Nursing Administration Commons^™

Don’T Fall For It: Just-In-Time Staff Education To Reduce Patient Falls On An Adult Telemetry Unit, Forrest Wilcox, Kyle Knight, Jennifer Paiz, Zaira Garcia-Vega

Master's Projects and Capstones

Objective: Patient falls remain a leading cause of preventable harm among hospitalized adults and carry significant clinical and financial consequences. On an adult medical-surgical telemetry unit at this study site, a one-year review of 45 fall events found that most falls occurred among patients classified as high risk on the Morse Fall Scale, frequently without continuous observation or consistent purposeful rounding. Aim: The aim of this project is to reduce falls on the telemetry unit to the national benchmark of 3.2 falls per 1,000 patient days within a 6-month period. Methods: A just-in-time (JIT) education intervention was delivered to registered …

Cultivating Civility: A Multicomponent Approach To Reducing Workplace Incivility In An Assisted Living Facility, Sanam Bral, Kaylyn Chang, Catherine Dinh, Sanjil Kumar, Truc Mai Moon

Master's Projects and Capstones

Workplace incivility remains a common challenge in healthcare, negatively affecting communication, staff well-being, and the quality and safety of resident care. Baseline survey findings from a faith-based assisted living facility in Southern California identified concerns related to workplace incivility, psychological safety, and gaps in staff knowledge of available reporting resources. This project aimed to reduce workplace incivility by improving staff knowledge and recognition of uncivil behaviors, with a target of at least 90% staff training attendance among nursing, assistive nursing, and medical technicians, and 80% attendee-reported high confidence level (agree or strongly agree) in recognizing incivility and understanding reporting options. …

Confidence Versus Competence: Addressing Nursing Knowledge Gaps In Catheter Care To Reduce Catheter-Associated Urinary Tract Infections, Leslie Anne Villanueva Bautista

Master's Projects and Capstones

Catheter-associated urinary tract infections (CAUTIs) remain among the most prevalent and preventable healthcare-associated infections (HAIs), contributing substantially to patient morbidity, mortality, prolonged hospitalization, and healthcare expenditures. Most hospital-acquired UTIs are related to urinary catheters, and this burden costs the United States alone an estimated $340 to $450 million annually (Yang et al., 2022). CAUTIs are UTIs that occur in patients with indwelling urinary catheters. This quality improvement project aimed to increase adherence to existing bladder scanning protocols and strengthen urinary catheter care to prevent CAUTI. Baseline staff nurse knowledge was obtained, and reinterpretation of the facility’s existing protocols and bundles …

Draining The Risk, Holding The Line: A Nurse-Driven Approach To Catheter-Associated Urinary Tract Infection Prevention, Thy Nguyen

Master's Projects and Capstones

Catheter-associated urinary tract infections (CAUTIs) remain among the most common preventable healthcare-associated infections, with CMS eliminating reimbursement for hospital-acquired cases since 2008. Within a five-unit, high-acuity microsystem at an urban acute care hospital, four CAUTIs were documented between January and July 2026 despite established prevention protocols. Adherence gaps were identified in catheter necessity assessment, maintenance practices, and nurse-driven removal protocol use. This quality improvement project was guided by the Johns Hopkins Evidence-Based Practice framework and Lewin's Change Theory. A targeted nursing education intervention addressing bladder scanning, dependent loop identification, and catheter care bundle adherence was implemented across the microsystem over …

Improving Pain Reassessment Within One Hour Of Pain Medication Administration, Geraldine B. Macalma

Master's Projects and Capstones

Abstract

Problem: Timely reassessment of pain is often missed or inconsistently documented, creating a gap between evidence-based standards and actual nursing practice. This inconsistency prevents evaluation of intervention effectiveness and contributes to unmanaged pain, reduced patient satisfaction, and safety concerns.

Context:  Pain reassessment is a critical component of evidence-based pain management, ensuring that nurses evaluate the effectiveness of interventions and adjust care accordingly.  Competing priorities and documentation challenges often lead to inconsistent reassessment, affecting patient comfort, safety, and overall quality of care.

