• Predictors of the First-year Nursing Student at Risk of Early Departure

      Martin, Kathleen M. (2008)
      Purpose and Objective of Project: The purpose of this project was to identify factors associated with early attrition, with particular emphasis on factors associated with minority nursing students. A logistic regression model was used to determine the predictive power of a variety of student "pre-entry attributes" (Tinto, 1993). These characteristics are a sub-set of the model proposed by Vincent Tinto (1993), and are derived directly from the theoretical framework. Tinto's (1993) theory of college student departure, "A Longitudinal Model of Institutional Departure", guided this author's identification of variables which may affect nursing student retention. The theory of college student departure utilizes a longitudinal approach to the problem of college student departure. Tinto's model (1993) describes the interaction of student "pre-entry attributes" with student goals and commitments, institutional experiences and academic and social integration (p. 114). Several pre-entry attributes were analyzed to determine which of these characteristics, if any, place nursing students at an increased risk of attrition in the first year of a two-year nursing program. This study took place at Frederick Community College, an accredited, two-year institution located in Frederick, MD. If predictive attributes are identified they may be used by the Frederick Community College nursing administrators and faculty to improve the identification of students who are at increased risk of early departure from the nursing program. Early departure is defined as the failure or withdrawal failing from one of the three first-year nursing clinical courses. The attributes under investigation include student course-taking behaviors. Should certain coursetaking pattems be predictive of early departure from the nursing program, admission policies may be examined and modified to consider these conditions. Early identification of the "at risk" student has been posited as an important first step in reducing nursing student attrition (Campbell & Dickson, 1996; Symes, Tart, & Travis, 2005).
    • Nursing Informatics Certification and Competencies: A Report on the Current State and Recommendations for the Future

      Halimi, Miriam (2009)
      Background: Nurses have worked in informatics roles for nearly 40 years, but the phrase "nursing informatics" was not seen in the literature until 1984. Since then, nursing informatics has established itself as a professional specialty. The American Nurses Credentialing Center (ANCC) is the official certifying organization for nurses. The ANCC has offered basic certification in nursing informatics since 1994, but it does not offer advanced certification in this specialty. As a result of revised certification that took place July 2008, the informatics competency level of the current exam is unclear. However, descriptions of informatics competencies for different levels of nursing practice developed since 2000 may link the competences tested in the exam more closely to the informatics nurse specialist than to the generalist level of the experienced nurse. The American Medical Informatics Association (AMIA), with a grant from the Robert Wood Johnson Foundation, has initiated work to develop a certification process in Clinical Informatics, intended to be offered to physicians. Recognition of clinical informatics as a medical specialty is unprecedented. As with other medical boards, it would be possible to offer certification to doctorally prepared non-physicians who are working in the field. Objectives ofthis study: • To clarify the level of the current nursing informatics certification offered by ANCC • To advise the ANCC regarding the need, if any is discovered, for other or different levels of certification • To investigate the similarities and differences in the content and criteria for certification in nursing informatics as offered by ANCC and in clinical informatics as AMIA proposes • To formulate a recommendation as to whether Clinical Informatics certification offered by AMIA should be available as an advanced level of certification for Nurse Informaticians. Methodology: This study used a two-round Delphi methodology to elicit opinions from experts about certification in nursing informatics. IRE approval was obtained. The first round of the study consisted of 8 open-ended questions about nursing informatics certification based on the core content ANCC Nursing Informatics Certification exam and AMIA's core content for clinical informatics certification. The second-round survey, based on the information obtained from the first survey, contained nine statements that respondents were asked to rate on a 7 point Likert scale ranging from strongly disagree to strongly agree. Both surveys were administered electronically via Survey Monkey. Responses were anonymous. Conclusions: This study found consensus among experts on the similarities and differences between the competencies and core content of nursing informatics and clinical informatics. Experts agreed that there is much overlap between the competencies required for nursing informatics certification and those proposed for clinical informatics certification, but that each field retains some distinctive features. Recommendations are formulated for ANCC and AMIA on how to proceed with their respective certifications.
    • Building the Evidence - Use of the Electronic Health Record in the Measurement of Nurse Practitioner Performance

