Nursing Doctoral Work

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Addressing Advance Directive in Rural Primary Care North Dakota: Implementing a Tool for Healthcare Providers
(North Dakota State University, 2019) Heisler, Ryan Michael
Advance directives are legal documents developed as a tool to allow patients to express their wishes and allow healthcare providers to educate and converse with their patients on disease prognosis and management. Advance directives promote shared decision making, thus enhancing quality medical decisions, improving quality of care at end-of-life, and under certain circumstances, even decreasing healthcare costs by refusing aggressive treatment (Garrido, Balboni, Maciejewski, Bao, & Prigerson, 2015; Hickman & Pinto, 2014). In the United States, less than 30% of the population have a completed advance directive (De Vleminck et al., 2013; Dunlay, Swetz, Mueller, Roger, 2012). The purpose of this project was to increase advance directive rates by 20% at a rural clinic in patients older than 65 years of age with heart failure, stage IV cancer, end-stage renal disease, and/or chronic obstructive pulmonary disease. Advance directive rates and advance care planning facilitator rates were electronically gathered prior to two educational in-services. Educational in-services were given to a total of 24 healthcare professionals, and after each in-service, a confidence Likert scale survey was given to each participant. Four months after the first educational in-service, advance directive rates and advance care planning facilitators rates were electronically gathered. Four months after the first educational in-service, advance directive rates remained unchanged with 211 of 490 (43%) patients having an advance directive. A total of 11 advance care planning facilitator referrals were made. Confidence Likert scale surveys found the education increased participants’ knowledge of advance directives, confidence with initiating advance directive discussions, and likeliness of increasing advance care planning discussions.
Addressing Cervical Cancer Disparities Among American Indian Women: Implementing an Educational Module for Healthcare Providers
(North Dakota State University, 2015) Peltier, Allison Evelyn
Many minority populations throughout the United States experience significant cancer-related disparities affecting their quality of life. American Indians represent one group of individuals who experience significant disparities in cancer screening, treatment, and health outcomes (Horowitz, 2012). Although effective screening exists, American Indian women are disproportionately affected by cervical cancer compared to other demographic groups. In relation to cervical cancer, American Indian women experience a higher prevalence, a more rapidly rising incidence, and higher mortality rates, which may be related to an interplay of unique risk factors, barriers in healthcare access, and cultural influences on health seeking behaviors (Schmidt-Grimminger et al., 2011). While primary care providers have an opportunity to reduce health disparities, significant gaps exist related to awareness of cervical cancer disparities among American Indian women (Rogers & Cantu, 2008). Many healthcare providers do not routinely discuss cervical cancer screening recommendations with American Indian patients and feel their inadequate understanding of cultural beliefs serves as a barrier to increasing discussions about cervical cancer (Jim et al., 2012). Enhancing healthcare providers’ knowledge of cervical cancer disparities may help facilitate the provision of culturally competent care and improve the quality of care for American Indian women. Based on the need for enhanced awareness of cervical cancer disparities among American Indian women, a continuing education module was developed in collaboration with the American Association of Nurse Practitioners Continuing Education Center. The module incorporated information on American Indian culture, contributing factors to cervical cancer, and barriers to healthcare experienced by the population. The module was evaluated through pretest, posttest, and evaluation questions. Data were collected for approximately three months with a total of 203 participants. After completing the module, nearly half of the participants (48.5%; n = 99) reported they planned to modify their practice, and approximately 71.5% (n = 145) of the participants planned to discuss screening recommendations routinely or often. Six pretest and posttest content-related questions demonstrated learning occurred as a result of the module. Overall, the results indicate the continuing education module had a positive impact on the participants and enhanced their awareness of cervical cancer disparities among American Indian women.
