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.

As the incidence of acute and chronic wound conditions rises and wound dressing protocols become more complex, uninsured patients lacking access to specialty wound care are challenged to manage their own wounds. Understanding multistep dressing change protocols may be inhibited by low health literacy. Low health literacy is associated with reduced disease knowledge and self-care. Little evidence of health literacy effects on wound patients is available nor are literacy-sensitive educational interventions that address wound knowledge and self-care. Improved outcomes occur in all health literacy levels in other diseases with the use of literacy-sensitive educational interventions that incorporate more than one literacy strategy over multiple sessions. To examine the effectiveness of a literacy-sensitive wound education intervention on wound knowledge and self-care, an evidence-based pilot project was conducted in an urban wound clinic.

A convenience sample of 21 patients received a literacy-sensitive wound education intervention consisting of spoken and written communication over several sessions. Instruments measured health literacy level, wound knowledge, dressing performance, and wound healing status. There was a significant increase in wound knowledge scores in all literacy groups from baseline to visit two (p < .01) and four (p < .01). Dressing performance scores remained consistently high through visit four in all literacy levels. All participant’s wounds progressed toward wound healing significantly from baseline to visit two (p < .01) and four (p < .01). Incorporation of a literacy-sensitive education intervention with supportive literacy aids over several sessions supports improved wound knowledge and dressing self-care and can affect healing in patients of all health literacy levels.

Functional GI disorders are categorized as a group of chronic symptoms that are considered to have no abnormalities that can account for patient’s illnesses. Included in this category are those patients with irritable bowel syndrome. Functional GI issues are an important public health concern as they are becoming increasingly more common; they can be disabling and can cause significant socioeconomic burden in regard to health care costs, productivity and disability. There is strong evidence that probiotics have the potential to reduce IBS symptoms. Unfortunately, probiotics are underutilized in the clinical setting.

The purpose of this project is to increase knowledge and self-efficacy in patients with functional GI symptoms regarding the use of probiotics for symptom management. Patients in an outpatient GI practice in Southwestern United States with chronic functional GI symptoms were shown an educational video regarding the origins and benefits of using probiotics to manage chronic symptoms. Knowledge of probiotics, self-efficacy and willingness to utilize probiotics was measured by asking participants to complete a modified Health Belief Model survey before and after viewing the video. Patient demographics were collected. There were 75 participants (n=75) who participated in the project with a mean age of 40.3 years (SD=15.41), 85% female and 15% male. Wilcoxon signed rank test were used to analyze changes in paired data with significant improvements in self-efficacy (Z=3.93, p< .01), benefits of probiotic use (Z=4.33, p<.01) and decreased barriers to probiotics use (Z=-4.31, p<.01). After participants viewed the educational video, 95% of patients indicated they would try probiotics (CI 95%, p<.01) versus 65% of patients who would try probiotics before viewing video. In conclusion, education regarding using probiotics to manage functional GI symptoms improved patient’s self-efficacy and their willingness to use probiotics to manage their symptoms. Keywords: probiotics, GI disorders, diarrhea, IBS, constipation, abdominal pain, self-efficacy.

INCREASED EDUCATION AND SELF-EFFICACY IN PROBIOTIC USE:
Education and Self-efficacy of Probiotic Use in Patients with Chronic Gastrointestinal Symptoms
Functional gastrointestinal (GI) disorders are categorized as a group of chronic symptoms that are considered to have no structural or biochemical abnormalities that can account for patient’s illness. Included in this category are those patients diagnosed with irritable bowel syndrome (IBS). IBS is chronic GI disorder characterized by abdominal pain accompanied by altered bowel function, gas and bloating without the presence of organic disease (Mapel, 2013). Functional gastrointestinal symptoms typically include complaints of long-standing issues (greater than 3 months) of diarrhea, abdominal pain, constipation, gas and bloating.

Background:
Thirty to fifty percent of cancer patients undergoing chemotherapy will experience
chemotherapy induced nausea and or vomiting (CINV) despite the use of antiemetic prophylaxis Uncontrollable CINV can lead to complications that add extra stress to patients, increase in healthcare costs, and utilization of resources. CINV can lead to chemotherapy dose reductions, treatment delays, chemotherapy changes, or discontinuation of treatment. Guidelines exist to better prevent and treat CINV. Evidence supports the use of guidelines to prevent CINV, however patients still suffer from CINV often due to a lack of guideline adherence.

Objectives:
The purpose of this project was to increase CINV guideline adherence by increasing knowledge of antiemetic guidelines utilizing an educational intervention for providers and nurses at an outpatient oncology office.

Methods:
A brief educational intervention on CINV and recommended NCCN guidelines was
conducted with providers and nurse (n=6) at an oncology practice in Southwestern United States. An evaluation to assess change in knowledge was performed using a pre and post test format. Statistical analysis was performed using descriptive statistics, McNemar tests and Wicoxan Signed Rank Test.

Findings:
There was a significant effect on knowledge of NCCN antiemetic guidelines (Z=-1.89, p=0.059, mean 2.5) post intervention. There also was a significant impact on likelihood to use guidelines in practice (Z=-1.89, p=0.059, mean 2.5). Increasing awareness and likelihood to CHEMOTHERAPY INDUCED NAUSEA AND VOMITING 3 follow recommended guidelines may improve CINV symptoms in patients undergoing chemotherapy and improve the treatment outcomes for these patients.

Type II Diabetes Mellitus has detrimental effects on the human body. A1C levels reflect the attachment of glucose to hemoglobin-the protein in red blood cells that carries oxygen. Elevated A1C levels are an indicator of how controlled diabetes is. Uncontrolled diabetes not only affects glucose levels, but has detrimental repercussions in other organs of the body, causing peripheral vascular disease, risk of developing dementia, periodontal or gum disease, skin infections, neuropathy in lower and upper extremities, renal damage, erectile dysfunction, decreased blood flow, and cardiac conditions among others.

A diet low in calories positively affects glucose levels in the body. Type II Diabetes can be easily controlled when lifestyle modifications are included in the plan of care. Among those modifications, diet is an effective intervention for the management of this condition.
Establishing a diet among the patients that have an elevated A1C is the plan of care and ultimate goal for this project. The Mediterranean diet has demonstrated decreased blood glucose levels, improved weight control and enhanced quality of life.

Skin and soft tissue infections (SSTI’s) are a significant health concern with serious potential implications. Evidence suggests the importance of implementing a severity stratification tool to improve early identification of SSTI’s. The aim of this evidence based project is to examine if educating healthcare staff on the use of a severity stratification tool would increase staff knowledge of SSTI's. The sample consisted of 18 participants, 12 healthcare providers and 6 healthcare staff at a correctional facility in the Southwestern United States. A pre-and posttest design, including an educational session was implemented.

A 14-item multiple choice self-developed questionnaire was used to evaluate participants’ knowledge of identifying and ranking SSTI’s using the CREST tool. A one tail paired t-test was performed to compare the pre-and post-test case study scores for the healthcare provider group. A significant increase from pre-test to post-test case study scores was found (t(13)= -6.19, p < 0.00). Of the healthcare providers, 57% found the tool “moderately helpful.” Of the non-provider sample, 50% found the tool “extremely helpful” and plan to use the tool “all of the time.” The findings of this study suggest that implementing an educational session on a wound severity stratification tool improves staff knowledge and increases the likelihood of the tool being used in practice. Recommendations for future research include larger sample sizes across a variety of regional correctional facilities to further explore the use and knowledge of the tool in practice.