All posts by dkgonzales3

Reflection for DNP II

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This semester for me has been intense in the beginning to now knowing which direction I am heading in.  It is hard to believe that we are already getting close to the presentation of our project for graduation! It has gone very quickly from the time I began this program.

Before applying to the DNP program, I must have called or emailed Dr. Manry, a dozen times (maybe not that many); I was not sure at my age (over 59, LOL!) if I should be in a doctorate program. However, working with students that were DNP or those that were MSN bridged to DNP; they were so pleased with the knowledge they received and what it added to their practice.  I decided “why not, I just want to complete the program before retirement and hopefully before passing!”  The truth, I have no regrets. I am very happy that I am able to offer an organization or facility the wisdom I have collected through the years and perhaps help those coming up in this profession.  And I will have a doctorate! Dang! At my age!

I was devastated at the beginning of this semester with the dismissal of my IRB to UNM.  It was also unbelievable to me that the head of the IRB would not give an answer for 7 weeks, even though he knew he was not going to sign the proposal. Where are ethics? But, with the assistance of Dr. Manry and Dr. Keenan, we switched to a survey method of data collection.  And it proved to be excellent. They both were so supportive and helpful.  And I was determined to not let that rejection slow me down!   The information which I have researched this semester is so very important to the Nurse Practitioner.  How we can practice safely and provide safety for our patients.  Guidelines are so easy to follow, they are road maps to our practice. Designed to be evidence-based. It still amazes me that others in our profession do not utilize them.  More to come on that at “Scholars Day.”

In summary, I would like to share a piece of my “Reflection Paper” with you:  “With the addition of the title of “DNP”, it will bring recognition and with that some entitlement in practice.  With years of experience as an FNP and CNM (no longer an active CNM), I have the background to be valuable to most areas of practice.  And for that, I am thankful.  Education is something we will never have taken away from us.  Being an RN(Age 22), BSN(36), MSN/FNP (Age 41), CNM(age 42), and now DNP (Age 61), on the horizon has built the woman I am today.  We are never too old to learn and be the best at the care we give to our patients and to each other.”

It has been wonderful interacting with all of you this semester.  I am looking forward to next semester completing this program and our projects with you!  Happy Thanksgiving and Merry Christmas and a very Happy New Year to you all!

Kay

 

Preliminary Data: What Am I Learning?

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I will be talking with Dr. Pahls by phone on the 19th next week.  I will have more of an idea of how to proceed with the analysis of the data.

I have been working on the revisions within my project paper. As I am sure, the rest of you have as well — several changes. I have added to the literature review. It is looking at things that relate to the survey, which I did, looking at barriers to adhering to guidelines.  It was interesting (one thing new,, I guess).  Clinical inertia ” is the failure of a healthcare provider to initiate or intensify treatment when indicated ” (Cowart, 2018).  This can be seen in people with diabetes; for example, a provider knows there is perhaps a guideline for changing a medication or what is recommended, yet chooses not to follow it.
Because of a lack of knowledge or bias, or disagreement, do not follow guidelines.  This happens with chronic pain management with opioids.  Providers know that there is a CDC Guideline for chronic pain management with opioids; yet, they choose not to follow for reasons mentioned.  I should rephrase, some are not familiar with the guideline, some do not care about the guideline.  The review which I read discussed the need for further research into clinical inertia as it relates to lack of adherence to prescribing opioids for chronic pain, and why there was lack of use of the CDC guideline.  It was very interesting and was the first time that I had seen this term used.  The authors were concerned with “knowledge synthesis” that was related to a lack of adherence for safe prescription of opioid management of chronic pain.  This, of course, their review does not include patients that have chronic pain related to cancer (Rash, et al., 2018).  My survey does go into what might be barriers.  Listed were 1) Lack of knowledge; 2)Not enough time with the patient; and 3) Lack of support from the organization.

I will give a low-down after I have a structured analysis of the data.