      Wilson, Janice (2009)
      Background: Health care providers are required to demonstrate evidence of ongoing competence or performance. This is especially crucial for nurse practitioners working in critical care arenas, like the Neonatal Intensive Care Unit (NICU). Neonatal nurse practitioners (NNP) working in these settings must competently perform multiple high risk procedures, like the percutaneous insertion of central catheters (PICC), yet performance for these providers and outcomes for these procedures are often not visible. In addition few frameworks exist that adequately measure them. Purpose: The main purpose of the project was to determine if an evidence based electronic PICC line note could be utilized as a tool to evaluate NNP PICC line performance or outcomes in a Neonatal Intensive Care Nursery Setting. The objectives of the project were as follows: 1.) Determine what tools if any, are utilized by Baltimore-Washington area NICU’s to evaluate NNP PICC line insertion performance or competence 2.) Evaluate the perception of eight commonly used performance measurement tools. 3.) Build and implement an evidence based electronic PICC line note embedded within the electronic health record, for NNP providers to use in the NICU at Mercy Medical Center. 4.) Using data analysis software, analyze the PICC line note elements to determine the usability of the note as a tool to measure NNP PICC line performance. 5.) Evaluate the note implementation process and NNP satisfaction with the updated PICC line note format. Methods: Baltimore Washington area NICU’s were surveyed to determine what tools they use to measure NNP PICC line performance, and what their perceptions were of those tools as measures of NNP PICC line performance outcomes. Using GE Centricity Perinatal Software, an evidence based electronic NNP PICC line procedure note was developed and implemented. A post implementation survey was conducted using the Clinical Information Systems Evaluation Scale. SPSS was used to analyze both survey results as well as the outcomes of the PICC line note. Results: Out of 14 NICU’s surveyed, 78.6% (N=11) do not measure NNP PICC line outcomes or performance. Of the 21.4 % (N=3) that do measure NP PICC line performance, two used the electronic health record to do so, but felt that it was less than adequate to measure NNP PICC line performance (M = 1.7, SD = 0.6). Eighty one percent of note fields were completed in the insertion section of the note, 85% of fields were completed for the adjustment part of the note and 88% of the removal note fields were completed. The implementation was viewed as moderately to highly successful with a CISIES total score of 3.2. Conclusions: NNP PICC line performance is not routinely measured in local Baltimore Washington area NICU’s. The successful implementation of a clinical information system, in this case an evidence based electronic NNP PICC line procedure note, demonstrates the potential power of the electronic health record to serve as a tool in the evaluation of NNP performance, outcomes and competence.
    • Use and assessment of a Palliative Care Nurse Practitioner on a Pancreatic Cancer Web Site

      Grant, Marian (2010)
      Patients with pancreatic cancer and their families struggle with physical and emotional issues. They could benefit from palliative care services, but may not have access to them. The Internet has become an important source of health information and a link between patients, families and health care providers. The purpose of this capstone project was to 1) determine if patients and their families would use a Web page where they could access a palliative care nurse practitioner (PCNP); 2) to identify the palliative care needs of the patients and families who accessed the PCNP; and 3) to determine the helpfulness of the Web page. Participants were recruited to the PCNP Web page from the Johns Hopkins Pancreatic Cancer Research Center’s (JHPCRC) Web site. A mixed method design was used to determine 1) the volume of participation with the PCNP Web page, 2) patient and family member needs, and 3) the usefulness of the Web page. Participants could post their questions to the public comments section of the PCNP Web or send the PCNP a private email. There also was a link to an online survey to gather demographic and evaluative information. The PCNP Web page was visited 650 times by 395 unique individuals over an 8-week period. Participants spent an average of 4 minutes and 4 seconds on the PCNP Web page. Half, 49%, came from a link posted on the discussion board of the JHPCRC Web site. Forty-eight participants posted a total of 55 questions or sent individual emails to the PCNP. The majority were from female family members of patients with pancreatic cancer. The majority of questions (66%) fell into one of the eight domains of palliative care. Of these, most of the questions, 42%, asked about physical aspects of pancreatic cancer with the next largest domain, 11%, being psychological concerns about the illness and the risks of developing it. The other third of questions had to do with non-palliative aspects of pancreatic cancer and its treatment. Twenty participants (5% of total visitors) completed the online survey. Most survey respondents were female, family members, middle-aged, white, and college-educated. Although statistical significance was not achieved, most survey respondents found the PCNP website helpful. It was considered easy to use and participants found information and support there and recommended that the PCNP page should be an on-going resource. Access to a PCNP is an important resource for patients with pancreatic cancer and their family members. The Internet can be used to offer information, support and advice to patients and families dealing with a life-threatening illness.
    • Development and evaluation of a surveillance instrument for monitoring and cataloging staff injuries in a state mental hospital

      Perdue, Georgia L. (2010)
      This quality improvement study was designed to: 1) review staff injury documentation instruments of public and private mental health facilities and other hospitals in different geographic areas, 2) develop an instrument to document staff injuries and their context, and 3) test the usability/acceptability and the ability to reliably capture relevant data elements.
    • Advanced Directives in Nursing Homes

