Theses and Dissertations at Montana State University (MSU)
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Item Impact of kinship navigator program on rural kin caregiver wellbeing(Montana State University - Bozeman, College of Education, Health & Human Development, 2024) Foluso, Ayomide Adefunke; Chairperson, Graduate Committee: Brianna Routh; This is a manuscript style paper that includes co-authored chapters.More than 2.6 million children live in kinship families without their parents. Kinship caregivers provide care for children whose parents are unable to care for them, yet often face significant challenges that can impact their wellbeing and the caregiving situation. In line with the passing of the Family First Prevention Services Act in 2018, Kinship Navigator Programs are required to submit for evaluation in the Title IV-E Prevention Services Clearinghouse to seek federal reimbursement. This study evaluated the efficacy of the Montana Kinship Navigator Program in improving caregiver wellbeing through its intervention (Enhanced Case Management) compared to a service-as-usual control (Information and Referral only). The quasi- experimental design compared caregivers in the intervention group (n=59) to the control group (n=33) across measures of wellbeing, services accessed, and navigator assistance at case closure. Data was collected through surveys and program records. The preliminary findings support wider implementation of enhanced case management services. Analysis showed significantly higher wellbeing in the intervention group across domains of coping, enjoying life, and average wellbeing compared to controls. Navigator assistance was significantly higher for the intervention group and positively correlated with multiple wellbeing domains across all participants. Financial and health service accessed showed positive associations with improved health wellbeing across participants. Financial resources emerged as particularly important for improving wellbeing for rural kinship caregivers. White non-Hispanic caregivers were more likely to access more services and navigator support compared to Black, Indigenous, and other People of Color, who in turn were more likely report higher stress. This demonstrates the need for training and culturally informed navigator support to promote equitable access. Implementing enhanced intervention could better address the complex needs of kinship families, particularly in underserved rural communities where resources are limited. MTKNP's recognition by the Clearinghouse and state legislators can result in a more sustainably funded program and positive wellbeing outcomes for kin caregivers and their kin children.Item Optimizing virtually-based communication among tribal primary care facility team members to improve patient care(Montana State University - Bozeman, College of Nursing, 2023) Meeks, Sarah Ann Skuhetka; Chairperson, Graduate Committee: Elizabeth A. JohnsonBackground: Effective communication among healthcare providers is linked to patient safety and improved patient outcomes but requires leadership accountability, team engagement, and organizational structure. Improving communication exchange at a tribal primary care facility among staff during group meetings may positively impact patient care and outcomes for American Indian and Alaska Native people who already experience disproportionate chronic health issues. Objective: The aim of this Doctor of Nursing Practice (DNP)/quality improvement project is to improve effective communication among tribal healthcare staff during weekly staff meetings by incorporating TeamSTEPPS framework in the form of structured technology platform etiquette, using targeted agendas, and utilizing leadership follow-up and feedback to enhance the care provided. Methods: Descriptive statistics and qualitative findings were used. Five weekly meetings that included a blend of multidiscipline and multicultural staff were observed for baseline assessment of perceived satisfaction among health care providers and review of the frequency of interruptions with non-agenda items, etiquette interruptions, and the number of missed opportunities for leadership to provide timely follow-up/feedback. The literature review was conducted to identify evidence-based or informed communication interventions. Intervention: Based on the literature review, Team Strategies and Tools to Enhance Performance and Patient Safety was used to guide the intervention. The three interventions included improved structure through agenda sharing, enhanced expectations in the form of chat/emoji use for discussion to discourage interruption, and enhanced leadership through well-planned follow-up. Results: Outcomes included improved communication exchange regarding an increased number of staff who participated in agenda sharing, a decrease in frequency of "hi-jacked" agenda items, an increase in frequency of staff who used chat/emoji features, and a decrease in frequency of interruptions. The frequency of missed opportunities for leadership to follow-up with staff on agenda items increased. Improvement in communication elements was observed in all but follow-up and resolution. Conclusions: The insights gained from this quality improvement project may further the understanding of optimizing communication in the tribal healthcare setting. Further studies related to how tribal culture influences the exchange of communication are needed in order to continue improving upon healthcare team communication in an effort to improve patient health outcomes.Item Increasing postpartum depression screening in the postpartum period(Montana State University - Bozeman, College of Nursing, 