• Celiac Disease Diagnosis Among Primary Care Nurse Practitioners: A Quality Improvement Project

      Martin-Plank, Lori; Reimann, Morgan; Martin-Plank, Lori; Wiley, Luz; Hepworth, Joseph (The University of Arizona., 2017)
      INTRODUCTION: Celiac disease (CD), an inflammatory condition of the small bowel, is now recognized as the most common of the autoimmune disorders (Kenrick & Day, 2014). Unfortunately, due to poor awareness among primary care providers (PCPs) this disease remains highly underdiagnosed despite its increasing prevalence (Catassi & Fasano, 2008). Aims of this quality improvement project were to examine current knowledge and practices of nurse practitioners in the primary care setting that influence the screening and diagnosis of CD. METHODS: A 32-item survey was sent out to nurse practitioner primary care providers (NP- PCPs) in the Dallas-Fort Worth Metroplex over a four-week period. The survey assessed demographic characteristics, knowledge and clinical practices of nurse practitioners as it relates to CD diagnosis. Data was analyzed using SPSS and descriptive statistics. RESULTS: Eighteen valid responses were received for analysis. The majority of respondents reported having no familiarity with the American College of Gastroenterology (ACG) and National Institute for Health and Care Excellence (NICE) guidelines. Two thirds of the respondents reported their education did not properly prepare them to accurately diagnose celiac disease. The vast majority also reported they do not test patients, pediatric or adult, using any celiac related blood test. The same results were true for patients being sent for intestinal biopsy. Although able to list typical symptoms of CD, many respondents were unaware of atypical symptoms. Most also omitted family history as important when considering celiac related testing. CONCLUSIONS: Overall NP-PCPs are not aware of and therefore do not follow clinical guidelines related celiac disease. It is clear that NP-PCPs need to be made aware of the prevalence of this disease and should be directed to follow evidence-based practice guidelines in their primary care practices. One step for doing this includes providing better education for NP- PCP students. Educators should include lectures or discussions about CD in their curriculum and provide students with resources such as the NICE and ACG guidelines. For practicing NPs, free continuing education can be offered. Lastly, clinicians who are aware of the high rates of underdiagnosis can present CD related information at conferences and meetings.
    • A Description of Clinical Pharmacist Services in a Nurse Practitioner Managed Outpatient Clinic with Recommendations for Future Studies

      Boesen, Mark; Webster, Sam E.; College of Pharmacy, The University of Arizona (The University of Arizona., 2009)
      OBJECTIVES: The purpose of this study is to describe clinical pharmacist services in a nurse practitioner (NP) run clinic and how clinical pharmacists might influence prescribing. METHODS: The description of the clinical pharmacist services is based on a 12-week experience of a clinical pharmacist and senior student pharmacist working with the nurse practitioner and nurse practitioner students. A questionaire was developed and consisted of items relating to the nurse practitioners ability to identify possible interactions of OTC medications, herbals and prescription medications. In addition, the questionnare assessed the comfort level of NP’s taking a prescription medication history, checking a patient’s prescription formulary, and selecting appropriate medication therapies. The questionaire uses a retrospective pretest format and was tested as a method of collecting data on how a pharmacist influenced NP prescribing. The site selected for this study was the Arizona State University Center for Healthcare Innovation (ASU Center) located in the heart of Downtown Phoenix (3rd Ave and Van Buren). RESULTS: Only one nurse practitioner worked at the ASU Center. The facility is new to the neighborhood and does not see many patients. The nurse practitioner partner in this project responded that working with a clinical pharmacist on a regular basis, with more patients would definitely help her hone skills necessary to identify interactions and prescribe according to a patients formulary. CONCLUSIONS: Pharmacists provide value-added services in an ambulatory care clinic run by nurse practitioners and provide valuable education and consultation on drug interactions. Pharmacist influence can be measured successfully to using a questionnaire in a retrospective pretest-posttest study design.
    • Exploring Patient-to-Provider Communication of Childhood Adversity in Primary Care