      Morgan, Tracie L. (2010)
      Background: Nursing homes are becoming the place where Americans choose to live their final stages of life, providing end-of-life care for the over 65 population. Despite the focus on patient centered care and shared decision-making, three out of four people did not complete Advanced Directives in 2004. Purpose: The purpose of this study was to: I) assess the feasibility of an educational intervention on advanced directives within a Nursing Home setting; 2) evaluate if the education improves knowledge and attitudes about advanced directives; and 3) determine if attendees complete the Maryland Life-Sustaining Treatment Options (LST) form after the education. Design: A feasibility study, using quasi-experimental, pre-test/post-test, design was used. The intervention was a one day, one and half hour educational program using the End of Life Nursing Education Consortium (ELNEC) Ethics and Advanced Directives Module. Sample/Setting: A convenience sample of six patients with decisional capacity from a Maryland Nursing Home was used. Data Collection: Survey data were collected pre and post intervention. A Participant Intake Form was used to collect demographic and medical information. The Advance Directive Knowledge Assessment Survey and Advance Directive Attitudes Assessment Survey were used pre-and post-intervention to measure change in knowledge and attitudes. Additionally, a Follow up Interview was conducted to obtain additional information from participants regarding how they have used the information obtained from the Program, as well as the subsequent completion of the Maryland LST form. Results: The education program did not improve participant knowledge regarding advanced directives. There was, however an improvement in attitudes regarding advanced directives, with median score improvements from pre-intervention (Md=35.5) to post-intervention (Md= 37.5), z= -2.003, p< 0.045. In the Follow-up Interview, seven days post-educational program, 80% of participants stated, "they will use the information learned in the future," and 100% of the participants discussed the information learned within the first week, post-program, with either a family caregiver, health care provider, or Nursing Home staff. None of the participants completed a Maryland LST form. Conclusions/Implications: As a result of this Educational program, there was a marked improvement in the participants' attitudes towards advanced directives in this Maryland Nursing Home. Although there was not an improvement in the participants' knowledge regarding the same, the Follow-up Interviews suggested that the information provided during the educational program did positively impact their beliefs and did increase their awareness of the content. This allowed the participants to have repeat conversations with their family, health care providers, and Nursing Home staff. Although the study is generally feasible, consideration for future use of this study needs to be directed toward a more diverse ethnic population, the instruments used, and the inclusion of family and/or Durable Power of Attorney (DPOAs).
    • A Program to Increase Bariatric Surgery Referrals Through Clinical Practice Guidelines

      Reedy, Shannon (2010)
      Obesity has reached epidemic levels in our country. Clear clinical practice guidelines (CPGs) are available that address identification, evaluation, and treatment of overweight and obese adults. These CPGs are based on the best evidence available and include dietary, exercise, behavioral, pharmacologic, and surgical interventions 1. Despite these guidelines and data on the efficacy, safety and technical advances of bariatric surgery 2, 3, the overall attitude of patients and providers toward bariatric surgery is negative 4-10. Although there has been a consistent increase in the number of bariatric surgeries being performed, the numbers are still low compared to the number of obese Americans 11. There is compelling evidence in favor of bariatric surgery as a treatment for morbid obesity, yet few patients are being referred to bariatric surgeons 3. One reason that may be is there is a great deal of misinformation about bariatric surgery and many providers have not read or received education treatment of obesity and on bariatric surgery 4-10. Specifically, referrals from Greater Baltimore Medical Associate (GBMA) providers to the Comprehensive Obesity Management Program (COMP) at Greater Baltimore Medical Center (GBMC) are lower than the national average. The purpose of this capstone project was to develop a program for Greater Baltimore Medical Associate (GBMA) primary care providers on the clinical practice guidelines for the identification, evaluation, and treatment of overweight and obese adults including bariatric surgery. Primary care providers from an existing database were surveyed to develop a list of items to include in the education program. Sixty primary care providers were emailed and sixteen providers responded to the internet survey. The majority of the providers selected six of the eleven items to be included in the program. The program was developed based on these recommendations. The program was piloted in two out of fifteen GBMA practices. The Bariatric Surgery 3 program was advertised to the GBMA providers by email and in a print advertisement in their lounge lunch room. Seven providers attended the program. All of the participants felt the program would improve how they cared for their obese patients and believed that because of the program they were more likely to adhere to the clinical practice guidelines for diagnosis, evaluation and treatment of obesity. Six of seven of the participants felt that the program improved their opinion of bariatric surgery. In addition, all of the participants felt that because of the program they were more likely to refer their obese patients to a bariatric surgeon. Use of current clinical practice guidelines, simple tools and face-to-face meeting with primary care providers may improve the care of obese patients. This program will be replicated at other GBMA practices and should be considered at other practices locations. Future data collection would be helpful to determine if, in fact, the program does improve the care of obese patients, increase the use of clinical practice guidelines and increase appropriate referrals to bariatric surgeons.
    • Factors Which Influence Job Satisfaction in Nursing Assistants in Nursing Homes