Addressing Lyme Disease: An Educational Module for Healthcare Providers
(North Dakota State University, 2017) Greseth, Sheila
Since its identification over 40 years ago, Lyme disease has continually spread, and the number of cases have significantly increased in the northeastern and northcentral United States. The Center for Disease Control and prevention (CDC) estimates that approximately 30,000 individuals in the United States per year are diagnosed with Lyme disease (2016). Lyme disease is a vector-borne disease that is caused by Borrelia burgdorferi, a bacteria transmitted by the Ixodes scapularis tick. The disease presents in numerous ways, often making the diagnosis difficult. Healthcare providers have the opportunity to reduce and prevent health complications associated with Lyme disease, but substantial knowledge gaps are present in relation to the overall care of patients with the disease (Hill, 2013). In addition, numerous healthcare providers within the United States have reported not feeling confident in their knowledge level of tick-borne disease (Brett et al., 2014). By facilitating healthcare providers learning through a continuing education module, they may improve their practices and provide more competent, safe, and high quality care for patients with Lyme disease. With the apparent need for increased knowledge and awareness of Lyme disease among healthcare providers, a continuing education module was constructed for distribution with the American Association of Nurse Practitioners Continuing Education Center. Information on the prevention, diagnosis, and treatment of Lyme disease was incorporated into the module to educate healthcare providers. The online module evaluated Lyme disease knowledge through a pretest, posttest, and evaluation survey. Approximately 10 weeks of data were collected with a total of 305 healthcare provider participants. As a result of the continuing education module, learning was demonstrated by improvement on 17 of 18 pretest and posttest content-related questions. Additionally, approximately 93% (n = 283) of participants felt the continuing education module enhanced their current knowledge base. In summary, results demonstrated that the continuing education module impacted the participants positively by advancing their knowledge of Lyme disease prevention, diagnosis, and treatment.
Addressing Student Depression on Campus: Barriers and Assets
(North Dakota State University, 2015) KappelmanBeyer, Dianne
Prevalence of depression among college students is noted to be approximately 30% per college and university campus with an overall national average for severe psychological problems, including depression, at approximately 86% (Field, Diego, Pelaez, Deeds, & Delgado, (2012). Outcomes of undiagnosed depression lead to heightened levels of stress and dangerous behavior patterns, such as drug and alcohol consumption, poor academic achievement, high rates of college dropout, chronic and progressive mental illness, and suicide (Deckro et al., 2010). Depression prevention is important for college student health because of the chronic, recurrent and progressive nature of the disease along with student academic success, college retention, and overall quality of life (Buchanan, 2013). Purpose of this practice improvement project was to impact student health at North Dakota State University (NDSU). The project was accomplished by investigating students' depression-prevention practices, current practices for universities, and evidence-based practice. Several NDSU departments participated in the interviewing of staff members' investigation process for information gathering. Depression prevention is imperative for emerging adults within the college and university system. Providing depression prevention strategies would not only benefit the student, but also the university with improved student retention. Recommendations for depression prevention are to employ a nurse practitioner specialized in mental-health, as this would fulfill the overall student mental-health care needs by utilizing a depression prevention model such as the Peden cognitive behavioral group intervention, depression education for students either individualized or classroom by adding a chapter regarding depression to University Studies 189, and provide mental-health care services. Strategies for college and university student depression prevention practices were investigated at public university websites and published articles. Existing research was available through library access. Through this investigative research process, the Peden Cognitive Behavioral Group Intervention (CBGI) was determined to be a valid, evidence-based depression prevention model for college students. Results and recommendations from this practice-improvement project were presented to NDSU stakeholders to advocate for a student depression model among university students. This practice improvement project examines the importance of being proactive with depression prevention along with evidence-based recommendations leading to healthier student populations, more student safety, and improved student retention.
Adult ADHD Self-Report Scale: Implementation in a Primary Care Setting
(North Dakota State University, 2015) Treumer, Taryn Nicole
Attention Deficit Hyperactivity Disorder (ADHD) is a chronic, highly prevalent, neurodevelopment disorder in children, which often persists into adulthood. A gap exists among healthcare providers' knowledge of adult ADHD and current screening practices in the primary care setting. The purpose of the project was to improve screening and identification of adult ADHD in the primary care setting by enhancing provider knowledge and awareness of the disorder. A need was identified at a small, rural, facility in Midwestern, North Dakota to improve adult ADHD screening practices; thus the adult ADHD Self-Report Scale version 1.1 (ASRSv1.1) was implemented among a group of providers for a five month time period. The ASRSv1.1 is a six question rating scale which was created by a group of ADHD experts and copyrighted by the World Health Organization. The sensitivity of the tool is 68.7 percent while the specificity rate is a remarkable 99.5 percent. For the practice improvement project, providers were instructed to screen patients displaying signs and/or symptoms of inattention, hyperactivity, impulsivity, depression, anxiety, substance abuse, etc. If the screen was found to be a positive, recommendations were to refer the patient to a mental healthcare professional. The results of the project demonstrated an overall improvement in the screening process for adult ADHD. An increase of patients referred for further diagnostic testing of adult ADHD was found. Providers felt the ASRS v1.1 was a helpful in screening and determining the course of care for the patient. Recommendations from the practice improvement project for future research include replicating the study with a larger sample size; providing easy access to the ASRS v1.1; and screening patients identified as routinely missing appointments for ADHD.
