HEALTH LITERACY IMPROVEMENT PROJECT 1 Health Literacy Improvement Project Yvette K. Combs College of Nursing, East Carolina University Doctor of Nursing Practice Project Dr. Dianne Marshburn July 18, 2021 HEALTH LITERACY IMPROVEMENT PROJECT 2 Abstract Limited or low health literacy has been linked with negative patient outcomes, higher healthcare costs, and difficulty in healthcare decision making. The goal of the Doctor of Nursing Practice project is to improve the health literacy of pediatric caregivers by offering a reliable resource that provides information on childhood illnesses, suggestions for symptom relief for minor illnesses and injuries, and care guides to assist in decision making. Educational resources utilized were the American Academy of Pediatrics’ KidsDoc mobile app, navigational instructions for HealthyChildren.org, or a book about childhood illnesses. Participants included 75 pediatric caregivers visiting a not-for-profit rural hospital emergency department for a non-urgent illness. Telephone interviews at four and eight weeks were conducted to determine the impact of introducing the educational resources on pediatric caregivers’ health knowledge. Major findings from the project indicate an increase in mobile device utilization, a preference for mobile apps as an educational tool, and an increase in health knowledge of pediatric caregivers. Results imply that technological-based health information such as the KidsDoc app can improve patient outcomes, impact nursing practice, and reduce healthcare costs. Future studies on technology-based educational resources and its effects on health literacy are recommended. Keywords: health literacy, technology, childhood illnesses, mobile applications HEALTH LITERACY IMPROVEMENT PROJECT 3 Table of Contents Abstract ………………………………………………………………………...……………..…. 2 Section I: Introduction …..………………………………………………….….……....….…..… 6 Background ………………………………………………………….….……………..… 6 Organizational Needs Statement …………………………………….….……………….. 7 Problem Statement …………………………………………………….….…………..…. 9 Purpose Statement ……………………………………………………….…..………...… 9 Section II: Evidence ………………………………………………………………….…….…... 11 Literature Review …………………………………………………………….…….…... 11 Evidence-Based Practice Framework …………………………….…………………..... 15 Ethical Consideration and Protection of Human Subjects ……………………………... 16 Section III: Project Design …………………………………………………………………...… 19 Project Site and Population ……………………………………………………..….…... 19 Project Team …………………………………………………………………….…...… 20 Project Goals and Outcomes Measures …………………………………….….……..… 21 Implementation Plan …………………………………………………………….…...… 23 Timeline ………………………………………………………………………………... 25 Section IV: Results and Findings ………………………………………………………………. 27 Results …………………………………………………………………………..........… 27 Discussion of Major Findings ……………………………………………………......… 30 Section V: Interpretation and Implications ………………………………………………......… 33 Costs and Resource Management ……………………………………………….…...… 33 Benefits ………………………………………………………………………………… 33 HEALTH LITERACY IMPROVEMENT PROJECT 4 Implications of the Findings ……………………………………………….….…..…… 34 Sustainability ……………………………………………………………………..….… 36 Dissemination Plan ……………………………………………………………....…….. 37 Section VI: Conclusion ……………………………………………………………………....… 39 Limitations and Facilitators …………..………………………………………….......… 39 Recommendations for Others ………………………………………………………….. 40 Recommendations for Further Study ……………………………………...…….…...… 40 Final Thoughts ………………………………………………………………...……..… 41 References ………………………………………………………………………….….……..… 42 Appendices ………………….………………………………………………………...……...… 46 Appendix A: Demographics Comparison Chart …………………………….….…....… 46 Appendix B: Literature Review Matrix ……………………………………………...… 47 Appendix C: PDSA Worksheet ………………………………………………………... 53 Appendix D: SMART Objectives, Interventions, and Outcome Measures ……………. 54 Appendix E: Telephone Follow-up Survey ………………………………………….… 55 Appendix F: Code Sheet ...………………………………………………...………....… 56 Appendix G: Data Collection Tool ……………….………………………………..…... 57 Appendix H: Script for Presentation of Educational Tools ……………………….…… 58 Appendix I: Participation Form ……………………………………………………..…. 60 Appendix J: Instructions for KidsDoc Symptom Checker ……………………….……. 61 Appendix K: Script for Follow-up Telephone Interview ……………………………… 62 Appendix L: Timeline for Project Implementation …………………………….….…... 64 Appendix M: DNP Project Timeline ………………………………………………..…. 65 HEALTH LITERACY IMPROVEMENT PROJECT 5 Appendix N: Recruitment Data ………………………………………………………... 66 Appendix O: Number of Illnesses Reported in Telephone Survey …………………….. 67 Appendix P: Educational Tool Usage ……………………..………………………...…. 68 Appendix Q: Telephone Survey Results ………….……………………………………. 69 Appendix R: Comparison of SMART Objectives and Results …………………….…... 70 Appendix S: DNP Project Budget ………………………………………………...……. 