      Lerner, Nancy B. (2010)
      High turnover of nursing assisants in long term care facilities results in poor quality of care and decreased quality of life for nursing home residents. Turnover is related to job satisfaction and can be improved by improving job satisfaction. The purpose of this project was first to explore the relationships between job satisfaction and factors known to affect job satisfaction in an existing data set of 556 nursing assistants from 12 Maryland nursing homes. The second purpose of the project was to develop a guideline and user friendly tool to assist Directors of Nursing in improving job satisfaction in their own facilities. A multiple regression analysis was performed to identify the relationship between job satisfaction and facility, age, gender, education, years of experience, self-esteem, self-efficacy and outcome expectations for performance of restorative care activities, and observed performance of restorative activities. A step wise approach was used. Three variables entered the model, accounting for 7.1% of the variance in job satisfaction. The variables positively associated with job satisfaction were length of experience as a nursing assistant and performance of exemplary nursing care demonstrated through performance of restorative care. Self esteem was negatively associated with job satisfaction. The remaining variables did not enter the model. An evidence based guideline for evaluating and improving job satisfaction and reducing turnover in nursing assistance was developed based on the study results and existing literature. Strategies for improving job satisfaction which were proven to be effective were included. A three step, checklist tool was developed from the guideline to assist administrative staff in the evaluation and improvement of job satisfaction and turnover in their facility. Job Satisfaction in Nursing Assistants 6 Enhancing job satisfaction and reducing turnover is a problem with multiple causes and multiple potential solutions. For Directors of Nursing, shifting through the potential interventions can be daunting. The guideline and tool can assist in addressing and resolving job satisfaction problems and, through more satisfied nursing assistants, improve quality of care and quality of life for long term care residents.
    • B-type Natriuretic Peptide Levels as Predictors of Significant Rejection in the Heart Transplant Population: A Practice Guideline Based on Evidence

      Skojec, Diane Vail (2010)
      B-type natriuretic peptide has been identified as a potential non-invasive marker of allograft rejection but the evidence supporting an absolute correlation ofthis neurohormone's elevation with cellular rejection and allograft dysfunction is weak. A within-individual change over time has been shown to provide a more accurate measure of acute rejection and may support the use of empiric therapy prior to rejection confirmation by endomyocardial biopsy. Identifying a noninvasive approach to the detection of rejection and developing a clinical practice guideline based on this has the potential to decrease risk, blunt cost, and provide those who care for this population with an adjunct method to recognize significant rejection, thereby assisting in the diagnosis and treatment of a potential life-threatening situation.
    • Implementation of an education program to improve Smith Island, Maryland residents' knowledge and attributes of healthier eating practices and benefits of physical activity

      Windemuth, Brenda (2011)
      Introduction: Obesity rates in the United States have drastically increased over the past twenty years. According to the Center for Disease Control and Prevention, the obesity rate for adults has nearly doubled since 1990, reaching as high as 32.2 percent among adult men and 35.5 percent among adult women (Flegal, 2010). Obesity is associated with increased health risks for many health related conditions which include diabetes, cardiovascular disease, stroke, cancer, sleep apnea, and a modestly elevated risk for all cause mortality. Educating the community on healthy eating and exercise practices is one strategy to develop skills which can then be used to facilitate behavioral changes. One rural community with increased obesity rates is Smith Island, Maryland. This community has special challenges to obtain a healthy lifestyle including a unique aspect of cultural sensitivity and need to be given the opportunity for obesity prevention in an isolated environment. Although there have been small measures to reduce obesity. These have isolated events, but a program has been established for this community. Purpose: The objective of this capstone project was to determine if a cultural sensitive educational program increases the knowledge of healthy eating practices and benefits of physical activity among residents of Smith Island. Design: A one-group, pre-test post-test, pre-experimental design was used to compare knowledge scores of Smith Island residents before and after an educational program on healthier eating and benefits of physical activity. Sample: A convenience sample of 25 residents living on Smith Island was recruited to participate in the program. Data Sources: The subjects completed a pretest prior to participating in a culturally modified educational program based on Dietary Guidelines for Adult Americans. Participants completed a post-test after the program had been given. Results: A dependent t-test was used to determine if there is a difference between pre-test and post-test attitudes and scores following the educational intervention. Overall, participants scored higher on the post-test as compared to the pre-test (t=.28, p<0.001). Additionally, the participants felt more confident in making changes in their food choices (t = -4.64, p<0.001) and making a nutritious meal for their families (t= - 4.54, p< 0.001). Conclusions/Implications: There was an increase in knowledge of healthy eating practices and benefits of physical activity in a rural community through the use of culturally sensitive educational tools. Thus, the implications of the study demonstrate the need for culturally appropriate educational tools that focus on improving healthier eating habits and benefits of physical activity as a plausible strategy to reduce risk for obesity.
    • Lung Cancer Provider Education and Referral Criteria for Palliative Care

