One out of 2 women and 1 out of 5 men over age 50 will sustain a fragility fracture (FF) in their lifetime. The risk of a 2nd FF increases dramatically after the 1st fracture and can lead to pain, disability, and mortality. Despite the evidence that secondary prevention programs are effective, the local facility did not have a formal mechanism to address this need. The purpose of this project was to design a program for secondary prevention of FFs and to address the need for a program for secondary FF prevention that was sustainable locally. The program was designed for facility patients age 50 or older who sustained a wrist fragility fracture within 6 months. The reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework was used to guide the project and program evaluation. A needs assessment was conducted prior to developing the program and included secondary data from the facility's provider survey. The 'Own the Bone' program, a nationally recognized program, was chosen as the intervention model. The 'Own the Bone' program provided a registry data for performance measures which assisted in the development of the program. The program included a short survey for providers to assess satisfaction with the referral process, and a telephone survey to referred patients who chose not to attend. Patient satisfaction with the program incorporated the Standardized Clinician Group Consumer Assessment of Healthcare Providers and Systems survey. Data collection and analysis plans were provided to the site with recommendations for implementation. This program was the 1st step in closing the local research-practice gap of secondary fragility fracture prevention. The project offers an opportunity to promote positive social change through the prevention of FF in a setting that had not previously addressed the problem.

Obesity is a major U.S. public health epidemic. A review of the current literature identified a lack of obesity counseling with individuals. The gap in practice was a lack of understanding of nutrition, nutrition labeling, and how foods affect health. The objective of this project was to identify the community assessment need related to obesity and then educate APRNs on ways to better communicate with obese patients. This project focused on an education program for advanced practice registered nurses (APRNs) on using the 5 A's framework for obesity counseling to improve their knowledge and skill in counseling their overweight and obese patients in a rural primary care clinic. Knowles' adult learning theory was used to develop the education project. The education program was presented to and evaluated by 2 APRNs at a rural health clinic. The providers requested the information be placed online so they could give the presentation their undivided attention. The audio-based PowerPoint presentation and printed copies of the presentation content were e-mailed to each of the providers. The presenter went to the clinic 3 days after placing the presentation online to obtain the evaluations and answer any questions. An impact evaluation assessed the presenter, audience learning experience, and confidence and skill of the participant. The participants reported they had a better understanding of the reality of the obese population and how they could improve their communication by using the 5 A's method of assessment. Both participants reported the presentation was clear and easy to understand. A recommendation was made to conduct a future quality improvement project expanding the use of the educational program. This project has the potential to impact social change by improving health care education and ultimately reducing obesity.

Information from anecdotal interviews at a practicum site indicated a lack of training for advanced practice providers (APPs) in core competencies critical for effective practice in a heart failure (HF) unit. The goal of this project was to assess the APPs' verbal reports and develop HF unit-specific training for APPs. The practice-focused question examined whether unit-specific training for HF APPs improved knowledge and skills in HF management. The Johns Hopkins nursing evidence-based practice model and Knowles's adult learning theory were used to create a survey, a focus group, and a pre/posttest assessment of knowledge and skills gap. Descriptive and inferential statistics could be used to analyze pre/post survey data, and thematic analysis could be used to analyze focus group data. Assessment data could be used to develop a targeted HF program based on identified skill deficiencies. The implications of this project related to social change are the potential to increase APPs' knowledge, job engagement, and retention. The program could affect length of stay and 30-day readmission of patients in the HF unit.

Radiography has seen most development over the last 30 years with the evolution of new technologies, but perhaps more significantly changes in education models and radiographer roles. The development of advanced and consultant posts has facilitated the growth of the profession, although the evidence base is still evolving. Through a number of research projects this thesis will explore the growth in the radiography evidence base with specific reference to the extending role of the radiographer in image interpretation. Parallel clinical and academic developments have provided evidence of a scholarly profession which is slowly establishing its place through publication and a growing research base.

Child maltreatment in the pediatric population is becoming more prevalent in today’s society and is being seen more frequently in the primary care setting. Universal prevention of child maltreatment plays a significant role in nursing practice. The American Academy of Pediatrics set forth guidance for pediatricians to practice when assessing a pediatric patient for maltreatment; however, such guidance is not available for advanced practice nurses and little to no training is provided in the clinical setting. In order to accurately identify the child who is a suspected victim of maltreatment, advanced practice nurses must possess the ability to assess, evaluate, refer, investigate, and provide appropriate outcomes for the child and his/her families. The purpose of this Doctor of Nursing (DNP) project was to create an on-line learning tutorial for advanced practice nurses regarding the prevention of child maltreatment in the clinical setting. The goal of the on-line learning tutorial was to address the crucial role advanced practice nurses have in the prevention of child maltreatment and promote the well-being and safety of children. This project used a quasi-experimental, one-group, pre-test/post-test design to determine the effectiveness of an on-line learning tutorial related to child maltreatment. The pre-test and post-test would determine the inferences on the effect of the intervention by examining the differences in the pre- and post-test results. This study provided significant evidence demonstrating that an on-line learning tutorial on the implementation of child maltreatment prevention in the clinical setting was an effective means for increasing knowledge of nurse practitioner graduate students on child maltreatment. The results demonstrated a significant increase in the test scores of the participants after viewing the on-line learning tutorial, indicating the tutorial was effective.

