DNP Role in Equality and Justice

The final months of the program were devoted to completing my data for the program initiative evaluation. There were 25 children and teens with their parents (mothers) enrolled in the program during the first month, but only 15 were seen by the third month of the program. The participants received 3 monthly low-intensity behavioral modification counseling sessions targeting certain eating/dietary habits and behaviors, physical activity and sedentary behaviors associated with overweight and obesity. The Stage 1 Prevention Plus Protocol developed by the Expert Committee is a treatment protocol for overweight and obese children that can be given in the office/clinic or primary care setting. It involves active parental participation, and it is patient-centered because it uses motivational interviewing counseling techniques to help improve the families' levels of self-efficacy and readiness to change. It empowers them to be major decision-makers in the change process, setting their own goals based on their willingness and perceptions.

At the end of the third month visit, I was able to give each participant a Certificate of Completion and a sporting item, which I purchased from a small amount of scholarship award that I received from a nursing professional organization. I am still finalizing my written report and will be presenting the findings to the health center next May.

Children receive their Certificate of Completion and a sporting item at the end of the project.

This Service Leaning Project provided much needed access to childhood obesity treatment and prevention services to socioeconomically at-risk populations who visit the federally qualified health center (FQHC) for primary care. The FQHC had 4 clinical sites, but the project was piloted only in 2 sites. The target population for the health center was largely Hispanic followed by black non-Hispanic, with annual incomes 200% below the federal poverty limit. Interestingly, 92% of the participants seen on the first month of the program were Hispanic, 45% of the mothers had elementary education or less and 33% had middle school, and 78% had family incomes < $20,000/year. These data are consistent with national data reflecting the racial/ethnic and socioeconomic disparities that exist in childhood obesity prevalence.

Programs or interventions developed or designed to address complex issues such as childhood obesity, and those that involve behavioral change needs to be culturally sensitive, patient- and family-centered, supported by evidence and based on theory. And this is true for any kind of intervention that needs change to improve outcomes.

The two questions to answer for this final blog are the following:

What is my role as an educated and privileged citizen in our society in creating a society rooted in equality and justice? 


As a DNP-prepared nurse, my role is to ensure that healthcare delivery models/interventions/programs takes into consideration the cultural background, values, beliefs, and perceptions of the individual/population's. Additionally, the type of setting, the type of neighborhood or community, the educational background of the families/population, their SES need to be identified and respected. The future of our healthcare system is uncertain, but I know that in whatever area of practice I may be in, respect for the dignity of the human life in all of life stages from the moment of conception until the time of death will be at the forefront of everything I do. I am responsible and accountable not to men-but to God-for the knowledge and skills I am privileged to have as a DNP-prepared nurse.


What have I learned about myself and what are my future plans?

The greatest thing I've learned about myself is that I am capable of initiating change in any healthcare setting I may be in, and that I am now more confident that I can lead big projects or program initiatives such as this. As I present the findings of my project this May, I have recommendations that I will make before the Peer Review Committee and if they want to follow these recommendations, I will provide my services for free as a service to my community.

My partners in this project: DNP Student (Mimi Ramos) at the left upper photo and the dietician (Cristina Morales) at the right. Below to the left is the Special Projects Officer of the health center and my DNP Mentor, Penny Pabst with the dietician.

Progress of Pilot Study: Child/Adolescent Overweight and Obesity Prevention Program in a FQHC

Description of Activity
This is an update of my Service Learning Experience (SLE), which also happens to be my DNP Capstone Project. For those who may not have read my previous posts, my project is the implementation of a child/adolescent overweight and obesity prevention program based on expert recommendations at a federally qualified health center (FQHC) in Southwestern Texas. This past January 2012 was the first month of a 3-month program. During this month, the registered dietician (RD) and I enrolled eligible participants to the program that were either referred by the providers for overweight, obesity, or weight management or siblings of these children/teens recruited by the RD. Consents were signed and pre-intervention data were obtained. Pre-intervention data covers the following information:

• Baseline weight and BMI
• Children/Teens and parent characteristics
• Eating habits, physical activity levels, sedentary behaviors
• Identifying a priority goal or behavior/habit to change 
• Identifying perceived levels of Willingness/Importance and Confidence
• Identifying perceived barriers, benefits, and solutions to change habits/behaviors
• Previous experiences with MD, RN, RD visits pertaining to overweight/obesity care