2023) Courville, Diamond; Chairperson, Graduate Committee: Amanda H. LucasPostpartum depression (PPD) affects approximately 15% to 20% of mothers and is the most common obstetric complication and leading cause of maternal mortality, which can be avoided with identification and intervention. The Plan-Do-Study-Act cycles were used throughout a 4-week pre- and post-intervention in a primary practice that provides postpartum care, whose PPD screenings were inconsistent and without a standardized screening tool. Descriptive statistics were used to evaluate post-intervention changes. By providing education to all clinicians, adding the Edinburgh Postnatal Depression Scale (EPDS) into standard provider practice, developing an algorithm for PPD screening and mental health referral, and developing patient education through a maternal wellness packer, the project aimed to enhance PPD screening up to 100% by project completion. When postpartum patients screened positive, the goal was that 100% of these patients were offered a referral to mental health and a maternal wellness packet. The goal of 100% staff education was achieved. Although the limited 4-week timeline allowed for only two postpartum patients, the 100% PPD screening goal was met and both were offered a referral and the maternal wellness packet, of which only one accepted services. Consistent universal PPD screening with standardized screening tools, such as the EDPS and PHQ-9, and process provided by the project's workflow process, increased overall PPD screening rates allowing for early identification and intervention.Item Implementation of a mental health pre-visit process in a rural primary care clinic: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Kaufman, Tori Rae; Chairperson, Graduate Committee: Jamie M. Besel; This is a manuscript style paper that includes co-authored chapters.Background: United States rural residents have limited access to mental healthcare. Nearly half of Montana's population is designated rural. Maximizing resources in resource-deficient regions requires creative strategies and process implementation to streamline workflow to achieve sufficient care. Local Problem: A rural Eastern Montana primary clinic has attempted to address its rural community's limited mental health resources by employing a psychologist. There is no new mental health patient pre-visit process at the project site. The purpose of the project was to implement a pre-visit process to improve the psychologist's ability to effectively care for the patient population. Methods: The Iowa Model Revised guided this quality improvement (QI) project. Process changes evaluations occurred at week three, week six, and postintervention. Interventions: A new mental health patient pre-visit process and packet were created, including a standardized Mental Health History Questionnaire (MHHQ). Educational in-services and staff completion checklists were performed to promote adherence to the process change. Results: The project goals were achieved: 95% of the new mental health patient pre-visit packets were mailed within two days of referral acceptance, 75% of new mental health patients returned their MHHQs, and 100% of staff reviewed and signed the new mental health patient pre-visit process. Conclusion: The project improved the psychologist and staff's new mental health patient workflow process. The psychologist noted an increase in patient preparedness and satisfaction, a decrease in time to diagnosis/treatment, and a slight decrease in the initial mental health evaluation duration.Item Improvement of cervical cancer screening in a rural primary care setting: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Kelleher, Katie Carla; Chairperson, Graduate Committee: Amanda H. Lucas; This is a manuscript style paper that includes co-authored chapters.Background: Cervical cancer (CC) is the fourth most diagnosed cancer among women. Cervical cancer screening (CCS) is a vital component of routine health care, as any individual with a cervix is at risk of developing cervical cancer, and nearly all diagnoses of aggressive cervical cancer are directly associated with a lack of screening, underscreening or inadequate follow-up of abnormal results. Unfortunately, the number of women overdue for CCS continues to increase gradually nationally and in Montana. Local Problem: At a rural primary healthcare clinic in northwestern Montana, 37.0% of patients have a current CCS completion documented, compared to Healthy People's 2030 benchmark of 84.3%. Methods: Participants included female patients ages 21-65 who presented to the clinical for an annual exam. Using the Plan-Do-Study-Act cycle, the intervention outcomes were measured biweekly throughout the six-week initiative. Measures assessed included: Adequate CCS eligibility determination, proper CCS documentation with the EHR, and the overall site CCS completion percentage. Data was collected over six weeks, de-identified, and analyzed using percentages and bar graphs. Interventions: Literature supported a multifactorial approach to standardize workflows and documentation practices among the nurses and medical assistants (MA) through the provision of educational material and a CCS clinical decision tree. Key process changes included offering of same-day CCS screening, follow-up scheduling prior to the patient leaving, and EHR alert creation if patient records were requested. Results: A total of 30 patients presented to the clinic. 100% of patients who presented to the clinic were assessed for CCS eligibility. 