      Reville, Barbara (2011)
      Problem: Individuals diagnosed with advanced lung cancer encounter a life-limiting illness compounded by a high symptom burden and quality of life issues. Despite evidence of complex care needs during many phases of the illness and evidence supporting the contribution of palliative care interventions to relieve symptom burden and psychosocial distress, health care providers typically delay referrals to palliative care until the final days of life. Numerous barriers contribute to limited utilization of palliative care by lung cancer providers including: lack of knowledge about palliative care, uncertainty about criteria for palliative care, timing of referral to palliative care in the disease trajectory, and attitudes about palliative care or the role of specialists. Published data on lung cancer referrals to a palliative care consultation service (PCS) at the researcher’s institution indicated that referrals were made for 8% (n=118) of lung cancer patients admitted over a 3.5-year period. Referrals occurred late in the disease trajectory and late during the hospital stay (6-day median pre-consult length of stay ([LOS]). To improve referral to palliative care, palliative care experts recommend evidence-based education of providers about palliative care and the use of referral criteria to identify eligible patients Objective: 1. To develop and implement a multi-faceted educational intervention including referral criteria for lung cancer providers (physicians and nurse practitioners) caring for hospitalized lung cancer patients. 2. To assess the impact of the interventions on outcome measures indicative of provider referral patterns compared to previously published baseline data. Design: A single group post-test only quasi-experimental design was used to measure outcomes (number of referrals, reasons for referral, pre-consult LOS, performance scores and patient LUNG CANCER PROVIDER EDUCATION AND REFERRAL CRITERIA 2 discharge disposition) following implementation of the educational intervention including referral criteria. Sample: Two inpatient oncology provider teams in an urban teaching hospital with 700 beds. Methods: The intervention consisted of a didactic presentation to key oncologists and nurse practitioners about palliative care needs of lung cancer patients, the role of the palliative care consultation team, and the referral criteria followed by education outreach visits to 4 oncologists and 2 nurse practitioners to reinforce the educational content. The investigator also attended weekly interdisciplinary oncology team meetings to provide written copies of referral criteria. Data Source: Baseline and post-intervention data from the Palliative Care Service database. Results: Data were collected for 2.5 months following the initial didactic education session and introduction of referral criteria. Lung cancer remained the diagnosis most frequently referred to the PCS. Oncology providers referred 21.4% (n=3) of all lung cancer admissions to PCS post intervention, compared to 20.5% (n=32) during the baseline period. Ten patients with cancers other than lung cancer were also referred, and their data aggregated with lung cancer referral data. Patients were mostly female (53%), African American (61.5%), and had a mean age of 58.7 years. The top reasons for referral were end of life issues, goals of care discussion, and advanced care planning in the post-intervention sample, similar to baseline data. Following the intervention, more referrals for pain management (31% versus 18%) were made compared to baseline data and the pre-consult LOS was shorter (median-1 day). Additionally, more patients were discharged alive (100%, n=13 versus 70%, n=83), and more were enrolled in hospice (77%, n=10 versus 41%, n=48). Implications: The study design, a short data collection period, and small number of lung cancer referrals limited interpretation of the impact of this intervention. LUNG CANCER PROVIDER EDUCATION AND REFERRAL CRITERIA 3 The addition of non-lung cancer referrals to the data analysis showed promising trends favoring the intervention but lack of a baseline comparison was a limitation. Dissemination of initial results will be presented to oncology providers and a longer data collection period will ensue.
    • Creation of an Evidence-Based Program Evaluation Design for Preceptor Programs

      Bindon, Susan L. (2011)
      The role of the preceptor in orientation and the use of preceptor development programs to teach preceptors to be effective during the orientation process are supported by the literature. The characteristics of effective preceptor programs are outlined and studied in the literature. The literature supports the use of pre and post tests to evaluate knowledge and nurse retention rates to evaluate outcomes. However, these are only two measures which provide limited information to evaluate preceptor program effectiveness. A comprehensive evaluation for a preceptor program is needed, which includes measures from the participant, stakeholder, and organizational perspectives. The purpose of this capstone project was to develop a comprehensive preceptor evaluation using Donabedian’s Structure-Process-Outcome framework (1966) combined with the theory of Nursing Intellectual Capital (Covell, 2008) as an evaluation blueprint. The goal of the project was to develop a useful comprehensive evaluation design for hospital-based preceptor programs. Method: A survey-based quality improvement project was completed to determine the usefulness of an evidence-based Preceptor Program Evaluation Blueprint. Guided by the blueprint, surveys were used to gather data regarding the Structure, Process, and Outcomes of the LifeBridge Health Preceptor Development program from four different participant perspectives. These convenience samples included twenty-two new graduate nurses, nineteen nurse educators, twenty nurse leaders, and one hundred fifty preceptors. Results: Data from stakeholders revealed an overall satisfaction with the preceptor development program from all key stakeholder groups, yet also revealed uneven perceptions regarding other outcomes such as cost savings and impact on overall new graduate nurse retention, despite data to support positive changes in these organizational metrics. As predicted by the theoretical framework used for the project, weaknesses identified in Structure (identification of individuals responsible for follow-up) were also present in the Process and Outcomes feedback. The same held true for strengths in the Structure elements (preceptor workshop design), which also were consistent throughout the Process and Outcomes data. Changes to the program will be made based on the data from four key participant groups across all three elements of the LBH preceptor program. Conclusion: The evaluation blueprint was extremely helpful in guiding a comprehensive program evaluation and highlighting strengths, weaknesses, and inconsistencies of the program. Using the blueprint, staff development educators can identify, modify, and measure, and monitor key areas both during and after preceptor programs, to help support changes and lead to further enhancements and improvement. Streamlining and simplification of the blueprint is recommended to make it more accessible and usable for educators evaluating preceptor programs.
    • Vitamin D Supplementation and Glycemic Control in Patients with Type 2 Diabetes