During this process, we've identified areas that need revision to improve efficiency and efficacy of the process. I've revised some forms to make it simpler and more straight-forward for the participants; therefore, yielding more meaningful data. I am presently tallying the data and identifying missing data  I plan to retrieve from the participants on their second month visit with the RD. I constantly communicated with the RD during this month, reviewing with her the process, providing feed-back, and obtaining her feed-back, as well. I also try to consistently communicate with my mentor (Special Projects Officer of the health center) through e-mail.

This February, the RD will continue to follow-up with the participants and evaluate their progress in terms of their set/identified goals and to review their perceived levels of willingness/importance and confidence to change, identified barriers, benefits, and solutions. I am also consistently reviewing the goals/objectives of the project with the RD so that we can continually keep our focus in improving patient outcomes and her practice. 

Observations

Although I only have a very small sample size (n = 26), this first month experience represents or depicts what is known about childhood overweight and obesity: vulnerable populations, eating habits, sedentary behaviors, and physical activity levels, parental characteristics. Almost all children we've enrolled, except for two are of Hispanic/Latin American descent and all but one have at least an overweight/obese parent. Although it is beyond the scope of this project to identify the psychological/emotional impact of being overweight and obesity on children/teens, I've observed its link to poor self-esteem. There's one teen who attempted to commit suicide, one who wants to quit school, one who keeps to herself because of always being teased, and so on. Most of the participants identified being more physically active as their priority goal. Children/teens who reside in unsafe neighborhoods tend to stay inside the house instead of playing outside. Most of the children/teens come from low-income families, some with single parents, and a few mothers articulated lack of support from their spouses in efforts to live healthier lifestyles. Families are verbalizing their awareness of the implications of being overweight/obese to health and future quality of life.

From the RD's perspective, she is the only RD for the entire health center that covers 4 clinical sites. She covers adult and pediatric referrals and oftentimes need to make the phone call herself to set appointments with the patients. She had requested for extra support from other personnel to make these phone calls but has not been successful. 

Future Plans and Learning Points

For the entire month of February, I plan to obtain some missing data when participants meet with the RD during the second visit. I also need to ensure that the RD completes viewing the 4-part Motivational Interviewing videos from the Let's Go! website. I need to complete data analysis of pre-intervention data and start writing my final report. March will be the third and last visit of the participants with the RD. At this time, post-intervention data will be obtained, certificates of program completion and tokens of appreciation (e.g. basketballs, volleyballs, soccer balls, skipping ropes, hoola hoops) will be handed out once evaluation surveys are completed. I also plan to meet with the RD and my mentor this February for a mid-project evaluation.

I've learned during the first month visit how important it is to make the families feel that the health professional/RD is truly present to help them through this ordeal using Motivational Interviewing as a means to assist families improve their self-efficacy. I've also realized the importance of being the leader of this project at every step of the way. It can't be delegated nor can I be complacent at any point. I need to be flexible and pro-active, be able to foresee/anticipate potential issues, and intervene or make appropriate changes on time. Constant communication with the team is also one of the most critical elements of the project. It really is so much convenient to stay home and relax, but this project is a commitment to serve a vulnerable and disadvantaged population. Getting out of my comfort zone to see this project unfold gives me a sense of gratitude to do a project that can greatly benefit children and their families in the community. But above all, I see this as a means to be faithful to the deeper calling of service to others.

How Service Learning Made Me a Better Person

Service Learning: Implementing a dietician-led child and adolescent overweight and obesity prevention program in a federally qualified health center

After obtaining my IRB approval from Regis University, I was asked by the health center's medical director to present the project to the health center's Peer Review Committee (PRC), who unanimously approved the project. After the presentation, I met with the dietician who will be leading the program and discussed in detail the promotional plan and the logistics of the project. We planned to have posters posted at the waiting areas of each health center where the program will be piloted and to have educational brochures printed in English and Spanish. The posters and brochures are all downloaded for free from the Let's Go! Website, but printing is not for states outside of Maine. 

