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.