      Lazear, Janice (2011)
      Purpose: Treatment guidelines for the management of patients with type 2 diabetes (T2DM) and vitamin D deficiency do not exist. The primary purpose of this project was to describe repletion rates, prescribing patterns and monitoring patterns for patients with T2DM and vitamin D deficiency. This is a first step in the development of management guidelines. A secondary purpose was to examine glycemic control before and after correction of vitamin D hypovitaminosis. This was done in order to determine if future interventional studies examining the efficacy of treating vitamin D deficiency for patients with T2DM are warranted. Significance: In the United States 25.8 million (8.3%) individuals have diabetes; 90 to 95% have T2DM. The disease is responsible for increased morbidity and mortality as well as annual costs in the billions. Vitamin D deficiency in the United States is estimated to affect 70% of Caucasians and 95% of African Americans. A link between T2DM and vitamin D deficiency has been described. However, guidelines for vitamin D repletion of individuals with T2DM are not available, and the effect of vitamin D repletion on glycemic control has not been well studied. Methods: This project was a non-experimental retrospective audit of electronic medical records used in the outpatient diabetes department of a University Medical Center. Data were collected from the Epic documentation system. Descriptive statistics were used to describe care processes, and a paired samples Student t-test was used to examine A1C levels before and five to eight months after vitamin D repletion for subjects successfully repleted. Results: A total of 366 subjects qualified for inclusion in the study. Follow-up testing ranged from one to twelve tests per subject with a mean of 2.6 (SD = 1.5) and a range from 0 to 12 tests. Successful repletion rates per follow-up period ranged from 4.7 to 23.6%. Five to eight months after initiation of vitamin D, only 97 subjects (26.5%) were successfully repleted. Within this group results demonstrated a significant decrease from an initial to a follow-up mean A1C value (8.33 ± 0.69 vs 7.9 ± 1.3), indicating improved glycemic control (t = 3.58, p = .001). Conclusions: Treatment guidelines and standardization of care for patients with T2DM and vitamin D deficiency are needed. Further investigation is needed to investigate why the majority of patients were not successfully repleted. The findings of improved glycemic control for subjects with repletion also indicate a need for interventional studies with randomized controlled trials to investigate the effect of treating vitamin D deficiency on glycemic control.
    • Utility of a Nutrition Education Web Site to Supplement Prenatal Care

      Wierwille, Lauren (2011)
      Objective: Prenatal nutrition education is lacking in the clinic during routine prenatal care due to a myriad of barriers including decline in provider knowledge, time limitations during visits, and insurance constraints for dietician and nutritionist referrals. Online resources are an effective way to reduce such barriers to prenatal education by providing a flexible and available source of information. The purpose of this evidence translation project was to develop, implement, and evaluate the utility and uptake of a prenatal nutrition education Web site in the University of Maryland Medical System (UMMS) outpatient clinics as a supplement to routine prenatal care. Methods: This project used a single group, post-test only, non-experimental descriptive design to evaluate the utility and uptake of a prenatal nutrition education Web site entitled "Pregnancy Nutrition for Healthy Babies" in the UMMS clinics. Twenty prenatal care clinicians were recruited to participate using convenience sampling. The Diffusion of Innovations (001) theory by Everett Rogers was the foundation for implementing the Web site into the clinics. Data were collected from surveys completed by clinicians after they had incorporated the Web site into their prenatal care practices for approximately one month in order to evaluate their experience with utilizing the site as a supplementary nutrition education tool. Results: The snowball effect occurred and resulted in 19 clinician respondents who completed an anonymous and confidential survey to evaluate the utility of the Web site in the clinic based on five domains of the 001 model. An average of 81 patients were seen per week by the providers, and about 95% of the providers referred more than half of these patients to the Web site. Likewise, approximately 95% of the providers said that more than half of their referred patients engaged in further discussion about nutrition-related topics following the referral. The mean overall utility of the Web site in the clinic was determined to be 4.28 on a 5-point Likert scale. Based on the responses provided, the Web site was perceived to have a relative advantage mean of 4.03, a compatibility mean of 3.71, a complexity mean of 4.05, an observability mean of 3.81, and a trialability mean of 3.95. In totality, 89.5% of clinicians said that the "Prenatal Nutrition for Healthy Babies" Web site was a tool that they would regularly refer their prenatal care patients to for nutrition education, Conclusion: Internet Web sites can be effective tools for increasing prenatal nutrition education as supplements to routine prenatal care. The utility and uptake of a prenatal nutrition education Web site was found to be favorable in the UMMS outpatient clinics. The results were consistent with the evidence for increased utility and uptake of Web-based innovations within organizations when implementation is based on the 001 theory.
    • Exploring Parental Perceptions Regarding Surgical Pain Management Practices in a University Pediatric Inpatient Setting

