Nursing (Doctor of Nursing Practice)

Cardiovascular disease (CVD) is the number one killer of women. Surprisingly, only about half of women are aware of this risk. Statistically, heart disease kills about 1 in 5 African American and Caucasian women. Lifestyle behavior choices such as obesity, lack of exercise, consuming an unhealthy highly processed diet, smoking, and an intake of greater than 1 drink per day of alcohol increases a women’s risk for CVD. These risk factors are avoidable. These lifestyle behavior choices are modifiable and with improvements to each behavior they will decrease the women’s risk. Health and Wellness Coaching is a proven intervention to improve lifestyle behaviors that negatively impact chronic medical conditions. The development of a tailored lifestyle self-management intervention by a Nurse Practitioner in a Nurse Practitioner Wellness Clinic will address each of the lifestyle behavior choices to ultimately decrease the risk of cardiovascular disease and provide education that allows these changes to be enduring.

Background: Substance use disorders have increased in the U.S. in the past 20 years, with opioid abuse causing over 70,000 deaths from 1999 to 2019. The growing public health problem necessitates developing a patient-centered educational toolkit. Patients on benzodiazepines who are at increased risk of morbidity and mortality are not engaged in their benzodiazepine management and need a specific educational tool to provide the necessary knowledge for medication management. In addition, there is currently no patient education to improve benzodiazepine safety or evidence-based program to enhance the partnership between the prescriber and the patient in many offices. Method/Design: The investigator developed an evidence-based patient education toolkit to enhance patients' knowledge about the safe use of Benzodiazepines and the risks of chronic Benzodiazepine use. Forty-one participants completed a voluntary pre, and post-survey focused on benzodiazepine-related knowledge and willingness to decrease or cease use. This improvement project aimed to (i) educate and improve the patients' understanding of safe Benzodiazepine use. (ii) Increase patient's readiness to decrease or ease long-term Benzodiazepine use. Participants: A convenient sample of 41 patients prescribed benzodiazepines at the behavioral health clinic was selected. Results: Results of linear regression indicated that patients improved their knowledge regarding safe benzodiazepine use after using the patient-centered toolkit. However, no statistically significant changes were observed in patient willingness to decrease or cease benzodiazepine use. Conclusion: The patient-centered toolkit is useful in improving patient knowledge regarding safe usage of benzodiazepines. However, the toolkit was not beneficial in changing the patients’ willingness to cease or decrease benzodiazepine usage. Nevertheless, findings are helpful in nursing practice and should be used to inform current practice. Future investigators should improve the toolkit by completing projects focused on how the toolkit can be made more effective or used in more focused interventions.

This researcher described the current Fee for Service (FPS) Model to gain information regarding Nurse Practitioner Service awareness in Pennsylvania and introduced the practice model of Direct Primary Care (DPC). The respondents provided information related to the research question of: What are community members' knowledge of alternative pay models for primary care services provided by a Nurse Practitioner? What are community members' willingness to participate in alternative pay models for primary care services rendered by a Nurse Practitioner? The research showed access problems as >70% of respondents indicated difficulty to scheduling an appointment taking more than 24 hours. It was determined that >28% of respondents found the DPC model more attractive than their current care model, an example of perceived value. This research showed scalability potential meaning other Nurse Practitioners who wish to pursue the DPC practice model in their geographical area could reproduce similar data collection efforts to learn the perception in their state or locality. It is believed that burnout associated with healthcare providers is high and DPC provides an alternative practice model to curb burnout, engage patients and heighten health outcomes while focusing efforts on a smaller practice size., Copyrights are retained by the author. Please contact Neal Garverick for further use of this material.

