DNP Practice Inquiry Projects

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https://hdl.handle.net/10790/2426

The Doctor of Nursing Practice (DNP) is a terminal degree in nursing focusing on nursing leadership and application of research into practice. The DNP program is also designed to prepare the nurse at an advanced level of nursing practice specifically as a Family Nurse Practitioner (FNP) and as leaders and administrators for health care organizations. The program emphasizes the development of the student’s capacity to impact the clinical setting as leaders and educators and to utilize clinical research to improve and transform health care. Our program is based on the understanding that nurses provide services which include the direct care of individual clients, transcultural nursing care, management of care for rural populations, administration of nursing systems, and development and implementation of health policy. The program encompasses health economics, cultural diversity, chronic care management, health promotion, and disease prevention in rural communities and will create a cadre of new nursing faculty who can immediately address the nursing faculty shortage. Advanced practice nurses with practice doctorates will address significant practice issues in a scholarly way, adopt broad system perspectives for health promotion and risk reduction, and act as agents of change that transform client/community care, participate in the on-going evaluation of health care outcomes, and assist in the translation of research that leads to positive nursing practice changes.

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A Transcultural Nursing Approach to Secondary Prevention of Pressure-Related Foot Injury in Micronesian Migrants in Hawai’i with Type 2 Diabetes Mellitus
(2019-08-21) Norris-Taylor, Joyce; Thornett, Tracy; Davis, Alice
The newest members of the State of Hawai’i come from Micronesia under provisions of The Compacts of Free Association (COFA). In Micronesia, COFA citizens face unique challenges as a result of their association with the United States including the legacy of nuclear testing along with ongoing damage as a result of rising sea levels with saline leaching making land uninhabitable as the total land mass is diminishing. COFA citizens have the legal right to come to the United States and they are coming for educational opportunities, employment opportunities, and for health care. In Hawai’i, the Micronesian population has been met with prejudice, injustice and neglect. The health care issues of Micronesia include both the communicable diseases of a developing area as well as the noncommunicable diseases of a developed region including type 2 diabetes mellitus. Poverty, lack of natural resources, poor nutrition, and a sedentary lifestyle promote both communicable and noncommunicable diseases in this vulnerable population. Migration to Hawai’i provides opportunities to receive education, employment, and health care not available in native lands. The high prevalence of type 2 diabetes in COFA migrants presents many opportunities to pursue secondary prevention measures in this population. In the Micronesian population traditionally, as is common in tropical climates, footwear is minimal or nonexistent leaving feet exposed to injury. The overarching goal of this project was to address one aspect of secondary prevention in the Micronesian migrant population residing in East Hawai’i, preventative foot care in the diabetic. With the aid of a cultural interpreter a pilot study was conducted with participants surveyed as to footwear preferences. With the expert advice of a podiatrist and the guidance of the cultural interpreter, prototype safer alternatives to commonly worn footwear were developed. The prototypes were trialed over a one-week period after which a secondary survey was performed. Of the prototype trial participants, 100% liked the shoes, wore the shoes, and desired to keep the shoes. Cultural adaptations are required for successful promotion of self-management of chronic conditions including obesity and diabetes. Collaboration with COFA stakeholders will afford better outcomes for Micronesian citizens. To date, the healthcare community has failed to engage this population largely due to Western medicine ethnocentrism and paternalism. This pilot study demonstrated the willingness of the Micronesian migrant community to partner with healthcare providers for rational lifestyle changes to improve overall health.
Access to Care: Investigating the Perception and Experience of Native Hawaiian During COVID-19
(2021-06-08) Paikai, Kawailehua; Pagan, Joan; Daub, Katharyn
Native Hawaiian data collection and dissemination continue to be underrepresented and often inaccurate. While there is progress in how the government collects data on Native Hawaiian Pacific Islander (NHPI) populations, there is still a lack of accurate and reliable health data to assess access to care and healthcare utilization in the Native Hawaiian community. The COVID-19 pandemic exposed the need for data disaggregation and appropriate funding for Native Hawaiians and the organizations that serve them. Native Hawaiian health outcomes have been highly affected by the pandemic, and there is limited data to address access to care and health inequities. This project's scope is to pilot a screening tool to collect and analyze data from the Native Hawaiian population regarding their perception and experiences to access care during the COVID-19 pandemic.