71 Appendix T: Doctor of Nursing Practice Essentials …………………………………… 72 HEALTH LITERACY IMPROVEMENT PROJECT 6 Section I. Introduction Background Healthy People 2030 newly defined personal health literacy as “the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others” (Office of Disease Prevention and Health Promotion [ODPHP], 2020b, para 1). In addition to defining personal health literacy, Healthy People 2030 included a definition of organizational health literacy to acknowledge that organizations are responsible for addressing health literacy (ODPHP, 2020b). Many Americans suffer from limited literacy skills, and nine out of ten adults struggle with limited health literacy (ODPHP, 2017). Limited or low health literacy has been linked to increased mortality rates, poor general health status, difficulty in health decision making, poor medication management, more hospitalizations, higher utilization of emergency care, and higher healthcare costs (Heijmans et al., 2015). One of the foundational principles and overall goals of Healthy People 2030 is the attainment of health literacy (ODPHP, 2020b). This Doctor of Nursing Practice (DNP) project provides an opportunity to implement a health literacy improvement intervention that aligns with Healthy People 2030’s foundational principle and overall goal of attainment of health literacy. This DNP project site is a not-for-profit hospital serving a rural, underserved population with a mission to ensure exceptional healthcare for the people and a vision to be an outstanding community hospital (Lenoir UNC Health Care, 2020). To fulfill the vision of being an outstanding community hospital, the organization identifies community health needs, develops initiatives, and connects community members to resources to improve the population’s health status. According to the Office of Disease Prevention and Health Promotion, populations consisting of older adults, racial and ethnic minorities, lower-income levels, people with less HEALTH LITERACY IMPROVEMENT PROJECT 7 than a high school degree, and non-native speakers of English will most likely experience low or limited health literacy (2010). Appendix A displays a comparison chart of the project site’s community demographics versus North Carolina’s demographics. The North Carolina rural community selected for this DNP project is comprised of higher percentages of older adults, African Americans, and people living in poverty than North Carolina, as well as a lower median household income. Furthermore, this county has a lower percentage of residents with a high school diploma or college degree and higher dropout rates. The demographics of this community make its population most likely to experience limited health literacy. Partnering with the organization to implement a DNP project to improve health literacy supports the organization’s mission and vision by connecting community members to educational resources such as the American Academy of Pediatrics’ symptom checker or a book about childhood illnesses and injuries. Organizational Needs Statement During the 2017 Community Health Assessment, the organization identified responsible parenting as a priority health need and has been working to provide funding and educational resources to improve the community’s parenting skills (Lenoir County Health Department, 2018). The goal of the DNP project is to improve the health literacy of pediatric caregivers by offering a reliable resource that provides information on childhood illnesses, suggestions for symptom relief for minor illnesses and injuries, and care guides to assist in decision making. Improving the health literacy of pediatric caregivers coincides with the organization’s aim to improve parenting skills. The objective to increase the health literacy of the population (HC/HIT- R01) has been identified in Healthy People 2030 as a high priority with an emphasis in developing evidence-based interventions to address it (ODPHP, 2020b). Healthy People 2020 HEALTH LITERACY IMPROVEMENT PROJECT 8 addressed the problem and listed health communication and health information technology as a topic with objectives to increase health literacy skills (ODPHP, 2020a). There were two objectives (HC/HIT-4 and HC/HIT-5) included in the health communication and health information technology topic pertaining to this health literacy improvement project. The first objective was to increase the proportion of patients whose doctor recommends health information resources to help them manage their health. The other objective was to increase the proportion of persons who use electronic personal health management tools. These objectives are addressed by recommending a trusted, reliable resource and encouraging its use by pediatric caregivers at this site. This project has the potential to meet the three arms of the Institute of Healthcare Improvement’s Triple Aim Initiative. By