Aspirin Use for Primary Prevention of Cardiovascular Disease
(North Dakota State University, 2019) Frauenberg, Sarah
Cardiovascular disease (CVD) is a major cause of morbidity and mortality in the United States and aspirin is a well-known medication strongly associated with CVD prevention. Aspirin has undeniable benefits in the role of secondary prevention of CVD, however, the benefits are ambiguous when associated with primary prevention. The decision to start aspirin for primary prevention becomes complicated due to aspirin’s effect on coagulation and the risk of gastric ulceration. The United States Preventive Services Task Force (USPSTF) has level B recommendations in place regarding the use of low-dose aspirin (81 mg) for primary prevention of CVD. 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 guideline and CVD calculator offer healthcare providers an easy-to-navigate tool to determine proper patient use of aspirin. However, despite the USPSTF guideline, appropriate aspirin use remains suboptimal. Successful adoption of the 2016 USPSTF guideline on aspirin use for primary prevention of CVD by providers in two rural North Dakota communities was the goal of this practice improvement project. The project began with education to providers and staff at the rural clinics regarding the USPSTF guideline and the ACC/AHA calculator. Following the educational session, implementation of the USPSTF guideline occurred for three months. Evaluation was performed through the use of a post-implementation survey. Results of the project demonstrated increased knowledge and usage of the guideline and a positive viewpoint related to implementation of the guideline with the providers in both of the communities having plans to sustain use in future practice. Data were also collected at a health screening fair in one of the rural communities to validate whether patients were taking aspirin per USPSTF guideline. Data gathered from the fair concluded only 59% of patients (41 out of 70) were taking, or not taking, aspirin appropriately according to the USPSTF guideline. Conclusively, primary care providers would be well served by using the ACC/AHA calculator and 2016 USPSTF guideline with all patients 40-79 years of age to determine appropriate use of aspirin for primary prevention of CVD.
Assessing North Dakota Nurse Practitioners' Knowledge of the National Comprehensive Cancer Network's Treatment Guidelines for Adult Cancer Pain
(North Dakota State University, 2013) Schoenberg, Lisa Maire
The purpose of this project was to determine if access to the National Comprehensive Cancer Network's guidelines on the treatment of adult cancer related pain increased nurse practitioner knowledge and utilization in practice. The guidelines were provided to nurse practitioners who practiced within an oncology setting in North Dakota to assess whether their knowledge of pain management increased and if they found the guidelines to be a useful tool to have in practice. A pre-intervention questionnaire was sent to the participants to gain demographic information, including, age and gender, type of certification, primary area of practice, number of years practicing as an nurse practitioner, hours spent in clinical practice per week, and the average number of oncology patients seen per week. In addition, the pre-intervention questionnaire evaluated current treatment modalities the participants utilized in treating cancer related pain. After receiving the pre-intervention questionnaires, the National Comprehensive Cancer Network's guidelines were distributed to the participants who agreed to utilize them for the duration of this project. The participants were given the full guidelines, a pocketbook of the guideline's algorithms, and instructions for utilizing the phone application of the guidelines. A post-intervention questionnaire was sent out three months after the guidelines were distributed assessing their impact on nurse practitioner practice. Overall, the participants felt that the guidelines increased their knowledge on treatment modalities for cancer related pain and found them to be a useful resource in practice. From this project we can assume that the evidence based guidelines provided from the National Comprehensive Cancer Network are beneficial for novice and experienced nurse practitioners practicing in oncology.
Assessing Postpartum Depression in the Refugee Population in a Primary Care Setting
(North Dakota State University, 2019) Kamara, Aminata Sankoh
Mental health is an area lacking emphasis in the United States healthcare systems. Many patients have suffered due to the decrease in focus and resources required to help individuals struggling with mental disorders (Lieberman, Goldman, Olfson, Pincus, & Sederer, 2017). While the struggle for adequate screening for mental illness continues, minority populations, such as refugee women, are affected more due to multifactorial risk factors and lack of treatment emphasis (Ganann, Sword, Thabane, Newbold & Black, 2016; Lieberman et al., 2017). Due to the increase in the number of refugees that migrate to the United States, particularly in the Midwest, healthcare providers must continue to enhance their knowledge on risk factors of mental illness in vulnerable populations, such as refugee women, and implement evidence-based practices that will promote the best possible patient outcomes. The practice improvement project aimed to increase healthcare provider awareness of the increased risk of postpartum depression (PPD) in refugee women compared to other patient populations and improve incidence rates of PPD during the first year of the postpartum period in refugee women. The project took place at a primary care clinic where the Edinburgh Postpartum Depression Scale (EPDS), an evidence-based screening tool for identifying risk for PPD, was implemented over a two-month period assessing for PPD. The results of EPDS were compared to the standard previously used Patient Health Questionnaire (PHQ-2) results over two months. A 30-minute educational session was given to the providers regarding how to assess for PPD, risk factors, providing culturally sensitive care, utilizing appropriate evidence-based screening tools for PPD, treatment options, and the results comparing the EPDS to the PHQ-2 implementation. Pre and post-survey evaluations were completed by the providers to evaluate the educational session and provider knowledge. Results indicated an increase in provider confidence and knowledge in assessing for PPD and caring for refugee women during the first year postpartum. The EPDS screening tool indicated PPD in more refugee women, suggesting the EPDS to be a more sensitive screening tool for PPD in refugee women when compared to the PHQ-2. The providers preferred to continue using the EPDS instead of the PHQ-2.