References

Cowart, K. (2018). Overcoming clinical inertia in diabetes management: Pharmacist opportunities. U.S. Pharmacist. Retrieved from https://www.uspharmacist.com

Rash, J.A., Buckley, N., Busse, J.W., Campbell, T.S., Corace, K., Cooper, L., Flusk, D., Iorio, A., Lavoie, K.L., and Skidmore, B., (2018).  Healthcare provider knowledge, attitudes, beliefs, and practices were surrounding the prescription of opioids for chronic non-cancer pain in North America: protocol for a mixed-method systematic review. Systematic Reviews, pp. 1-7.  doi: 10.1186/s13643-018-0858-7

UPDATE: 11/23/19

I wanted to let you all know that I did have an appointment with Dr. Pahls last week.  At first, he felt that I would not need statistical analysis, as it was a survey.  I was a little disappointed at first; then I asked him about “comparison” data.  To compare, for example, “those in practice for 1-5 years as compared to those in practice for 10-20 years, etc.” there were differences.  Then he mentions the “Chi-Square” analysis.  Which this would work well for what I wanted to do. This quantitative analysis would also add validity to my project. When looking into “Chi-Square” formulas. I was like, “holy cow, that is not going to be easy.”  But, I am up for that challenge.

Kay

Leadership, Challenges, Strategies & Hiccups

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Overall my project is on-time. Now, I will revise and get the proposal and the Survey to Dr. Pahls (statistician) at Hays, and get a time set up to speak with him concerning the statistical analysis.

Things are running smoothly at this time.  Data has been collected, it went reasonably well (240) responses to the survey (I thought it was 235). It was interesting that the largest group to respond were NPs that were in practice for 1-5 years.  I do feel that NP education now is more focused on EBP, guidelines are critical.  Compared to 22 years ago, when I first began practice as an NP, there are more states which are lifting the restriction to NP practice. This does make a difference.

I was asked recently to take a survey from a doctorate student that was an NP working on her Ph.D. with the University of Nebraska; she was reviewing states NPs who have full practice authority; did demographics make a difference? It was an excellent survey. I am confident she was going to get great information.  She was surveying 4 states that had full independent practice, New Mexico was one of them.

Kay

Data Collection; Issues & Triumphs

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I have launched the data collection, which is “Survey of attitudes & barriers to the utilization of the 2016 CDC Guideline for Chronic Pain Management with Opioids.”  After an initial 7 weeks of pure anxiety, I was able to switch mid-stream to a survey method of data collection for my project.  Two weeks ago I did send the survey via Survey Monkey to 1600 New Mexico NPs.  To date: 10/18/18, I have received 234 replies.  Not what I have expected, but there is excellent information. I will be wrapping up the survey in the next week or so. Putting at 2.5 weeks. One reminder has been sent out on day five, to do the study.  I have received a few personal emails of individuals that know me from New Mexico, knew this was my project, and were very supportive and excited.  A few of them did not do the survey as they were not NPs that did any form of pain management (they wanted me to know).  So far, the data is >70% family NPs, the most significant response group that has been in practice for 1-5 years. 15% have been adult NPs.  These two groups were my targets.  The rest have been urgent care/ER NPs.  They did not manage chronic pain but were passionate about using the CDC guideline. They did provide Narcan to any patients with an opioid script.

The most significant barrier to using the guideline that I could see was: Not enough time with my patients.  And lack of education on chronic pain management with opioids.

What would help them utilize the guidelines:

1. They want an EMR Template based on guidelines 55.71%;

2. Policy Development that correlates with the CDC Guideline(40%) ( A question which stemmed from lack of organization support)

3. More time with the patient 42.86%

4. Patient Education material 41.90%

5. Education on chronic pain management 34.76%

Over 40% expressed not being comfortable with the guidelines.  Over 30% felt very pleased. And the rest comprised of those that either felt the instructions did not apply to the practice. And there was 1 that did not think the guidelines were helpful.

It will be interesting how this all breaks down statistically. What I did get from this was; they are concerned about this epidemic, and over 90% felt this guideline and using it was extremely important and that this did impact their practice in a big way.