BACKGROUND: Stroke survivors fall 7 times more annually than same-aged healthy adults; and most fall within the first 2 to 6 months post stroke after transition of care home from the acute setting. These falls cause hip fractures and other bodily injury, further compounding post-stroke mobility, fear of falling, social isolation, and social dependence while collectively yielding poorer outcomes at greater financial burden. PROBLEM: To date, no fall prevention program has targeted stroke survivors as they prepare for transition of care home from the acute setting. PURPOSE: The purpose of this practice inquiry is to develop an evidence-based fall prevention program aimed at empowering acute stroke survivors preparing for transition of care home from the acute setting. METHODS: An extensive literature review was synthesized to assess post-stroke falls epidemiology, contributing factors, potential consequences, and the current status of ameliorative interventions. A modified conceptual framework based upon the Science of Unitary Human Beings, theories of health empowerment, cognitive plasticity, and cognitive reserve was created to synergistically inform fall prevention program development. Literature review synthesis and modified conceptual framework collectively informed subsequent construction of a mixed theory-outcome-activities approach logic model to systematically guide proposed program implementation and evaluation plans. RESULTS: A novel evidence-based empowerment-focused fall prevention program was developed for acute stroke survivors preparing for transition of care home from the acute setting. CONCLUSION: The multi-interventional Patient Empowerment at Transitions of Care Fall Prevention Program for Stroke Survivors inspires a paradigm shift in the way stroke professionals and survivors view recovery and inherent survivor potential. The proposed fall prevention program is informed by a solid theoretical foundation and rigorous literature review of high-level evidentiary support. Moreover, existing dynamic funding opportunities promote subsequent program implementation and evaluation facilitated by Patient-Centered Outcome Research Institute grant pursuit.

Purposes/Aims: The purpose of this study was to determine the professional, workplace and personal factors that significantly relate to advanced practice nurses' (APNs) self-efficacy to treat intimate partner violence (IPV).Rationale/Conceptual Basis/Background: IPV affects one in three women in the U.S. and is the leading cause of maternal death during the prenatal and first year post-partum periods. Older women victims suffer earlier death from all causes. IPV is under diagnosed and undertreated based on large surveys of emergency departments and outpatient clinics. APNs are providing health care to large numbers of potential victims, thus they are important as diagnosticians and treating clinicians. Methods: A national quantitative survey of APNs was performed with the aim of obtaining APNs from diverse specialties, geographic areas, and demographics within the U.S. Participants completed an electronic survey using modifications of standardized questionnaires on professional factors of hours of previous IPV education, IPV knowledge, years in practice, current practices, role belief, and self-efficacy to treat IPV. A new scale was developed to test workplace factors of screening tools and protocols, institutional, and community supports. Personal factors of age, gender, past IPV experience, vicarious trauma (VT), resilience, and general self-efficacy were tested using previously validated tools. Results: A sample of 494 APNs was obtained. Respondents were demographically representative of U.S. practicing APN population. Findings from this study indicate that APNs' current self-reported practice behaviors regarding IPV, total hours of IPV education, age in years, role belief, resilience, absence of VT and IPV knowledge are the most significant contributors to APNs' self-efficacy to treat IPV. Implications: APNs with strong clinical experience with IPV, more hours of IPV education, older age, belief that it is their role to treat IPV, and greater IPV knowledge, reported the best self-efficacy to treat IPV. Educational institutions should provide more formal and ongoing education in IPV. VT in APNs who treat IPV should be further explored. Health care organizations should provide continuing IPV education and provide work environments that promote the treatment of IPV for APNs to effectively identify and engage in treatment those patients who may be victims.