Assessing the Health Needs of Women Reentering the Community After Incarceration
(North Dakota State University, 2017) Banley, Katie Beth
This dissertation work, guided by the social ecological model, sought to assess the physical, mental, social, and spiritual health needs of women reentering the community after incarceration from the perspective of the women themselves. Women participating in a group substance treatment program at a residential transitional facility were recruited for voluntary participation in focus groups (n=19) and semi-structured interviews (n=12). Community-based recommendations were developed based on identified needs. One-quarter of the interviewed women had hepatitis C, while 83% had at least one mental health diagnosis. The women described physical and mental health consequences of abuse, largely inflicted by family and significant others. Their close relationships were characterized by complexity, especially with mothers and children – sometimes inciting feelings of isolation or despair, other times, self-efficacy or heightened spirituality. Within the community, the women experienced problems accessing, and finding common ground within the healthcare system. They perceived barriers to timely and adequate mental health treatment in three categories: primary care providers were unwilling/unable to treat them; excessive wait times precluded access to specialty mental healthcare; and they generally distrusted the system. They viewed staff support within the transitional facility as a major contributor to their success or failure. They also desired exercise opportunities and healthier food choices within the transitional facility. Community activities, such as spiritual or religious meetings contributed to a sense of belonging, but they desired more opportunities for positive community involvement. On the societal level, gaining safe, affordable housing and financial stability were major hurdles. In addition, stigmatization from society was experienced on many levels. Finally, recommendations were made to the transitional facility to promote and remove barriers to exercise and healthy foods, to develop and maintain a culture of trauma-informed care among all staff members, and to promote the development of healthy, prosocial community connections. Primary care facilities were recommended to address adverse childhood events and adult trauma, and to foster innovative strategies to provide timely and effective mental healthcare. Finally, policy-makers were recommended to consider pursuing legislation allowing expungement, and to develop and implement strategies to provide safe, affordable housing options to those with criminal records.
Assessment and Management of Concussion in Young Athletes: A Primary Care Module
(North Dakota State University, 2015) Kleinjan, Christa Marie
Concussion is a common sports injury in young athletes with the potential to cause negative consequence for the athlete due to improper concussion management and premature return-to-play. Primary care providers are often responsible for diagnosing, treating, and making return-to-play decisions for young athletes. Despite the recent onslaught of literature advocating for physical rest, cognitive rest, graduated return-to-play protocol, and appropriate referral, many providers neglect to include these recommendations in their treatment plan and patient education. An educational program “Concussion in Young Athletes: A Module for Primary Care Providers” was developed and delivered to primary care providers to address and improve these areas in practice. The module included three video vignettes to assess current and potential changes to provider treatment recommendations and an online PowerPoint Presentation. Data were collected for six weeks with 15 providers participating. Sixty-four percent of practicing providers diagnosed or treated a young athlete in the past year. One third of providers indicated they neither received concussion training during their MD, NP, or PA preparation nor completed training outside of their preparation. In the pretest, seventy-three percent neglected to include a return-to-play protocol in their recommendations for resuming sport. This was reduced to 40% following the module. In the pretest, one third of providers failed to refer an athlete with persistent concussive symptoms to a specialty provider. While little change was observed in the overall number of providers recommending physical rest, cognitive rest, and at school accommodations, notable improvements were made in the number of providers recommending return-to-play protocols and appropriate referrals for athletes with prolonged concussive symptoms. Comparing the cumulative pre and posttest scores, following the module providers scored an average of +2.7 points, or 11%, higher. After the module all providers (n=15, 100%) reported planning to make changes to their practice and general increases in knowledge and confidence were seen. After viewing the module, provider responses revealed improved practice recommendations and implemented return-to-play protocols. Results of the module indicated that additional educational opportunities for primary care providers should be advertised, offered, and possibly required to improve practice of managing concussions in young athletes.