      Simone, Shari (2011)
      Background: Reports of inadequate pain assessment and management have resulted in the development of regulatory and professional standards and guidelines about pain management. However, there continues to be a high prevalence of pain in hospitalized children and continued evidence that parents perceive pain management to be suboptimal. Low parental satisfaction with pediatric pain management at a large academic medical center prompted the need for practice improvement. Although, identifying gaps in best pain practices are critical to reducing pain in hospitalized children, strategies to improve satisfaction must include understanding the perceptions and expectations of parents to improve organizational performance related to patient and family satisfaction. Purpose: The objective of this capstone project was to explore parental perceptions regarding surgical pain management. Design: A descriptive, non-experimental survey was used to interview parents of children with acute surgical pain management. Sample: A convenience sample of 30 parents of post-surgical children admitted to the pediatric inpatient units at a large academic medical center was interviewed. Methods: An assessment survey was developed for the purpose of this project and underwent content validation by a series of experts. Structured interview conducted up to 48 hours after surgery. A subset of parents (n=ll) whose child received patient-controlled analgesia (PCA) was re-interviewed after discontinuation. Results: Post-operative pain occurred in 96.7% of the children, of whom one-half experienced moderate pain some or most of the time in the 24 hours prior to the interview. Eighty percent of the parental subset reported their child had pain some to most of the time after the PCA was discontinued. Although, 67% of the parents (n=20) were completely satisfied with the nurse's pain management at the first interview, 6 of these parents reported decreased satisfaction during the second interview. Parents of children whose post-operative pain was managed by the pain team were very satisfied with the early post-operative pain management; however, pain relief was perceived as less effective in the late post-operative period when managed by the surgical team. Forty percent of parents from both interviews identified earlier pain treatment, alternative pain treatment options and increased nursing availability as areas for improvement. Implications: Parental perception of suboptimal pain control warrants improvements in pediatric pain management. The parental suggestions for improvement opportunities provide valuable information in designing QI strategies to optimize pediatric pain management unit practices. Findings also suggest the need for improved collaboration with the pain team during the first 24- hours after transition from PCA to around-the-clock analgesia. In addition, development of best practice pain protocols to standardize care for the pediatric surgical population may smooth transitions in pain management.
    • Development of a Bariatric patient Readiness Assessment Tool (BRAT) for the Emergency Department.

      Jones, Dennis W. (2011)
      The current obesity epidemic in the U.S. and the chronic conditions associated with obesity and morbid obesity, present many challenges to healthcare providers, particularly in the hospital Emergency Department (ED). EDs are often not well equipped to care for the morbidly obese patient, which presents risks to safe patient handling for both patient and provider. The purpose of this study was to develop an assessment tool to determine the readiness of the ED to care for and handle the morbidly obese patient. Currently published guidelines by the Facilities Guidelines Institute (FGI) and the National Association of Bariatric Nurses (NABN) were applied to the development of the tool. The tool assesses policy, equipment, space and structural requirements, and patient handling and moving tasks. A two phase non-experimental, exploratory study in a convenience sample of five EDs was conducted applying a usability testing model to determine the tool's usability and utility. Four of the five hospital EDs agreed the tool was easy to use and helpful in determining their readiness to safely care for the morbidly obese patient. The tool was found to be usable on a limited basis. Additional application of the tool on a larger scale is recommended. [Key words: readiness assessment tool, morbidly obese, Emergency Department]
    • Improved Patient Safety Using Health Information Technology to Coordinate Medication Reconciliation between Patients and Providers

      Burke-Bebee, Suzie (2011)
      Medical errors remain a major safety problem a decade after the Institute of Medicine reported that 98,000 related deaths a year occur in U.S. hospitals (10M, 2000; Landrigan et al., 2010). Medication errors possibly account for one third of the medical errors (Milch, et. aI, 2006). Although medication reconciliation is an accepted standard of care for patients by organizations and providers, very little scientific evidence is available to make practice recommendations for the primary care setting. The purpose of this proposed project will be to evaluate the effectiveness of using secure wellness reminders sent to Veterans via their personal health record (PHR) prior to their scheduled appointment in a Veterans Administration outpatient clinic. The alert will ask them to view their medication listed in their PHR, to print and update this list, and to bring the paper copy for their next scheduled clinic visit. This modified patient list will be used by the provider to compare medications listed in the provider's EHR during the MR process in the outpatient clinic. Of primary interest will be any medication discrepancies identified after the project's intervention. This study is considered a proof of concept, quality improvement study in that the Veteran's PHR (MyHealtheVet) has the capability for alerts. Yet, it is unknown if Veterans will receive and review the reminders and if they will respond as instructed. The project will inform future research studies in the best use of innovative technologies for medication reconciliation when applied to the primary care setting. The results of this study will assist in building and translating evidence into the practice for improving medication reconciliation and enhancing patient safety.
    • Improving Provider Compliance in the Use of an Asthma Action Plan for Patients with Asthma in an Outpatient Setting