Interventions: Guided by a Plan-Do-Study-Act framework, the intervention included documentation of a safety round, purposeful hourly rounding, …

Enhancing Patient Understanding: Standardizing Cardiac Medication Education Using Teach-Back For Heart Failure, Nicole Valerie Hediger

Master's Projects and Capstones

Problem: The transition from hospital to home places heart failure (HF) patients at risk for medication errors, nonadherence, deterioration, and rehospitalization. In a 28-bed medical-surgical telemetry microsystem, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores indicated an opportunity for improvement: “Communication About Medicines” composite score of 47.9%; 62.5% of patients reported being informed about the medication purpose, and 33.3% reported that staff described potential side effects.

Context: A cohort of HF patients was selected to test teach-back methodology and improve patient understanding. Nurse champions volunteered for a 5-month improvement project.

Interventions: Teach-back methods were implemented. Nurse leader rounding …

Evaluation And Continuation Of Oncology Nurse Mentorship Program, Gurpreet K. Kang

Master's Projects and Capstones

Problem: Newly hired nurses on a busy inpatient leukemia and lymphoma subspeciality unit experienced challenges after transitioning into specialty oncology practice. This resulted in decreased confidence, increased risk of medication errors, and a 40% unit-based annual turnover rate. The cost of replacing one staff nurse is $61,000.  Exit interviews determined root causes of turnover rates, nurse confidence.

Context: A quality improvement program was envisioned to optimize patient and organizational outcomes on a 25-bed inpatient unit to evaluate and sustain an oncology nurse mentorship program.

Interventions: Over one year, cohort 1 (n=8) and follow up 2^nd cohort (n=7) was implemented …

Improving Diabetic Retinopathy Screening Among Adults With Diabetes In Boston, Massachusetts: A Policy Brief For Primary Care Implementation, Amber L. Auger

Capstones

No abstract provided.

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, …

Improving Fluoride Varnish Application Rates In A Pediatric Primary Care Microsystem, Roman G. Roxas

Master's Projects and Capstones

Problem

Childhood caries is a preventable public health issue disproportionately affecting the underserved. National guidelines recommend fluoride varnish (FV) application during well‑child visits. In California, fewer than 15% of children under age six received FV. In a pediatric primary care clinic, baseline performance was 11% in 2025.

Context

A six‑month quality improvement project was implemented. Key barriers included reduced team cohesion, workflow variability, unclear roles, and underutilized electronic health record (EHR) prompts.

Interventions

The change package standardized medical assistant–led workflows, activated EHR prompts, and provided targeted education. Leadership reinforcement through regular huddles supported adoption, consistency, and team engagement.

Measures

Outcome …

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 …

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. …

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 …

Dnp Final Report: Enhancing Self-Regulated Learning And Metacognition For First-Semester Undergraduate Nursing Students, Carla S. Biondillo

DNP Final Reports

Background. First-year undergraduate nursing students often struggle to adapt their learning strategies to the higher-order thinking and clinical reasoning demands of nursing education. Ineffective study habits, low academic self-efficacy, and limited self-regulated learning (SRL) skills are consistently identified as predictors of attrition, which ranges from 20–50% nationally and internationally.

Purpose. At an academic medical center in rural East Texas, first-semester students report academic overwhelm and inadequate study strategies, consistent with national trends. A structured, evidence-based faculty coaching intervention targeting SRL and metacognition was found to be feasible within the collaborative, student-centered organizational culture.

Methods. A quality improvement (QI) design …

Improving Medication Reconciliation Compliance In Home Health Admissions, Paula A. Petrie-Rivas

All Doctor of Nursing Practice (DNP) Scholarly Projects

Background: Clinician compliance with medication reconciliation at a home health agency was below regulatory expectations, with agency performance significantly lower than state and national averages. Workflow inefficiencies, inconsistent clinician practices, and limited training contributed to noncompliance, increasing the risk of medication discrepancies, preventable rehospitalizations, and Medicare reimbursement penalties.

Aim: This quality improvement project implemented a standardized medication reconciliation workflow using the Agency for Healthcare Research and Quality’s MATCH toolkit to improve clinician compliance during admission to home health.

