Digital Commons Network^™

Implementation Of Visual Bed Indicator Lights To Improve Fall Prevention Processes, Andrea Leffew

Master's Projects and Capstones

Problem: Inpatient falls remain a significant patient safety concern associated with preventable patient harm, prolonged hospitalization, and increased healthcare costs. Routine fall bundle validations identified inconsistent adherence to safe bed configuration practices, such as beds left raised and bed alarms turned off.

Context: A 3-month quality improvement project was implemented on a 20-bed medical-surgical telemetry unit within an integrated healthcare delivery system at a 130-bed community hospital in Northern California, which was experiencing an increase in inpatient falls and fall-related sentinel events.

Interventions: Implementation of bed-monitoring technology with visual indicator lights that provided real-time feedback on bed configuration.

Measures: The …

Reducing Primary Cesarean Births Among Nulliparous, Term, Singleton, Vertex (Ntsv) Patients Through Structured Multidisciplinary Communication, Toyin Ajani

Master's Projects and Capstones

Background: Primary cesarean birth among nulliparous, term, singleton, vertex (NTSV) patients remained a persistent quality and safety concern in obstetric care. Unnecessary cesarean birth was associated with increased maternal morbidity, neonatal complications, prolonged recovery, higher healthcare costs, and adverse outcomes in subsequent pregnancies. Problem: A Northern California labor and delivery unit identified an elevated NTSV cesarean birth rate of 26.8%, exceeding the national benchmark of approximately 23%. Variability in provider communication, inconsistent labor management practices, and lack of standardized interdisciplinary collaboration contributed to this quality gap. Context: The project was conducted in a high-volume labor and delivery microsystem serving a …

Improving Peer Feedback Participation Through Psychological Safety Interventions In Labor & Delivery Nurses, Lindsey C. Hora

Master's Projects and Capstones

Abstract 

Background: Labor and Delivery (L&D) units require effective communication, speaking up, and team learning to support safe care. Psychological safety informed this quality improvement project as a contextual strategy to strengthen peer feedback engagement.  

Problem: Peer feedback participation among eligible L&D registered nurses at a large acute care hospital in Santa Clara, California, was 14.29% (N = 112) below the 30% project target and 80% organizational target. Low participation limited routine feedback for professional development, recognition, and team learning.

Interventions: Interventions included psychological safety education, peer feedback reinforcement, workflow integration, platform navigation support, dedicated completion time, and unit champions. …

Optimizing Life Care Planning For Palliative Home Health Care Patients, Lilian Muraya

Master's Projects and Capstones

Problem: In this home health palliative microsystem, many seriously ill patients begin care without timely goals‑of‑care conversations or documented advance directives, leading to fragmented communication and potentially avoidable emergency visits and rehospitalizations.

Context: This quality improvement project took place in a hospital-based home health palliative care program in Northern California, where an interdisciplinary team identified inconsistent Life Care Planning (LCP) practices and variable staff comfort with conducting goals‑of‑care discussions.

Intervention: A structured LCP workflow was developed so that newly admitted palliative home health patients receive a goals‑of‑care discussion and advance directive review within 7 days of start …

Same-Day Cancellation Reduction In An Ambulatory Surgery Unit, Anthone Dalit Vengersammy

Master's Projects and Capstones

Problem: Same-day surgical cancellations in the outpatient surgery setting remain a significant operational and patient care challenge. Preventable cancellations negatively affect patient experience, operating room efficiency, staff productivity, and healthcare costs. 

Context: A microsystem and organizational culture assessment identified several factors contributing to same-day cancellations, including unclear preoperative instructions, incomplete medical clearance, inconsistent patient education, lack of standardized workflows, unclear staff responsibilities, and communication gaps among interdisciplinary teams. SWOT and gap analyses were used to identify opportunities for improvement and guide intervention planning.