Assessment of Obese Children within a Family-Based Intervention Pilot Study
(North Dakota State University, 2013) Agnello, Kelly Shannon
About one third of children in the United States are overweight or obese. Multiple comorbidities coincide with obesity affecting children physically and emotionally, which in turn impacts obese children’s quality of life. Despite the increased prevalence and negative consequences of pediatric obesity, few evidence-based practice or generalizable assessment tools exist. The purpose of this project is to transition a generalizable, evidence-based pediatric obesity assessment tool from research into practice in a local pediatric obesity program which can later be utilized in primary care in order to implement early intervention with obese children. The pediatric obesity specific quality of life measurements for children and their parents, “Sizing Me Up” and “Sizing Them Up,” were presented to two providers with clinical expertise from a local family-based obesity intervention outpatient program. These specific measurements, along with height, weight, BMI, and readiness for change assessment, were utilized by the providers at the beginning and end of the 10-week program consisting of 10 families. Evaluation of the assessment tool was conducted through a Likert Scale survey of the providers to determine the utilization, ease, and difficulty of use of the pediatric obesity assessment tool. The providers evaluated the tool as having quality utilization, good clinical battery, and ease of implementation. Therefore the tool is ready for implementation into primary care. By transitioning an evidence-based pediatric obesity assessment tool from research into practice, advanced practice nurses will be able to more accurately and fully assess obese children so that interventions can be implemented expeditiously.
An Assessment of Psychological Distress and Resilience among Nurse Practitioner Students
(North Dakota State University, 2018) Nelson, Carrie
Medical doctors and medical students experience increased prevalence of depression, anxiety, suicidality, suicide, stress, and burnout when compared to the general public. Along with suffering from increased rates of psychosocial distress, medical students and medical doctors often do not seek medical help for their mental health symptoms and are left to suffer in silence. Nurse practitioner students face similar challenges as medical students, yet the literature has not explored the mental health status and needs of nurse practitioner students. Healthcare providers may feel unable to seek help for mental health conditions due to fear of losing their license or fear their professional reputation could be damaged, compounding the problem. The concept of building personal resilience in healthcare providers has emerged as a possible way to combat poor mental health and burnout in healthcare providers. Healthcare providers who are more resilient are less likely to suffer from poor mental health outcomes. The purpose of the project was to evaluate if nurse practitioner students suffer from poor mental health during their time in graduate education and if resiliency scores predict psychological well-being. Survey questions about help-seeking behaviors and validated surveys for depression, anxiety, suicidality, stress, burnout, and resiliency were administered to first, second, and third-year students before the start of fall semester 2017, and again near the end of fall semester 2017. Thirty-seven students completed the baseline assessment and 33 completed follow-up surveys. Depression and burnout scores increased significantly from baseline to follow-up, while other measures did not change significantly. Resiliency scores appeared to negatively correlate with depression, anxiety, and stress scores at baseline assessment. At baseline, no students endorsed high-risk suicidal behaviors, and at follow-up, three students (9%) scored high risk. At follow-up, 15% of the sample met criteria for moderate to severe depression and 21% met criteria for moderate to severe anxiety, both of which would benefit from medical interventions. Study findings highlight the significant mental health challenges nurse practitioner students face during their education. Academic programs should recognize these difficulties and implement interventions to support student well-being during the academic training period.
Autism Spectrum Disorder (ASD) in North Dakota. Database to Screening: Bridging the Gap Between What We Know and Where to Go
(North Dakota State University, 2019) Stavig, Trevor
Autism spectrum disorder (ASD) is a developmental disability that can cause persistent deficits in social communication, behavior, and development. The effect of ASD differs from individual to individual, thus it is considered a spectrum disorder. Early screening and intervention are essential for improving outcomes. However, primary care providers’ screening rates remain low even though the diagnosis of ASD is possible in children who are 2 years old or younger. On average, children are 4 years or older at the time of diagnosis. The purpose of this project was to provide primary care providers with the tools needed to screen for ASD at well-child visits and to provide a list of resources for local ASD services. The second purpose was to form an alliance with the North Dakota Department of Health for the purpose of producing and distributing the toolkit to healthcare providers statewide. The ASD toolkit includes an ASD screening algorithm, M-CHAT-R and a local resource guide. At the Autism Spectrum Disorder Task Force’s business meeting on August 20, 2018, seventeen members listened to a presentation about the project. Following the presentation, members provider verbal input and feedback about the project; however, members did not return the survey about the toolkit. That task force verbally offered support to move forward with the toolkit project. A second survey requested feedback from primary care providers about the effectiveness and utility of the ASD toolkit. The small return rate, N=10, was disappointing and not sufficient for generalized results. However, provider respondents showed an interest in ASD education, and that the toolkit would useful in practice. Future research should include a larger population working in primary care in urban and rural settings. Data obtained after the providers had the opportunity to use the toolkit in practice would allow for analysis of the toolkit’s usefulness. Instead of only surveying providers prior to toolkit use, in the future, provider surveys conducted after 3, 6, and 12 months of toolkit use in practice are recommended.