improving the health of the population, improving the patient experience, and reducing the healthcare costs, the project addresses all three of the Triple Aim dimensions (Institute for Healthcare Improvement, 2020b). Empowering patients by increasing health literacy has been proven to promote health and well-being, plus it helps patients make informed healthcare decisions (Paterick et al., 2017). Through empowerment, the health of the population can be improved. Strong health literacy has been linked to more effective patient engagement (Heath, 2017). Improvement in health literacy enhances patient engagement leading to a positive patient experience. Limited health literacy is associated with increased medication administration errors, more inpatient and emergency department care, fewer preventive services, and higher health care costs (Brega et al., 2015). Improvement in health literacy can reduce healthcare costs by increasing preventive services and reducing emergency department care. In pursuit of the organization’s desire, the national goals of Healthy HEALTH LITERACY IMPROVEMENT PROJECT 9 People 2020, and the IHI Triple Aim Initiatives, a health literacy intervention will prove to be beneficial to the hospital, the community, and society. Problem Statement Health literacy has been a subject of interest for public health since Healthy People 2010 highlighted the disparities associated with limited or low health literacy. Limited or low health literacy disproportionately impacts people of lower socioeconomic and minority groups’ ability to search and use health information and adopt healthy behaviors leading to worse health outcomes and higher costs (ODHPH, 2010). Parents with limited health literacy are less likely to address their children’s preventive and health care needs, negatively impacting their health and well-being (Buhr & Tannen, 2020). Emergency departments across the United States face overcrowding, long wait times, and an overuse of emergency medical care for non-urgent illnesses. It is estimated that more than half of the 22.3 million pediatric emergency department visits are nonurgent (Lepley et al., 2019). While numerous factors influence the parent’s decision-making when seeking medical care for a child with a mild acute illness or injury, limited health literacy is an independent predictor of emergency use (Drent et al., 2018). One study by May et al. (2017) concluded that health literacy-related interventions that improve parent understanding of mild acute illnesses, the severity of illnesses, and where and when to seek care could reduce non-urgent emergency department use. Purpose Statement The purpose of the DNP project is to introduce a reliable resource with trusted health information to pediatric caregivers visiting the emergency department for a non-urgent illness. The resource will be used to improve health literacy so pediatric caregivers can make informed HEALTH LITERACY IMPROVEMENT PROJECT 10 healthcare decisions. This health literacy improvement intervention could enhance parenting skills by increasing knowledge of childhood illnesses, suggesting first aid treatments, and providing care guides to assist in healthcare decision-making. HEALTH LITERACY IMPROVEMENT PROJECT 11 Section II. Evidence Literature Review The DNP project’s search strategy included computerized focused searches in databases Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, and Google Scholar in June 2020. Selection criteria for the literature review were established in advance. Studies published within the last five years in the English language and published in scholarly (peer-reviewed) journals with full text available were included. Literature published before the last five years, in languages other than English, and not published in a scholarly journal with full text available were excluded. The search was conducted using the initial keywords “health literacy” AND “parents” AND “emergency department.” There were 1433 articles identified as relevant to the subject. After the broad search, a Boolean/phrase search using keywords “childhood illnesses” AND “child health” AND “mobile applications” OR “technology” was used to filter the results yielding 127 articles. After screening the abstracts and titles, articles pertaining to health literacy interventions for pediatric caregivers using technology and using Melnyk & Fineout-Overholt’s model, twelve studies with Levels of Evidence V or higher were retained for review. See Appendix B for the literature matrix. Current State of Knowledge The idea or concept of health literacy has spawned numerous research studies, journal articles, and discussions that examine the health literacy phenomenon and have led to quality improvement within the healthcare delivery system. Improvement in health literacy of the population was identified as an objective for Healthy People 2010 