Capstone Project: Assessment of an Orthopedic Primary Care Fellowship for Nurse Practitioners

Capstone Project: Assessment of an Orthopedic Primary Care Fellowship for Nurse Practitioners

DNP Student(s): AJ Benham & Kathleen A Geier (Winners of the Pegge Shuman Houser Award)


The literature reveals that in the face of growing demand for musculoskeletal care in an aging population, clinicians lack adequate preparation to confidently and competently manage common orthopedic conditions in primary care settings (Freedman & Bernstein, 1998; Freedman & Bernstein, 2002; Lynch, Schmale, Schaad, & Leopold, 2006). Providing focused orthopedic education to primary care physicians has been shown to improve both confidence and competence in delivering musculoskeletal care (Lynch et al., 2006). The purpose of this study is to assess primary care nurse practitioners’ (NPs’) musculoskeletal knowledge and confidence, and to determine if providing focused orthopedic education in the form of a post-masters fellowship will improve their knowledge, and confidence.

Subjects were recruited from a group of NPs participating in a pilot presentation of the Orthopedic Primary Care (OPC) Fellowship. A quasi-experimental within subjects design was used to compare subjects’ pre- and post-program responses to surveys measuring orthopedic knowledge and confidence. Demographic data were collected for investigation of potential influence of extraneous variables on subjects’ orthopedic knowledge and confidence.

The knowledge and confidence surveys used were identical to those developed and validated by United States (U.S.) medical schools for assessment of physicians’ orthopedic knowledge and confidence (Freedman & Bernstein, 1998; Lynch et al., 2006). Survey data were collected and stored online. Subjects created unique identifying numbers allowing for comparison of individual pre- and post-survey responses. An independent data analyst was engaged to compile and analyze survey results. Results indicate that, like their physician colleagues, primary care NPs can improve musculoskeletal knowledge and confidence with focused education and practice opportunities.

Capstone Project: Patient Empanelment: A Strategy to Improve Continuity and Quality of Patient Care

DNP Student: Ellen Christiansen (Winner of Outstanding Capstone Project Award)


Purpose: The purpose of this study was to determine the effect of patient empanelment (where each patient is assigned a designated primary care provider) on continuity and quality of care.

Background: Research indicates that patients benefit from a long-term relationship with a primary care provider (PCP), and that continuity of care results in improved health maintenance and decreased hospitalization (Saultz & Lochner, 2005). Nonetheless, the system of care in some federally-qualified community health centers (FQHCs) tends to undermine continuity of care. Health care services are provided by any provider who happens to be available, care is fragmented, no single provider is responsible for a patient’s treatment outcomes, and provider-patient relationships are not fostered.

Methods: The established patients in three rural FQHCs were empaneled to designated PCPs and care teams. This study used a quasi-experimental pre-intervention/post-intervention design to compare the continuity and quality of care for the FQHCs’ patients before and after empanelment. Continuity and quality of care indicators included percentage of patients’ visits with their designated PCPs, and completion of cervical, colorectal, blood pressure, and other laboratory screenings. Data were collected at baseline and 6 months post-empanelment.

Results: After six months, 100% of the FQHCs’ established patients had been assigned a designated PCP, and quality indicators were improving in every category.
Discussion: The results of this study tended to support the importance of continuity of care with a designated PCP.

Capstone Project: BRCA Risk Assesment in Primary Care: The Value of an Educational Module to Address Clinical Application

DNP Student: Reena Haymond


Clinical practice guidelines by the U.S. Preventative Task Force advise that women be screened for increased risk for harmful BRCA gene mutations that significantly increase a woman’s predisposition to hereditary breast cancer and/or ovarian cancer , so that risk reduction options can be implemented. Unfortunately, research indicates that knowledge deficit among nurse practitioners may explain current evidence indicating overall low utilization of this clinical practice guideline in primary care settings.

The purpose of this project was to develop and evaluate an educational module intended to increase nurse practitioner knowledge of BRCA risk evaluation and management in order to facilitate adherence to clinical practice guidelines. A single group pre-test post-test study was conducted at a continuing education seminar to determine if a newly developed educational module is an effective means of increasing knowledge regarding this subject matter. Pretest and posttest data assessed nurse practitioner knowledge from a convenience sample of 49 participants.