Clinical inertia is the failure to initiate or intensify treatment in a timely manner in people with type-2 diabetes mellitus (T2DM) in primary care (PC) where collaborative care can be an approach to overcome inertia. Diabetes care network (DCN) is a telehealth based collaborative care model to address clinical inertia in the PC environment. In DCN, initial care was delivered via E-Consult by hub diabetes team for Veterans with A1c of 9% or higher and the longitudinal collaborative care delivered by PC liaison with weekly team huddle. To study the difference in the clinical outcomes with DCN vs PC practices, we compared the DCN cohort (97.7% male, 90.8% white, with a mean age 67.2 (8.9), with a PC cohort (100% male, 94.9% white, mean age: 68 year (10.5), with A1C >9%). Methods: Means (SD), frequencies. and percentages were presented. The DCN cohort had a significant decline in the baseline A1C of 10.2% (1.4), to 8.1% (0.99), 7.6% (0.96), 7.5 % (0.86) at 3, 6, and 12 months while A1c in PC cohort stayed poor with baseline A1C of 10.1% (0.89), to 10.2% (1.69), 9.7% (1.74) and, 9.5% (1.83) at 3, 6, and 12 months. Patients who achieved A1c less than 8% in DCN cohort were 38 (43.6%), 56 (64%), and 56 (64%) at 3, 6, and 12 months and were 1(1.7%), 5(8.5%), and 6(10.2%) at 3, 6, and 12 months in PC cohort. An A1c of less than 7% was achieved in DCN cohort in 10 (11.4%), 21 (24.1%), and 23 (26.4%) patients at 3, 6, and 12 months and only 1(1.7%), 0(0%), and 0(0%) patients achieved A1c less than 7% at 3, 6, and 12 months in PC cohort. Our study shows participation in the DCN telehealth program for 1 year was associated with significant improvement in A1c. This improvement was not seen within the PC with traditional care practices. Thus, addressing clinical inertia in PC will need a paradigm shift in current practices. The proposed collaborative approach of DCN can overcome clinical inertia in PC and improve care for people with T2D by supporting PC access to specialty care expertise, decreasing the burden of diabetes care for patients and PC providers.

During the COVID-19 outbreak in the spring of 2020, the nursing department responsible for facility-wide heart failure (HF) interdisciplinary communication was disbanded and redirected to other hospital needs. With that change and the subsequent lack of cohesive educational efforts, the hospital readmission rate climbed to 29.85%. This hospital system has consistently had readmission rates greater than the Centers for Medicare & Medicaid Services (CMS) national benchmark of 21.9%, which is both detrimental to our patients and the hospital to incur readmission penalties yearly. Before this program began there was no process to transition care from inpatient to outpatient for the HF population; key members that touched HF patients operated in silos. Based on consistently high readmission rates and the need for improved outcomes, a comprehensive HF discharge program was designed and implemented house-wide. Transitional care coordination includes providing education, scheduling post-discharge follow-up appointments, and providing HF toolkits. There was a retrospective analysis of data three months after the implementation of QI initiatives. Our facility’s all-cause 30-day readmission rate has progressively declined by 7.63% since the HF transitional program’s implementation (Study period 25.37% down to 17.74%). Readmission average rate for 2019 was 24.9% (n=241) (July 6-September 30, 2019) and compared to after implementation in 2020 was 22.56% (n=195) (July 6-September 30, 2020). Overall, we have found having an advanced practice provider (APP) led multi-disciplinary program to be the best practice for the HF population while improving outcomes and the ability for self-care while decreasing 30-day readmission.

Background: According to the Centers for Disease Control, (CDC, 2018) at least thirty percent of outpatient antibiotics are unnecessary. A retrospective 2018 study by Incze, M.A., Redberg, R.F. and Katz, M. found forty nine percent of antibiotic prescriptions in the urgent care setting were for inappropriate diagnosis. The aim of this study was to educate providers on one method of reducing antibiotic prescriptions and incorporate new patient instructions into the electronic health record. Participants included physicians associates and nurse practitioners.
Methods: The Quality improvement approach of Plan Do Study Act was utilized for this project. A literature review was completed to study methods of antibiotic stewardship. The electronic health record system was queried for delayed prescribing discharge instructions. Informal discussions among providers revealed absence of a cohesive approach to reducing unnecessary prescriptions for antibiotics.

Interventions: A PowerPoint was emailed to all providers on the use of delayed prescribing for antibiotics along with a Likert-Scale survey on provider perceptions of implementation. New instructions for patients on delayed prescribing of antibiotics was added to the existing electronic health record system. For a period of 30 days the number of times delayed prescribing instructions sheets were printed for patients was monitored along with the number of patients seen at each location. The provider survey was also reviewed.