Barriers to New Nurse Practitioner Job Satisfaction
(North Dakota State University, 2018) Weiser, Deanna Joyce
Novice Nurse Practitioners (NPs) face many challenges in the first few years of practice. A novice NP was defined as a NP who has practiced for two years or less. The focus of this practice improvement project was to investigate what novice NPs in North Dakota perceive as barriers to successful role transition, job satisfaction, and how organizational climate affects job satisfaction. A convenience sample of novice NPs (N=14) were recruited through three separate venues. The Misener NP Job Satisfaction Scale© (MNPJSS) and the Nurse Practitioner – Primary Care Organizational Climate Questionnaire (NP- PCOCQ) were chosen to measure the project objectives. Survey statistical analysis consisted of means and standard deviations due to a small sample size. The MNPJSS assesses intrinsic (emotional) and extrinsic (environment) NP job satisfaction (Misener & Cox, 2001) and the NP-PCOCQ evaluates organization climate in relation to NP job satisfaction (Poghosyan et al., 2013a). The MNPJSS has six subscales, four extrinsic, and two intrinsic factors affecting job satisfaction. The extrinsic factors rated highest were related to fair evaluation, social contact at work, and immediate supervisor. The intrinsic factors were time spent in patient care, patient mix, and sense of accomplishment (Misener & Cox, 2001). The factors with the least satisfaction were related to bonuses and other compensation. Independence in practice, having a mentor, and feeling valued were organizational satisfiers. Lack of professional visibility and poor relations with administration were identified barriers. Several studies have found that autonomous practice is one of the most important factors in NP job satisfaction (Choi & De Gagne, 2015; De Milt, Fitzpatrick, & McNulty, 2011; Faraz, 2016; Faris, Douglas, Maples, Berg, & Thrailkill, 2010; Misener & Cox, 2001). Nevertheless, laws limiting NP practice authority persist. There are 234,000 NPs in the U.S. and the number of NP graduates increases exponentially each year, in 2015-2016 there were 23,000 NP graduates (AANP, 2018, January 22). The first step to ease transition to practice is to identify and limit barriers for NPs entering the workforce.
Chronic Pain Management: Implementing Best Practice Strategies
(North Dakota State University, 2017) Wallace, Jenna
The purpose of this project was to improve the monitoring of chronic pain patients at a rural primary care clinic by creating and implementing a chronic pain flow sheet and pain visit template within the electronic health record. These evidence-based tools were developed using published guidelines regarding the monitoring of chronic pain patients. The clinic has three providers, one physician and two advanced practice providers, and provides primary care along with an extensive amount of chronic pain management. An initial survey was performed on the three providers via a questionnaire along with open discussion regarding their current chronic pain management practice. All providers reported treating chronic pain patients was difficult and the electronic health record was currently not user-friendly when monitoring chronic pain patients. The flow sheet and pain visit template was designed by the project leader (writer) and created by the Computer Information Systems (CIS) department. Once it was created, an initial chart review and flow sheet implementation was performed on a sample population of adult chronic pain patients at the clinic. Providers were educated on the available flow sheet along with the pain visit template available for use. A six-month chart review was conducted to evaluate the project and determined how the flow sheet and template were utilized. A post-implementation survey, similar to the initial questionnaire, was also dispensed and analyzed. Results indicate providers do plan to use the designed monitoring tools but there were some barriers standing in the way of consistent use. The chart review found an increase in presence of pain contracts signed and filed within the last year, but a decrease in the presence of a pain visit within the last four months, urine drug screen within the last six months, and the prescription drug monitoring program checked within the last six months.