100% of eligible patients were offered CCS. 84.6% of patients had correct CCS documentation by the staff within the EHR, with four patients lacking proper documentation. A 4.1% increase was seen in the overall facility CCS completion percentage, reaching a total CCS completion percentage of 41.1%. Conclusions: Implementing education, standardized workflows, and the use of the CCS clinical decision tree improved CCS documentation and completion rates.Item The mental wellness conversation curriculum: better understanding the gap between facilitator training and community conversations(Montana State University - Bozeman, College of Education, Health & Human Development, 2024) Sutphen, Katharine Nora; Chairperson, Graduate Committee: Michelle U. Grocke-DeweyThis thesis whether the MSU Extension Mental Wellness Conversation Curriculum (MWCC) is effective in terms of adequately preparing newly trained facilitators to lead their own community based MWCC conversations. The MWCC is a mental health and wellness conversation pedagogy designed to be delivered in rural communities by community volunteer facilitators. The Social Ecological Model (SEM) explains the nuance of this program and incorporates supporting studies that leverage community-based and volunteer-led techniques. The results from the volunteer training evaluation data, a pre-and post- survey, indicate a positive change in awareness, knowledge, and beliefs among the 24 facilitators regarding specific mental health and wellness content presented in the training. The results indicate high favorability from volunteers regarding their experience at the MWCC training and optimism about the future of MWCC as a mental health and wellness program. However, despite favorable and statistically significant improvements from pre and post training data, there has been stagnation among community volunteers leading their own MWCC conversations. In response to this finding, a follow up exploration into possible explanations was conducted. Results indicated the importance of volunteer training as a predictor of volunteer engagement success. Additionally, the following themes were explored to understand the impact they had on MWCC volunteer engagement: 1) the duality of agency and autonomy in volunteering, 2) the explanatory power of the Self-determination Theory as it relates to volunteer motivation, 3) the importance of volunteer recruitment strategies and clear objectives, 4) the value of skills-based volunteering, and 5) the importance of content delivery within a training to maximize future engagement. Minor adaptations to the MWCC training and evaluation efforts would be beneficial for improved volunteer engagement going forward. Future research suggestions include further exploring how social context and environmental factors may impact the success of community based MWCC conversations.Item Implementation of a multidose naloxone protocol in a rural volunteer emergency medical service: a safety-diven quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Overstreet, Riesa Rachael; Chairperson, Graduate Committee: Stacy Stellflug; This is a manuscript style paper that includes co-authored chapters.Background: Opiate overdose (OOD) deaths are increasing in Montana. Emergency medical technicians (EMTs) are the primary prehospital providers in rural areas and the first contact for many OOD patients. In the last ten years, many states have added naloxone administration to the EMT scope. Now, EMTs administer a third of the naloxone given nationally. Local problem: A rural volunteer EMS experienced patient contact times longer than the duration of naloxone's action. State protocols allowed EMTs to administer one dose of intranasal naloxone. Methods: The Iowa Model--Revised guided the quality improvement (QI) project, which aimed to provide standardized, evidence-based interventions to improve the identification and treatment of patients with OOD, expedite their arrival at definitive care, and ultimately improve patient survival. Interventions: The project team created an evidence-based multidose OOD protocol for the volunteer EMS based on the EMT, scope of practice, and the practice environment. Naloxone and protocol training, badge cards, and substance use identification training supported the protocol implementation. Results: Overall, EMTs reported protocol use for patients with any signs and symptoms of OOD 71% of the time, increasing throughout the implementation period. Fifty percent of patients with evidence-based OOD signs and symptoms received naloxone. Conclusion: The QI project demonstrated that volunteer EMTs could apply the protocol to identify and treat patients with evidence-based signs and symptoms of OOD with similar accuracy to EMS providers nationally. Interdisciplinary partnerships in resource-limited rural settings can support QI efforts and increase the representation of rural populations in the literature.Item Improving health outcomes by reducing vitamin D deficiency in a rural clinical setting: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Pollard, Saije Madisen; Chairperson, Graduate Committee: Julie Ruff; This is a manuscript style paper that includes co-authored chapters.Vitamin D deficiency strongly correlates with high morbidity and health risks such as fatigue, mood irregularities, and muscle weakness. As of 2023, there are over one billion people of various ages suffering from vitamin D deficiency (Almuqbil et al 2023). A rural Wyoming clinic lacked a standardized process to screen for vitamin D deficiency, yet the condition is highly prevalent within their patient population. This quality improvement project aimed to implement a standardized vitamin D screening process within the rural Wyoming clinic. Patients were screened and offered a blood draw to obtain their vitamin D levels at each office visit. If