Access to Healthcare in Hawai’i: Entrepreneurship for Advanced Practice Nurses
(2020-04-01) Green, Kelly; Ayers-Kawakami, Jeanette; Hensley, Patricia
It is undeniable that Advanced Practice Nurses (APNs) have the knowledge, skill, and leadership ability that are valuable for meeting the healthcare challenges of rural communities. They can be instrumental in solving the shortage of primary care providers in underserved areas of Hawai’i through entrepreneurship. In 2013, over 807 Advanced Practice Nurses lived and worked in the State of Hawaii; however, only 3.6% or 308 are considered self-employed (LeVasseur, 2013; LeVasseur & Qureshi, 2015). If more APNs practiced independently in either ambulatory clinics or privately owned practice, this could alleviate the shortages seen in rural communities. The literature describes areas that prevent APNs from private practice including, legal and regulatory obstacles, ethical and personal barriers, and limited knowledge in entrepreneurship. The purpose of this project was to develop and pilot an entrepreneurial workshop to increase entrepreneurial intentions among APNs/DNP students. Through educational offerings will APNs seek out entrepreneurship to design independent practices that include, but not limited to, improving accessibility, affordability, quality, patient safety, and patient outcomes. Two independent groups were analyses and compared for their entrepreneurial intentions, the nurses’ group and the University of Hawai’i at Hilo business students. The educational offering suggests that the entrepreneurial curriculum needs to exist at all graduate-level of nursing programs to increase more APNs working independently in rural and underserved areas. Recommendation for future project design includes incorporating a larger sample size.
Advance Directives: Educating via Learning Modules
(2019-05-28) Lovell, Joyce; Thompson Pagan, Joan; Ayers-Kawakami, Jeanette
Advance directives are legal documents that express an individual’s medical choices for life-sustaining treatment when the individual cannot speak for himself. A health care agent is someone who will execute the medical choices when the individual is incapacitated. The documents must be completed when the individual is of clear mind. Without an advance directive, the medical staff must do everything to prolong life. It is important to have an advance directive speak for you when you cannot. It is well-known that families suffer when forced to make life and death decisions. An advance directive will alleviate the stressful decisional-burdens associated with the end-of-life phase. In other words, an individual can reduce their family’s suffering by completing an advance directive which will allow an individual’s end-of-life wishes to be known. Despite the availability of advance directives and end-of-life planning resources, completion rates for advance directives remain low with less than 25% of Americans completing advance directives. It has been found that interactive education increases an individual’s drive and comprehension of the subject matter. The aim of this Practice Inquiry Project (PIP) was to create an electronic learning module that would increase an individual’s understanding of advance directives, their uses, their importance, and to increase the motivation needed to complete the said documents.
Alternative Healthcare Institute in Tai Chi Qigong
(2016-11-30) Chen, Hui; Davis, Alice
Compelling evidence in Alternative / Complementary Healthcare practices, such as in Tai Chi and Qigong (TCQ) studies has demonstrated consistent health improvements in population health. If the evidence can be utilized to reduce health risks and improve the health of adult population in Hawai’i, this may lead to advancing the chronic healthcare management in Hawai’i, and in turn, this may also lead to reducing billions of dollars in medical costs to treating disease. The Alternative Healthcare Institute (AHI) proposes the establishment of an AHI TCQ program based on (1), the most current evidence based research studies, (2) the evaluation of participants from an existing TCQ program, (3) feedbacks from a TCQ practitioner and local primary care providers, and (4) feedback from potential TCQ participants. The program will aim to advocate and create options for alternative healthcare practices in Hawai’i.