A Collaborative Hypertension Clinic Pilot Program in a Rural Primary Care
(North Dakota State University, 2020) Pink, Nicole Catherine
In 2019, there were about seventy-million Americans with uncontrolled high blood pressure (BP) or hypertension (HTN) (Kitt, Fox, Tucker & McManus, 2019). Hypertension is the leading cause of preventable deaths worldwide (Stephen, Halcomb, McInnes, Batterham & Zwar, 2019). Uncontrolled HTN contributes to stroke, myocardial infarction, and renal failure, and is the most modifiable risk factor for heart disease and death (American Academy of Family Physicians [AAFP], 2019; Oparil & Schmider, 2015). Patients living in rural America have an increased prevalence of HTN and their access to preventative health services is lower (Buford, 2016; Caldwell, Ford, Wallace, Wang & Takahashi, 2016). The increased prevalence of HTN in rural communities does not positively correlate with optimized blood pressure control, which poses a gap in care (Buford, 2016). A multidisciplinary collaboration between registered nurses (RNs) and providers may improve patient outcomes (Ford et al., 2018). The implementation of a collaborative HTN Clinic in a rural setting had the potential to improve BP outcomes by increasing access to services. The practice improvement project established a HTN Clinic as a collaborative effort between RNs and providers in a rural community. Providers and RNs were educated via modules regarding the protocol and participants took surveys before and after implementation to determine effectiveness and if the HTN Clinic should continue after conclusion of the practice improvement project. The HTN Clinic intervention implemented education for hypertensive patients with an emphasis on medication compliance and lifestyle modifications, as well as medication adjustments through nurse-led protocols. Despite a short duration of implementation and evaluation, positive results were observed. All HTN Clinic patients had improvement in BP measures and were controlled by the end of the four-week implementation period. Overall, patient access, wait times for appointments, and BP measures for all hypertensive patients improved after implementation. The providers’ and nurses’ knowledge increased through completion of a detailed curriculum. The provider and RN surveys indicated support for continuing the HTN Clinic to improve HTN management and clinic providers felt that the HTN Clinic helped improve their time with patients and quality metrics.
Colorectal Cancer Screening: A Collaboration with Public Health and Primary Care to Increase Colorectal Cancer Screening in a Rural North Dakota Community
(North Dakota State University, 2019) Bond, Laura Ann
Colorectal cancer (CRC) is the second leading cause of cancer related deaths in the nation (Centers for Disease Control and Prevention [CDC], 2017a). Recommendations are to screen adults, ages 50-75 years (United States Preventative Services Task Force [USPSTF], 2016). While 64.4% of the population, ages 50-75 years, in North Dakota (ND) are participating in colorectal cancer screening (CRCS), there is a nationwide challenge to increase CRCS to 80% (National Colorectal Cancer Roundtable [NCCR], 2017; North Dakota Comprehensive Cancer Control Program [NDCRC], 2017). The North Dakota Colorectal Cancer Roundtable (NDCCRT) accepted the challenge and recommended four strategies to increase CRCS; this project focused on the implementing FluFIT (fecal immunochemical test) Clinics. The purpose was to increase public awareness through education at FluFIT sites and increase screening rates with possible FIT to participants meeting screening criteria during the 2017-2018 influenza seasons (NCCR, 2017). Potential participants, ages 50-75 years, coming to FluFIT sites for influenza vaccination were provided informational brochures and asked to fill out a survey regarding knowledge and factors impacting CRCS decisions to increase public awareness and aide future planning for improved screening processes through the ND county Public Health Department. Public Health collaborated with a primary care clinic in town to each host the FluFIT sites. The staff involved from both entities included nurses and clerical staff present at FluFIT sites, and health care providers from the Primary Care Clinic to enter orders for FIT screenings and follow-up on results. There were a total of 31 participants. Only five of these participants met criteria for CRCS with FIT testing between all sites, though none were able to complete screening through the FluFIT sites. The number of distributed informational brochures totaled 347. Despite limited participation, the project increased community awareness on CRCS. The results also provided the ND Public Health Department with information on CRCS knowledge and beliefs to impact further research and identify barriers, while also supporting current literature that indicates there are unscreened individuals in ND. This project can assist future projects to merge the gap of the unscreened CRC population, leading to optimal health outcomes.
