Capstone Project: Assessment of an Orthopedic Primary Care Fellowship for Nurse
Practitioners
DNP Student(s): AJ Benham & Kathleen A Geier (Winners of the Pegge Shuman
Houser Award)
Abstract:
The literature reveals that in the face of growing demand for musculoskeletal care in an
aging population, clinicians lack adequate preparation to confidently and competently
manage common orthopedic conditions in primary care settings (Freedman & Bernstein,
1998; Freedman & Bernstein, 2002; Lynch, Schmale, Schaad, & Leopold, 2006).
Providing focused orthopedic education to primary care physicians has been shown to
improve both confidence and competence in delivering musculoskeletal care (Lynch et
al., 2006). The purpose of this study is to assess primary care nurse practitioners’
(NPs’) musculoskeletal knowledge and confidence, and to determine if providing
focused orthopedic education in the form of a post-masters fellowship will improve their
knowledge, and confidence.
Subjects were recruited from a group of NPs participating in a pilot presentation of the
Orthopedic Primary Care (OPC) Fellowship. A quasi-experimental within subjects
design was used to compare subjects’ pre- and post-program responses to surveys
measuring orthopedic knowledge and confidence. Demographic data were collected for
investigation of potential influence of extraneous variables on subjects’ orthopedic
knowledge and confidence.
The knowledge and confidence surveys used were identical to those developed and
validated by United States (U.S.) medical schools for assessment of physicians’
orthopedic knowledge and confidence (Freedman & Bernstein, 1998; Lynch et al.,
2006). Survey data were collected and stored online. Subjects created unique
identifying numbers allowing for comparison of individual pre- and post-survey
responses. An independent data analyst was engaged to compile and analyze survey
results. Results indicate that, like their physician colleagues, primary care NPs can
improve musculoskeletal knowledge and confidence with focused education and
practice opportunities.
Capstone Project: Patient Empanelment: A Strategy to Improve Continuity and Quality
of Patient Care
DNP Student: Ellen Christiansen (Winner of Outstanding Capstone Project Award)
Abstract:
Purpose: The purpose of this study was to determine the effect of patient empanelment
(where each patient is assigned a designated primary care provider) on continuity and
quality of care.
Background: Research indicates that patients benefit from a long-term relationship with
a primary care provider (PCP), and that continuity of care results in improved health
maintenance and decreased hospitalization (Saultz & Lochner, 2005). Nonetheless, the
system of care in some federally-qualified community health centers (FQHCs) tends to
undermine continuity of care. Health care services are provided by any provider who
happens to be available, care is fragmented, no single provider is responsible for a
patient’s treatment outcomes, and provider-patient relationships are not fostered.
Methods: The established patients in three rural FQHCs were empaneled to designated
PCPs and care teams. This study used a quasi-experimental pre-intervention/postintervention design to compare the continuity and quality of care for the FQHCs’
patients before and after empanelment. Continuity and quality of care indicators
included percentage of patients’ visits with their designated PCPs, and completion of
cervical, colorectal, blood pressure, and other laboratory screenings. Data were
collected at baseline and 6 months post-empanelment.
Results: After six months, 100% of the FQHCs’ established patients had been assigned
a designated PCP, and quality indicators were improving in every category.
Discussion: The results of this study tended to support the importance of continuity of
care with a designated PCP.
Capstone Project: BRCA Risk Assesment in Primary Care: The Value of an
Educational Module to Address Clinical Application
DNP Student: Reena Haymond
Abstract:
Clinical practice guidelines by the U.S. Preventative Task Force advise that women be
screened for increased risk for harmful BRCA gene mutations that significantly increase
a woman’s predisposition to hereditary breast cancer and/or ovarian cancer , so that
risk reduction options can be implemented. Unfortunately, research indicates that
knowledge deficit among nurse practitioners may explain current evidence indicating
overall low utilization of this clinical practice guideline in primary care settings.
The purpose of this project was to develop and evaluate an educational module
intended to increase nurse practitioner knowledge of BRCA risk evaluation and
management in order to facilitate adherence to clinical practice guidelines. A single
group pre-test post-test study was conducted at a continuing education seminar to
determine if a newly developed educational module is an effective means of increasing
knowledge regarding this subject matter. Pretest and posttest data assessed nurse
practitioner knowledge from a convenience sample of 49 participants.
This data was analyzed to determine the effectiveness of the educational module.