      Bundy, Elaine Y. (2011)
      Problem: Improved patient asthma outcomes, operationally defined as decreased acute care visits, reduced missed days from school and work, and decreased nocturnal awakenings due to asthma symptoms, have been demonstrated through the use of a symptom based written asthma action plan (AAP) in reducing acute care visits (Gibson & Powell, 2004; Zemek, Bhogal, & Ducharme, 2008). However, despite the research and guideline recommendations that support the use of AAPs, these plans are routinely not used by providers. In fact, only 25 percent to 56 percent of all asthma patients receive an AAP (Rank, Volcheck, Li, Patel, & Lim, 2008). Thus, the purpose of the Capstone project was to improve provider compliance in an outpatient office in the use of a symptom based AAP. Methods: The Capstone quality improvement (QI) project was conducted during a specific two month period (coinciding with the study period in the fall and winter of 2010) in a suburban outpatient allergy and asthma clinic in Glen Burnie, Maryland. The QI project involved an educational in-service on the use of an AAP and a system procedural change (placing a blank AAP on each patient’s medical record at the time of visit). A retrospective medical record review was conducted from all eligible medical records of patients greater than six years of age diagnosed with asthma that were seen in the office during the two month study period following the educational in-service in order to assess the use and completeness of the AAP (N = 42). The rate of proportional change (percentages) in compliance in the use of an AAP after the educational in-service and system procedural change was analyzed and reported. Results: A statistically significant improvement in provider compliance to the use and completion of a symptom based AAP was found at eight weeks following an educational in-service and system procedural change. A statistically significant change (p < .001) in provider IMPROVING PROVIDER ASTHMA ACTION PLAN COMPLIANCE 2 compliance was found as evidenced by a 79 percent (33/42) increase in the use and completion of a symptom based AAP following the intervention (education and system procedural change) as compared to less than 5 percent (2/42) rate of compliance prior to the intervention. Discussion: The role of the Doctor of Nursing Practice (DNP) is to synthesize the evidence and implement the best evidence and recommended national guidelines. The QI project paralleled the role of the DNP in the implementation of evidence based research and guidelines in conducting an educational in-service and system procedural change to improve provider compliance in the completion and use of a symptom based AAP within an organization. The project demonstrated the effectiveness of an educational in-service in improving provider compliance in the use of and the completion of a symptom based AAP.
    • Behavioral Factors Associated with Glycemic Control in Diabetic Veterans

      Mastella, Laura (2012)
      Background: Veterans have a higher prevalence of Type 2 diabetes than the general population, and experience more problems with glycemic control, placing them at greater risk for complications. The primary purpose of this study was to examine two self-management behaviors in a sample of diabetic veterans, and to evaluate indicators of adherence to diabetes treatment regimes and glycemic control. Our hypothesis was that veterans who maintained logs and refilled medications on time would have better glycemic control than those who did not perform these specific behaviors. Methods: We examined a convenience sample of 261 adult Type 2 diabetic veterans seen in Vet Fitness Clinic at VAMHCS from 2006-2009. All subjects were treated with prescribed medications as part of their routine diabetes care. Based on related studies, we identified Self-Monitoring of Blood Glucose (SMBG) and medication refill procurement as behavioral predictors of Hemoglobin A1c outcomes. Results: Using a dependent samples t test, improvements in HbA1c from first to final contact in clinic were evaluated. As an expected clinical outcome related to treatment, statistically significant improvements were seen in HgA1c from baseline to discharge (t 16.5,p=.000), however, 60% of the veterans were able to reach goal values (baseline mean 9.10%, ±2.1 0, discharge mean 7.40%, SD ± 1.21). The strongest behavioral predictor of glycemic control was medication refill (1= 3.11, p=.002). Maintenance of 5MBG logs did not produce significant improvements in HbAlc< (t= 0.33, p=.74). Conclusions: Despite timely medication refills, 40% of the subjects did not attain optimal HgA1c, values. Actual adherence to medications cannot be established using refills as an indicator. While 5MBG logs have been associated with improvements in some studies, we did not find the same relationship here. We believe that other unmeasured self-management behaviors may be vitally important in optimizing glycemic control in veterans. For example, health literacy, which is known to be lower in veterans, warrants further examination, as veterans need working knowledge in order to self-manage all aspects of their disease.