Kay

Challenges and Implementation

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I did finally submit my project to the FHSU IRB on September 30th. Whew! It had to be in by the 7th of October. Keeping my fingers crossed that I do not have to change much.  Again, the main challenge to date was waiting on the UNM IRB; and I waited for 7 weeks. That is not necessary to put a student through that. If an organization such as the University IRB in New Mexico felt that they would not sign it because; A: I was no longer an employee with UNM, and B: It was not the right form.  Do you not think they would have told someone! A dysfunctional system. Instead; a very diligent Research Director for the College of Nursing kept putting herself self-out there daily to get this signed. She was always dismissed. There is a learning curve here; 1. Communicate; 2. Be ethical ; 3. Be a role-model to others.  I do feel relief, however; just glad to be moving.

I plan to send the surveys out as soon as I get IRB FHSU approval. I would imagine 2-3 weeks should be enough time to get the reviews back. Survey Monkey, does quantify the information some statistical analysis; however, for in depth-review; it will go to FHSU statistician. I have re-worked the theory (Lewins Change); it has been modified to the survey and the change in the structure of this project. I think it is exciting, I do hope the NPs in New Mexico find it helpful to them, make them feel, and be familiar with the, 2016  guideline from the CDC on Chronic Pain Management with Opioids. Each state seems a little different on how Primary Care manages opioids for their patients.  My focus remains in New Mexico. For the most part, they are very progressive in adhering to the guidelines from the CDC. Thanks to an Attorney General that is on top of this epidemic (Hector Balderas).

The next blog will be more organized as I will actually be putting the project together.

10/3/19  UPDATE:  MY PROJECT IS APPROVED! I received my “Exempt” letter today from FHSU IRB. YAY!!!   Kay

Implementation Check Points-DNP II

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The update on my project since the last blog; I found out just a few weeks ago that UNM IRB would not sign my project proposal. This went on from July 31st to the first part of September.  I had to escalate to a higher power the need to get this signed or not so that I could move on.  The Director of the IRB for the UNM College of Nursing was helping me with this; she was dismissed multiple times no reason given for the “one” signature that I needed. This individual did not sign citing I was not an employee of UNM any longer, and I was not a student with UNM.  However, if we would have known this week’s earlier, we could have submitted an agreement with FHSU and UNM, which may have been accepted. I had to switch to a survey which will be going out to NPs in the state of New Mexico. The study developed was done with Survey Monkey (which I just got done); will need to redo the FHSU IRB BEFORE October 7th and submitted by that date to be able to send the Survey later in October.  I received assistance from Dr. Keenan and Dr. Manry on how to manage this situation and the new direction we needed to take.  It will by no means be as strong of a study. However, it will still yield valuable information on the attitudes, beliefs, and barriers to practice with guidelines from nurse practitioners.

My new proposal:  “Assessment of attitudes, beliefs & barriers of New Mexico nurse practitioners on the utilization of the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.”

I created a simple time-line (check points) for the new and current proposal.  The yellow arrow represents the very start and “yield”.  The “green” is a go; the “red” is stop and evaluate.  This will be tweeked as I continue over the next few weeks and will most likely change.

 

 

Initial DNP Blog–Kay Gonzales

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My proposal: ” Does the use of an evidence-based guideline for opioid therapy improve adherence of chronic pain managment to current standards of care?”

The purpose of this review is to  improve provider knowledge and safe practice in prescribing an opioid for chronic pain in a primary care clinic by adherence to the use of the 2016 CDC Guideline for chronic pain management.  This guideline helps improve safety by the prescriber and prevention of un-intended overdose.  Many providers are not aware of the CDC guideline to provide safe care.

Concerns about this project:  At this time it is still awaiting “one” signature so that it may proceed through the University of New Mexico’s IRB process.  This has been most frustrating for me; it has been setting in an inbox for one persons signature since 7/31/19. It is being escalated to academics to see if we can get this individual to sign so that it may go through the process. The clinics Medical Director is  on board with the project.  I anticipate no problems with the clinic. This is a chart review.  I will be assigned a research assistant who will actually be the one to collect all the data for this project.  By doing this the sample (providers of the clinic) will be de-identified when I receive the harvested data.

Timeline: Definitely a concern.  As this may put me one to two months behind.  I am assured that as soon as the process is concluded, they are swift with getting data to the researcher.  After approval from UNM, the proposal still has to go through the FHSU IRB process before the implementation begins.  I do hope to have some sort of resolution by the end of next week.