Participants scored a mean of 11 (23%) on the pretest and a mean of 34.67 (85%) on
the posttest out of a total of 41 possible points, demonstrating increase in knowledge of
BRCA risk evaluation and management following participation. Results demonstrated a
statistically significant increase in knowledge (p < 0.0001, paired t test).
These results support the utilization of the newly developed educational module as an
effective strategy for increasing primary health providers’ knowledge of this subject
matter. Nurse practitioners with increased knowledge of this subject matter may be
better positioned to evaluate and provide care for women with increased risk for a
BRCA gene mutation, in adherence with clinical practice guidelines.
Capstone Project: The Development, Education, Implementation, and Evaluation of
Evidence-Based Practice for the Prevention of Hospital Acquired Pressure Ulcers
DNP Student: Jodi Hein
Abstract:
Background: The development of hospital acquired pressure ulcers (HAPUs) has been
associated with poor care. The National Quality Forum (NQF) considers HAPUs never
events. The federal government has identified HAPUs as a public health concern. In
addition, the Centers for Medicare and Medicaid (CMS) will not pay for HAPUs. Promise
Hospital of East Los Angeles (PHELA) has a high HAPU rate and the nursing staff has
lacked education in pressure ulcer prevention (PUP) and treatment.
Purpose: The purpose of this project was to develop and implement a pressure ulcer
prevention program (PUPP) in a long-term acute care (LTAC) hospital and assess the
effectiveness of this program on HAPU rates.
Methods: A clinical practice guideline (CPG) tool was developed and the nursing staff
were educated and trained in skin assessment and the use of the CPG tool. Using a
quasi-experimental design, we compared HAPU rates pre-education to HAPU rates
post education and the use of the CPG tool.
Results: The data were collected from January 2012 through October 2013. On
average, HAPU rates decreased from 3.2% to 1.8% per month. There was a positive
correlation between education and use of the CPG tool to a decrease in HAPU rates.
Discussion: This project demonstrated successful outcomes with a decrease in the
HAPU rates per month. Using an evidence-based CPG tool along with education is an
effective way to lower HAPU rates and improve patient care in LTAC settings. Applying
evidence-based research is an effective way to improve knowledge and understanding
and will improve treatment options and patient care.
Capstone Project: The Nursing Engagement Development Project:
Developing, Nurturing, and Sustaining Work Engagement
DNP Student: John Hurley
Abstract:
The focus of this project was the development of work engagement among staff nurses
in a pediatric emergency department. The study addressed the following question, “Can
levels of work engagement be increased through the creation of, and participation in a
nursing engagement development project?”
The project was of six weeks duration and included weekly reflective reading and the
writing of reflective journals on the topic of work engagement. The participants were
sixteen nurses with a minimum of five years of staff nursing experience. The
participants all were concurrently employed in the same pediatric emergency
department.
The design was a one group quasi-experimental design that included quantitative and
qualitative data analysis. The quantitative data analysis used a pre-intervention and
post-intervention survey focused on work engagement and burnout. The qualitative data
analysis employed descriptive and interpretive evaluation approaches. Both the
quantitative and qualitative evaluations demonstrated an increase in levels of work
engagement at the completion of the project. The conclusion of the study is that the
project was an effective way to develop work engagement among the staff nurses of
this department.
Capstone Project: A System Change to Expand Scope of Practice in the Retail Clinic
to Include Evaluation and Management of Hypertension for Patients that Otherwise
Lack Access to Car
DNP Student: Lena Jesrani (Winner of the Erin Fry Memorial Award)
Abstract:
A pilot study in one retail clinic was conducted to determine whether a change in scope
of practice could successfully expand the access of care to patients with chronic health
problems such as hypertension.
The following were developed for use in this study: an algorithm to determine need for
hypertension treatment, computerized decisional support presenting guidelines for
treatment by the Nurse Practitioner (NP) based on best practice guidelines, illness
perception guidelines as a patient self-report to guide medical counseling efforts, followup procedures for patient care, and a training module to introduce the changes in policy
and practice. Suggestions are made for effective coordination with policymakers and
quality management committees.
The present study may pave the way for future studies to determine if retail clinics are
an effective means of management of chronic condition in patients who lack access to
health care.
