Nursing Doctoral Work

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Adolescent Mental Health: A Community Needs Assessment
(North Dakota State University, 2022) Hammer, Michael
Depression among adolescents has been trending upward with approximately 3.2 million adolescents aged 12-17 having at least one major depressive episode in the United States (U.S.) in 2016. The incidence of depression also rises with age among adolescents, with depressive episodes at 4.8% for 12-year-olds, 11.8% for 14-year-olds, and as high as 18.5% in adolescents aged 17 years. Interventions aimed at understanding mental health needs of adolescents and reducing barriers to care are essential to improve overall health outcomes for this population. The goal of this community needs assessment was to better understand adolescent mental health and determine the needs of adolescents who experience mental health problems in rural areas. A qualitative approach was used to elicit the perspectives of adolescents, healthcare providers, educators, and parents regarding the mental health needs of adolescents in rural North Dakota. Individual, semi-structured interviews were conducted with a total of ten participants from the four target groups. Facilitators to maintaining mental health were identified as support from family/friends, healthy diet, adequate sleep, limiting social media, avoiding video games, and physical activity. Barriers to discussing and accessing mental healthcare included stigma, confidentiality/privacy, shortage of mental health professionals, lack of routine discussion, lack of a standardized curriculum in schools, time, lack of understanding by adolescents, and healthcare provider/parent relationship. Based on the interview results, recommendations were made to school administrators and clinic personnel to address the needs of adolescents in rural areas with mental health problems. Recommendations for school administrators included a universal approach to address students about mental health and implementation of a mentor program. The clinic received recommendations for implementation of telehealth services to expand capabilities and implementation of youth-friendly services to create a more welcoming environment for adolescents. The results of this community needs assessment revealed that adolescents identify anxiety and depression as top health priorities; however, barriers, such as fears of judgement, stigma associated with mental health, and lack of access to care, may prevent them from seeking care. Further research is needed to identify resources and interventions to improve the overall health and well-being of adolescents in rural areas.
Adolescent obesity pathway: Updating clinical practice guidelines in primary care
(North Dakota State University, 2024) Fechtner, Amanda
Obesity has become a public health crisis with the prevalence of pediatric obesity being one in five children in the United States. The effects of the COVID-19 pandemic and widening social disparities are driving obesity rates up. Preventing obesity in children should be priority but despite our society’s best efforts, children are crossing the BMI threshold and entering an obese BMI range. Advances in medication options are showing promising results for adolescents with obesity when combined with a healthy diet and exercise. Additionally, surgical options are proving to be safe and sustainable options for children 14 years and older. Clinicians who care for adolescents have received minimal education on treatment guidelines for adolescents with severe obesity. This evidence-based practice improvement project sought to find out if providing education on assessment and treatment of obesity in adolescents and providing a sample of clinical practice guidelines to reflect the 2023 American Academy of Pediatrics practice guidelines would adequately provide knowledge to increase clinician confidence in treating adolescents with obesity. The primary goal of this project was to increase the knowledge of clinicians about effective weight loss treatments for adolescents, including bariatric surgery, increase clinician confidence in treating adolescents with obesity, and decrease weight bias barriers. An education session was presented which comprised of education on reducing weight bias perceptions, treating pediatric obesity with lifestyle changes and medications, and when to refer to bariatric surgery. Of the 40 healthcare providers that attended the education, five clinicians filled out the pre- and post-survey. The surveys included six questions asking about confidence in discussing, assessing, and treating obesity in adolescents, the Beliefs About Obese Persons tool, and three questions to assess the quality and effectiveness of the education as a whole. The education was found to increase clinician’s confidence in bringing up the subject of obesity, formulating a treatment plan, and using professional language. More education is needed to adequately educate clinicians on when an adolescent should be referred to the bariatric surgery clinic. Additionally, the education decreased the participants’ belief that an individual is solely responsible for their obesity.