Results: Provider survey demonstrated favorable attitudes toward antibiotic stewardship. The delayed prescribing instruction set was utilized twenty-seven times over the thirty-day period. There were 2,579 patient encounters during the study for a 0.9% utilization rate.

Conclusions: This was a new process in the clinic where the study was completed and though the utilization was low there was favorable consensus among providers on the value of antibiotic stewardship. There are many opportunities going forward including tracking diagnosis codes along with antibiotic prescriptions and following up to determine how many delayed prescriptions were filled. This research can provide a starting point for any outpatient facility looking to decrease rates of antibiotic prescribing.

Long-acting injectable antipsychotics (LAIs) are underutilized pharmacological treatment options for those with schizophrenia. Research examining psychiatric prescribers' relationship with LAIs hypothesized that their knowledge deficits, uninformed attitudes, and poor prescribing practices contribute to the underutilization of LAIs in clinical practice. There is a gap in the literature regarding educational interventions to address psychiatric prescribers' knowledge deficits, uninformed attitudes, and poor prescribing practices. The purpose of this Doctor of Nursing Practice (DNP) research project, based on the Knowledge to Action Framework, was to develop and evaluate the impact of a web-based educational toolkit on the knowledge, attitudes, and practices of psychiatric prescribers. A seven-part web-based module that included a presentation of the created educational toolkit regarding LAIs and a before and after knowledge, attitudes, and practices questionnaire was hosted on an online-open source learning management system and disseminated to psychiatric prescribers. Findings indicated that the web-based educational toolkit slightly improved the knowledge, attitudes, and practices of psychiatric prescribers regarding LAIs. It also revealed a relationship between a positive change in attitudes and psychiatric prescribers practicing in a hospital setting. This DNP research project reflects the essentials of the DNP degree. It contributes to the body of knowledge of psychiatric nursing, created a lasting reference tool for prescribing LAIs, filled gaps in the literature regarding LAIs, supports the use of continuing web-based education and toolkits, and serves as a catalyst for other studies regarding LAIs.

Nurse residency programs (NRPs) have been instrumental in assisting to bridge the theory-to-practice gap commonly experienced by new graduate nurses (NGNs). NRPs have also proven useful in improving retention, work satisfaction, confidence, and competence (Spector, et al., 2017; Ulrich, et al., 2010; Rosenfeld, & Glassman, 2016). Despite the overwhelming literature to support implementation of NRPs in all hospitals, to date, in the United States, only 31 hospital sponsored NRPs are accredited by the Commission on Collegiate Education in Nursing (CCNE) (AACN, 2019). Currently, public documentation on the number of NRPs accredited by the American Nurses Credentialing Center (ANCC) are unavailable. Additionally, in Pennsylvania, only 2 hospital sponsored NRPs have obtained national accreditation. NRP accreditation holds health care organizations accountable and proves these programs have demonstrated quality. For an organization to undergo a significant change initiative, such as accreditation, a state of readiness must be present or created (Franquiz & Seckman, 2015).

Migraines are a common and debilitating medical issue. Many patients are turning to complementary and alternative medicine to either augment or replace conventional medical treatment for this. However, it is unclear what their primary care providers’ attitudes are toward the use of CAM and the PCP’s knowledge base in this area. This study was designed to determine PCPs’ attitudes towards CAM and if a brief educational presentation regarding CAM modalities frequently used for migraines had any impact on their attitude towards CAM. There was a pre survey, a Power Point presentation discussing common CAM used for migraines, and a post survey. This was a small study, with 13 participants completing the pre survey and 10 completing the post survey. There was no significant difference between the pre and post intervention groups (p=0.46, significance level of <0.05). However, both groups had a mostly favorable attitude towards CAM. Gender, work setting, and credentials did not impact attitudes towards CAM. Acupuncture, relaxation therapy, massage, and chiropractic care were the CAM modalities that the providers felt the most comfortable discussing. The findings from this study can be used as a guide for future educational offerings and CAM services in the area. Suggestions for future research include offering a continuing medical education credit to boost participation.