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Advancing nursing practice

Sly is one of eight students in the DNP program鈥檚 inaugural cohort, all of them advanced practice nurses who are pursuing a rigorous degree program that aims to improve individual patient practice and advance the field of clinical nursing. The students, all of whom teach at CSON, will graduate in December 2020. At that point, they will become certified Doctors of Nursing Practice, the highest advanced practice nursing degree recognized in the U.S.

Candidates for the DNP, one of two doctoral programs Connell offers, are expected to develop both clinical expertise and a comprehensive understanding of epidemiology, organizational leadership, and health care systems.

Rather than writing a dissertation that generates new research鈥攁 Ph.D. requirement at the Connell School and in most other nursing programs鈥攕tudents in the DNP program apply existing research findings, along with their clinical and classroom experience, to an evidence-based 鈥減ractice change project鈥� dedicated to improving health care outcomes for a particular patient population.

Because Connell鈥檚 DNP program launched only in fall 2019, these are the first students who have undertaken these projects. At the turn of 2020, a small group was working with Hebrew SeniorLife (which provides care, housing, research, and teaching) on projects involving music and memory and person-centered care. But as the number of COVID-19 cases rose in Massachusetts in mid-March, the students鈥� in-person clinical visits to health facilities were suspended.

So, the DNP cohort regrouped and picked practice change topics they could study remotely.

New ways of nursing

Working from home, CSON鈥檚 first DNP candidates communicated using Zoom, email, texts, and phone calls. They learned to use statistics software programs and other tools and went through the rigorous process of obtaining approval to conduct their research from Boston College鈥檚 Institutional Review Board. While juggling the demands of work, school, and family responsibilities, the colleagues also enjoyed collaborating.

鈥淚t was a lot of work,鈥� says Allan Thomas, a certified registered nurse anesthetist on the N95 respirator project team. 鈥淏ut there was a lot of laughter and learning and feeling really good about making a difference.鈥�

The challenges of self-monitoring

Clinical placements鈥攖he hospitals, clinics, and other health care settings in which students acquire firsthand experience in their fields鈥攁re a critical part of nursing education. To safely enter these sites and avoid spreading the coronavirus, Connell students must check themselves for COVID-19 symptoms.

鈥淵ou have to be able to demonstrate that you鈥檙e monitoring for symptoms and are symptom-free before you can go in [to clinical settings],鈥� says DNP candidate Maureen Connolly, a certified adult nurse practitioner. 鈥淣ursing is unique in that we鈥檙e so physically close to our patients. We鈥檝e got to figure out a way to do this.鈥�

So, when choosing a topic for a practice improvement project to pursue for the rest of the semester, Connolly鈥檚 DNP team of four decided to explore whether a group of nursing students could regularly check themselves for COVID-19 symptoms twice a day.

With help from the University鈥檚 Research Services staff, they created a symptom self-monitoring tool and then recruited student participants from Connell鈥檚 Direct Entry Master鈥檚 program. The 16 who volunteered received an email twice a day (at 7 a.m. and 7 p.m.) with a link to an anonymous survey that asked respondents to document whether they were experiencing any COVID-19 symptoms, such as feeling feverish or experiencing a headache, shortness of breath, or new loss of smell. (The team used a secure web platform to record its responses.) Participants could fill out the assessment by smartphone or computer; it took only a few minutes. Anyone who felt unwell was advised to seek medical help.

To the surprise of the DNP candidates, only half of the 16 participant volunteers fully completed the symptom-tracking survey during the 10-day study period. The other eight missed one or more of their symptom checks.

鈥淚n this highly motivated group of students, we thought the completion rate would be higher than 50 percent,鈥� says project group member Sherri St. Pierre, a certified pediatric primary care nurse practitioner.

鈥淥ur feasibility study showed that 10.8 percent of the symptom survey was not completed, and a total of 38 instances of symptom monitoring was not documented,鈥� notes team member Catherine Conahan, a certified nurse practitioner and oncology certified nurse.

What accounted for the lapses? The team found that technology glitches and changing daily schedules kept some study participants from consistently checking for symptoms twice a day. Another factor, the DNP candidates concluded, is that students need a compelling reason to self-assess鈥攚hich some may not have felt during the study. In contrast, if they miss a day of symptom screening during the semester, 鈥渢hey may not be able to go to their clinical placements, and then they could not finish the program,鈥� notes team member Donna Cullinan, a certified family nurse practitioner. She says their project shed light on some of the challenges nurses face when encouraging behavior change among their patients: 鈥淎s nurses, we鈥檙e always telling people to change behavior.鈥�

Connell students aren鈥檛 using the monitoring instrument this fall; instead, those on campus are expected to check for COVID-19 symptoms once a day using Boston College鈥檚 official health-assessment tool for students, faculty, and staff. Some CSON students may also have to follow specific screening guidelines at the clinical sites where they do hands-on training.

Teaching safe respirator reuse

To develop their project on teaching safe N95 mask reuse, Sly and three fellow DNP candidates watched hundreds of instructional videos on mask wearing available through many health organizations. At the time, they found none that showed viewers how to redon a contaminated respirator.

With the help of Sly鈥檚 son and daughter, they produced their own three-minute video and created a simple illustrated guide on how to properly don, doff, redon, and store a respirator for extended use during shortages.

To test the materials鈥� effectiveness, the doctoral degree candidates recruited 15 graduate nursing students to participate in a mask-handling simulation, conducted virtually because of the pandemic. Using their video and guide as an intervention, the DNP group set up individual Zoom sessions and asked each participant to create a clinic-like space in their home. Team member Nanci Haze, a certified pediatric nurse practitioner, then talked each student through a scenario that involved caring for an 87-year-old COVID-positive patient with only one N95 mask to last all weekend.

鈥淭hey go in [to the virtual room] and I prompt them, 鈥楤egin the process of donning a brand new N95,鈥欌�� Haze explains. Each student donned, doffed, and redonned the respirator once, watched and read the group鈥檚 video and pamphlet, then repeated the process. Team members scored how well each step was performed, according to Beth McNutt-Clarke, a clinician who specializes in pressure injury prevention and wound management.

After the exercise, the DNP group discussed with each participant how the simulation went. They reviewed N95 tips, such as wearing a well-fitting respirator when caring for several patients with the same respiratory infection, instead of removing it between encounters, to limit the times one touches the mask.

The team found that after viewing their educational materials, all of the participants improved their mask-handling skills.

Refined over the summer, the video and guide are now being used to help Connell students prepare for PPE use in various situations, including before they begin their clinical placements. And the materials are extending the school鈥檚 reach beyond campus: in late September, an article the DNP students co-wrote with their CSON faculty mentors about proper handling of N95 respirators was published in the online journal American Nurse, and the authors were awaiting publication of another article in Nursing Management.

Hoping to reach nurses practicing in a range of settings, from home care to rural communities, the team posted their video on YouTube in late summer 鈥渟o anyone can benefit,鈥� says Sly, who adds: 鈥淚t鈥檚 a way to keep nurses safe.鈥