Adolescent Sexual and Reproductive Needs in Rural ND: A Needs Assessment
(North Dakota State University, 2020) Pomonis, Hailey Sierra
In order to reduce sexual risk behaviors and related health problems, preventative and educational measures must be implemented to help adolescents adopt lifelong attitudes and behaviors that support their health and well-being. Given the period of adolescence is a time of increased risk, positive health practices are vital. The end goal of this quality improvement project is to help form positive health practices during the period of adolescence, this in turn will create a healthy and strong passageway into adulthood. A qualitative approach was used to elicit the perspectives of adolescents, health providers, educators, and parents regarding the sexual and reproductive health needs of adolescents in rural N.D. Individual, semi-structured interviews were conducted with five participants in each target group. It was evident in the provider interviews that there was a range of approaches to addressing sexual and reproductive health with adolescents. Their approaches ranged from very comprehensive, to more limited in the discussion of sexual and reproductive health with the adolescents they saw in their clinic. The fact that the amount and quality of information adolescents received was entirely dependent upon which individual provider they happened to see means that both consistency and quality of information was compromised. The educators described little to no experience discussing sexually education with adolescents. The only educator participant who actively educated adolescents on sexual and reproductive health was a health educator within a rural school system. The parent participants stated that adolescents need more open and honest education regarding sexual and reproductive health. The adolescent participants gave one-worded responses; they did not expound on any questions they were asked. The interviewer asked for an expansion on their one-worded answers, but the adolescents would repeat what they had said initially. The adolescent participants were asked about sexual and reproductive health messages given to them by either health care providers, educators, or parents. Their responses consisted of abstinence is best, and the consequences of sexual experimentation. If this is the adolescent participants’ truthful answer, it is concerning on many levels.
Advance Care Planning and Advance Directives: Implementing Online Education for Healthcare Providers
(North Dakota State University, 2022) Murphy, Hannah
Advance directives (ADs) summarize goals or preferences for future care regarding life-sustaining treatment and designates a surrogate decision-maker in the event a patient is unable to make healthcare decisions. These legal documents are especially important for providing patient autonomy and allowing people to communicate their medical care preferences to family, friends, and healthcare professionals. Two thirds of Americans have not completed an advance directive and 70% of Americans (more than 1.7 million) die of chronic diseases. Benefits of ADs include: autonomy during end-of-life, honored preferences, enhanced quality of medical decisions, less emotional distress, and even a decrease in healthcare costs. Approximately 60% of patients stated that they are open to talk about advance care planning (ACP); however, only 21% percent of providers reported talking frequently about matters related to ACP or end-of-life care. Literature review findings revealed that providers lack training and education about ADs and ACP conversations, leading to discomfort in skills, confidence, and knowledge about having these essential discussions. The purpose of this practice improvement project (PIP) was to increase nurse practitioners’ knowledge of facilitating ACP conversations, and completion of AD among patients living with a chronic disease, over the age of 65, seen within the primary care setting. A total of 14 healthcare professionals participated in a one-hour educational webinar posted on the North Dakota Nurse Practitioner Association (NDNPA) website over a three-month time period between September 30, 2021 and December 30, 2021. Pre/post Likert scale surveys were administered to each participant electronically via Qualtrics. Confidence Likert scale surveys found the education increased participants’ knowledge, confidence, and understanding of ACP and AD. PIP findings also demonstrated an increase in understanding of the Serious Illness Conversation Guide and an increase in both confidence and likeliness of increasing and initiating ACP conversations with patients. Education on ACP and AD resources should continue to be provided for healthcare providers online. Future research should look into how providing ACP and AD education directly affects AD rates in patients living with a chronic disease, over the age of 65, seen within the primary care setting.
Advance care planning: implementing online education for rural primary care providers
(North Dakota State University, 2024) Kurtz, Jessica
Advance care planning (ACP) can assist patients and their families in navigating personal and medical choices at the end-of-life; however, these conversations often transpire too late. Primary care providers (PCPs) frequently develop extended relationships with their patients, especially those with chronic disease, and possess opportunities throughout a patient’s lifespan to assess when ACP conversations could be initiated. Unfortunately, many PCPs lack confidence in leading ACP conversations, although they are willing to facilitate them. Despite the alarming number of people living with chronic disease and documented benefits of ACP, advance directive completion remains low. According to previous research, online ACP education for PCPs can bridge gaps in end-of-life care by increasing overall perceived knowledge, confidence, and understanding of ACP and advance directives. The purpose of the practice improvement project was to improve rural PCPs perceived knowledge and confidence in facilitating ACP discussions and to increase the completion rate of advance directives among adults living with chronic disease(s) seen within the rural primary care setting. The theoretical underpinning for this DNP project was Lewin’s Theory of Behavior Change. Project implementation occurred within a federally qualified health center comprised of eight clinics throughout rural North Dakota. The project’s design methodology was a quantitative, quasi-experimental study using a convenience sample of eight PCPs employed within the federally qualified health center. Participants could access the ACP educational webinar, surveys, and posttest for four weeks. Four participants (50%) participated in the practice improvement project and acquired continuing education credit from the North Dakota Board of Nursing. The surveys aided in assessing participants’ reported ACP knowledge, confidence, perceived benefits of ACP, and prior experiences in initiating advance directives and ACP conversations before and after viewing the webinar. The outcomes of the practice improvement project objectives were evaluated and demonstrated an increase in participants’ perceived knowledge and confidence of ACP, an increase in PCPs' reported knowledge of the Serious Illness Conversation Guide, and an improved understanding of the role of ACP facilitators.