AN ORGANIZATIONAL APPROACH TO BURNOUT IN ADULT FOSTER HOME CAREGIVERS IN HAWAI`I
(2021-05-18) Supnet, Kimberly; Daub, Katharyn; Norris-Taylor, Joyce
Caregiver burnout is an adverse psychological event that a person experiences in relation to long-term and emotional stress that is brought about by work that entails helping other people. Caregiver burnout may compromise patient safety by affecting patients’ mortality rates and increasing their risk for abuse and neglect, and it may impact the physical and mental health of caregivers, reduce their eagerness to help patients, and increase caregivers’ turnover rates. Clients living in adult foster homes are a vulnerable population who are often explicitly dependent on their caregivers; they are unable to perform ADLs, prepare their own meals, comply with medications, and/or verbally express their needs. Caregiver burnout in adult foster home caregivers must be investigated especially as the elderly population increases and as more adults with disabilities are placed in adult foster homes. This project examined burnout in adult foster home caregivers in Hawai`i, determined its effects on caregivers and client care, and identified organizational means for its prevention and management. Adult foster home caregivers from three case management agencies in Hawai`i were asked to complete an anonymous sociodemographic online survey on Survey Monkey and to participate in three online focus groups through Zoom. The online survey contained five Likert-scale questions that inquired about caregivers’ age, sex, number of adult foster home clients in their homes, years of caregiving experience, and the number of hours spent caregiving per week. Three (N=3) caregivers responded to the survey, and their responses were not analyzed. Thirteen (N=13) caregivers participated in the online focus groups. These caregivers were asked to respond to ten questions about burnout, job demands and resources, and case management agencies’ management of burnout. Their responses were manually transcribed verbatim, manually analyzed using thematic analysis, and electronically analyzed using MAXQDA. Four themes were identified: caregivers’ impression of burnout, relief, training, and support. Data gathered from the focus groups were combined with data from the literature to develop a presentation about the organizational management of burnout in adult foster home caregivers. The presentation was sent to 21 case management agencies in Hawai`i. These agencies were asked to respond to anonymous online pre- and post-tests on Survey Monkey before and after reviewing the presentation. The surveys contained two Likert-scale questions about agencies’ knowledge about burnout and their likelihood of implementing interventions to manage burnout among adult foster home caregivers. Three (N=3) responses were collected and analyzed using paired-samples t-test with JASP 0.14.1 software. The results from the pre-test and post-test indicate that case management agencies’ review of the burnout presentation did not result in any significant improvement in their knowledge or likelihood of implementing organizational methods of managing burnout. Based on the data collected in this study, a combination of the JD-R model and the action research framework is recommended in the development of organizational interventions to manage burnout among adult foster home caregivers. Case management agencies should identify adult foster home caregivers’ most valuable job resources and provide enough of these resources to caregivers on an ongoing basis to manage burnout and to protect caregivers and clients from the consequences of caregiver burnout.
Antipsychotic Medication-Associated Weight Gain: Development of an Evidence-Based Management Algorithm and Practice Guideline for Primary Care Providers
(2016-11-30) Thornett, Tracy; Davis, Alice
Obesity is a growing public health concern. Although people from all walks of life are affected by obesity, rates of this chronic disease are especially high among individuals with mental illness. Of particular concern are patients who take antipsychotic medications, as weight gain is a well-established side effect of many of these drugs. This practice inquiry project investigated the problem of antipsychotic medication-associated weight gain by applying the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology to develop a preliminary evidence-based practice guideline and algorithm for use by primary care providers. As part of the project, an interdisciplinary panel of key stakeholders evaluated the proposed guideline for both quality and applicability. The results of this evaluation are discussed with future revision and expansion of the guideline in mind. Additionally, implications for advanced nursing practice are examined and strategies for promoting safe, effective, patient-centered, and equitable health care are suggested.
ARCH/E-ARCH & RACCP-AFH Integration
(2016-12-27) Arzaga, Noemi; Daub, Katharyn
Assuming the role of caregiving is never an easy task whether it is done out of love, devotion or simply being responsible for honoring the familial obligation. Decisions to care may occur suddenly due to emergent reasons, or it may be planned, but whatever the reason may be, long-term care decisions should be seamless and not cumbersome. The better equipped the individual is in knowing the available resources, the less anxiety and burdensome it will be for the patient and their family. As life expectancy improves along with the unprecedented rate of baby boomers reaching retirement age, there is a great need for workers or caregivers to care for the elderly. Trends have shown that long-term care services that the elderly tend to utilize are those less restrictive than nursing homes. Thus, a rapid growth and demand in supply for alternative services such as those provided in a residential care setting in an Adult Residential Care Home (ARCH) or Adult Foster Home (AFH) are seen. The historical separation of ARCH & AFH for the State of Hawaii, however, has long created overwhelming inefficiencies to care and management that are burdening the consumers, providers, and the state alike. A need of a polished integrated system that improves residents’ quality of care, lowers operating cost, improves coordination of care, and helps caregivers and providers with the most vulnerable fragile persons, the elderly in the community, is greatly needed. All and all, policy engagement through education, evaluation, examination, and the development of new process methodologies with adaptation of new concepts for integration are key initiatives to taking a stand and making a difference. Community-based care services that fit the needs of the consumers without a major overhaul in their livelihoods and budgets are vital today and in the future.