We plan to have the posters posted in the three sites before the end of the year in preparation for a January 2012 start date, which will end on March of 2012. Certificates and ribbons will be given to every child/adolescent who completes the three-month program with a parent or caretaker as full participant of the program. A policy will then be created to have the program be the standard of care for child and obesity prevention/treatment at the health center. After the project, we would be able to describe the sample population, their baseline and post-intervention eating habits, physical activity levels, sedentary behaviors (screen time in particular), perceived readiness to change, and perceived barriers, benefits, and solutions. Any issues encountered during the pilot phase will be addressed before the full adaptation of the Stage 1 Prevention Plus approach recommended by the Expert Committee.

Healthcare disparity exists when inequalities occur between and among different groups when compared to each other (Shi & Singh, 2011, The Nation's Health). It is a result of a complex interplay of genetics/hereditary, environmental, and behavioral factors, and is most commonly associated with poverty and lack of education (US DHHS). Health disparity is also most often associated with race/ethnicity and socio-economic status. Children from low-income families, Mexican teenage boys, and African-American girls are disproportionately affected by obesity. Disparities in health care among Medicaid children exist when compared with privately insured children (Medstat, 2005). 

Federally qualified health centers provide primary health care to medically underserved populations. Instituting a prevention/treatment program for children and adolescents at the health center will provide much needed access to evidence-based prevention/treatment programs that are patient/family-centered, timely, efficient, effective, safe, and ethical. 

The longitudinal Service Learning Experience reinforced the need of working in interdisciplinary teams as recommended by the Institute of Medicine (2003). Communicating effectively, coordinating, and collaborating with partners from the health center are essential components for the success of the program. The experience helped me develop my confidence in myself and helped me to go beyond my comfort zone to ensure that quality preventive care is available to children and adolescents affected mostly by overweight and obesity. I plan to continue doing so until the program is finally the standard of care for the health center.  I also plan to keep myself updated about the issue and developments in the practice and care for overweight and obese children and adolescents.

When is service to others just?

"Students, in the course of their formation, must let the gritty reality of this world into their lives, so they can learn to feel it, think about it critically, respond to its suffering and engage it constructively. They should learn to perceive, think, judge, choose, and act for the rights of others, especially the disadvantaged and oppressed." - Peter-Hans Kovenbach, S.J. - 


Do you see your doctoral level service learning experience contributing in any way to that quote? How?

My service learning experience is also my Capstone Project for the Doctor of Nursing Practice (DNP) Program with Regis University. I have done an extensive systematic review of evidences and examined both scientific evidences and expert opinions of clinicians and scientists. After many hours of intense literature search, I zeroed in on the Child and Adolescent Overweight and Obesity Prevention Program recommended by an expert committee that was convened by the American Medical Association, Human Resources and Services Administration, and the Centers for Disease Control in 2005 to revise the previous recommendations (National Initiative for Children's Healthcare Quality, 2007). The recommendation for the treatment and prevention of child and adolescent overweight and obesity is a four-staged approach and for Fort Bend Family Health Center (FBFHC) in Richmond, TX, the most appropriate intervention is the Stage I Prevention Plus.

I am, at the moment, waiting for the Regis University Institutional Review Board to do a full review of my project proposal. In the meantime, I am also planning to obtain the promotional materials I will need once the project starts. These includes posters, brochures, flyer, and rewards for the children who will be participating in the prevention program.

FBFHC is a community health center designated as a federally qualified health center. Therefore, they serve the medically underserved populations of three neighboring counties in various community health center (CHC) locations. Implementing the prevention program in these CHCs will address an urgent global issue that disproportionately affects children from poor families and those from racial and ethnic minorities, particularly Hispanic boys and African-American girls (Ogden and Carroll, 2010).

As I move along into the DNP Program, I learned how to develop strategic and business plans - applying the concepts and principles in developing my Capstone Project. One of the vital components of business and strategic plans is monitoring the regulatory climate and how this may hasten or impede the implementation of child and adolescent overweight and obesity program. I learned that the Affordable Care Act of 2010 is a very comprehensive plan that will greatly impact the healthcare of all Americans. The hope is to improve healthcare access for all Americans; however, there is a great amount of dollars involved when the full reform is implemented and debate ensues between Republicans and Democrats and various states are taking the case up to the highest courts to repeal the health care reform. Although it is not my intention to judge whether the reform is worth it or not, I am seriously reflecting on the short-term and long-term implications of this act on the nation's economy and overall health.