Advanced Practice Provider Experiences Precepting Nurse Practitioner Students
(North Dakota State University, 2021) Kaspari, Carly Rose
Preceptors for nurse practitioner (NP) students are in increasingly short supply. Enrollment in NP programs has increased at 14.5% from 2008-2017 each year. The increase in NP students has created an increased demand for qualified preceptors and increased competition among other healthcare professional programs for clinical placements. Additionally, clinical preceptors, specifically advanced practice providers (APP) often report feeling unsupported in the role of a preceptor. Support and understanding for preceptors from clinical leadership is imperative as the demand for preceptors continues to grow, clinic leadership must understand preceptor experiences and how to best support APPs who serve in this role.The purpose of this project was to explore the experience of APPs who serve as preceptors to NP students in an outpatient primary care clinic setting. Data regarding the attitudes and experiences of APP preceptors were collected via a quantitative electronic survey. Twenty-two primary care APPs completed the survey and provided valuable insight into the preceptor role. Participants expressed attitudes regarding support from clinic leadership, existing and potential preceptor resources, and incentives and barriers to precepting. The data were analyzed and summarized in a presentation to project stakeholders at the collaborating facility. The Sanford preceptors described the preceptor experience as overall positive and expressed intent to continue precepting. Preceptors reported feeling well supported by clinic administration and graduate nursing faculty and expressed confidence in their ability to interpret precepting policies and NP student clinical objectives. Preceptors ranked intrinsic factors such as enjoyment of the role as a top reason to precept and overwhelmingly ranked time constraints as the largest barrier to precepting. The presentation included research findings and recommendations from the review of literature with strategies for improving the preceptor experience.
Adverse Childhood Experiences Among College Students: Best-Practice Recommendations for Student Health Clinicians
(North Dakota State University, 2021) Ostlund, Rachel Marie
Adverse childhood experiences (ACEs) are highly prevalent and considered a global public health crisis (Forgash, 2015). ACEs are associated with toxic stress resulting in severe impairment of the cardiovascular, endocrine, and immune systems (Asmussen et al., 2020). Consequently, the ten categories of ACEs have been linked to multiple risk factors for unhealthy behaviors and nine of the 10 leading causes of death in adults (Asmussen et al., 2020). A crucial component to mitigating the effects of ACEs is through identification of those exposed. Ideally, screening for ACEs occurs after the age of 18 years and prior to the onset of disease. Thus, the college setting is an opportune time to address ACEs given the prevalence of ACEs and the high rate of unhealthy behaviors occurring among college students (Karatekin, 2017). Many evidence-based practices have been established to address ACEs; however, there remains a gap in specific guidance for the student health setting. Therefore, a needs assessment was conducted to assess existing strengths and resources and identify needs for student health clinicians to address ACEs among college students. A two-phase mixed method design was utilized to obtain data from six clinicians at North Dakota State University Student Health Services clinic using an electronic survey, an informational guide, individual interviews, and a presentation of the results to stakeholders. Findings from the needs assessment informed best-practice recommendations for student health clinicians to address ACEs among college students. Recommendations include the following: 1) enhance clinician understanding of ACEs and trauma-informed care; 2) provide specific guidance for student health clinicians; 3) address barriers to utilizing the ACE screening tool; 4) incorporate the ACE screening tool in the student health setting; 5) identify students with ACEs based on ACE-associated symptoms; 6) assess risk for toxic stress; 7) develop therapeutic relationships; 8) provide evidence-based interventions to regulate the stress response; 9) assist in building resilience; 10) promote protective factors; 11) encourage positive coping mechanisms; 12) educate patients on ACEs, toxic stress, risk for ACE-associated health conditions, and signs of distress; 13) offer referrals as indicated.