This data was analyzed to determine the effectiveness of the educational module. Participants scored a mean of 11 (23%) on the pretest and a mean of 34.67 (85%) on the posttest out of a total of 41 possible points, demonstrating increase in knowledge of BRCA risk evaluation and management following participation. Results demonstrated a statistically significant increase in knowledge (p < 0.0001, paired t test).

These results support the utilization of the newly developed educational module as an effective strategy for increasing primary health providers’ knowledge of this subject matter. Nurse practitioners with increased knowledge of this subject matter may be better positioned to evaluate and provide care for women with increased risk for a BRCA gene mutation, in adherence with clinical practice guidelines.

Capstone Project: The Development, Education, Implementation, and Evaluation of Evidence-Based Practice for the Prevention of Hospital Acquired Pressure Ulcers

DNP Student: Jodi Hein


Background: The development of hospital acquired pressure ulcers (HAPUs) has been associated with poor care. The National Quality Forum (NQF) considers HAPUs never events. The federal government has identified HAPUs as a public health concern. In addition, the Centers for Medicare and Medicaid (CMS) will not pay for HAPUs. Promise Hospital of East Los Angeles (PHELA) has a high HAPU rate and the nursing staff has lacked education in pressure ulcer prevention (PUP) and treatment.

Purpose: The purpose of this project was to develop and implement a pressure ulcer prevention program (PUPP) in a long-term acute care (LTAC) hospital and assess the effectiveness of this program on HAPU rates.

Methods: A clinical practice guideline (CPG) tool was developed and the nursing staff were educated and trained in skin assessment and the use of the CPG tool. Using a quasi-experimental design, we compared HAPU rates pre-education to HAPU rates post education and the use of the CPG tool.

Results: The data were collected from January 2012 through October 2013. On average, HAPU rates decreased from 3.2% to 1.8% per month. There was a positive correlation between education and use of the CPG tool to a decrease in HAPU rates.

Discussion: This project demonstrated successful outcomes with a decrease in the HAPU rates per month. Using an evidence-based CPG tool along with education is an effective way to lower HAPU rates and improve patient care in LTAC settings. Applying evidence-based research is an effective way to improve knowledge and understanding and will improve treatment options and patient care.

Capstone Project: The Nursing Engagement Development Project:

Developing, Nurturing, and Sustaining Work Engagement

DNP Student: John Hurley


The focus of this project was the development of work engagement among staff nurses in a pediatric emergency department. The study addressed the following question, “Can levels of work engagement be increased through the creation of, and participation in a nursing engagement development project?”

The project was of six weeks duration and included weekly reflective reading and the writing of reflective journals on the topic of work engagement. The participants were sixteen nurses with a minimum of five years of staff nursing experience. The participants all were concurrently employed in the same pediatric emergency department.

The design was a one group quasi-experimental design that included quantitative and qualitative data analysis. The quantitative data analysis used a pre-intervention and post-intervention survey focused on work engagement and burnout. The qualitative data analysis employed descriptive and interpretive evaluation approaches. Both the quantitative and qualitative evaluations demonstrated an increase in levels of work engagement at the completion of the project. The conclusion of the study is that the project was an effective way to develop work engagement among the staff nurses of this department.

Capstone Project: A System Change to Expand Scope of Practice in the Retail Clinic to Include Evaluation and Management of Hypertension for Patients that Otherwise Lack Access to Car

DNP Student: Lena Jesrani (Winner of the Erin Fry Memorial Award)


A pilot study in one retail clinic was conducted to determine whether a change in scope of practice could successfully expand the access of care to patients with chronic health problems such as hypertension.

The following were developed for use in this study: an algorithm to determine need for hypertension treatment, computerized decisional support presenting guidelines for treatment by the Nurse Practitioner (NP) based on best practice guidelines, illness perception guidelines as a patient self-report to guide medical counseling efforts, follow-up procedures for patient care, and a training module to introduce the changes in policy and practice. Suggestions are made for effective coordination with policymakers and quality management committees.

The present study may pave the way for future studies to determine if retail clinics are an effective means of management of chronic condition in patients who lack access to health care.