A good move on the part of President Obama was the establishment of a Task Force on Childhood Obesity to develop an inter-agency action plan in tackling the issue (Obama, 2010). Another development that excited me was the release of the National Prevention Strategy on June 16, 2011 (National Prevention Council). With the cost of US healthcare exceeding most of the industrialized countries, it is inevitable for the country to shift gear and focus more on wellness and disease prevention. In this prevention strategy, two of the seven priorities - healthy eating and active living - are reflective of the nation's effort to address obesity. It is my hope that the diffusion of childhood obesity prevention will be hastened by the collaborative efforts of various coalitions and collaborations between the public and private sector nationwide.

I am seriously contemplating on pursuing my involvement in the prevention of childhood obesity in the community after graduation. As a faithful steward of God's children, as a nurse, and as a mother, I am accountable to use the knowledge and skills, time, and talents given to me by God for the good of others, especially the disadvantaged and the poor. Although the ever changing social, economic and political climate in the country can either slow down or facilitate local and national efforts to alleviate childhood obesity, this will not deter me from doing whatever I can, in whatever little way I could, to make this world a better place for the children. Assisting community health centers and clinics in providing families with the tools, knowledge, and resources to make healthy choices about their nutrition and lifestyle can transform the nation, one community at a time... and save a generation of children who may be the first generation to "live sicker and die younger than the generation before them" (Robert Wood Johnson Foundation, 2011).

The Challenge

What was the best/worst/most challenging thing that happened this semester?

• The best and most challenging things that happened this semester are the following: being able to finish the Project Proposal for my Capstone Project, which is also my service learning experience and turning in my IRB application form to my Capstone Chair. I found making the Project Proposal very challenging because I needed to address a lot of aspects pertaining to evidence-based practice initiatives or outcomes research (e.g. study design, validity, reliability, finding the right measures/tools to use, addressing sampling, etc). It was a rigorous process and I wanted to ensure that I am able to address all the important aspects of the pilot study so that those who will read it will clearly understand the design and method of analysis I will utilize. 
• The challenging part of the the IRB application process is in making the consent and going through all the measures/tools I will use and having them translated to Spanish prior to submission, since any changes after the IRB needs to go through IRB again. So I needed to be very sure that the measures are accurate and that there will be no more changes after I submit them for IRB. The IRB Application was easier with the project proposal, but having finished both makes me able to take a deep breath and say: "Another step closer to the finish line." 
• The worst thing, as always, is losing several sleepless days and nights to finish a lot of the work involved in the Capstone Project process. Everything I do is a challenge, but I don't see any of those as bad. I always see what is beyond the present and this helps me to keep on going. I am looking forward to being able to start something that the agency will truly benefit from to improve their agency outcomes, and patient outcomes; something that is sustainable and beneficial for the children and their families. 

What can you do differently as an individual and as a professional to support and advocate for some of the issues you encountered during your service learning experience? 

• A big issue in the prevention and treatment of childhood obesity is the lack of funding to operate a the program that we will pilot through this Capstone Project. The dietician's previous nutrition program was funded for 2 years, but that funding already expired. What we are hoping is to be able to use the results of this pilot study for writing a grant proposal. This program needs funds to be able to produce the pamphlets, handouts, and posters on an ongoing basis to give to the families and to use in the clinic examination rooms. Although these are downloadable from the Web site, printer paper and ink are still needed to be able to print them out. We also need to buy a chest with educational toys and books for the kids to choose from as a reward for positive behavior changes.
• If I had the time, I would have applied for small a grant from childhood obesity coalitions to fund this project, or I could have planned a fund raiser in out Parish or sold lemonade in front of the house. I could have also went to my professional nursing organization and asked their help to raise funds for this project. Anything would help. But I didn't have the chance to do any of these.

This has been another challenging semester. But it makes me feel good that we have reached this far. Everyday is a step closer to the finish line. The best reward is being able to do something for the children and families who are disproportionately affected by overweight and obesity. I truly hope that this preventive program will prove to be something that can empower the community to live healthy lives.