      Pace, Thaddeus W. W.; Strauch, Kimberly; Carrington, Jane M.; Reed, Pamela G.; Stauber, Leah S. (The University of Arizona., 2021)
      Approximately 64% of US adults have reported at least one adverse childhood experience in their lifetime. Research reveals that individuals who experience adverse events during childhood are more likely to have a greater number of health disparities in adulthood compared to adults who have not experienced traumatic events during childhood. Despite this knowledge and a growing awareness that ACEs are a significant predictor of an array of health disparities, identifying childhood adversity among adults in primary care is not a mandatory clinical assessment standard. This is largely because primary care providers are unaware of these relationships and often ill-equipped with the communication skills and training needed to elicit this clinically relevant information. Compounding this problem is that clinical communication focused on childhood adversity has not been well described in the extant literature. Thus, the purpose of this research was to better understand factors that influence how NPs communicate with adult patients about childhood adversity in the context of the primary care setting, including the use of the EHR as tool for such communication. Guided by the literature and underpinned by Carrington’s (2012) Effective Nurse-to-Nurse Communication Framework and Bandura’s (2004) Social Cognitive Theory, an emerging model of Patient-to-Provider Communication of Adverse Childhood Experiences (The PPC-ACE Model) was developed. Using the PPC-ACE Model, a qualitative descriptive study was conducted with 15 US-based primary care NPs. NPs participated in semi-structured interviews, which were recorded, transcribed verbatim, and analyzed via manual inductive thematic analysis. Data was triangulated using Atlas.ti and the Goodwin statistic. A total of 455 thematic units were abstracted from the data and organized into 31 categories and 32 subcategories. Findings from this study were all significant. Categories with the highest level of participant emphasis were Facilitators of Communication (Goodwin statistic = 0.83), Communication Approaches (Goodwin statistic = 0.78), Barriers to Communication (Goodwin statistic = 0.77), Provider Biases (Goodwin statistic = 0.73), Scope of Practice (Goodwin statistic = 0.7), Diversity in Practice Models (Goodwin statistic = 0.67), and Secondary Trauma (Goodwin statistic = 0.67). Outcomes of this study will inform future research in nursing education, nursing practice, health policy, and nursing informatics.
    • Identifying Acute Care Nurses Practitioners' Knowledge, Attitudes, Behaviors and Practice on Current Thyroid Dysfunction Management in Acute Care

      Rigney, Ted; Chu-Peterson, Angel L.; Rigney, Ted; DuBois, Janet; McRee, Laura (The University of Arizona., 2016)
      ABSTRACT Thyroid disease is one of the most common endocrine disorders in clinical practice. Critical illness is often associated with alterations in thyroid hormone functions. Thyroid dysfunction is a serious matter if managed inaccurately; it may increase morbidity and mortality. The purpose of this Doctor of Nursing Practice project is to identify the knowledge, attitudes, behaviors and practice of advanced practice nurses (acute care nurse practitioners (ACNP) and adult gerontology acute care nurse practitioners (AGACNP)) on current thyroid dysfunction management in the acute care setting. The DNP project demonstrated that most acute care nurse practitioners believe that TD screening, diagnosis and management is important in the acute care setting. The survey results also indicated that most of the AGACNP/ACNPs would initiate treatment while managing patient in an acute care setting and will likely collaborate with endocrinology for overall management or follow ups to ensure quality and comprehensive care in management of TD. Keywords: thyroid disease, thyroid dysfunction, identify, knowledge, attitudes, behaviors, acute care
    • Nurse Practitioners' Use of Ultrasound to Diagnose Kidney Stones in the Emergency Department

      Sheppard, Kate G.; Schmidtmann, Amanda; Sheppard, Kate G.; Daly, Patricia; Wiley, Luz (The University of Arizona., 2016)
      Background: Kidney stones are a common, painful disorder that can affect as many as one of 11 people in the United States (Goldfarb & Arowojolu, 2013). The gold standard for diagnosing kidney stones is currently computed tomography (CT). However, because CT scans emit radiation during the exam, they could be causing more harm than good. According to recent research, ultrasound may be used to diagnose kidney stones with close to similar accuracy and reliability. Ultrasounds are also safer and more cost effective for patients and the healthcare system. Purpose: The purpose of this project is to describe nurse practitioners (NPs) use of ultrasound to diagnose kidney stones in the emergency department (ED). The information from this project was compared with the recent literature and used to develop an evidence-based practice recommendation for diagnosing suspected kidney stones in the ED. Methods: A 15-item survey was mailed to emergency department NPs across the United States. Descriptive statistics were used to analyze the quantitative results. One open-ended question was also posed, and findings were grouped by commonalities of clinical experiences. Results: Analysis of survey responses indicates that all of the respondents use CT scan to diagnose kidney stones. However, the majority of the respondents also feel that ultrasound could be used in the ED to diagnose kidney stones. The results also demonstrate that even though there is no nationally or internationally accepted standardized guideline for diagnosing kidney stones in the ED, many EDs across the country are instituting their own protocols.
    • Physician Readiness for Nurse Practitioners in the Emergency Department

      McRee, Laura; McGee, Angela Ann; McRee, Laura; Reed, Pamela G.; Davis, Mary Patricia (The University of Arizona., 2017)
      Background: Emergency Department (ED) overcrowding is a national healthcare problem, and despite awareness and efforts to alleviate excessive patient volume, it continues to be an epidemic. One improvement technique proposed is to increase employment of independently licensed APRNs in the ED. Objective: The objective of this study was to determine if LMC and USACS physicians are willing and ready to implement and collaborate with NPs in the ED. Design and Methods: A non-experimental descriptive study design was employed, and sixty emergency medicine providers were surveyed. Eighteen participants (14 MDs, 4 DOs) completed an online questionnaire which consisted of 21 Likert-style questions, an open-ended question, and six demographic questions. Research questions: 1) What are physician perceptions regarding the tasks and resources required for NPs to practice in emergency medicine? 2) What are physician perceptions regarding the need, importance, and benefits of NPs in the ED? 3) What are physician perceptions of contextual factors regarding NPs’ working in the organization? Results: Entire Questionnaire: Mean = 2.02 (SD = .35); Subscale 1: Mean = 2.13 (SD = .33); Subscale 2: Mean = 1.79 (SD = .48); Subscale 3: Mean = 2.06 (SD = .49). Conclusion: This study concludes that, overall, there is a readiness to change among the USACS physicians. Evaluation of subscale 2 and 3 from this study indicates that USACS physicians are willing and ready to implement an NP service in LMC's ED. Furthermore, while discrepancies occurred in subscale 1, these differences can be mitigated through education, credentialing requirements, and policy development.
    • A Study of Nurse Practitioner Characteristics and Knowledge of Drug-Drug Interactions