Interventions: Quality improvement interventions were implemented through iterative Plan-Do-Study-Act (PDSA) cycles. Strategies included revising preoperative patient instructions, …

Effectiveness Of The Smart Me-De Digital Program On Health Literacy And Glycemic Control In Newly Diagnosed Type 2 Diabetes, Nongnaphat Rungnoei, Siriporn Kruttakart, Natthapan Phianthanyakam, Pakaporn Klinhom, Umaporn Nokpaet, Jintipa Sirikunwiwat, Burong Jaitham

Journal of Health Research

Background: Individuals newly diagnosed with type 2 diabetes often have limited knowledge and self-management skills, leading to poor glycemic control and increased complications. This study evaluated the effectiveness of the Smart ME-DE Digital Program in improving health literacy and glycated hemoglobin levels among newly diagnosed individuals with type 2 diabetes.

Methods: A quasi-experimental study was conducted with seventy participants recruited from diabetes clinics at three hospitals in a central province of Thailand. They were selected using simple random sampling and matched by gender, age, and baseline HbA1c levels, and allocated to an experimental or comparison group. The experimental group received …

Quality Improvement Project: Advancing Personalized Depression Care In Outpatient Psychiatry, Jillian K. Benoit

Doctor of Nursing Practice Projects

Depression is a leading cause of disability worldwide, yet inconsistent use of evidence-based assessment and treatment strategies contributes to gaps in the quality of psychiatric care. A needs assessment at a community outpatient psychiatric clinic identified inconsistent documentation of measurement-based care (MBC), shared decision-making (SDM), and patient education during depression treatment. The purpose of this quality improvement project was to evaluate whether implementation of MBC and SDM improved depression treatment documentation among psychiatric providers over a 4-week period. Guided by Lewin’s Change Theory and implemented using the Iowa Model of Evidence-Based Practice as the implementation framework, this quantitative one-group pretest-posttest …

Quality Improvement Project Simulating Ethics: Improving Ethical Decision-Making In Nursing Undergraduates Through Simulation And Faculty Training, Shannon Brown

Doctor of Nursing Practice Projects

Nursing faculty often report limited confidence in teaching ethical principles, despite the essential role ethics plays in preparing students for complex clinical decision-making. This quantitative, quasi-experimental pre/post quality improvement project evaluated whether a structured ethics education module incorporating simulation could impact faculty confidence in teaching ethical principles. Guided by Lewin’s Change Theory and the Jeffries Simulation Framework, the project examined how organizational readiness for change and structured simulation design influence faculty development outcomes. Nursing faculty in a baccalaureate program participated in a single simulation-enhanced ethics session. Data were collected through anonymous pre/post Qualtrics surveys, and faculty confidence was measured using …

Improving Exam Scores: Alternative Next Generation Questions In Curriculum, April Morgan

Doctor of Nursing Practice Projects

Evidence identifies clinical judgment deficits among newly licensed nurses, supporting the integration of the National Council of State Boards of Nursing (NCSBN) Clinical Judgment Measurement Model (NCJMM) and Next Generation NCLEX (NGN) strategies. Inconsistent NGN implementation and Assessment Technologies Institute (ATI) Comprehensive Predictor performance established the local problem. This quality improvement project evaluated the impact of implementing NCJMM-aligned NGN instructional strategies, including unfolding case studies and bow-tie questions, on students’ first-attempt achievement of the ATI Comprehensive Predictor benchmark and faculty outcomes. The primary aim was to increase the percentage of students achieving the ATI Comprehensive Predictor benchmark of 76.2% on …

Standardizing Hypertension Care In An Occupational Medicine Clinic: A Quality Improvement Project, Carolyn Duncan

Doctor of Nursing Practice Projects

Hypertension remains a leading modifiable risk factor for cardiovascular disease, and inconsistent implementation of evidence-based hypertension management may contribute to variability in patient education, documentation, and follow-up care. This quality improvement project evaluated an evidence-based educational program and a standardized hypertension management workflow, based on the 2025 American College of Cardiology/American Heart Association (ACC/AHA) hypertension guidelines, in an occupational medicine clinic. Guided by the Iowa Model of Evidence-Based Practice, Kotter's 8-Step Change Model, and the Plan-Do-Study-Act framework, the intervention aimed to impact staff self-efficacy, documentation of lifestyle education, and follow-up appointment scheduling. A quantitative quasi-experimental pre-post design was used with …