and continued to be an area of focus for Healthy People 2020 and now is a subject for Healthy People 2030 (ODPHP, 2020b). It has been established that lower education levels, older ages, lower incomes, and multiple HEALTH LITERACY IMPROVEMENT PROJECT 12 morbidities were associated with lower levels of health literacy (Heijmans et al., 2015). Evidence supports that the low health literacy of pediatric caregivers was associated with more non-urgent emergency department use (May et al., 2017). Nearly two-thirds of pediatric caregivers inaccurately assess their child’s illness as severe due to low health literacy (Lepley et al., 2019). Current Approaches to Solving Population Problem Current approaches to solving the problem of low health literacy include strategies for educational interventions in schools, communities, and healthcare offices. Educational health information has been analyzed for ease of understanding, desired medians, and distribution preferences to improve health literacy (Drent et al., 2018). As reported in the Agency for Healthcare Research and Quality’s Health Literacy Universal Precautions Toolkit, the average American adult reading level is at an 8th-9th grade reading level, and 20% of Americans read at the 5th grade level (Brega et al., 2015). Therefore, it is recommended that written materials be designed for 5th grade reading levels. Strategies to use when choosing or writing education materials include making messages clear with short, concise non-medical jargon, choosing the font and font size that is easily read, incorporating visuals, considering cultural differences, and selecting a layout that is easy to follow. Easy to understand verbal explanations involve effective communication and strategies that will help a patient understand health issues. Strategies for effective provider-patient communication include using plain, non-medical terminology, listening carefully, using the patient’s own words, making eye contact, and speaking clearly at a moderate pace. The teach-back method is an approach to confirm the patient’s understanding of the material by asking the patient to repeat health information and instructions back to the provider. The teach-back method can improve understanding and adherence, decrease canceled appointments, and improve patient satisfaction and outcomes. In addition to these strategies to HEALTH LITERACY IMPROVEMENT PROJECT 13 improve health literacy, exploring technology access and utilization has been researched in efforts to promote health literacy. Health literacy interventions such as mobile apps or web-based software have shown promise for future positive health outcomes with the potential to reduce healthcare disparities (Donovan et al., 2020). Evidence to Support the Intervention The health literacy intervention objectives are to introduce a reliable educational resource to pediatric caregivers, increase their knowledge of childhood illnesses, suggest first aid treatments for minor injuries, and provide care guides for healthcare decision making. At-risk populations for low health literacy include older adults, minorities, low income, less than high school graduate education, and non-native speakers of English (ODPHP, 2010). When comparing the project’s site’s county to state averages, the county has a 19.2% higher ratio of African Americans, an 8.5% higher proportion of poverty level adults, and a 7% lower rate of individuals who are high school graduates (United States Census Bureau, 2019). In addition, the Hispanic population in the county is the fastest-growing segment of the population (Lenoir County Health Department, 2018). These figures alone place the county as a high-risk area for healthcare consumers with low health literacy. The project site provides care to residents in the county and other surrounding rural counties, so health literacy interventions are needed to improve the population’s health outcomes. According to the Healthy People 2020 Mid-Course Review, between 2007 and 2014, the number of people aged 18 and over who used their mobile devices to access the internet increased from 6.7% to 56.8% (National Center for Health Statistics, 2016). These staggering statistics give rise to the idea of improving health literacy by providing information via the handheld mobile device. According to one study, cell phones have the potential to deliver HEALTH LITERACY IMPROVEMENT PROJECT 14 electronic health information to a vast number of patients at relatively low costs (Ladley et al., 2018). The use of technology, specifically mobile cellphones with internet access, could be a valuable tool to improve health literacy. The American Academy of Pediatrics designed a mobile app and an interactive tool located on the website HealthyChildren.org called the KidsDoc symptom checker. This internet software can be used as an educational tool to promote health literacy