Aspirin and Statin Use for Primary Prevention of Cardiovascular Disease
(North Dakota State University, 2022) Carriveau, Natalie Jean
Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the United States and aspirin and statins are well-known medications associated with CVD prevention. There are well-known benefits of aspirin for secondary prevention of CVD, but aspirin’s role in primary prevention remains controversial. The decision to start aspirin for primary prevention is individualized to the specific patient and situation. Statins are a drug used as first-line therapy in cholesterol management, though there is a complicated relationship with adherence due to real and/or perceived safety issues associated with statin use. The decision to start statins needs to be determined on an individualized basis. The United States Preventive Services Task Force (USPSTF) has level B recommendations for low-dose aspirin (81 mg) and level B recommendation for statins in primary prevention of CVD. However, preliminarily updated recommendations for aspirin use in late 2021 are proposing the decision to change aspirin use to a level C recommendation. In addition, the American Heart Association (AHA) and American College of Cardiology (ACC) developed a calculator in 2013 to determine a patient’s 10-year CVD risk. The guidelines coupled with the risk calculator offers providers a valuable decision-making tool. However, despite available guidelines and the calculator, aspirin and statin prescription and adherence remains suboptimal. The purpose of the project was successful adoption of the 2016 USPSTF guideline on aspirin and statin use for primary prevention of CVD by North Dakota State University (NDSU) staff participating in a NDSU Health Screening. The screening collected participant data, recorded data into the calculator, and provided recommendations based off the USPSTF guidelines for participants to discuss with their primary care provider (PCP). Evaluations were performed through use of post-implementation surveys. Results demonstrated proper participant use of aspirin and statins according to USPSTF guidelines, with a majority expressing awareness of the guidelines. Participants reported a positive viewpoint of the calculator and intent to provide results to their PCP. Conclusively, the project supports use of the 2016 USPSTF guidelines regarding the use of aspirin and statins for primary prevention of CVD along with the risk calculator in health screenings and primary care.
Assessing Burnout and Resiliency Among Nurse Practitioners
(North Dakota State University, 2021) Sogard, Kezia Renea
The topic of burnout among medical doctors (MDs) has depicted a strong correlation to MD education and career with burnout, ultimately causing negative psychological and physical outcomes. Research has shown that resilience is a concept that has often been associated with MD ability to respond to stress and decrease burnout. Beyond MDs, the population of nurse practitioners (NPs) has been minimally researched in relation to burnout. NPs are at heightened risk of burnout, comparable to MDs, in relation to rigorous education requirements, large workloads, long work hours, rising demands of documentation, and increased technological advances within health care. The purpose of this PIP was to explore the prevalence of burnout and resiliency in correlation with demographic risk factors in practicing NPs who attended the NDNPA conference in fall 2020 in order to initiate education and practice recommendations. Survey questions regarding coping mechanisms, demographic risk factors, and validated tools for resilience and burnout were administered to practicing NPs during the virtual conference. Forty-four NPs completed the survey. Scores reflected moderate to high levels of burnout within the sample. Resilience was mildly below the national average. Lower burnout among those working in team settings was found to be statistically significant. NPs working on productivity-based pay had the highest levels of resilience. Participants who utilized more coping mechanisms had higher resilience scores. Data did not find a significant relationship between burnout and resilience. Study findings support the recommendation for larger, longitudinal research, perhaps more focused on burnout and organizational influence(s) to better understand the topic. The findings from this study are supportive of recent literature regarding MDs, which suggests that resilience is not the sole answer to addressing burnout. Other recommendations include NPs reviewing the newest research on burnout and the psychological impact certain specialties can entail. Healthcare organizations can consider increasing team-based work environments, as well as advising NPs to apply to team-based positions. Using multiple coping mechanisms is suggested to develop higher levels of resilience, as the concept of resilience likely remains a beneficial quality.
Assessing Burnout and Resiliency in Doctor of Nursing Practice Students
(North Dakota State University, 2024) Habib, Mary
This project aims to further assess the issue of burnout among Doctor of Nursing Practice (DNP) students, a population that remains understudied in the context of burnout research. DNP students, who concurrently function as registered nurses, graduate students, and novice nurse practitioners (NPs), can face many challenges in their academic journey. The rigorous demands of didactic and clinical coursework have been shown to impact academic success and overall well-being. Existing literature highlights high levels of burnout among DNP students, which affect various aspects of their lives, including personal time, sleep, and relationships. Resilience has been identified as a potential strategy to mitigate burnout, with more resilient individuals experiencing lower rates of burnout and an improved quality of life. By assessing the correlation between these factors, the aim is to shed light on the prevalence and causes of burnout symptoms in DNP students and explore the levels of resiliency within this population. A quantitative descriptive survey was conducted to collect data on burnout and resiliency levels among DNP students. Thirty-one DNP students completed the survey. Burnout scores reflected moderate to high levels in second and third-year students, with first-year students experiencing the lowest rates of burnout. Resiliency scores were below the national average, with third-year students experiencing the lowest levels of resilience. The cynicism component of burnout correlated negatively with resilience, while the professional efficacy component of burnout correlated positively with resilience. There was no correlation observed between the emotional exhaustion component of burnout and resilience. Furthermore, DNP students with resilience exposure experienced lower rates of cynicism and were found to be more resilient than participants who had no resilience exposure. These findings strengthen the theory that utilizing resilience is useful in decreasing burnout severity and increasing resilience. The outcomes of this practice improvement project hold significant implications for the mental health and well-being of DNP students. Interventions can be developed by individuals and educational institutions to potentially prevent and reduce the likelihood of burnout. This project addresses an urgent need for research in this area and underscores the importance of prioritizing the mental health of healthcare professionals in training.
