Theses and Dissertations at Montana State University (MSU)
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Item An improved approach to screening of eating disorder risk in a pediatric psychiatric care facility(Montana State University - Bozeman, College of Nursing, 2022) Smith, Christopher Scott; Chairperson, Graduate Committee: Molly SecorEating disorders (EDs) have emerged as a prominent but underrecognized problem in the pediatric population from lack of screening. Reviewed were multiple screening tool options for risk of EDs to utilize in the admission assessment at a pediatric psychiatric care facility, resulting in the use of the Sick-Control-One-Fat-Food (SCOFF) questionnaire. Additionally, screening on admission was moved from nursing staff to that of the project's population--the medical group of nurse practitioners (NPs) who facilitated referrals based on results. The goals of this quality improvement project included a 100% screening rate for all patients aged 6 to 18 years admitted to the facility and a subsequent 100% referral rate for all positive screenings to psychiatry and the registered dietitian. These changes were implemented at the facility over eight weeks with weekly data collection and analysis comparing weekly census reports to SCOFF screened admissions and positive screenings to the number of referrals made. Every two weeks in the implementation, Plan-Do-Study-Act (PDSA) cycles were used in meetings with the medical group NPs to address and overcome barriers in implementation. The results showed overall improved screening rates, but the goals of 100% screening and 100% referral rates were not met. An average of 88% screening rate and 85% referral rate for positive screenings were achieved. Findings of this study inform future practice to utilize a risk for EDs screening tool that is valid, reliable, brief, and easy to score implemented in similar populations. Additionally, more time should be allowed in implementation--at least 12-weeks to allow for more data collection and PDSA cycle completions.Item Screening and documentation of social determinants of health in primary care(Montana State University - Bozeman, College of Nursing, 2022) Hudik, Breanna Noel; Chairperson, Graduate Committee: Amanda H. LucasSocial determinants of health (SDOH) are the conditions of the environments in which people live, work, learn, and play that influence their overall health outcomes. The project's purpose was to increase SDOH screening and documentation in a small, family nurse practitioner-led, primary care practice where social needs were not routinely screened for or addressed during patient encounters. The patients participating in the quality-improvement project completed the 11-item Accountable Health Communities Health-Related Social Needs screening tool developed by the Centers for Medicare and Medicaid. The screening tool was provided to all new patients and patients scheduled for routine annual wellness care during a 7-week period. The completed screening tools were provided to the family nurse practitioner (FNP) to review and subsequently assign an International Classification of Disease (ICD) diagnosis code in the patient's electronic health record (EHR), if unmet SDOH needs were identified. The project also collected data on the number of eligible patients screened and the number of screening tools scanned into screened patient's EHRs. The results of the quality-improvement project include that 90% of eligible patients were screened for unmet SDOH needs, with 84% of those screening tools uploaded into the EHR. Lastly, the ICD diagnosis codes entered by the FNP were tabulated using a frequency table, and insufficient housing was the most frequently identified unmet SDOH need in the patient population screened. Insufficient housing accounted for 33% (4 of 11) of the total number of unmet SDOH needs identified. The quality-improvement project highlighted the importance of screening and documenting SDOH as they provide deeper insight into the complex role unmet SDOH plays in the overall health of patients. The project also shed light on future avenues the FNP can pursue to cater to needs identified in their patient population with the screening tool, including referrals to community resources such as affordable housing options or housing voucher programs.Item Effectiveness of trauma nurse practitioner-led patient-centered discharge plan: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2023) Stricker, Lisa Genevieve; Chairperson, Graduate Committee: Alice RunningTrauma Nurse Practitioners (TNPs) in Trauma Centers have been shown to expand the multidisciplinary team approach in caring for that patient population. TNPs create opportunities for increased patient throughput, decreased length of hospital stay, increased staff support for TNP collaboration, and the development of a comprehensive, detailed, patient-centered discharge plan. To evaluate peer-reviewed evidence-based articles assessing the impact of TNPs in developing a patient-focused, detailed discharge plan, a review of current literature (2007-2022) was completed by searching CINAHL, Google Scholar, PubMed, and Web of Science using mesh terms "trauma nurse