Serving the Health Needs of the Underserved Individuals and Families of the Community

My service learning for this semester is a continuation of my service learning experience from last semester. It is also my Capstone Project; hence, it is a longitudinal service learning experience where I hope to make a lasting impact on the lives of the target population of my Capstone Project.

On my initial post, I have discussed the service learning site in detail. However, I would like to give a brief overview about the agency, this time focusing on their mission and vision, which defines who and what they are to the community and the people they serve.

Fort Bend Family Health Center, Inc. is a private, not-for-profit community health center that provides individual and family health care services to Fort Bend and Waller Counties in Texas. The services they provide include medical, laboratory, dental, nutrition, and optical services in four different locations. The target population they serve are those whose incomes are at or below 200% the federal poverty guideline. They do not deny anyone, regardless of income or ability to pay. Therefore, people from neighboring counties also come to the health center to get the health care they could not afford elsewhere. Funding is primarily through United Way Agency of the Greater Houston.

Mission Statement:
Fort Bend Family Health Center, Inc. is committed to improving the quality of life for underserved individuals and families by promoting good health through the delivery of quality integrated services.  We are dedicated to providing our services with compassion and respect.

Vision Statement:
Fort Bend Family Health Center, Inc. will be a vital part of a collaborative system that enables every man, woman, and child to achieve a personal vision of wellness. Toward that end, staff members enjoy and anticipate returning to work daily and go home every night knowing that a positive difference has been made in the lives of others.

Values: Diversity, Integrity, Respect, Excellence, Compassion, Teamwork

DNP's Role in Promoting Health and Wellness in Underserved Population

My role in this agency is to identify a feasible evidence-based preventive program for the pediatric population to improve the agency's, the dietician's, and the patients' outcomes. For this mission, I have done an extensive systematic review of evidence to identify the best approach or intervention. Implementing a program in the hopes of decreasing the prevalence of childhood overweight and obesity is not easy. I realized I need to abide by certain rigorous standards to ensure validity of my project. 

The different DNP roles I embody in this Capstone Project and Service Learning Experience are the following:

1. Essential III. Clinical Scholarship and Analytic Methods for Evidence-Based Practice-

I am a volunteer in the agency, but at the same time, I am helping the agency identify an evidence-based preventive program or protocol that will be serviced by the dietician. This required an extensive search of the evidences and identifying a study design and analytic method most suitable for the aims of the project and the resources that are available. It would be difficult for an individual to engage in evidence-based practice without the right education. So now I can appreciate more the importance of clinical scholarship in EBP. One cannot stand on its own. Although DNPs are not engaged in the development of theories like the PhD nurses are, application of research to practice still requires ample amount of knowledge and expertise in outcomes research. 

2. Essential VI. Interprofessional Collaboration for Improving Patient and Population Health Outcomes-

I have been in collaboration with the agency's registered dietician and Special Projects Officer to continually update them with the progress of the project and to get their feedback. I have also collaborated with a few people from the scientific community to obtain guidance, advice, and direction for the Capstone Project. I am also fortunate to have the support of one of the Expert Committee members Dr. Sarah Barlow, although we have not actually met yet. She is actually the lead author of The Expert Committee's Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent overweight and Obesity: Summary Report (2007). Collaboration with the appropriate people is integral for the success of this project. Since I am the team leader, so to speak, I have to make the initiative to meet and collaborate with the people who are able to provide guidance and feedback to ensure that this preventive program is based on the best available evidence out there.

3. Essential VII. Clinical Prevention and Population Health for Improving the Nation's Health

Childhood obesity is not just a national epidemic, but a global health issue that is affecting tens of millions of children. If no action is taken to prevent the rising prevalence of child and adolescent overweight in the country, these generation of children might not live long enough as their parents and grandparent will or have lived. Childhood obesity is linked with a lot of medical conditions such as type 2 diabetes, hypertension, hyperlipidemia, asthma, and sleep apnea and others. There really is no evidence as to what is the best intervention to prevent and treat obesity in the primary care setting. Therefore, the strategy to halt the rising prevalence of obesity is prevention. If effective prevention programs using the best available evidence are implemented in the communities throughout the nation, this is going to make a huge impact on population health and subsequently, the nation's health. For this reason, I feel greatly accountable for ensuring the agency that this is the best available evidence. 