Assessing Parental Knowledge and Attitudes Towards Human Papillomavirus Vaccination in a Rural Primary Care Clinic
(North Dakota State University, 2021) Holman, Jessica Benitez
Human Papillomavirus (HPV) is the most common sexually transmitted infection worldwide. The complications from HPV can be deadly and yet some of the most dangerous serotypes can be prevented with a vaccine. Unfortunately, HPV vaccine initiation and completion rates remain significantly below that of other adolescent vaccines in North Dakota as well as throughout the United States. Low HPV vaccine uptake may be due to a number of factors including lack of knowledge, misconceptions and myths, and healthcare barriers, such as weak or missed provider recommendation and lack of vaccine availability. This practice improvement project assessed parents’ attitudes, knowledge, and intent to vaccinate in McKenzie County, North Dakota, where HPV vaccine rates are amongst the lowest in North Dakota. A validated survey was provided to parents before and after watching a short video on HPV vaccination. Additionally, providers at Anova Family Health Clinic in Watford City, North Dakota, were educated on parental survey results and given suggestions to improve intent to vaccinate. The results of the project demonstrated some improvements in parental knowledge related to HPV infections; however, improvements in parental knowledge were not noted related to HPV vaccination, demonstrating gaps still exist. Parental attitudes towards the HPV vaccine did improve related to vaccine efficacy, but there was no increased intent to vaccinate among parents after the video education. The majority of parents also reported they do not have enough information about the vaccine to give it to their child, demonstrating a need for further parent education. As a result of the practice improvement project, providers reported understanding education needs amongst parents and the ability to identify additional barriers to HPV vaccination. In conclusion, more research is needed to better understand parents’ attitudes, knowledge, and intent to vaccinate in McKenzie County, North Dakota. With additional research, healthcare professionals can change their practice to reflect these needs. Furthermore, outreach at other clinics in McKenzie County, North Dakota need to occur to target a more representative sample. Through improved knowledge of parental education needs and barriers to HPV vaccination, healthcare providers can help increase HPV vaccination uptake and improve health outcomes.
An assessment of barriers to nurse practitioners’ utilizing pharmacogenetic testing for depression
(North Dakota State University, 2024) Entzel, Sierra
As a leading cause of disability worldwide, depression is considered a chronic disease. Medication management is the first-line treatment for moderate to severe major depressive disorder. Medications are selected based on provider experience and preference with a trial-and- error” approach. These medications may take several weeks to reach therapeutic dosing. If it is not tolerated or ineffective for treating the disease, then the medication regimen is changed, requiring a minimum of 4-6 weeks to determine efficacy. This trial-and-error approach to depression treatment can lead to patients living with persistently debilitating depressive symptoms for months, increased healthcare costs due to continued need to seek medical follow-up, or patients discontinuing care due to lack of efficacy early in treatment attempts. In a post-market release study regarding the efficacy of antidepressant use, results indicated that 11% of the United States population takes an antidepressant. Depressed patients that do not benefit from the first antidepressant they are prescribed is 60% (Alemi et al., 2021). Pharmacogenomic testing (PGT) is beneficial in disease management by determining individual genotype responses to specific medications. Incorporating PGT into routine care for depression can lessen the time it takes to reach disease remission as well as avoid any adverse medication effects. Despite the known benefits of PGT, it continues to have a slow adoption rate in clinical practice. Nurse Practitioners (NPs) surveyed aided the co-investigator in assessing current rates of NPs utilizing PGT as well as identifying barriers to use. Understanding limits for using PGT can contribute to developing targeted education in hopes of enhancing the uptake of PGT for managing depression into routine clinical practice. use. Understanding limits for using PGT can contribute to developing targeted education in hopes of enhancing the uptake of PGT for managing depression into routine clinical practice.