Blood Pressure Management with the use of Technology in Rural Hawaii
(2023-05-27) Dowling, Autumn; Ayers-Kawakami, Jeanette; Pagan, Joan
The health care delivery system has evolved over centuries with the use of technology to manage care for those who live in rural communities. Due to the COVID-19 pandemic a public health emergency (PHE) has extended insurance policies so telehealth services (THS) could become available for primary care clinics. Although it became the new norm, and despite the benefits of THS, health care centers will continue to face challenges as new policies are in effect which may limit the delivery of health care options for primary care providers. Without innovative solutions to utilize technology as a part of primary care services, patient care will continue to be inadequate making it less cost-effective. One major challenge that providers will continue to encounter is the health literacy issues related to chronic disease management (CDM). One of the major risk factors for life threatening events is hypertension (HTN). Otherwise known as high blood pressure (HBP). The purpose of this project is to develop and deliver an interventional educational program (IEP) with the use of zoom and PowerPoint applications that focus on managing HBP among adults who reside within a rural community where access to primary care is limited. The chronic care model (CCM) and logic model (LM) was used as a guide to develop and design a project plan to implement the IEP in effort to increase health literacy core measures of one’s knowledge and confidence levels. Pre- and post- Hypertension Evaluation Lifestyle Management (HELM) scores and Blood Pressure Management Self Efficacy scale (BPMSES) scores were compared. The results indicated an increase in knowledge and confidence levels in all areas of managing HBP through lifestyle and treatment goals, the use of an automatic blood pressure monitor (ABPM), recognizing the 5 levels of BP numbers, and partnering with providers to manage HBP.
Bridging the Knowledge Gap in Ostomy Management
(2021-05-06) Iwamoto, Jaryn; Van Hoose, Diane; Norris-Taylor, Joyce
Inadequate ostomy patient education leads to poor post-operative adjustment and lower quality of life for ostomates. Many factors contribute to the insufficient preparation of ostomates to manage their stomas after hospital discharge; these factors include shortened hospital length of stays, limited availability of Certified Wound, Ostomy, and Continence Nurses (CWOCNs), and inadequate nursing knowledge, confidence, and skills in ostomy management. Staff nurses are an essential part of ostomate’s post-operative adjustment because they are present during every aspect of the care continuum and are able to educate patients to attain their healthcare goals. The purpose of this Practice Inquiry Project (PIP) was to develop a continuing education (CE) ostomy management course and test this new platform by 1) opening the conversation between nurses on ostomy care, 2) establishing mentoring opportunities between the instructors and learners, and 3) exploring nurses’ learning and support needs and preferences. The goal was to improve staff nurses’ ability to care for ostomy patients by addressing the gap in ostomy knowledge, confidence, and skills. This CE ostomy course evaluated if participants gained a better understanding of ostomy concepts and higher levels of confidence in managing ostomy patients. Shrigley’s Theory of Attitude Concept and Science Teaching was integral in the design of this project as it describes the relationship between cognition and behavior in contributing to changes in attitude. A Logic Model was used to plan and evaluate this project. In comparing the results from the pre-tests, post-tests, 2-week post-tests, and surveys; the intervention was successful in teaching registered nurses how to care for ostomy patients.
Changing the Stigma of the Homeless in Nursing Students
(2019-05-16) Ohara, Laura; Daub, Katharyn; Ayers-Kawakami, Jeanette
Stigmatization of individuals and groups of people can directly affect their health. Ideally, health professionals are blind to stigmatizing patients in their care and would provide them with the same attention, resources, and care. However, many studies have observed that stigma exists among healthcare providers and that stigmatization affects the care provided. Stigmatizing patients by healthcare workers leads to poorer health outcomes and social isolation. A review of the literature discovered a recurrent theme of how nurses’ negative perception of the homeless client acted as a barrier to them accessing healthcare. Given that Hawai‘i has the highest homeless rate per capita in the U.S. and that homeless individuals have multiple health needs, healthcare professionals will encounter homeless people in their practice. It is therefore imperative to train future healthcare providers to deliver ethical, compassionate care without prejudice and stigma to persons who are homeless. Interventions to decrease stigmatization from healthcare providers of vulnerable population would theoretically increase compassionate care and improve health outcomes. The purpose of this project was to develop and pilot a multi-modal education seminar in an undergraduate nursing program to alter perceptions of homeless persons and decrease stigmatization. An analysis of the participants’ perceptions of the homeless before and after the education seminar demonstrated a statistically significant decrease in stigma of the homeless particularly in the 20-30 year-old age range. The pilot project provided evidence that a multi-modal educational seminar can impact stigma perceptions. Further expansion to a larger sample group of students is recommended.