practitioner," "trauma," "staff satisfaction," "throughput times," and "patient-centered plan of care." Thirty-nine articles were found and, of those, 28 are included in this review. Evidence supports the TNP's role in developing patient-focused discharge plans leading to increases in communication, increased focus on planning for unmet needs, efficiency in rounding, and decreases in length of stay. These changes result in increased satisfaction from physicians and nursing staff related to the TNP-centered role in discharge plan development. TNPs can be a valuable addition to trauma services as they coordinate the development of a comprehensive, individualized plan of care for patients throughout the hospital stay, allowing for a successful transition of care.Item A quality-improvement initiative: implementation of a screening process for eating disorders in outpatient psychiatry(Montana State University - Bozeman, College of Nursing, 2022) Potts, Alexandra Mae; Chairperson, Graduate Committee: Amanda H. LucasEating disorders (EDs) are one of the most life-threatening and disabling mental health conditions and have a significant prevalence in men and women of all ages worldwide. Despite their severity and improved treatment outcomes with early identification, EDs are not frequently disclosed by patients or proactively screened for by many medical providers. ED screening is an effective, safe, quick, and cost-effective way to assess for the presence of EDs, allowing for further medical provider evaluation. An outpatient psychiatric setting is an optimal place to screen for EDs due to the concurrence of these with other mental health conditions treated in this setting. The Doctor of Nursing Practice (DNP) quality-improvement (QI) project aimed to implement within the outpatient psychiatric clinic setting an ED screening process using the Eating Disorder Examination-Questionnaire Short (EDE-QS), focused on enhancing nursing processes with nurse mentoring and psychiatric mental health nurse practitioner (PMHNP) assessment. A 6-week implementation period took place between January 3, 2022, and February 11, 2022, including a participating PMHNP and their scheduled patients. The following procedures took place: (1) Stakeholders were educated on the DNP process and purpose by the DNP student; (2) The clinic front desk staff gave each patient an EDE-QS screener at check-in to be completed with other screening tools already utilized by the provider; (3) The patient brought these completed screeners back to the registered nurse (RN) upon nursing intake; (4) The RN scored the EDE-QS screeners, and positive screeners, scores of 15 or greater, were given to the PMHNP by the RN at patient hand-off; and (5) The PMHNP had the opportunity to further assess for EDs during the visit and manage the ED, if present, at the PMHNP's discretion, either by managing in the outpatient psychiatric clinic or by referring to an ED treatment center. Findings paralleled literature that described the EDE-QS as an effective screening tool for EDs and suggested that mentoring and education of nurses, along with pre-implementation process development, can standardize workflow and the integration of new screening processes into practice.Item Perceptions of the nurse practitioner in the hosptial setting(Montana State University - Bozeman, College of Nursing, 2020) Cunningham, Marji Rae; Chairperson, Graduate Committee: Polly PetersenThe practice of nurse practitioners (NPs) has evolved over the last 60 years. This evolution has taken the NP from practicing mainly in a family-practice setting into various other settings such as the hospital environment. The knowledge and associated role of the NP is often confusing for healthcare professionals. The purpose of this project was to gain insight from Medical Doctors (MDs) and Doctors of Osteopathy (DOs) regarding their perception of NP scope of practice, educational background, and appropriate utilization in the hospitalist's position. A Likert-scale questionnaire was deployed to MD and DO providers from two different facility types in central and eastern Montana using a snowball sampling method. The two facility types were hospitals that currently utilize NPs in their inpatient settings and hospitals that do not utilize NPs in their inpatient settings in Montana. A total of 51 questionnaires were sent out with a response rate of 47%. Along with demographic data, the questionnaire included three umbrella themes: MDs'/DOs' perceptions regarding the NPs' educational background, NPs' scope of practice, and the utilization of NPs in a hospital setting. The results from the questionnaire suggest that MDs/DOs do not understand the differing roles or educational processes of the APRN, specifically the Family Nurse Practitioner (FNP) versus the Acute Care Nurse Practitioner (ACNP). The results also showed strong support by MDs/DOs for the NP to work in a hospital setting, especially in urban areas. These findings support the need for changes in organizational hiring and regulatory policy consistent with independent state APRN practice regulations and the LACE Consensus Model. Enhancing hiring practices can lead to increased educational opportunities