Assessment of Health Literacy and Preferred Learning Style of Patients in a Rural North Dakota Primary Care Clinic
(North Dakota State University, 2022) Holt, Cassie Rose
Individuals with low health literacy face many difficulties within the healthcare system, including seeking medical care in inappropriate places, foregoing appointments and preventative health screenings, and misunderstanding self-care instructions. This leads to more hospitalizations, increased healthcare expenses, and use of healthcare resources. Low health literacy is especially significant in rural populations, where there are additional barriers to healthcare such as geography, distance, weather, inadequate financial resources and lower socioeconomic status, and lack of primary care and specialty providers. Furthermore, providers often do not consider patients’ preferred learning styles, which may be significant for those who have difficulty understanding instructions. Patient education may be more effective if teaching strategies are individualized to each patient. The purpose of this project was to assess the health literacy and preferred learning style of patients at a primary care clinic in rural North Dakota and educate healthcare providers in the respective clinic on health literacy and teaching methods, which has the potential to enhance patient education and learning. The implementation of this practice improvement project included assessing patients’ health literacy levels and preferred learning styles and an educational session for rural healthcare providers. Health literacy levels and preferred learning styles were tested using the Rapid Estimate of Adult Literacy in Medicine (REALM) and Visual, Auditory, Reading/Writing, and Kinesthetic (VARK) tools, respectively. The education session utilized a presentation to discuss health literacy in rural populations and the importance of assessing health literacy and learning style. A pre- and post-test and follow-up survey assessed providers’ knowledge of the importance of testing health literacy and preferred learning style, available tools, and their intent to utilize these tools in practice. The results of the project indicate there continues to be gaps in knowledge related to risk factors of low health literacy, tools available to measure health literacy and learning styles, and consistent utilization of health literacy and learning style information when educating patients. The project was successful in raising awareness of the problem of low health literacy in rural populations but reflects the need for healthcare facilities to provide education for their healthcare team on these topics.
Associations between human papillomavirus vaccine hesitancy and resistance and social media engagement
(North Dakota State University, 2024) O'Keefe, Katherine
Human Papillomavirus (HPV) is one of the most common sexually transmitted infections worldwide. More than 13 million Americans are infected each year. Typically, HPV infections will resolve without treatment, and many infected individuals are asymptomatic. However, in some cases, these infections can lead to penile, oral, vaginal, cervical, and/or anal cancer. With the rise in HPV infection rates, the need for vaccination is crucial in prevention of HPV-related infections and cancers. The CDC recently changed HPV vaccine guidelines to include individuals ages 27-45. Regardless of guideline changes, HPV vaccination rates are lower than other recommended vaccines, which may be due to antivaccination campaigns. The purpose of the practice improvement project was to identify attitudes, beliefs, and barriers towards HPV vaccination and sources of vaccine information among residents, ages 18-45, in a rural North Dakota county. The project was conducted between May 2023 and June 2023. Participants completed an online survey via Qualtrics to assess views, social media usage, influences, and any potential barriers to HPV vaccination. Each participant who completed the survey were provided links to websites for further information on HPV and the vaccine. Over 30% (n=9) of the 28 participants utilized search engines for their health and vaccine information, while 29% (n=8) utilized their primary care provider. Approximately 5% (n=2) of the participants utilized social media sites for their health and vaccine information. A majority (n = 18; 64.3%) of participants report they would receive the HPV vaccine if recommended by a provider. Rural providers were educated on survey results and determined that changes within their practice were needed to increase HPV vaccination rates. Providers identified the importance of increasing HPV vaccine uptake to help better serve their community. These providers planned to display an HPV infograph within their clinic and continue to offer the HPV vaccine at annual wellness visits. Continued HPV vaccine education provided by healthcare professionals is imperative to enhance HPV vaccine confidence and uptake, which has the potential to reduce morbidity and mortality associated with HPV and HPV-related cancers.
Barriers to Seeking Preventative Care for Men Living in Rural North Dakota
(North Dakota State University, 2022) Johnson, Stanley
The purpose of this evidence-based practice improvement project (PIP) was to identify perceived barriers to seeking primary and preventative healthcare by males living in a rural North Dakota community. Research has shown that men in the United States live shorter lives and are more likely to die of many common causes of death than females. These facts may be partially explained by the idea that men are less likely than women to regularly see a healthcare provider. Health disparities also exist between rural and metropolitan communities as well. Individuals living in rural areas have been found to die more frequently of potentially preventable causes, have higher incidence of obesity, and shorter life expectancies than those living in metropolitan communities. The objectives of the PIP included: 1) Identifying actual and perceived barriers to seeking annual preventative care examination and screening by adult males, ages 19-65; 2) increasing healthcare professionals’ knowledge of the barriers to seeking annual preventative care among adult males in the community; and 3) implementing at least two recommendations to improve healthcare utilization and reduce barriers within the rural clinic by the end of the project implementationMale volunteers were recruited to complete a survey identifying potential barriers to seeking preventative healthcare. The results were then communicated to healthcare providers practicing in the survey area along with evidence-based recommendations for breaking down identified barriers to increase utilization of services by males in their community. Twelve participants completed surveys. Barriers identified included poor health literacy/education, clinic hours conflicting with responsibilities, not wanting to discuss emotions and masculine ideas, and cost of healthcare. Recommended interventions included education at multiple levels, implementing male-focused health initiatives, and male-focused education/information in the clinic. After one month, the coinvestigator revisited the participating clinic. At that time, the clinic had opted to not implement the recommended interventions citing COVID-19 pandemic.