Chronic pain patient perceptions of primary care provider pain education
(2021-01-11) Gallegos, Angelina; Pagan, Joan; Daub, Katharyn
Chronic pain in the U.S. affects millions of adults and the numbers are expected to continue rising, alongside rates of chronic disease which often accompany chronic pain. It has become increasingly complex to manage chronic pain which is only further complicated by the opioid epidemic. While the primary care setting is most often where chronic pain patients are treated, the focus is often primarily on the physical complaints. Current best practices suggests primary care provider education incorporate a biopsychosocial approach to support the best possible outcomes. Current evidence suggests that holistic primary care provider education is necessary to achieve optimal outcomes and efforts should be focused on improving self-management. This project examined chronic pain management education delivery by primary care providers to identify potential gaps in education from the patient's perspective. A survey was developed with 40 items based on the Pain Assessment Screening Tool and Outcomes Registry (PASTOR), currently used by the military. The electronic survey was completed entirely online, with a total sample of 26 adult participants. The survey research revealed the largest deficits in pain education related to areas of behavioral change. The results indicated a need for improving education delivery to include a broader range of topics affecting chronic pain. Increasing knowledge of pain influencing factors can support more successful self-management in patients. The survey results informed practice improvement recommendations, using a two-pronged educational approach to improve chronic pain care education delivery in the primary care setting. Prong one was the development of a comprehensive patient pain education poster for primary care offices. Prong two was a provider education brochure detailing survey results and pain practice resources.
Controlling Diabetes - Are Clinical Practice Guidelines the Answer?
(2017-01-13) Wong, Allyson; Davis, Alice
Diabetes is a challenging disease that affects almost every organ system in the body. Every 17 seconds, someone is diagnosed with diabetes (Awareness Matters, n.d.). The World Health Organization (WHO, 2003) predicts that 350 million people worldwide will have type 2 diabetes by 2030. Meanwhile, the International Diabetes Federation (IDF) believes nearly 400 million people have some form of diabetes today, and this number is expected to climb to 600 million over the next 25 years. To paint a clearer picture, this means one in ten people will be diagnosed with diabetes by 2035 (American Broadcasting Company [ABC], 2013). According to the Hawai’i Island Beacon Community website (2013), Hawai’i island is approximately the same size as the state of Connecticut; and while Connecticut has 34 major hospitals, the Big Island of Hawai’i has three. Sixteen percent of Hawai’i island residents report not having a primary-care provider (North Hawaii Outcomes Project, 2011). Hawai’i island providers are overwhelmed with patient loads, and patients experience long wait periods when trying to see a provider. The global epidemic of type 2 diabetes requires an innovative approach to prevention and treatment. The role of culture and socioeconomics must be acknowledged in the development of new interventions to prevent and control the disease. A clinical practice guideline (CPG) is essential to providing the best evidence-based care to patients with type 2 diabetes. The state of Hawai’i faces a significant healthcare problem. There is an overwhelming prevalence of type 2 diabetes in Hawai’i and a severe lack of primary-care providers to handle the diagnosis and management of this disease.
