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Item Skin Cancer Screening in Primary Care Using Dermoscopy(North Dakota State University, 2020) Lubitz, Erin ElizaSkin cancer rates continue to rise affecting millions of individuals annually. While cutaneous malignant melanoma comprises a fraction of total skin cancers diagnosed, melanoma is associated with a poor prognosis and higher mortality rate when compared to other forms of skin cancer. The greatest risk factor for skin cancer is the amount of ultraviolet light exposure making skin cancer the most common preventable form of cancer. In conjunction with primary prevention, part of secondary prevention measures involves performing routine skin examinations. According to data from the National Health Interview Survey, only 8% of individuals who had seen a primary care provider in the previous 12 months had a skin examination performed (Johnson et al., 2017). A low rate of skin examination can largely be attributed to current professional guidelines from the United States Preventative Services Task Force (2016) not supporting routine skin screening of all patients. Despite the recommendation, primary care providers are consistently faced with the need to evaluate skin lesions. Other barriers identified include lack of training and practical screening methods. Dermoscopy is a noninvasive technique for identifying skin lesions. Based on the need for improved screening practices and identified barriers, a brief educational session and resource on skin cancer and dermoscopy was presented to primary care providers at an urban family practice clinic in eastern North Dakota. Following the educational session, a three-month implementation period provided time for providers to implement their knowledge and dermoscopy skills in practice. The purpose of the project was to increase knowledge, improve accuracy of identifying skin lesions, and increase provider confidence using dermoscopy. Evaluation using a pre-implementation survey of providers in the clinic found the primary care providers felt comfortable with their baseline knowledge of skin cancer but did not feel confident in their ability to use a dermoscope. Most of the participating providers deemed their level of knowledge regarding dermoscopy to be at a novice level. Results of the post-implementation found providers felt more comfortable using dermoscopy and knowledge in dermoscopy overall improved from novice to advanced beginner or competent.Item Advance Care Planning and Advance Directives: Implementing Online Education for Healthcare Providers(North Dakota State University, 2022) Murphy, HannahAdvance 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.Item Aspirin and Statin Use for Primary Prevention of Cardiovascular Disease(North Dakota State University, 2022) Carriveau, Natalie JeanCardiovascular 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.Item 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 RoseIndividuals 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.Item Identifying Risk for HIV and Implementation of PrEP Amongst Primary Care Providers(North Dakota State University, 2020) Gross, Kayli ChristineThe purpose of this project was to improve primary care provider knowledge, attitude and behaviors related to the current HIV-screening and PrEP implementation guidelines. Surveys were conducted among five primary care providers at a Midwest VA Healthcare System before and after an HIV and PrEP-related education. The surveys were anonymous, and participation was voluntary. Each participant received a survey by pen and paper to self-assess their HIV-screening and PrEP prescribing intention, comfort-level with HIV prevention practices, and knowledge before and after the presentation by using Likert scales, true/false, and correct answer recall questions. Of the eligible 11 providers in attendance of the presentation, six of the 11 (54.5%) participated in the surveys. One participant was excluded as he/she did not submit his/her completed presurvey, which rendered the survey incomplete for data analysis. The included participants (n=5) worked in General/Primary Care, were either a MD (2 of 5) or NP (3 of 5), who have practiced as their current clinical title for less than 5 years to greater than 25 years. Responses were measured based on the FREQ procedure as the sample size was small. Following the intervention, there was no overall increase in intent to follow the current CDC HIV screening guidelines however intention prior to the intervention was already high. Following education, the providers’ ability to identify those at risk for HIV increased by 60% (3 of 5), and comfort-level in identifying those at risk for HIV whom are PrEP eligible increased by 80% (4 of 5). Of these providers, there was an 80% (4 of 5) increase in provider self-rated comfort-level in discussing PrEP with high risk patients post-education. Each provider rated their intention to prescribe PrEP after the intervention on a Likert scale, as “Probably” or “Very Probable,” which was a 60% (3 of 5) provider improvement. Overall, responses indicated an improvement of provider knowledge, attitudes, and behavior after receiving HIV screening and PrEP education. Findings of this project are comparable with previous research, this project, however, did not evaluate actual provider change in practice following education.Item Advance care planning: implementing online education for rural primary care providers(North Dakota State University, 2024) Kurtz, JessicaAdvance care planning (ACP) can assist patients and their families in navigating personal and medical choices at the end-of-life; however, these conversations often transpire too late. Primary care providers (PCPs) frequently develop extended relationships with their patients, especially those with chronic disease, and possess opportunities throughout a patient’s lifespan to assess when ACP conversations could be initiated. Unfortunately, many PCPs lack confidence in leading ACP conversations, although they are willing to facilitate them. Despite the alarming number of people living with chronic disease and documented benefits of ACP, advance directive completion remains low. According to previous research, online ACP education for PCPs can bridge gaps in end-of-life care by increasing overall perceived knowledge, confidence, and understanding of ACP and