Nursing

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Research from the School of Nursing. The website may be found at https://www.ndsu.edu/nursing/

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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.
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 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.
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.
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.
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.
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 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 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 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.
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.

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