Decreasing Fluid Overload in Hemodialysis Patients in a Rural Clinic: Providing Multilingual Educational Brochure with Images
(2024-05-30) Cremer, Alma; Ayers-Kawakami, Jeanette; Hensley, Patricia
Fluid overload is a common issue for hemodialysis (HD) patients due to required fluid restrictions. Maintaining fluid restriction can be very difficult for this population. Chronic kidney disease is defined as kidney injury or damage resulting in an inability to filter the blood efficiently. Kidney damage results in waste and fluid accumulation in the body, which causes other organs to malfunction. With end-stage renal disease (ESRD) or kidney failure, patients without kidney transplants who receive HD treatment have regimented fluid and diet restrictions. The alteration of fluid intake and diet modifications are often very challenging for ESRD patients. With the coexistence of other diseases, such as diabetes and hypertension, these patients take many different types of medications concurrently. This often creates a substantial financial burden, depression, and other personal issues for these patients. Fluid overload in patients undergoing HD treatment is common due to difficulty managing fluid intake, which may be related to language barriers. Filipino patients with language barriers may not completely understand the English language during educational orientation regarding fluid and sodium restrictions. Providing a brochure with images and translations into Tagalog (Philippines national language) dialects could be very helpful. There are approximately 60 Filipino HD patients served by the project clinic, and Tagalog is primarily spoken by approximately 50% of these patients. The brochure should aid HD patients in understanding fluid intake restrictions. Education of fluid and sodium restrictions should be performed with HD patients frequently and continuously each treatment reinforcing the patient’s knowledge of the previous teaching with a multilingual educational brochure with images.
Development of a Nurse Practitioner Preceptor Training Program to Increase Readiness to Become a Preceptor
(2019-05-20) Miura, Miki; Daub, Katharyn; Hensley, Patricia; Chino-Kelly, Michelle
An increasing demand for nurse practitioners (NPs) to cope with a shortage of physicians has highlighted the urgency for expansion of NP programs. However, an insufficient number of preceptors limits the ability of NP programs to accept more students. Preceptor training not only increases NPs’ competency in teaching, but it also enhances their self-efficacy. Based on Bandura’s self-efficacy theory, improvement of NPs’ self-efficacy is likely to lead to positive changes in behavior, thus, it can enhance their willingness to participate in preceptorship and ultimately increase the NP’s readiness for a preceptor role. Preceptor training is highly desired by NPs, yet, there are a limited number of preceptor training for NPs available. The aims of this a practice inquiry project (PIP) were to develop a NP preceptor training program based on a literature review and to evaluate the program after implementing a pilot program. Literature shows that the One Minute Preceptor (OMP) model has been used among other healthcare disciplines and can promote effective and efficient communication between preceptors and students. An NP preceptor training program that teaches NPs about the OMP was created based on the literature review. For the second part of this project, a pilot test of the program was conducted and evaluated. A total of nine NPs participated in this pilot study. Four surveys were administered at three different points (pretest, posttest and three-month follow-up) to examine if the participants’ self-efficacy as a preceptor and willingness to become a preceptor improves after the piloted program. The results demonstrated that the piloted preceptor training improved multiple aspects of their self-efficacy and brought positive effects on preceptors’ decision to participate in preceptorship. Future studies should employ more participants to increase the power of the results.
Development of an Evidence-Based Pediatric Asthma Program for a Nonprofit Clinic Serving Underserved, Uninsured, and Underinsured Populations in Southern Nevada
(2016-11-29) Sarmiento, Armando; Davis, Alice
The purpose of this Practice Inquiry Project was to create a pediatric asthma management program for children age five and older, based on up-to-date evidence-based guidelines. The program was developed for the First Person Care Clinic, a free clinic that serves the underserved, uninsured, and underinsured population in Nevada. A microsystems analysis was performed to understand the clinic’s workflow and protocols for treating pediatric asthma patients. Analysis of current literature and vignette surveys helped in identifying topics included in the asthma management guide. Topics involved general asthma management and areas that needed to be improved in order to be consistent with current national asthma guidelines. An asthma management guide was developed and evaluated by an interdisciplinary team using the AGREE II methodology. Results from the evaluation indicated that providers recommended the management guide for use, but with an additional section that assists in the identification of comorbidities.
