Doctor of Nursing Practice (DNP) Final Projects

Background: Neonatal hypoglycemia (NH) is a common problem in the newborn period that resolves by 24-48 hours of life. Infants with known NH risk factors take longer to achieve blood glucose homeostasis. The leading cause of neonatal intensive care unit (NICU) admissions in otherwise healthy term and late preterm infants is NH.

Purpose: To determine the efficacy of dextrose gel in addition to oral feedings in NH treatment as compared to the previous practice of oral feedings alone. Lewin's change theory was used in staff education and project implementation.

Methods/Search Strategy: A keyword search of CINHAL, Cochrane, and PubMed with restrictions to English and publications within 5 years revealed supportive data for the practice change. IRB approval obtained prior to the practice change. Nurses screened all newborns for NH risk factors at birth at a tertiary hospital in the southwestern U.S. Infants with specific criteria received oral dextrose gel with timed follow-up blood glucose levels following an NH algorithm.

Findings/Results: Two groups of infants with similar gestational ages, birth weights, and risk factors for NH were compared pre and post-implementation of the EBP change. Infants in the first group (n=27) were all born prior to the start of the project and therefore were all treated with IV dextrose in the NICU after failing to maintain blood glucose levels within normal ranges with oral feedings alone. The second group of infants (n=27) was treated based on an updated NH algorithm after implementation of the use of oral dextrose gel. Of those 27 infants, 24 received oral dextrose gel for NH treatment. Of respiratory distress in addition to NH so these infants were excluded in the statistical analysis of NICU admissions. Therefore the post-implementation group only had 2 admission for primary diagnosis of NH. When comparing admission rates for hypoglycemia between the two groups, the first group had a 100% admission rate while the second group (those who received oral dextrose gel) only had a 9% admission rate for neonatal hypoglycemia (p<0.001). Upon further investigation it was found that these 2 infants admitted to the NICU with the diagnosis of NH had multiple risk factors present, including being infants of diabetic mothers which means they likely experienced refractory hypoglycemia after treatment with oral dextrose gel secondary to hyperinsulinism. Hyperinsulinism can lead to persistent and profound hypoglycemia in the newborn that is more difficult to treat, which is of clinical significance.

Implications for Practice: Early identification with timely follow-up blood glucose levels following intervention may be critical to successful treatment without requiring NICU admission. Nursing education and parental support are also paramount to success. If the change in NICU admissions for NH is statistically significant with a larger sample size, results may be shared with other facilities that traditionally transfer these infants for a higher level of care.

Implications for Research: Studies with larger sample size may generate more generalizable data with fewer outliers. Studies comparing neurodevelopmental outcomes among infants who received different NH treatments are necessary to determine long-term safety.

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.

Children often present to the emergency department (ED) for treatment of abuse-related injuries. ED healthcare providers (HCPs) do not consistently screen children for physical abuse, which may allow abuse to go undetected and increases the risk for re-injury and death. ED HCPs frequently cite lack of knowledge or confidence in screening for and detecting child physical abuse.

The purpose of this evidence-based quality improvement project was to implement a comprehensive screening program that included ED HCP education on child physical abuse, a systematic screening protocol, and use of the validated Escape Instrument. After a 20-minute educational session, there was a significant increase in ED HCP knowledge and confidence scores for child physical abuse screening and recognition (p < .001). There was no difference in diagnostic coding of child physical abuse by ED HCPs when evaluating a 30-day period before and after implementation of the screening protocol.

In a follow-up survey, the Escape Instrument and educational session were the most reported screening facilitators, while transition to a new electronic health system was the most reported barrier. The results of this project support comprehensive ED screening programs as a method of improving HCP knowledge and confidence in screening for and recognizing child physical abuse. Future research should focus on the impact of screening on the diagnosis and treatment of child physical abuse. Efforts should also be made to standardize child abuse screening programs throughout all EDs, with the potential for spread to other settings.

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.

Randomized controlled trials and systematic reviews of paired education involving both diet and activity recommendations have shown significant reductions in the advancement of adult (age 18 to 80) prediabetes to type 2 diabetes mellitus (T2DM). Paired education on diet and activity has been effective for persons from diverse races, ethnicities, and levels of education. For this project, the paired education focused on the dietary guidance of the Whole 30 plan and the current exercise/activity recommendations of the American Diabetes Association (ADA). The ADA recommends 30 min 5 x week or 60 min 3 x week of exercise, with no more than 48 hours between exercise occurrences.

Ten adults with HbA1C between 5.7%-6.4%, levels specified by the ADA as prediabetes, were invited to participate in the project at an outpatient wellness practice. Participants took a pretest on basic food and activity knowledge, received educational sessions on the Whole 30™ plan and activity recommendations from the ADA, then completed a posttest. Participants were scheduled for one month follow ups. At the 3 month follow up appointment, repeat HbA1C was drawn. Most of the patients (7/10) completed return appointments at the 3-month time frame. Statistically significant results were seen in diet and exercise knowledge using a paired T-test. Clinically significant reductions were seen in HbA1C averages as well as weight, BMI, and glucose levels.