for MDs/DOs regarding the various APRN roles, afford an organization the opportunity to hire an APRN that is appropriately licensed to work in a hospital setting, and provide clarity between the FNP and ACNP roles.Item Missing and murdered Indian women in Montana(Montana State University - Bozeman, College of Nursing, 2020) Cleavenger, Joyce Mabel; Chairperson, Graduate Committee: Susan LuparellProblem. Violence against women is more widespread and severe among American Indian women than among other North American women. Statistics reveal that American Indian and Alaska Native women experience ten times the murder rate of the national average and the highest lifetime rape (27.5%) prevalence in relation to all other ethnicities (14-21%). It is further estimated that three in five AI/AN women will be victims of domestic violence. There is a reason to believe that AI/AN women who are missing may be victims of human trafficking. Evidence suggests that chronic poverty, rape, homelessness, childhood abuse, and racism all play a part in human trafficking. Purpose. Nurse practitioners are a critical workforce in screening and early intervention for AI/AN women as these high-risk women often live in rural and isolated places where the safety net of police, social workers, support groups and safe houses are limited. The purpose of this project was to 1) explore nurse practitioners' knowledge and perceived educational needs related to Montana murdered and missing Indian women, and 2) provide appropriate follow up education with participants based on the findings. Methods. A convenience sample of ten Cascade County nurse practitioners with AI/AN women in their client panel participated in a semi-structured interview. A descriptive analysis of the transcribed interviews revealed gaps in what this sample of primary care providers knew about interventions for AI/AN women at risk for or who have experienced violence. Conclusions. The study produced updated recommendations on screening and referrals for Cascade County nurse practitioners.to use with clients. The results also suggest a need for the State Board of Nursing to offer continuing education on Montana's missing and murdered Indian women. It was also suggested the importance of sharing information on missing and murdered Indian women at one of the nurse practitioners' conferences.Item The nurse practitioner's perspective of the physician orders for life-sustaining treatment (POLST) form(Montana State University - Bozeman, College of Nursing, 2020) McAllister, Sarah Elizabeth; Chairperson, Graduate Committee: Stacy StellflugThe assessment, documentation, and implementation of a Physician Orders for Life-Sustaining Treatment (POLST) form are important for end-of-life care. As primary care providers, nurse practitioners have an important role in advanced-care planning, including the completion of POLST forms (Hayes et al., 2017). The purpose of this project was to better understand the self-reported practices and opinions of nurse practitioners as they assist patients in completing the form. The project was a partial needs assessment to inform later quality improvement (QI) work and used a survey design to assess and gain better understanding of the practices and opinions of nurse practitioners with the POLST form. Questions 1, 4, 6, and 8 were 'select all that apply' and Questions 2, 5, 7, and 9 required a single response. A total of 126 surveys were sent out with a response rate of 39.6%. Overall, nurse practitioners in Billings, Montana, were familiar with the POLST form (n=45, 90%). Half (n=28, 50%) of the nurse practitioners surveyed used the POLST form in their clinical practice despite having barriers to its completion such as it being time consuming (n=18, 25.7%). Over half (n=45, 60.0%) of the nurse practitioners surveyed believed that the most appropriate time to complete the POLST form was after a provider (any provider) discusses goals of care and medical treatments with the patient and/or family. Although some nurse practitioner respondents had no concerns with completing the POLST form (n=12, 21.1%), 21 of the respondents (n=21, 36.8%) reported issues regarding the understandability of the form for patients and/or families. Survey results showed familiarity of the POLST form is not a barrier to its completion in Billings, Montana, but 25.7% of the respondents believed the time it takes to complete the form was a barrier to completing it with patients and/or families. Nurse practitioners could include extra time in appointments or use annual wellness visits to discuss goals of care with patients and/or families. Future effort could also focus on reducing the amount of time nurse practitioners spend filling out a POLST form accurately and completely with their patients and/or families.Item De-escalation training for pyschiatric/mental health nurse practitioner students(Montana State University - Bozeman, College of Nursing, 2020) Hatfield, Carly Jordan; Chairperson, Graduate Committee: Dale MayerWorkplace violence towards nurses is occurring at alarming rates throughout Montana and the United States. Verbal de-escalation is recommended for the prevention and management of aggressive