DEVELOPMENT, IMPLEMENTATION, AND EVALUATION OF A NATIVE HAWAIIAN CULTURALLY APPROPRIATE TYPE 2 DIABETES INFORMATIONAL POSTER
(2020-06-02) Kam, Saba; Van Hoose, Diane; Norris-Taylor, Joyce
Native Hawaiians are disproportionately diagnosed with diabetes and have higher rates of diabetes-related morbidity and mortality compared to the rest of Hawai’i and the United States at large. Waianae Coast Comprehensive Healthcare Center (WCCHC) is a Federally Qualified Healthcare Center (FQHC) in the largest predominantly native Hawaiian community in Hawaii. WCCHC also serves surrounding underserved communities such as Nanakuli, Waiola, Waipahu and Kapolei. Health literacy is low among native Hawaiians in the Waianae and surrounding communities. Previous studies have demonstrated the improved effectiveness of tailoring native Hawaiian and Pacific Islander health initiatives to be culturally relevant. Culturally relevant interventions include aspects such as native and traditional foods, imagery, and language. The purpose of this Practice Inquiry Project (PIP) was to develop a culturally appropriate diabetes informational tool, or poster. The poster was then evaluated to determine if it helped participants gain a better understanding of diabetes recommendations and goals, and to determine if it increased intention for improved diabetes self-care behaviors. The Social Cognitive Learning Theory was instrumental in shaping the expected outcomes of this intervention, because it describes the relationship an individual has with environmental and cognitive factors in predicting behavior. The Logic Model was used as a planning and evaluation tool for this project, and addressed the potential impacts that the results of this project could have. Ultimately, the poster tool was found to be effective in promoting diabetes self-care knowledge and intention towards behavior. Furthermore, participants expressed gratitude that an informational tool was tailored to their traditional foods, culture and language.
Early Screening for Breast-Cancer-Related Lymphedema Using Bioimpedance Spectroscopy
(2020-04-01) Lazarte, Melford; Pagan, Joan; Norris-Taylor, Joyce
Breast cancer is a common cancer diagnosis in women. Management generally includes chemotherapy, radiation, and or surgery. The surgical option involves the removal of a suspicious or cancerous lump, based on diagnostic imaging or a needle core biopsy, respectively. The decision for surgery then takes place. Surgery could mean lumpectomy or mastectomy, with sentinel node biopsy or full axillary dissection. Although the option for bilateral mastectomies is not required, it is discussed openly in addition to clinical history, personal risks, and recurrences. After any combination of recommended management is accomplished, the risk for breast-cancer-related lymphedema (BCRL) is increased. The use of bioimpedance spectroscopy (BIS), a non-invasive tool similar to standing on a weighing scale, is approved by the U.S. Food and Drug Administration (FDA) as a safe screening method for BCRL. Like other available screening measures, BIS should be adopted into clinical practice. Adoption carries the possibility to improve the quality of routine breast cancer care. Purpose: To bring awareness of early BCRL screening with the use of BIS and encourage its adoption. Conceptual Framework: Population, Intervention, Comparison, and Outcome (PICO) format. Theoretical Framework: The Diffusion of Innovation (DOI) theory. Method and Instrument: Anonymous survey via Survey Monkey or Word document based on participant preference. The survey contained 22 simple questionnaires in the form of categorical, nominal, dichotomous, ordinal, or rank-order data. After one month of data collection, data from all 22 questionnaires were extrapolated into Excel spreadsheets. Participants: n = 12 clinics/providers through non-probability or convenience sampling of practice settings located in widespread areas of Maui. Research Design: Non-experimental, descriptive, cross-sectional research at a single point in time. Statistical Analyses: Chi-square (x2) test – which included a null (H0) hypothesis, alternative (HA) hypothesis, degree of freedom (df), probability value (p-value) or alpha () value set at 0.05 – and 95% confidence interval (CI) in select data of 22 questionnaires. Results and Discussions: Specific characteristics of participants were identified and paralleled current literature. This Practice Inquiry Project (PIP) needed to delineate the type of clinic, define the term “future,” and ask the type of adopter explicitly. The x2 test determined possible associations, but could not anticipate or quantify variability. Statistically, participants were not ready or not likely to adopt BIS in the future, yet BIS was recommended. There was n = 1 participant that had the BIS device. Also supported by statistics, barriers existed. The two common barriers were organizational/institutional and insurance/financial. Implications: Clinical diagnosis became apparent as the most commonly utilized method to screen or diagnose BCRL. BIS was statistically recommended. The adoption of BIS was associated with variability, again, which was not anticipated and could not be quantified. Such variability was recognized later as relative advantage, compatibility, complexity, triability, and observability – all of which was an essential part of the DOI theory. Due to the small sample size (n = 12), there was inherent sharing or overlap of patients within each practice that was also not foreseen. The specific characteristics and barriers that were determined could be pivotal not only in coming up with strategies for adoption but also for primary prevention. Recommendations: The n = 1 participant could become a leading innovator and be a part of an extensive future study – to establish clinical information surrounding BCRL from screening, to diagnosis, management, costs, insurance coverage, and challenges, even patient experiences. Instead of an online survey, attending or presenting in a staff meeting would be considered. The timeframe and research design could be modified respectively, for a few months and be retrospective or prospective. Such n = 1 participant would be the target population and identify a sample population within it based upon specific characteristics found in this PIP. By extension, the inherent sharing or overlap of patients could be circumvented. The PICO and DOI frameworks may be kept. The type of clinic, type of adopter, and range of time for adoption must be investigated explicitly. Variability should also be addressed. More rank-order data might be warranted to apply not only the x2 test but also the 95% CI in select data. Conclusion: Statistically, participants were not likely to adopt but recommend the use of BIS in early BCRL screening. Barriers go hand in hand with any changes in clinical practice; thus, they need to be addressed with practical or individualized strategies ahead of time. Perhaps then, the momentum for adoption and method of primary prevention would be gained. Even more, the quality of routine breast cancer care could be elevated not just in one clinic or Maui but throughout the Hawai’i state at large.