for childhood illnesses and injuries. The KidsDoc app was identified as the preferred method of education in one focus group study that explored the preferences of educational material for common childhood illnesses (Ohns, 2019). This study’s participants consisted of 30 low-income individuals with borderline limited literacy skills and at least one child or expecting a child. Due to the immediate access and wealth of information provided, the KidsDoc app was chosen over a written brochure, a book, and a 24-hour nurse call line. The app and interactive tool include symptoms for childhood illnesses and injuries, medication dosages for common medications such as acetaminophen and ibuprofen, first aid instructions, and parent advice with details when and where to seek medical assistance. A health literacy intervention, such as the utilization of the KidsDoc app or interactive tool, could provide a large number of parents with professionally validated healthcare information that could very well impact their caregiving and decision- making. There is limited evidence about the effectiveness of mobile apps and the use of websites in increasing parents’ knowledge of childhood illnesses and assisting them with their healthcare decision-making. The purpose of this project aims to explore this type of health literacy intervention and make suggestions for further projects on internet-based medical information technology. Projects such as this, if successful, may help to increase pediatric caregivers’ health literacy as well as assist them with healthcare decision-making. HEALTH LITERACY IMPROVEMENT PROJECT 15 Evidence-Based Practice Framework The Institute for Healthcare Improvement uses the Model for Improvement framework to guide quality improvement (Institute for Healthcare Improvement, 2020a). The Plan-Do-Study- Act (PDSA) cycle and the Rapid Cycle Improvement approach allow quality improvement team members to test interventions in a small setting, apply the PDSA cycle, and adjust the interventions as determined by the PDSA cycle review (Institute for Healthcare Improvement, 2020a). The SMART objectives used to track the intervention’s success consisted of a survey for pediatric caregivers to report their utilization of the American Academy of Pediatrics’ KidsDoc symptom checker. The survey assessed whether the utilization of the KidsDoc symptom checker increased their knowledge of childhood illnesses, provided necessary first aid techniques, and offered care guides that assisted in healthcare decision-making. The planning stage of the PDSA cycle included an analysis of inputs, activities, and output components needed to implement the program and identification of preferred outcomes. The doing stage of the PDSA cycle of quality improvement was executing the interventions at a rural hospital emergency department. Studying the outcomes to identify problems during the implementation of interventions was the next phase of the PDSA cycle. Lastly, the acting stage was the time to modify and repeat the process or, if completely successful, spread the quality improvement to other practices. The Plan-Do-Study-Act Worksheet provided by the Agency of Healthcare Research and Quality was utilized at least twice during the implementation phase of this quality improvement at the project site (See Appendix C). Through patient-centered quality improvement efforts, pediatric caregivers in the county can be empowered to manage their child’s health, gain the ability to make informed decisions regarding their healthcare, and possibly reduce the overuse of emergency departments for non-urgent childhood illnesses. HEALTH LITERACY IMPROVEMENT PROJECT 16 As noted earlier, the DNP project’s objectives were to increase caregivers’ knowledge of childhood illnesses and injuries by utilizing the educational tools to assist caregivers in their decision-making. At the time of participation enrollment, each participant provided a phone number and consent to be contacted via a phone call to complete the project’s evaluation process. The participants reported how often they used either the KidsDoc app, the web-based interactive tool, or the educational book to seek information about their child’s non-urgent illness or injury. Participants conveyed if they learned at least two facts concerning their child’s illness or injury. Lastly, participants indicated whether the mobile app or website assisted them to administer a first-aid technique. Appendix D provides details of the SMART objectives for the DNP project. The short telephone follow-up survey provided data to evaluate the project (See Appendix E). Data received from the follow-up survey was used to evaluate the project’s success plus make recommendations for future projects of this nature. The project’s findings could open the door to future health literacy technological interventions that could be applied to