C.O.P.E. Influence on Resiliency and Self-Efficacy in a Rural North Dakota School (Creating Opportunities for Personal Empowerment)
(North Dakota State University, 2021) Schwarzrock, Ariel Kristine
One in three teens is estimated to experience an anxiety disorder between 13 to 18 years of age. Developed mental health burdens in adolescents can go undetected and untreated. About 50% of those with mental health disorders noted in adulthood started by age 14 years. Therefore, adolescence may be a critical phase for developing positive coping mechanisms and one where nurse practitioners can proactively impact outcomes. Cognitive behavioral therapy (CBT) is an evidence-based strategy effective in decreasing mental health burden. Creating Opportunities for Personal Empowerment (COPE) is a program created for pediatrics using CBT strategies to manage emotions and promote healthy lifestyles. The purpose of the practice improvement project (PIP) was to improve resiliency and self-efficacy in junior high students at a rural North Dakota (ND) junior high school through COPE program implementation. Objectives included assessing if adolescent resilience and self-efficacy scores increased after implementation of the program with evaluation to make recommendations based on literature findings and project outcomes. The Integrated Theory of Health Behavior Change (ITHBC) helped guide the PIP and suggests adolescents can be taught to engage in healthy behaviors for effective mental health management through healthy coping skills and behaviors. A logic model helped guide and evaluate the program. The school counselor in a rural ND school became certified in COPE to facilitate and identified five students willing to participate. The COPE Teen seven-session program was implemented with parental consent and IRB approval; each session lasted approximately 30 to 45 minutes weekly in the school. Qualitative and quantitative data were collected via paper pre- and post- surveys for evaluation. Descriptive statistics were used to evaluate objectives. All data collected was entered and stored online in a Qualtrics database to aide security and statistical analyzation. Despite implementation during the COVID-19 pandemic, overall resiliency and self-efficacy scores increased for students after implementation. Students indicated they enjoyed the program and identified learned skills to be beneficial. The COPE program was recommended to continue in the school with further research and larger sample sizes to support proactive approaches to mitigate adolescent mental health care between the NP and school settings.
Childhood obesity conversations: Motivational interviewing in the brief primary care visit
(North Dakota State University, 2024) Mettler, Nora
Childhood obesity is a global epidemic that sets a child up for future health complications into adulthood. There’s no current consensus on approaching weight-related conversations with patients and families. Nurse practitioners (NPs) are in a unique position to recognize obesity and initiate weight-related conversations with patients and families. Unfortunately, formative educational programs under-educate practitioners in the conduction of obesity conversations, so there is a decreased confidence and resulting avoidance of weight-related conversations. This practice improvement project (PIP) aimed to increase provider confidence and utilize motivational interviewing techniques to initiate and sustain weight-related conversations with children and families with overweight or obesity. The PIP consisted of an hour-long educational video sponsored by the American Academy of Pediatrics (AAP) electronically sent out to new family practice providers in a Nurse Practitioner Fellowship Program (NPFP) and experienced providers in the rural weight-management clinic. Pre- and post-surveys were employed to evaluate perceived confidence and utilization in clinical practice. Surveys also aided in understanding obesity education through formative and continuing education. There were ten eligible participants, six from the NPFP and four from the weight management clinic. The PIP had a total of three participants who were all from the weight-management clinic. There were no participants from the NPFP. Through descriptive statistics, the co-investigator found that 2/3 of respondents had increased levels of perceived confidence regarding weight-related conversations with children and families with overweight or obesity. One participant indicated weight-related conversational training in formative schooling and all respondents reported weight-related conversational training through continuing education. One participant completed the one-month follow-up survey. The participant indicated he/she had implemented techniques presented in the video, but a larger population size is needed to make the results more meaningful. Although the results supported the purpose of the PIP, the co-investigator would recommend further research targeting primary care practitioners to determine the need for further education in the primary care setting. Although limitations existed, the education and delivery method met the needs of the participants. The co-investigator recommends implementing weight-related conversation education into primary care formative education and encourages practicing practitioners to seek out continuing education regarding weight-related conversations with patients and families.
Childhood Obesity Prevention: Infant Nutrition and Feeding Education
(North Dakota State University, 2022) Mecklenburg, Candace
Childhood obesity is a global concern, as of 2020 it affected 39 million children under the age of five. Obesity increases the risk of developing many health problems, including type-2 diabetes, hypertension, heart disease, asthma, sleep apnea, and others. Overweight and obese children are more likely to become obese adolescents and adults. Once obesity occurs, it is likely to persist as achieving and maintaining a healthy weight is more challenging. Many of the diseases related to obesity are now developing in children and adolescence. Preventing obesity from occurring has the most promising effect on tackling the issue. Researchers have found that food preferences and eating patterns are developed in the first two years of life, therefore, in order to prevent obesity from occurring, focus should be placed on nutrition during infancy. This practice improvement project aspired to increase parental knowledge regarding healthy nutrition and feeding during infancy. An educational session was conducted during a childbirth preparation class. A post education survey showed that participants did report an increase in their knowledge regarding healthy nutrition and feeding during infancy.