      Reel, Sally J.; Carithers, Cathrin Lynn; Berg, Judith A.; Malone, Daniel C.; Reel, Sally J. (The University of Arizona., 2011)
      Purpose: Drug-drug interactions (DDIs) place a burden on our nation and cause potential harm to patients. Awareness of potential DDIs is essential for safe prescribing. Nurse practitioners (NP) have prescriptive authority throughout the nation, however, little is known about NP prescribing habits. The purpose of this study was to identify NPs' demographic and practice characteristics, DDI knowledge and factors that influence this knowledge.Data Sources: A survey was administered to NP prescribers recruited from a national conference. Data was collected on demographics, practice and technological characteristics, and perceptions and knowledge of DDIs.Conclusions: Data from 305 questionnaires were analyzed. NPs correctly classified 31% of drug pairs. Nitroglycerin and Sildenafil (drug combination to avoid) was classified correctly by the most respondents (90.8%, n = 305); Warfarin and Gemfibrozil (drug combination to usually avoid) the fewest 15.7% (n = 302). A positive correlation was found between NPs in acute care hospital settings and DDI knowledge, indicating higher knowledge scores. Neither hierarchical linear regression model was significant at predicting NPs' DDI knowledge.Implications for Practice: Continuing education needs to be targeted to enhance NPs knowledge of potential clinically significant DDIs. The increased recognition of potential DDIs among NPs will enhance patient safety.
    • The Feasibility of Using a Theory-Based, Online Delivery Microlearning System to Educate Nurse Practitioners about Clinical Skin Examination for Melanoma

      Loescher, Lois L.; Stratton, Delaney Baker; Knight, Elizabeth; Shea, Kimberly (The University of Arizona., 2019)
      Background: The incidence of malignant melanoma (MM) has doubled in the United States over the past 20 years. Early diagnosis and favorable prognosis rely on patients’ accessibility to healthcare providers for clinical skin examination (CSE). Primary care nurse practitioners (PCNPs) can play a vital role in skin cancer early detection but are underprepared with the knowledge and skills to perform this function. Conceptual Framework: This study is guided by the information, motivation and behavior skills (IMB) model, which highlights the concepts of information, motivation, and behavioral skills that promote behavior change. The study also uses microlearning as a framework to deliver CSE education. Microlearning is the use of short-term, informal learning activities using small, but self-explanatory learning resources. Purpose: The purpose was to explore the feasibility of delivering and developing an evidence-based intervention to educate PCNPs about comprehensive CSE for MM. Aim 1 was to develop three evidence-based, brief skin cancer videos with content on comprehensive CSE skills (risk assessment, head-to-toe skin examination, skin lesion assessment) that are suitable for online, theory-based delivery to PNCPs in various formats. Aim 2 was to determine enrollment and retention rates, intervention adherence, and acceptability and usability of the intervention following completion of the one-week intervention. The exploratory aim was to explore preliminary associations among information, motivation and behavior skills for CSE behavior (practice). Methods: An expert panel of three dermatologists assessed content validity for the videos and the microlearning approach. For Aim 2, 10 PCNPs were recruited from a state NP conference. Feasibility measures included: enrollment and retention rates, and intervention adherence, usability (Brooke’s System Usability Scale) and acceptability (Attitudes Towards Web-based Continuing Learning Survey). For the exploratory aim, the associations among the IMB constructs were assessed using an adapted survey. Findings: Three short videos with content on comprehensive CSE for MM were developed. The enrollment rate was 35%, the retention rate was 83% and the intervention adherence was at least 50%. The mean average for usability was better (M = 85.8, SD = 10.6) with a range of scores from 72.5 (better) and 100 (superior). The mean for each of the acceptability constructs all ranged between “somewhat agree” and “mostly agree.” The mean score for the IMB constructs included: information (M = 91%, SD = 14%), behavior skills (ranking) (M = 60%, SD = 49%), behavior skills (survey) (M = 4.27, SD = .27, α = .72), and motivation (M = 3.18, SD = .62, α = .60). The average number of CSEs performed the week after the intervention was 11 (SD = 9) with a range of 1 to 26. Actual CSE practice had the strongest association with behavior skills (survey) (r = -.33); actual CSE practice shared 11% of the variation in exam scores (R2 = .11). Conclusion: Findings from this feasibility study provide a foundation for the use of the microlearning as a method for delivering brief CSE training to PCNPs. The findings also provide support for using the intervention in a future pilot randomized trial.