patients in health care settings. However, de-escalation training is not required to be provided in nursing education programs. The purpose of this project was to develop, implement, and evaluate simulation-based verbal de-escalation training for psychiatric/mental health graduate nursing students on the prevention and management of aggressive patient behavior. The de-escalation training included an education module and simulated scenario using a simulated patient behaving as an agitated psychiatric patient. Confidence levels before and after the training were measured with the Confidence in Coping with Patient Aggression (CCWPA) scale and de-escalation techniques were assess with the English Modified De-escalating Aggressive Behavior scale (EMDABS). Strengths and weakness of the de-escalation techniques used in the simulation were identified and discussed. Overall scores on the CCWPA increased after the training. All participants received EMDABS scores representing acceptable de-escalation techniques. Identified strengths include use of a calm demeanor and maintaining a safe distance. Weakness include use of emotional suppression, limited use of inference, and lack of confidence. De-escalation training can positively affect nurses' confidence levels for coping with patient aggression. Use of a simulated patient scenario can provide a high-fidelity mental health experience that is effective for practicing de-escalation techniques. Participants reported that they felt the training was beneficial to their education and recommended that de-escalation training with a simulated patient be required in all nursing education.Item The role of the doctorate prepared nurse practitioner in medical surge policy development and revision(Montana State University - Bozeman, College of Nursing, 2020) Dunshee, Chelsea Jean; Chairperson, Graduate Committee: Casey ColeDisasters and mass casualty events pose significant challenges to healthcare facilities. It is imperative as an organization to have a medical surge policy in place should a sudden influx in patients occur. Proper policy planning is required to ensure the policy in place works sufficiently to meet the healthcare organization's needs. The purpose of this project was to define the role of the Doctorate prepared Nurse Practitioner (DNP) in the medical surge policy development and revision process. This was accomplished by leading a quality and performance improvement project workgroup after performing a review of current literature and a Root Cause Analysis of a recent mass casualty patient surge incident at the organization. The results show that the role of the DNP as it relates to medical surge policy revision are to: (a) analyze policy processes and lead development and implementation of policies, (b) influence policy making process through participation on committees and educating policymakers on nursing processes, policy, and patient outcomes, and (c) act as a change agent and stakeholder. All recommendations made to improve the medical surge policy by the DNP student were accepted and utilized in the acting organizational EOP.Item Design of a primary care advanced practice nursing fellowship(Montana State University - Bozeman, College of Nursing, 2019) Weber, Anna Katherine; Chairperson, Graduate Committee: Jennifer SofieNew graduate nurse practitioners (NPs) can find the transition between student and independent practitioner to be difficult. Residency and fellowship programs are becoming a popular option to help support NPs with this transition. The Institute of Medicine has called for support through residency and fellowship programs. These programs have shown positive outcomes including increased job satisfaction, retention, positive patient outcomes, and increased interprofessional collaboration. A hospital located in the northwestern United States is struggling with NP satisfaction and retention. Purpose: A graduate scholarly project was initiated to design a fellowship for NPs in the primary care setting in response to this problem. Methods: The American Nurses Credentialing Center Standards, National Nurse Practitioner Residency and Fellowship Training Consortium Standards, a current program at the Carolinas HealthCare System, and the National Organization of Nurse Practitioner Faculties Competency areas was used as a foundation to the design. Guidance used was Benner's Novice to Expert Theory. Results: A twelve-month program was designed that includes didactic learning sessions, primary care clinical experience, specialty area clinical experience, interprofessional teamwork, and structured evaluation. Intended outcomes of the project for the sponsoring organization are 1) retention of NPs for twelve months after completion of the program and 2) increased employee satisfaction. The graduate nursing student concluded that more input from current programs and increased participation from the sponsoring organization would have made this project more successful. Further research into the best practice for evaluation tools for personnel and participants in these types of programs would also strengthen the design. Foundation based on current accreditation standards helps to strengthen this design.