Colorectal Cancer: Improving Screening Compliance with the Utilization of FIT-DNA (Cologuard)
(North Dakota State University, 2018) Hanish, Sarah Anne
Colorectal cancer (CRC) is the second leading cause of cancer deaths in the United States (U.S.), but with the appropriate screening processes, this staggering fact can change (CDC, 2018). Routine CRC screening is one of the most powerful defenses in the fight against CRC, yet screening remains substantially underutilized (American Cancer Society, 2017). The United States Preventative Services Task Force (USPSTF) recommends screening those at average risk starting at age 50 and continuing to age 75 (USPSTF, 2016). Despite current recommendations, it is estimated that only 58.9% of qualifying women and 56.7% of qualifying men in the U.S. have been screened for CRC (Cooper & Gelb, 2016). One proposed mechanism to improve CRC screening compliance is to offer patients screening options, keeping in mind that the best screening is the one that gets done (USPSTF, 2016). Fecal-immunochemical test-deoxyribonucleic acid (FIT-DNA) is a recently approved stool-based test that offers an additional screening choice for patients. The addition of FIT-DNA has the potential to increase CRC screening rates and providing education regarding current USPSTF recommendations could improve screening uptake. The purpose of this quality improvement project was to implement and evaluate educational deliverables distributed to healthcare workers and patients within a local health system, and to analyze the influence of these deliverables on CRC screening rates and FIT-DNA utilization. Electronic memos were delivered to providers and staff regarding up-to-date screening recommendations. In effort to promote autonomy and informed decision-making, an electronic, printable educational tool was developed and distributed to patients at average risk for CRC. Data were collected on CRC screening rates and FIT-DNA utilization pre- and posteducation implementation to evaluate if a positive trend existed. Although there were statistical and evaluative limitations of the project, findings showed that the distribution of educational tools trended with an increase in CRC screening rates and FIT-DNA utilization. Based on results of the evaluation, education to providers, staff, and patients on current screening recommendations, and offering patients more screening options, can improve CRC screening compliance.
Combating Youth Depression in Primary Care
(North Dakota State University, 2016) Chesley, Kayla Lynn
Youth depression is a serious mental health disorder that may have detrimental consequences. Half of all lifetime cases of mental illness begin before the age of 14 (Hagan, Shaw, & Duncan, 2008). Depression in youth is linked to increased morbidity and mortality, along with high-risk behaviors. Mental health and mood disorders are the leading cause of illness and burden among youth (Patel, 2013). Nationally, suicide is the third leading cause of death for individuals aged 15 to 24. In North Dakota, suicide is the first leading cause of death for individuals aged 15 to 24 (American Foundation for Suicide Prevention, 2016). Unfortunately, depression remains largely underdiagnosed and undertreated; only about 50 percent of youth with depression are diagnosed before they reach adulthood (Zuckerbrot, Cheung, Jensen, Stein, & Laraque, 2007). The purpose of this project was to improve the mental health of youth through increasing universal screening in the primary care setting, and improve the confidence and ability of the primary care provider to diagnose and treat youth depression. Primary care provider education was launched through collaboration with Essentia Health, providing education regarding youth depression focused on universal screening, identification of youth depression, and treatment modalities. To evaluate primary care provider education, a pretest/posttest was completed, along with key stakeholder interviews. Surveys demonstrated an increased intent to screen and increased confidence in identifying and managing youth depression. The interview with key stakeholders was used to determine the effectiveness and feasibility of universal screening and management of youth depression in the primary care setting.
A Concussion Toolkit Educational Session: Promoting Evidence-Based Management of Youth Concussion in a Rural Primary Care Setting
(North Dakota State University, 2018) Senger, Jean J.
Concussions are a form of mild traumatic brain injury, yet the potential short-term and long-term adverse effects are anything but mild. Concussions, especially if left undiagnosed or untreated, can adversely affect a student’s scholastic achievements, relationships, emotions, and long-term health outcomes. Despite the recent surge in concussion awareness, literature substantiates a gap in the knowledge and adherence to published concussion guidelines amongst primary care providers. Rural communities, with a lack of access to specialty providers, rely on primary care providers to ensure youth concussions are appropriately evaluated and managed to reduce both the short-term and long-term negative health outcomes associated with concussions. This practice improvement project (PIP) focused on increasing primary care providers’ knowledge and promoting evidence-based concussion management practices in two rural North Dakota communities. Through implementation of the PIP, rural primary care providers were educated on the latest evidence-based concussion management guidelines, given resources for clinical practice, and provided an opportunity to evaluate and treat a mock-concussion patient. Project implementation was comprised of a concussion educational session, which included concussion education and the introduction of a concussion toolkit, and a return skill demonstration, where providers applied their acquired concussion evaluation and management strategies on a mock-concussion patient. To assess the participants’ perceived self-confidence and likelihood of using evidence-based practices when evaluating and managing patients with concussions, a self-confidence evaluation survey was administered. The providers were also evaluated on their ability to evaluate and treat a concussion patient during the return skill demonstration. The results of the project indicated an overall increase in participant knowledge, self-confidence, and likelihood of following concussion management guidelines in their next encounter with a patient suspected of suffering from a concussion. The educational session, concussion toolkit, and return skill demonstration were effective interventions in promoting the use of concussion management guidelines by primary care providers in the rural clinic setting.

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