Capstone Project: A Certified Registered Nurse Anesthetist Policy Brief Identifying Barriers and Solutions for an Opt Out in Nevada

DNP Student: Phyllis Kantor


In the Institute of Medicine (IOM) 2011 Report titled “The Future of Nursing: Leading Change, Advancing Health” the IOM recommends that advanced practice nurses should practice to the full extent of their education and training. Currently in Nevada, barriers to Certified Registered Nurse Anesthetists (CRNA) ability to practice include: opposition from the American Society of Anesthesiologists (ASA), critical access hospitals (CAH) who do not employ CRNAs and surgeons’ inability to practice without access to anesthesia services. These barriers pose a significant threat to CRNA practice in rural Nevada.

The purpose of this 2-year descriptive correlational study was to provide the framework for a policy brief that identifies the barriers to anesthesia care and explores solutions, such as the opt out from the physician supervision requirement imposed by the Centers for Medicare and Medicaid Services. Data was gathered from a convenience sampling of 106 CRNAs from three different cohorts.

The findings of the data indicate that 94% of Nevada’s CRNAs feel qualified to practice without the supervision requirement identifying the most common barrier to practice as anesthesiologist/surgeon supervision issues. Furthermore, 80% of Nevada’s CRNAs indicated if barriers to practice were removed they would support an opt out. The state association presidents identified opt out as their solution to barriers to practice that resulted in a 64% rise in practice opportunities and a surge in satisfaction rates up to 91%. These findings indicate that Nevada’s CRNAs may be prepared for independent practice.

Capstone Project: Impact of an obstetric life support program on the knowledge level of the perinatal nurses

DNP Student: Raji Menon (Winner of Outstanding DNP Student Award)


Background: Resuscitation of obstetric patients is challenging when compared to resuscitation of non-pregnant patients. The alarming trend of rising maternal mortality in United States combined with the fact that at least half of the maternal deaths are preventable emphasizes the need for increased education among obstetric caregivers.

Purpose: This study utilized a quasi-experimental, one-group pre-test, post-test design by using a nine-item survey, developed by researchers from Stanford University Medical Center, California. Perinatal nurses (N=60) received training to enhance knowledge and skills to deal with maternal arrests. Participants were tested for knowledge immediately before and immediately after the training program.

Results: Data were analyzed using t-tests and analysis of variance (ANOVA). The specialized course was equally effective for those who had prior experience in obstetric resuscitation and those who did not have the resuscitation experience (F-statistic of F(df 1, 54) = 3.718, p = 0.059). Overall, the partial eta squared of 0.55 represented a strong effect of the specialized educational program focused on obstetric cardiopulmonary resuscitation.

Conclusion: The specialized course made a significant difference in the post-test scores from the pre-test scores for all perinatal nurses, regardless of prior obstetric resuscitation experience. This increased knowledge has the potential to reduce maternal mortality rates if applied in all obstetric care settings. Further research is needed to determine if knowledge is retained and to determine if mortality rates are affected when staff are trained; however, this training program may serve as a prototype for similar environments in other health care settings.

Capstone Project: Nursing Education to Improve Early Recognition and Management of Pediatric Sepsis

DNP Student: Joni Williams


Sepsis affects millions of children every year and is a leading cause of morbidity and mortality worldwide. Each year in the US sepsis is responsible for thousands of hospitalizations and more than $2 billion in health care costs. Although recommendations and guidelines have been published there are still challenges and gaps in care regarding pediatric sepsis. Barriers include knowledge deficits in the recognition of the symptoms, delays obtaining orders and diagnosis, laboratory results, and timely administration of medications. Pediatric sepsis is recognized as a major public health problem, leading cause of death, and significant challenge in the US despite advances in knowledge, guidelines, and treatments.

The purpose of this project was to increase the knowledge, skill, confidence, and competence of pre-licensure nursing students in the early identification and management of pediatric sepsis. Early detection has been demonstrated to decrease morbidity and mortality improving outcomes for children. Data were collected using convenience sampling at a nonprofit university in a school of nursing, in northern California. The study population was pre-licensure nursing students enrolled in a pediatric course. The design of the study was quasi-experimental using a sepsis knowledge questionnaire and METI SET, a didactic presentation, simulation and debriefing activities. It was hoped the conclusion of the project would reveal educational innovations such as didactic presentations used in conjunction with simulation/ debriefing activities would succeed in achieving increased knowledge, skill, confidence, and competence in the early management and recognition of pediatric sepsis.