Purpose/Aims: The aim of this study was to understand the health issues of a rural Southeastern Arizona border community. More specifically, this study used community assessment with ethnographic principles to: 1) Conduct a community assessment centered on definitions of health, access to care, quality of care, and health needs in a rural Southeastern Arizona border community; and 2) Compared the findings of this study to previous studies, models, and theories of rural nursing and rural health.Background: It is important to understand that each community has a unique set of health priorities that are dictated by these factors; making every rural community different. Much of the work that has been done in rural America has been performed in the Midwest, Southeast, or Northern states. There is limited information regarding Arizona or even Southern US border communities and whether previous work can be generalized to areas that have not been studied.Sample and Methodology: This study utilized community assessment with ethnographic underpinnings through the use of focus groups, key informant interviews, participant observation, and secondary data analysis of existing community data. Sampling for the focus groups and key informants was purposive. Focus groups included: 1) participants who use local health services and 2) participants who do not.Analysis: Lincoln and Guba's (1985) guidelines for rigor in qualitative studies was utilized. Thematic analysis and thick description were used to analyze data. Theoretical triangulation was performed between individual, group, and community level data with theoretical linkages made to community capacity theory and rural nursing key concepts.Implications and Conclusions: The location of this project, rural Arizona community, near the US-Mexico border, posed an interesting contrast to the proposed concepts widely being used today. From this study, healthcare leaders in this community are better equipped to provide relevant, high-quality, and safe services; but an informed community emerged that has an interest in promoting the health and well-being of the community as a whole.

Background: The overuse of the emergency department (ED) for non- critical patients has been associated with overcrowding and a rise in healthcare cost. Green Valley Fire Department (GVFD) has created a program, Fire-Based Urgent Medicals Service (FBUMS) with a nurse practitioner (NP). Patients can call 9-1-1 or the ""NP hotline"" and request to be seen by the NP instead of being immediately transported to the hospital via ambulance. Purpose: The purpose of this project is to evaluate the impact of the nurse practitioner led FBUMS, on ED visits and ambulance transports. Methods: A survey was mailed to all persons, age 18 and older, who were seen by the NP with FBUMS between February 2017 and March 2017. The survey asked about the reasons for contacting GVFD, the type of treatment received, and whether they went to ED after treatment. Data analysis: Descriptive statistics including frequencies, percentages, means and standard deviations were used to analyze each of the answered survey questions in Microsoft Excel©. Results: Surveys completed (n=42). The majority, 39 (92.9%) stated they did not receive care at the ED within 72 hours following their appointment with the NP, three (7.1%) stated they did. By dramatically decreasing transport to the hospital and associated ED treatment, it is estimated to have saved approximately $53,425 in ambulance costs and $54,210 in ED treatment for a total savings of $99,632.52. Conclusion: A Fire-Based Urgent Medical Service led by a nurse practitioner decreased emergency room visits and ambulance transports.

Thesis advisor: Karen S. Lyons / Background: Health equity is a complex phenomenon that embodies both the social determinants of health (structural and intermediary) and external factors, such as the health system. As a well-researched phenomenon, it is known that certain populations are more vulnerable than others to experiencing health inequities; specifically, those of low socioeconomic status, racial/ethnic minorities, older adults, and rural residents. However, gaps in knowledge exist in understanding why certain populations remain at higher risk of experiencing health inequities during a time of improved health insurance coverage and technological advances in health care. The purpose of this manuscript dissertation was to identify and address influential factors that serve as road blocks in achieving health equity, guided by the World Health Organization’s Conceptual Framework on the Social Determinants of Health. Methods: First, an integrative review was performed in order to determine current scope of practice restrictions and patient outcomes across the continuum of licensure for advanced practice registered nurses (APRNs), especially certified registered nurse anesthetists (CRNAs). Next, a secondary analysis of large national data set was done to identify the social determinants and risk factors for poor health effect among a national sample at high risk for poor health. And finally, a survey methodology study was completed to determine the roles that satisfaction with health care and physical function have on the perceived health status for rural, older adults in Massachusetts, and to explore the willingness of rural, older adults to use non-physicians for their health care needs. Results: The integrative review revealed the inconsistent use of APRNs at their full licensure. Nationally, APRNs had better geographic distribution in rural areas compared to physicians; yet many states continue to restrict APRN SOP. Second, across the U.S., older adults at the highest risk for poor health live in rural areas, are of lower socioeconomic status, and identify as racial/ethnic minorities. Third, both satisfaction with health care and the physical function of a small sample of older rural adults were significantly associated with physical health. And finally this body of work found that among a small sample of older rural adults, most were willing to use APRNs to meet their health care needs. Conclusions: With the ultimate goal of health equity it is necessary to empower those experiencing health inequities to be both aware of the problems as well as informed enough to push for change. Understanding why the experience of health differs among some individuals more than others helps to target change. The fusion of findings from this body of research has revealed a gap in health care that can be easily filled with simple policy change. APRNs at full SOP can generate means for high quality preventative, cost-saving care, and can better access the most vulnerable populations at a lower cost than physician counterparts. / Thesis (PhD) — Boston College, 2020. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.