Nurse Manager Perceptions Of Strategies To Overcome The Underutilization Of Nonpharmacological Pain Control Methods In Adult Acute Care, Landen M. Bonnell

Undergraduate Honors Theses

A basic patient right is to have pain adequately managed. However, research consistently indicates that many adult patients in acute care experience inadequately managed pain, which may contribute to adverse patient outcomes. Studies have shown that nonpharmacological pain management can lead to increased patient satisfaction, shorter hospital stays, and better patient outcomes. However, many barriers exist to nurses providing effective nonpharmacological pain control therapy, primarily including heavy workload and a lack of education and support. Currently, there is insufficient research on how to overcome these barriers. Four nurse managers with experience in nursing leadership were interviewed using a qualitative descriptive …

Online Group Neurobehavioral Therapy (Nbt) For Veterans With Epilepsy And Major Depressive Disorder (Mdd), Melissa F. Fadipe

Dissertations and Theses (Open Access)

Background: Veterans with epilepsy experience high rates of psychiatric comorbidity, most commonly major depressive disorder (MDD). Barriers to accessing mental health care—including geographic distance, transportation limitations related to seizure-related driving restrictions, and fragmented care between neurology and psychiatry, contribute to the underdiagnosis and undertreatment of MDD in this population. Neurobehavioral Therapy (NBT), a Cognitive Behavioral Therapy (CBT)-informed psychotherapy developed for individuals with seizures, has demonstrated benefits for psychological distress and quality of life. Internet-based interventions and short message service (SMS) text messaging offer promising strategies to address access barriers; however, limited research has examined the feasibility and acceptability of delivering …

From Birth To Better Health: Educating Mothers With Gestational Diabetes On Breastfeeding Benefits And Glucose Management, Jesse A. Soria Jr, Sarah Smith, Audrey Nolan Smith, Keeley Kosier

ELMSN E-Portfolio. A collection of Scholarly and Creative Works

Gestational diabetes mellitus (GDM) increases a mother's risk of developing type 2 diabetes mellitus (T2DM) later in life and can affect an infant's future health. Breastfeeding can help improve a mother's blood sugar control and may lower her future risk of diabetes, but many mothers with GDM do not know about these benefits. This quality improvement (QI) project evaluated a standardized education program on breastfeeding and diabetes prevention for postpartum mothers with GDM at the Family Birthing Center at St. Joseph's Medical Center (SJMC) in Stockton, California. The intervention included a 10- to 15-minute education session and an evidence-based educational …

Improving Mobility Awareness And Jh-Amp Tool Utilization On A Cardiac Care Unit, Courtney Joe, Clarissa Chaires, Jocelyn Martin, Eunice Sanchez

ELMSN E-Portfolio. A collection of Scholarly and Creative Works

The quality improvement project evaluated the impact of staff education and a unit-wide mobility awareness campaign on the use of the Johns Hopkins Activity and Mobility Promotion tools and patient mobilization in a 48-bed Cardiac Care Unit (CCU). The project involved registered nurses, nursing assistants, unit leaders, and adult cardiac patients represented by aggregate mobility data. A preliminary survey completed by 42 CCU staff members, CCU Partnership Council focus group, meetings with clinical nurse specialists, and a baseline unit audit identified inconsistent mobility practices, uncertainty regarding Johns Hopkins Highest Level of Mobility tool, and limited completion of in-room mobility signs. …

Mind Over Scrubs – A Peer-Led Anxiety Reduction Program, Nhi T. Tran, Angelica Dirige, Adeleke Fashola

ELMSN E-Portfolio. A collection of Scholarly and Creative Works

Nursing students experience elevated anxiety during the transition into accelerated programs, which can negatively affect academic performance, well-being, and retention. This quality improvement project evaluated Mind Over Scrubs, a peer-led anxiety reduction program for incoming Entry-Level Master of Science in Nursing students at the University of the Pacific, consisting of four 45-minute sessions on evidence-based coping strategies. Generalized Anxiety Disorder-7 surveys were administered at baseline, before and after each session, and at two- and four-week follow-ups; Wilcoxon signed-rank tests evaluated matched changes. Thirty-one of 62 enrolled students (50%) attended at least one session. Post-session scores fell below individual baselines for …