advance directives. The purpose of the practice improvement project was to improve rural PCPs perceived knowledge and confidence in facilitating ACP discussions and to increase the completion rate of advance directives among adults living with chronic disease(s) seen within the rural primary care setting. The theoretical underpinning for this DNP project was Lewin’s Theory of Behavior Change. Project implementation occurred within a federally qualified health center comprised of eight clinics throughout rural North Dakota. The project’s design methodology was a quantitative, quasi-experimental study using a convenience sample of eight PCPs employed within the federally qualified health center. Participants could access the ACP educational webinar, surveys, and posttest for four weeks. Four participants (50%) participated in the practice improvement project and acquired continuing education credit from the North Dakota Board of Nursing. The surveys aided in assessing participants’ reported ACP knowledge, confidence, perceived benefits of ACP, and prior experiences in initiating advance directives and ACP conversations before and after viewing the webinar. The outcomes of the practice improvement project objectives were evaluated and demonstrated an increase in participants’ perceived knowledge and confidence of ACP, an increase in PCPs' reported knowledge of the Serious Illness Conversation Guide, and an improved understanding of the role of ACP facilitators.Item Skin Cancer Screening: Implementation of Dermoscopy in Rural Primary Care(North Dakota State University, 2022) Lehn, Mitchell CharlesSkin cancer is the most common cancer in the United States and worldwide, and rates continue to rise (American Academy of Dermatology Association [AAD], 2020; Skin Cancer Foundation [SCF], 2020). Although there is disagreement about the reasons why, rural areas are more dramatically affected by skin cancer morbidity and mortality than their urban counterparts (Cunningham et al., 2019). Early detection of all skin cancers, especially melanoma, can improve morbidity and mortality rates (Hubner et al., 2018; Kricker et al., 2014). Secondary prevention strategies, such as naked eye skin examinations and dermsocopy, are critical in monitoring and identifying suspicious skin lesions. The results of naked eye examinations are often inconsistent because of varying clinician competence, confidence level, and time. When performed correctly and in adjunct with the naked eye examination, dermoscopy is more sensitive and specific at classifying skin lesions than naked eye examinations alone and use could help lead to the earlier diagnosis of cancerous skin lesions (Chappuis et al., 2016). However, many primary care clinicians do not have the skills or resources to use dermoscopy effectively. Dermoscopy training programs have increased skin lesion diagnostic accuracy and confidence among primary care clinicians, even in as little as a one-day seminar (Augustsson & Paoli, 2019). Because of this, an education seminar was implemented at a federally funded institution that provides primary care to rural residents of eastern North Dakota, western Minnesota, and northeastern South Dakota. The purpose of this practice improvement project was to improve overall care quality and skin cancer survival rates in rural areas through early and accurate detection by educating primary care clinicians on the use of dermoscopy. Pre- and post-implementation surveys were used to compare clinician knowledge of skin cancer, dermoscopy algorithms, opinions on the usefulness of dermoscopy, and comfortability with the practice of dermoscopy. Following the educational seminar, a three-month implementation period provided time for providers to implement their knowledge and dermoscopy skills in practice. Results of the surveys showed an increase in clinician comfortability and knowledge regarding dermoscopy use after the education seminar as opposed to before.Item Screening Adolescent Females for Eating Disorders in Primary Care(North Dakota State University, 2021) Thom, Brooke MarieIn recent decades, there has been an increased focus on the idealization of thinness and the pressure and expectancy to be thin, which contributes to a rising number of individuals that experience severe body dissatisfaction and body distortion, and in turn, eating disorders. Eating disorders are one of the most common chronic conditions within the youth population, approximately 13% of the adolescent youth population will suffer from at least one eating disorder by age 20, and a majority of those affected will be female. Rural health care providers encounter many health care disadvantages when detecting and treating eating disorders including physical location and distance to nearest healthcare or specialty service, ethnicity, and socioeconomic status. These disadvantages are often responsible for the inability of providers to prevent, screen for, identify, and treat eating disorders. The focus of this practice improvement project (PIP) was to determine how primary care providers in a rural clinic perceived the implementation of the Screening for Disordered Eating (SDE) in adolescent females ages 11-19. During implementation, the providers were also to identify and refer those scoring 2 or greater to a counselor, mental health specialist, and/or eating disorder specialist. Implementation began with an educational meeting explaining eating disorders and their prevalence, as well as the introduction and explanation of the SDE tool. A survey was then completed by the providers to assess the relevance of the information provided to their practice. During the implementation period, providers were to screen all adolescent females ages 11-19 using the SDE tool and refer those scoring 2 or greater. Participating providers then completed a post-implementation survey assessing their perceptions on the ease, accuracy, and applicability of the SDE tool. Overall, based on the post-implementation, providers believe screening for eating disorders is important and the SDE tool is easy and applicable to their practice. Screening for Disordered Eating completion rates (14.1%) and referral rates (17.4%) of those scoring 2 or greater were lower than expected. The prevalence of eating disorders continues to rise and continued use of the SDE tool in the primary care setting is strongly recommended.