-up care, and report high levels of unmet needs related to their cancer experience. To improve care for the increasing number of cancer survivors in the United States, survivorship care plans (SCPs) have been proposed as way to strengthen care coordination and improve patient outcomes.

Research suggests that SCPs have favorable impact on patient satisfaction and quality of life, however little research to date investigates the utility of SCPs in improving patient outcomes, adherence to follow-up recommendations, or patients’ confidence in self-care management. To further understand the role of SCPs in survivorship care, a pilot implementation of SCPs in colon cancer patients was implemented to gather data on the identified gaps.

There is an increasing number of cancer patients outliving their diagnosis and treatment and requiring more support as they transition to cancer survivors. To bridge this gap, survivorship care plans should be provided to all cancer survivors to provide post treatment plans of care, recommendations, and resources (Commission on Cancer, 2016). A quality improvement project was implemented in the urology practice of a National Cancer Institute-designated, academic hospital in Phoenix, Arizona to provide survivorship care plans to prostate cancer patients with surgical intervention as their cancer treatment.

Through interprofessional collaboration, the process change was designed and implemented with the residents and Physician Assistants of the urology practice. There was a 93% adherence rate in delivering the survivorship care plans during the project. The “Confidence in Survivorship Information” questionnaire was used to measure the patients’ confidence in survivorship information prior to and after receiving a survivorship care plan. A paired t-test showed statistical significance in improvement in confidence in the knowledge of long-term physical effects of cancer treatment, strategies for preventing and treating long-term physical effects, and resources available for family members who may be at risk. The project will continue in order to meet requirements for cancer programs established by the Commission on Cancer (Commission on Cancer, 2016).

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.

Cancer survivors meet survivorship with uncertainty due to a lack of uniform information provided post cancer treatment. The implementation of survivorship care plans (SCP) has been recognized by key stakeholders as the solution to transitional uncertainties. In fact, to achieve accreditation by the Commission on Cancer (CoC) cancer centers are required to deliver SCPs to cancer survivors within a year of their treatment completion. Research demonstrates SCP delivery results in significant improvement in patient satisfaction, coordination of care, and survivorship care knowledge.

In order to meet CoC standard 3.3 and bring understanding to SCPs function in cancer survivorship care a quality improvement project was initiated within an Arizona cancer center. SCPs were delivered at a survivorship visit to adult breast cancer patients. SCPs affect on survivors’ confidence in cancer self-care knowledge and care satisfaction was evaluated as well as the organization’s adherence to CoC standard 3.3 requirements. Identified survivors were scheduled for a survivorship visit where a SCP was delivered by a oncology provider.

Survivors perceived confidence in knowledge and satisfaction was measured using the modified 16-item Confidence in Survivorship Information Questionnaire (CSI). Questionnaires were completed pre and post survivorship visit. A paired t-test analysis was used to evaluate SCP effectiveness. There was an increase in the delivery of SCPs from zero to 57 with an 84 percent SCP delivery from August 2017 to January 2018. Survivors and providers verbalize value in SCPs.

No statistical significance was found in the comparison of SCPs affect on survivors’ confidence in cancer self-care knowledge and care satisfaction to that of standard follow-up care; however, when comparing the pre/post questionnaire averages an improvement was noted across the board.The prospect of this project is to unveil the impact SCP delivery at a survivorship visit has on the selected metrics. This project aids as a director for organization wide implementation for CoC standard 3.3 requirement compliance.