Capstone Project: A Certified Registered Nurse Anesthetist Policy Brief Identifying
Barriers and Solutions for an Opt Out in Nevada
DNP Student: Phyllis Kantor
Abstract:
In the Institute of Medicine (IOM) 2011 Report titled “The Future of Nursing: Leading
Change, Advancing Health” the IOM recommends that advanced practice nurses should
practice to the full extent of their education and training. Currently in Nevada, barriers to
Certified Registered Nurse Anesthetists (CRNA) ability to practice include: opposition
from the American Society of Anesthesiologists (ASA), critical access hospitals (CAH)
who do not employ CRNAs and surgeons’ inability to practice without access to
anesthesia services. These barriers pose a significant threat to CRNA practice in rural
Nevada.
The purpose of this 2-year descriptive correlational study was to provide the framework
for a policy brief that identifies the barriers to anesthesia care and explores solutions,
such as the opt out from the physician supervision requirement imposed by the Centers
for Medicare and Medicaid Services. Data was gathered from a convenience sampling
of 106 CRNAs from three different cohorts.
The findings of the data indicate that 94% of Nevada’s CRNAs feel qualified to practice
without the supervision requirement identifying the most common barrier to practice as
anesthesiologist/surgeon supervision issues. Furthermore, 80% of Nevada’s CRNAs
indicated if barriers to practice were removed they would support an opt out. The state
association presidents identified opt out as their solution to barriers to practice that
resulted in a 64% rise in practice opportunities and a surge in satisfaction rates up to
91%. These findings indicate that Nevada’s CRNAs may be prepared for independent
practice.
Capstone Project: Impact of an obstetric life support program on the knowledge level
of the perinatal nurses
DNP Student: Raji Menon (Winner of Outstanding DNP Student Award)
Abstract:
Background: Resuscitation of obstetric patients is challenging when compared to
resuscitation of non-pregnant patients. The alarming trend of rising maternal mortality in
United States combined with the fact that at least half of the maternal deaths are
preventable emphasizes the need for increased education among obstetric caregivers.
Purpose: This study utilized a quasi-experimental, one-group pre-test, post-test design
by using a nine-item survey, developed by researchers from Stanford University Medical
Center, California. Perinatal nurses (N=60) received training to enhance knowledge and
skills to deal with maternal arrests. Participants were tested for knowledge immediately
before and immediately after the training program.
Results: Data were analyzed using t-tests and analysis of variance (ANOVA). The
specialized course was equally effective for those who had prior experience in obstetric
resuscitation and those who did not have the resuscitation experience (F-statistic of F(df
1, 54) = 3.718, p = 0.059). Overall, the partial eta squared of 0.55 represented a strong
effect of the specialized educational program focused on obstetric cardiopulmonary
resuscitation.
Conclusion: The specialized course made a significant difference in the post-test scores
from the pre-test scores for all perinatal nurses, regardless of prior obstetric
resuscitation experience. This increased knowledge has the potential to reduce
maternal mortality rates if applied in all obstetric care settings. Further research is
needed to determine if knowledge is retained and to determine if mortality rates are
affected when staff are trained; however, this training program may serve as a prototype
for similar environments in other health care settings.
Capstone Project: Nursing Education to Improve Early Recognition and Management
of Pediatric Sepsis
DNP Student: Joni Williams
Abstract:
Sepsis affects millions of children every year and is a leading cause of morbidity and
mortality worldwide. Each year in the US sepsis is responsible for thousands of
hospitalizations and more than $2 billion in health care costs. Although
recommendations and guidelines have been published there are still challenges and
gaps in care regarding pediatric sepsis. Barriers include knowledge deficits in the
recognition of the symptoms, delays obtaining orders and diagnosis, laboratory results,
and timely administration of medications. Pediatric sepsis is recognized as a major
public health problem, leading cause of death, and significant challenge in the US
despite advances in knowledge, guidelines, and treatments.
The purpose of this project was to increase the knowledge, skill, confidence, and
competence of pre-licensure nursing students in the early identification and
management of pediatric sepsis. Early detection has been demonstrated to decrease
morbidity and mortality improving outcomes for children. Data were collected using
convenience sampling at a nonprofit university in a school of nursing, in northern
California. The study population was pre-licensure nursing students enrolled in a
pediatric course. The design of the study was quasi-experimental using a sepsis
knowledge questionnaire and METI SET, a didactic presentation, simulation and
debriefing activities. It was hoped the conclusion of the project would reveal educational
innovations such as didactic presentations used in conjunction with simulation/
debriefing activities would succeed in achieving increased knowledge, skill, confidence,
and competence in the early management and recognition of pediatric sepsis.