Know Your Birth, Jasmine Mckelvey, Reagan L. Hunt, Michaela M. David

ELMSN E-Portfolio. A collection of Scholarly and Creative Works

Maternal mortality remains a significant public health concern in rural Kenya because of limited healthcare resources, inadequate emergency obstetric training, and barriers to accessing timely, high-quality maternal care. This quality improvement project evaluated the implementation of the Know Your Birth educational intervention, a culturally responsive, simulation-based training program designed to improve healthcare providers' knowledge, confidence, and competency in evidence-based maternal and newborn care. The project was conducted at Sega Dispensary in Sega, Siaya County, Kenya, and included 26 healthcare staff members. Guided by the Plan-Do-Study-Act framework, participants completed a brief educational presentation followed by three interactive skills stations focused on …

Attrition Of The Midwifery Workforce: Understanding Factors Associated With Leaving The Profession, E. Brie Thumm, Amy H. Goh, Elizabeth G. Phillips, Zachary Giano

College of Health Professions Faculty Papers

OBJECTIVE: To understand why advanced practice midwives (certified nurse-midwives and certified midwives) leave the workforce.

STUDY SETTING AND DESIGN: A multi-method, multi-source investigation included secondary analysis of certification data of advanced practice midwives and a cross-sectional online survey with closed- and open-ended items. Advanced practice midwives' active certification data were used to compare self-reported demographic characteristics of advanced practice midwives who reported working in the discipline of midwifery to those who did not (n = 9704). A survey was conducted in 2022 with individuals who allowed their certification to lapse between 2017 and 2021 (n = 303) and individuals who …

The Effects Of An Educational Intervention To Enhance Knowledge And Awareness Of The Prevention Of Sexually Transmitted Infections Among College Students, Darcy Yates

Doctor of Nursing Practice Projects

Purpose

The DNP student implemented a single group pretest-postest design underpinned by the Health Belief Model to address the PICOT question: Among a purposive sample of college students at a mid-west college (Population) to what degree does participation in an evidence-based intervention providing information about STIs (Intervention), compared with before that intervention (Comparison), result in to an increase in knowledge and awareness regarding STI infections and associated risks and treatment options (Outcomes) over a six-week period (Time)?

Methods

The pretest and postest scores of 15 students for the 27 items in the Sexually Transmitted Diseases Knowledge Questionnaire (STD-KQ) were evaluated. …

Recover Well: Reducing Readmissions Through Nurse-Led Follow-Up After Urologic Surgery – A Quality Improvement Project, Candace Brigette Mike

Doctor of Nursing Practice Projects

Hospital readmissions within 30 days following urologic surgeries are often associated with catheter complications, infections, poor pain management, and limited patient understanding of discharge instructions and therefore represent a significant quality and safety concern for patients and institutions alike. The purpose of this quality improvement project was to evaluate whether implementing structured, nurse-led telephone follow-up in conjunction with standard discharge education reduced unplanned 30-day hospital readmissions among adult patients undergoing urologic surgery. Guided by the Logic Model framework, this project used a quasi-experimental, two-group pre- and post-intervention design to compare outcomes at a high-volume outpatient urology clinic in Houston, Texas. …

Quality Improvement Initiative To Improve Adherence To Ob Hemorrhage Policy And Standardize Pitocin Administration During Cesarean Sections To Reduce Postpartum Hemorrhage Risk, Lauren R. Litz, Monica Blauser