To close, I would like to quote the words that the Institute of Medicine released with regards to childhood obesity:
The obesity epidemic is a serious public health problem

that calls for immediate action to reduce its prevalence as well as its health and social

consequences. Therefore, the committee felt strongly that actions should be based on the best available evidence -  as opposed to waiting for the best possible evidence.

(IOM, 2004).

This project is in line with the mission and vision of the agency. It will serve the needs of the underserved population of the community who are very much affected by childhood obesity. Therefore, I must keep focused and keep my resolve to make this through, that I too may serve the needs of the underserved.

Reference:
IOM. (2004). Preventing childhood obesity: Health in the balance. Retrieved from the Website of IOM @ http://www.iom.edu/~/media/Files/Report%20Files/2004/Preventing-Childhood-Obesity-Health-in-the-Balance/ChildhoodObesity4pagerfixforwebpdf.pdf.

Learning experience of mind, heart, and hand

The service learning experience (SLE) I am engaged in for this program is a longitudinal service experience that will span the entire DNP program. Since my Capstone Project is also my SLE, I am very grateful for the opportunity to serve the disadvantaged segment of my community that is affected by childhood overweight and obesity.

For this project, I am closely working with the registered dietician (RD) at the health center to develop an evidence-based protocol to prevent childhood obesity. I have spent some time observing some nutrition counseling sessions she had with her clients. On one session, she had a Hispanic female client who had diabetes, hypertension, high cholesterol, and obesity. To top this off, she was just laid off from her job as a care taker for an elderly woman because she needed to take care of her own mother who has been in and out of the ICU for complications of diabetes and heart disease. Obviously, she was having some financial strain having no job while she was taking care of her ill mother.

When the RD started talking to her about how her diet and exercise plans have been going, she said she had to stop for a while because of what had happened to her recently. She sad that she has been eating out with her family to McDonald or What-A-Burger because it was so much easier to buy and eat out than to go to the grocery to pick out what to cook.

After a while, she made a commitment to start eating good home-cooked food again. When the RD asked about her plans to start going back to her routine exercise, she said she'll start the week after because she still wanted to rest for a few days. She asked if it was OK to count cleaning the house as her exercise for the day and she was told no; that it had to be a real exercise that will speed up her heart rate and with her weight, she was advised to do at least 30 minutes of brisk walking every day. At that point, she was no longer working and she had all the time she needs to exercise, but she finds this very hard to do. This is the lifestyle she is used to.

Obesity is indeed a multi-faceted issue that cannot be tackled head-on without a theoretical framework that will address the cultural barriers that impede the success of any program and intervention geared towards its prevention. A big part of the issue is behavioral in nature; therefore, it needs a holistic approach that will will tap into the dynamics of family and individual behaviors.

With this SLE/Capstone Project, I hope there will be a better understanding and commitment from the staff and the providers to take this issue seriously; that they are the ones who can empower these individuals and families to change their eating and lifestyle habits not just for cosmetic purposes, but for their overall health and quality of life. This cannot be possible without a collaborative and holistic approach between and among the health care professionals and the staff.

The greatest challenge for me is the element of time. I find myself always rushing with the limited amount of time I have. Nonetheless, all of these are not in vain. As I reflect upon what I have learned in the classroom and in the field, I find myself questioning and searching for answers to understand better the complexities and dynamics of health, illness, and humanity. It makes me pause to think about what I can do to make things better and how I can do it. This is nursing praxis that leads to emancipatory knowing. My nursing paradigm continues to evolve from individual-focused care to population-focused care. I realized that I need to shift my focus on preventive care because if the rate of childhood obesity if curtailed, millions of lives and billions of dollars will be saved.

I plan to continue working on this Capstone Project as my SLE throughout the program. When time is not longer an issue (that is after this program), I will continue doing volunteer services in any capacity that I can. Through the service-oriented program of Regis University that underpins the Ignatian Pedagogical Paradigm, service has become embedded in me that what I have learned from the mind has moved to the heart, and is now made manifest in the workings of the hand.