Evidence: Literature supports structured medication reconciliation as an effective strategy to improve safety during transitions of care. The MATCH toolkit provides a …

Poor Adherence To Established Clinical Guidelines In Outpatient Bladder Cancer Management, Melanie Boren

All Doctor of Nursing Practice (DNP) Scholarly Projects

Problem: The outpatient urology practice encountered challenges with adherence to Clinical Practice Guidelines (CPGs), primarily due to unfamiliarity and lack of operational accountability. This led to a low adherence rate of only 40% among patients with bladder cancer. Key issues included inadequate training and knowledge gaps regarding CPGs.

Aim of the Project: The project aimed to improve patient care and outcomes in bladder cancer treatment by enhancing patient retention and adherence to treatment protocols. Evidence-based interventions were implemented to optimize care delivery and support adherence to prescribed treatments.

Review of Evidence: A literature review highlights the effectiveness of nurse navigator …

Skin Is In: Promoting Breastfeeding Through Immediate Cesarean Skin-To-Skin, Autumn Spencer

All Doctor of Nursing Practice (DNP) Scholarly Projects

Problem: The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) and the American College of Obstetricians and Gynecologists identify immediate, uninterrupted skin-to-skin contact as a standard of care that improves neonatal stability, breastfeeding outcomes, and maternal satisfaction. Despite these recommendations, timely initiation following cesarean birth remains inconsistent. At the project site, skin-to-skin initiation averaged 72 minutes after birth, exceeding the 10-minute benchmark, and exclusive breastfeeding rates were below the national standard of 70%. Contributing barriers included workflow variability, unclear role expectations, and inconsistent communication.

Aim of the Project: The aim of the project was to improve infant and maternal …

Fall Tailoring Interventions For Patient Safety: A Program Evaluation, Shirley Morrison

All Doctor of Nursing Practice (DNP) Scholarly Projects

Problem: Falls with injury rates had increased for over two years at the project hospital until nurse leaders implemented a new fall-prevention intervention. Patient falls are the most common preventable adverse event in acute care hospitals, with approximately 700,000 to 1 million occurring annually in the United States. Before implementing the Fall Tailoring Interventions for Patient Safety (TIPS) toolkit, the hospital’s program lacked an evidence-based approach and a fall communication board to alert staff, patients, and families about the individual fall risk status, leaving a significant gap in patient-centered care.

Aim of the Project: The aim of the project was …

Reducing Catheter-Associated Urinary Tract Infections In Progressive Care, Kelli S. Bylsma

All Doctor of Nursing Practice (DNP) Scholarly Projects

Problem: Catheter-associated urinary tract infections (CAUTI) harm patients and increase healthcare costs. In fiscal year 2025, the progressive care unit reported a CAUTI rate 2.5 times the National Healthcare Safety Network benchmark of 1.0 infection per 1,000 catheter days. A gap analysis revealed that the project site lacked a policy mandating chlorhexidine baths for catheterized patients, resulting in suboptimal catheter hygiene and ineffective bactericidal intervention.

Aim of the Project: The aim of the quality improvement project was to reduce CAUTI rates by 50% through daily chlorhexidine baths for catheterized patients in the progressive care unit.

Review of the Evidence: Recent …

Extending The Global Impact Of Dnp Education: Integrating Scholarly Dissemination And International Practice Projects, Cynthia Plonien, Pricilla Muisyo, Deborah Behan, Kristine Cope, Cathy Brown

Nursing Faculty Publications & Presentations

The Doctor of Nursing Practice (DNP) Program at the University of Texas at Arlington initiated a global outreach effort in 2024 through two complementary strategies: expansion of a digital repository to support dissemination of DNP scholarly work and implementation of pilot DNP projects in Kenya. Together, these initiatives represent an integrated model for global engagement that combines knowledge dissemination with application of practice-based scholarship. The repository has facilitated international access to DNP projects, demonstrating significant global reach across multiple countries. Concurrently, a pilot project in Kenya was established through a strategic in-country professional partnership, enabling culturally relevant and sustainable implementation …