Doctor of Nurse Anesthesia Practice (DNAP) Manuscripts

Postpartum hemorrhage remains a leading cause of maternal morbidity and mortality, and Pitocin administration is an important component of hemorrhage prevention and management during cesarean delivery. Variation in Pitocin timing, dosing, method of administration, and adherence to evidence-based recommendations may compromise patient safety and create barriers to standardized obstetric anesthesia care. The purpose of this Doctorate of Nurse Anesthesia Practice quality improvement project was to evaluate current anesthesia provider practices for Pitocin administration during cesarean delivery, compare observed practices with the California Maternal Quality Care Collaborative hemorrhage toolkit and Society for Obstetric Anesthesia and Perinatology Enhanced Recovery After Cesarean recommendations, …

Enhancing Patient Outcomes In Obstetric Neuraxial Anesthesia: Evaluation Of A Structured Documentation Tool For Post-Dural Puncture Headache Tracking (Pdph), Jacqueline Saldana Tovar, Ahmad Hasaan

Doctor of Nurse Anesthesia Practice (DNAP) Manuscripts

The purpose of this Doctor of Nursing Practice (DNP) project is to evaluate the incidence, management, and practice variation of post-dural puncture headache (PDPH) in an obstetric population using retrospective data from standardized follow-up tools. The project aims to identify inconsistencies in procedural techniques, documentation practices, and adherence to evidence-based guidelines across anesthesia provider levels. By analyzing key clinical variables and patient outcomes, this project seeks to identify gaps in current practice, improve data reliability, and support the development of standardized protocols for PDPH assessment and management. Ultimately, the goal is to enhance quality of care, promote evidence-based decision-making, and …

Enhancing Sbar Documentation And Telecommunication Between Nursing And Anesthesia Teams In The Obstetric And Labor And Delivery Unit, Apollonia C. Anderson, Celeste Meda

Doctor of Nurse Anesthesia Practice (DNAP) Manuscripts

Effective communication during obstetric handoffs is essential for promoting maternal and neonatal safety, yet communication failures remain a significant contributor to adverse events due to inconsistent and unstructured handoff practices. This Doctor of Nursing Anesthesia Practice (DNAP) quality improvement project was developed following the recommendations of the 2025 DNAP project, which implemented the OB/L&D-specific SBAR tool. This project evaluated the use of this communication tool in areas of OB interdisciplinary team communication accuracy, efficiency, and collaboration, particularly during obstetric epidural requests within a community-based labor and delivery unit. Guided by the Plan-Do-Study-Act (PDSA) framework (Institute for Healthcare Improvement, 2020). Utilized …

Dnp Final Report: Improving Diabetes Self-Efficacy Through Nutrition Education: A Quality Improvement Project, Lakimberely S. Wooten

DNP Final Reports

Diabetes affects 12.7% of residents in Northeast Texas and is the 7th leading cause of death. Internal evidence indicates low health literacy and a heavy disease burden in the service area, underscoring the need for a standardized, low-cost, and feasible approach to nutrition education. This quality improvement project evaluated the feasibility of implementing an instructor-led nutrition education session. Guided by the Johns Hopkins Evidence-Based Practice Framework and the ADKAR behavioral change model, adult participants with Type 2 diabetes received instruction on the Plate Method. Participants enrolled in a 4-week, instructor-led diabetes education class completed a 1-hour, nutrition education session using …

​​Hospital-Acquired Pressure Injury Prevention In The Sutter Sacramento Cardiac Care Unit ​Qi Proposal, Angelina Lucido, Amy Roderick, Karly Link

ELMSN E-Portfolio. A collection of Scholarly and Creative Works

Background: Hospital-acquired pressure injuries (HAPIs) remain a significant source of preventable patient harm despite established prevention protocols. In the Cardiac Care Unit (CCU) at Sutter Medical Center Sacramento, inconsistent patient education and limited patient engagement were identified as potential contributors to ongoing HAPI occurrence. This quality improvement (QI) project evaluated whether implementing structured, individualized patient education could strengthen existing pressure injury prevention efforts.