applicable, patients were offered vitamin D supplementation. In concurrence with the lab draw, patients were asked to fill out a PHQ-9, GAD-7 and Fatigue Severity Scale (FSS) to track their mood and energy levels. The lab draws and screening questionnaires were repeated after eight weeks of supplementation. Screening for vitamin D deficiency improved from less than 20 percent prior to implementing the standardized process to over 90 percent after eight weeks of implementation. There was no significant correlation between PHQ-9, GAD-7, FSS and vitamin D levels. Eight individuals received the eight-week lab draw and 62 percent of these individuals had optimal vitamin D levels, 70-100mg/dL. The standardized vitamin D screening process was successful in increasing quality and frequency of screening; however, a significant correlation between mood, fatigue, and vitamin D levels was not found.Item Improving new patient cancer treatment education: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Wilcox, Jamie Michelle; Chairperson, Graduate Committee: Elizabeth A. JohnsonBackground: A cancer diagnosis invokes high levels of uncertainty and anxiety. Healthcare professionals task themselves with providing appropriate education to help patients traverse their cancer treatment experience. Effective communication and educational interventions help patients acquire appropriate coping strategies to manage the disease process and reduce uncertainty. Purpose: This project aimed to improve patient satisfaction and decrease anxiety and uncertainty through an enhanced patient education process. The project took place in a rural outpatient oncology center. Participants included newly diagnosed oncology patients receiving intravenous (IV) chemotherapy/immunotherapy and clinic staff. Method: This project used the Demming Cycle quality improvement method. The education components drew on the guidance of literature reviewed for best practices and national guidelines for patient education and teaching techniques. Data obtained through surveys from patients and RNs, observations from the project lead, and additional feedback from staff informed the development of the education visit components. Intervention: A nurse education visit was scheduled the week before IV treatment started and included a learning needs assessment, clinic tour, education on port-a-cath care, regimen-specific side effects and self-management, and how and when to contact the healthcare team. Nurses provided content using the teach-back method. Results: Patient and staff completed surveys over six weeks of implementation. Sixteen patients completed surveys. 100% (n=16) were confident they could manage their symptoms at home after the education visit. Thematic findings from survey responses regarding the most valuable education piece included Theme 1, logistics of treatment; Theme 2, anticipated side effects and management; Theme 3, other value of knowledge and education regarding managing the disease process. Nine nurses were surveyed 17 times during the project, with each nurse completing 1 to 2 education sessions. 88% (n=17) of nurses surveyed felt the education visit improved from the previous system, and 71% (n=17) of nurses found the teach-back method was supportive of patient outcomes surrounding patient education. Conclusion: Providing a structured education visit for new oncology patients receiving chemotherapy/immunotherapy improved patient confidence in identifying and managing symptoms and side effects of therapy at home. The teach-back method reinforced the education content and demonstrated an understanding of the material.Item Implementing standardized depression screening for adults in a rural setting: a quality initiative(Montana State University - Bozeman, College of Nursing, 2024) Downing, Kjersti Lee; Chairperson, Graduate Committee: Stacy Stellflug; This is a manuscript style paper that includes co-authored chapters.Background: Major depressive disorder (MDD) imposes a significant burden, affecting 15-17% of the population. Early detection and intervention are crucial to mitigate adverse health outcomes associated with untreated depression. Clinical guidelines recommend regularly screening patients for depression within the primary care setting. The Patient Health Questionnaire (PHQ) is a widely recognized and validated tool used for depression screening. Local Problem: A rural clinic in Eastern Montana elected to implement a standardized process for administering PHQ-2 and PHQ-9 assessments to their adult primary care population. Methods: The Iowa Model guided the implementation process over eight weeks. Intervention: Nursing staff administered a PHQ-2 to eligible adult patients during primary care appointments. A PHQ-2 score of > or = 3 triggered the nursing staff to administer the PHQ-9. Positive PHQ-9 scores (> or = 5) prompted provider notification and subsequent evaluation for depression. Patients diagnosed with depression or other mental health concerns received appropriate interventions and treatments based on clinical expertise. Data was collected and deidentified before entry into a spreadsheet for further analysis. Results: Nursing staff administered a PHQ-2 to 71.8% (n=326) of eligible patients over the eight weeks. Of those screened, 46 had a positive PHQ-2 result, and 30 had a positive PHQ-9 result. Providers evaluated 100% of patients with a positive PHQ-9, and all were determined to have varying severities of depression. Conclusion: The findings supported the efficacy of the PHQ in identifying depression within a primary care setting. Moreover, these measures promise to enhance mental health care delivery and outcomes in the rural primary care setting.