Effects of Weight Loss on Diabetes: A Practice Inquiry Project
(2018-12-21) Brewer, Emily; Pagan, Joan; Ayers-Kawakami, Jeanette; Chino, Michelle
Purpose: The purpose of this practice inquiry project was to evaluate the impact of weight loss on type 2 diabetes mellitus (T2DM). The overall goal of this project was to learn improved ways of treating diabetes and how to better achieve glycemic control in these individuals. The expected primary outcome was improved hemoglobin A1c (HbA1c) as weight loss was achieved. Expected secondary outcomes included decreased serum glucose, weight, BMI, blood pressure, and waist circumference. Methods: A secondary analysis of quantitative data from the initiation of a weight management program and throughout patient participation was conducted. This information was collected and documented, and a series of statistical tests were conducted to examine the overall impact of the intervention on key indicators and test relationships between certain variables. The study sample included 21 patients, studied over a 90-day program. All participants had a diagnosis of T2DM, obesity, and hypertension. Measurements were taken at baseline, 30 days, 60 days, and 90 days. Measurements included weight in pounds, body mass index (BMI), blood pressure, body fat percentage, waist circumference, HbA1c, and glucose levels. Results: The participants experienced a significant reduction in these measurements at each of the four measurements (Baseline, 30, 60, 90 days), though not all were considered statistically significant. Conclusion: The weight loss program improved patient outcomes by decreasing weight, BMI, body fat percentage, waist circumference, glucose, and HbA1c levels. This reduction of risks and complications of diabetes improves the quality of life of patients with diabetes.
END-OF-LIFE CONVERSATIONS: IMPROVING PROVIDERS’ COMPETENCE IN EOL CONVERSATIONS THROUGH AN EDUCATION MODULE
(2022-05-27) Sumida, Paige; Van Hoose, Diane; Thompson Pagan, Joan
Death and dying is complex, individual in nature, and often an intimidating topic for many. It is frequently a subject that is avoided or only discussed in private. However, it is essential for patients and providers to understand the resources available at the end of one’s life to help facilitate patient centered care and increased quality of life. Hospice is an end of life (EOL) service that provides comfort care and support for individuals and their family members. Comprehensive comfort care and psychosocial and emotional support for both the patient and their family members are provided with EOL care services. One major barrier to receiving EOL care services is inadequate communication between providers and patients. This is often due to a lack of provider education on difficult conversations, which leads to a lack of confidence and competence in one’s EOL discussion skills. The purpose of this Practice Inquiry Project (PIP) was to provide education for providers on strategies to engage in difficult conversations. The goal was to increase providers’ confidence and competence in initiating conversations about EOL care through an educational module. A logic model was used to guide the designing and planning of the project and the Knowles’ Theory of Andragogy theoretical framework helped guide the implementation and evaluation of this project. Participants completed an online education module. Pre- and post-surveys, pre- and post-Palliative Care Self Efficacy (PCSE) scale and pre- and post-Thanatophobia Instrument (TI) results were compared to determine if the education module was successful in increasing provider confidence and competence in EOL discussions. After providers completed the education module, there was an improvement in both PCSE and TI scores, which indicate an improvement in knowledge and confidence in EOL strategies, skills, and application in practice.

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