Methods: A seven-week QI project was conducted in the CCU using the Plan-Do-Study-Act (PDSA) framework. The intervention consisted of nurse-led, individualized pressure injury prevention (PIP) education supported by a standardized patient handout tailored to each patient's risk …

Reducing Falls In The Cardiac Care Unit: An Improvement Project, Andrea Otero, Aryanna Campa, Nia Butac

ELMSN E-Portfolio. A collection of Scholarly and Creative Works

Abstract

Background: Patient falls persist as a leading cause of preventable harm in hospitals, particularly among cardiac care patients who are at increased risk because of medication effects and mobility limitations. Despite existing fall `prevention measures in the Cardiac Care Unit (CCU) at Sutter Medical Center, Sacramento, 43 falls occurred, highlighting the need for improved patient education and consistent staff communication.

Purpose: This quality improvement project evaluated the effectiveness of implementing a standardized fall prevention communication script to reduce the average monthly fall rate in the CCU from 3.583 to fewer than 2 falls per month.

Methods: Using the Plan-Do-Study-Act …

Improving Clostridioides Difficile Prevention Practices Through Standardized Stool Collection And Hand Hygiene, Dunya Khateeb, Laura Martin, Jessica Zhang

ELMSN E-Portfolio. A collection of Scholarly and Creative Works

Healthcare-associated Clostridioides difficile (C. diff) infections increase patient morbidity, length of stay, and healthcare costs (Simor, 2010). Our quality improvement project seeks to reduce C. diff infection rates and enhance prevention practices on the Med-Acute Unit at Sutter Medical Center Sacramento (SMCS) by utilizing the Plan-Do-Study-Act (PDSA) framework. Interventions will be implemented between March 2026 and July 2026. The project examined whether introducing a standardized stool collection tote and improving hand hygiene compliance would reduce C. diff infection rates. Participants included all nursing staff on the unit. Data is being collected through observational hand hygiene audits, collaboration with the SMCS …

Staff Education On The Implementation Of An Evidence-Based, Suicide-Risk-Assessment Education Program For Psychiatric Staff, Yemurai Emily Dzikiti

Walden Dissertations and Doctoral Studies

Suicide is a major public health concern, and consistent suicide risk assessment is essential for patient safety in psychiatric settings. This Doctor of Nursing Practice staff education project addressed a knowledge gap in evidence-based suicide risk assessment among psychiatric clinicians in an outpatient mental health setting. The practice-focused question examined whether an evidence-based suicide risk assessment education program would improve clinicians' knowledge from pre- to post-education. The educational intervention consisted of a 60-minute in-person training session on evidence-based suicide risk assessment using the Columbia-Suicide Severity Rating Scale (C-SSRS) and the Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) framework. Ten psychiatric …

Improving Obesity Management In Primary Care Through Provider Education, Natalie Anderson

Doctor of Nursing Practice Projects

Background: Childhood obesity is a significant public health concern associated with metabolic, cardiovascular, and psychosocial complications. Despite the availability of evidence-based pediatric obesity management guidelines, adherence to these guidelines remains inconsistent in primary care settings. Purpose: This evidence-based quality improvement project aimed to determine whether provider education on the 2023 American Academy of Pediatrics (AAP) Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity, combined with implementation of an electronic health record (EHR) clinical decision support prompt, improved provider knowledge and adherence to guideline-recommended obesity management practices. Method: A pre-post quasi-experimental study was …

Enhanced Communication Is Fundamental In Providing Quality Care, Jacqueline Turcotte Rn, Msn, Ccrn

MaineHealth Maine Medical Center

No abstract provided.

The Effects Of Education And Training On Clinical Staff’S Knowledge, Perception, And Clinical Practice Of The Medication Reconciliation Process, Stephanie A. Williams

Doctor of Nursing Practice Projects

Medication-related harm affects approximately one in 30 patients in healthcare settings. Accurate medication reconciliation (MedRec) is essential for identifying medication discrepancies, preventing medication errors, and reducing adverse drug events. Clinical staff play a critical role in ensuring the accuracy of medication lists in primary care settings.

This evidence-based quality improvement project evaluated the effect of a structured MedRec training intervention on MedRec knowledge, perceptions, and practices among clinical staff in a primary care clinic in Southeast Texas. The project used a single-group, quantitative, quasi-experimental design. A convenience sample of 32 clinical staff members completed knowledge and perception assessments before and …