Childhood Obesity: Developing Early Nutrition & Feeding Education for Parents at Well Child Visits
(North Dakota State University, 2020) Benson, Ashley Lynn
Childhood obesity is an extensive problem in the United States and North Dakota (CDC, 2014). Significant health consequences are linked to obesity, including type two diabetes, hypertension, hyperlipidemia, cardiovascular disease, cancers, and psychological disorders (Pandita et al., 2016; Xu & Mishra, 2018). Obesity comorbidities, previously presented in later adulthood, now emerge in younger populations (Pandita et al., 2016). Unfortunately, treatment of obesity is not effective, and therefore, prevention must be the primary focus (Daniels et al., 2015; Pandita et al., 2016). Diet and eating behaviors have a significant impact on weight, and children develop taste preferences and lifelong eating behaviors within the first few years of life (Birch & Anzman, 2010; Daniels et al., 2015; IOM, 2011). Therefore, targeting interventions on feeding and nutrition in infancy may foster healthy habits for life and play a role in the prevention of obesity. Responsive feeding interventions hold promise in supporting healthy growth. Ellyn Satter’s Division of Responsibility promotes the responsive feeding relationship between parent and child. The purpose of the practice improvement project was to address childhood obesity prevention through the development of an educational curriculum on feeding and nutrition. The parent-focused education correlated with each well child visit (WCV) between the ages of two weeks and three years. A multidisciplinary team of representatives from pediatrics, behavioral health, and patient education was consulted to develop the education. Ten providers at Midwestern primary care clinics reviewed the educational curriculum and provided feedback on the content and methods to deliver the education to parents. Most providers found the content to be accurate (n = 7; 70%) and comprehensive (n = 8; 80%). Three providers suggested expanding on topics such as breastfeeding and mixing formula. Providers unanimously agreed that the curriculum is relevant and understandable. A formal literacy evaluation resulted in grade-level readability scores between the 6th and 8th-grade levels. Almost all providers (n = 9) believed the curriculum would be valuable for use in practice. The preferred delivery method chosen was one on one provider to parent education. The project clinic plans to pilot the curriculum with parents attending infant and toddler WCVs.
Colorectal Cancer Education: Utilization of an Inflatable Colon and Small Media at a Health Fair in Central North Dakota
(North Dakota State University, 2024) Himmelspach, Faune
Colorectal cancer is a prevalent and deadly disease, claiming thousands of lives each year. In the United States alone, over 150,000 individuals were diagnosed with colorectal cancer in 2022, and tragically, nearly 53,000 succumbed to its impact (National Cancer Institute [NCI], 2022). Notably, North Dakota faces a unique scenario, with incidence rates per capita surpassing the national average, yet colorectal cancer screening rates lag behind. This disconcerting situation in North Dakota emphasizes a need for targeted public health interventions, increased awareness campaigns, and improved access to colorectal cancer screening services. Early detection through screening is a pivotal tool in the battle against colorectal cancer, often identifying the disease in its precancerous or early stages, thereby significantly reducing mortality rates. Technologies are available and offer non-invasive, painless, cost-effective, and practical manners that can sometimes be tailored to the individual's preferences. Despite these advancements, the United States and North Dakota fall short of the 80% CRC screening benchmark established by the National Colorectal Cancer Roundtable. Shockingly, in 2020, only 63% of eligible North Dakotans underwent colorectal cancer screening, which is 10% below the national average and well below the national benchmark. High incidence rates, mortality rates, and increasing incidence of early-onset CRC indicate a need for immediate action. Efforts to bridge the gap between increasing incidence rates and low screening rates are essential to save lives and reduce the burden of colorectal cancer in North Dakota. This evidence-based scholarly project aimed to assess the impact of an educational intervention on colorectal cancer awareness and screening intent. The intervention involved scripted guided tours of a larger-than-life inflatable colon, a PowerPoint presentation set on loop, and educational handouts all strategically deployed during a health fair sponsored by the Missouri Valley YMCA in Bismarck, ND. Participants, ranging from 18 to 75 years old, engaged with the educational initiative, with the primary goal of enhancing their knowledge of colorectal cancer and influencing their intent to undergo screening. Additionally, the co-investigator sought to uncover and address perceived barriers to colorectal cancer screening within this specific demographic.

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