primary providers’ offices, health clinics, schools, and community centers. Ethical Consideration & Protection of Human Subjects When considering the health literacy improvement project’s ethical dilemmas, the target population was examined for any possible inequalities that may exist. Caregivers with low economic status and Spanish-speaking caregivers pose a threat for unequal participation and injustice. Assuring that every individual has the same access to health opportunities and equal treatment implies justice (Hennekens & Drowos, 2017). The DNP project introduced a mobile app or a website interactive tool as a reliable resource for healthcare information for pediatric patients. If a pediatric caregiver did not have a smartphone or internet access with a computer or tablet, the intervention would not be readily available for these participants. Excluding this HEALTH LITERACY IMPROVEMENT PROJECT 17 portion of the population would be unethical and would simply add to the social inequalities and injustices. To address this ethical consideration, a book by Dr. Barton Schmitt titled My Child is Sick, 2nd edition was provided for the caregivers with no internet access or devices. This book is written at a 6th grade reading level with visuals, dosing charts, and decision trees. The author of this book was the primary designer of the KidsDoc mobile application and the interactive website tool (Carey, 2016). The Spanish-speaking population in the project site community is 7.9% of the population and increasing rapidly (Lenoir County Health Department, 2018). The KidsDoc mobile app and website interactive tool can be downloaded in Spanish for this population. The book Que Hacer Cuando Su Nino Se Enferme (What to do for Health) by Gloria Mayer and Ann Kuklierus was provided for Spanish-speaking pediatric caregivers with no internet access or devices. This book contains information for more than 50 common childhood illnesses. The project aimed to increase health literacy by providing a reliable resource for all participants in an equitable, non-discriminatory manner. Also, this DNP project should not pose potential harm to this population, nor is there potential for anyone to be taken advantage of during the project implementation. The only personal data obtained was the participant’s first names and their phone numbers for follow-up calls. To protect the volunteer participants’ privacy and maintain their confidentiality, each participant was assigned a unique numerical identifier listed on a code sheet with their first name and phone number (See Appendix F). The code sheet was stored separately in a password protected nickel drive on the project site’s server under the title Nursing Research. The password protected laptop used for inputting the data was stored in a locked office at the project site. The project lead reviewed the Collaborative Institutional Training Initiatives (CITI) modules and received a certificate of completion to prepare for the formal approval process. The HEALTH LITERACY IMPROVEMENT PROJECT 18 Social and Behavioral Research Investigators and Key Personnel completed modules examined the sociological, psychological, and educational phenomena that may exist when involving participants in the project. The Essentials of Public Health Research examined justice, non- maleficence, beneficence, and respect for persons as well as informed consent and confidentiality topics. The CITI modules discussed possible ethical principles that may arise during the project. The Chief Nursing Officer approved the project after a discussion with the project lead, the project champion, the Emergency Department Medical Director, a local Pediatric Physician, and Senior Management. Furthermore, the facility’s Institutional Review Board (IRB) concluded the project did not warrant formal approval and were in agreement to support the project moving forward. Prior to the project approval, the Project Assessment Tool and the Implementation Tools Worksheet were submitted to the faculty mentor for approval. The project lead completed the Quality/IRB self-certification tool, and the faculty mentor reviewed and approved the materials. Once approved by the faculty mentor, the self-certification tool was submitted via Qualtrics to the University IRB where it was deemed as quality improvement and no further IRB review was required. After careful examination of all project materials by the DNP faculty, the proposed DNP project was approved. HEALTH LITERACY IMPROVEMENT PROJECT 19 Section III. Project Design Project Site and Population The DNP health literacy improvement project was designed to address limited health literacy in a vulnerable population for adverse health outcomes. The population at the project site was comprised of individuals from a community at-risk for limited or low health literacy, and several of these individuals are pediatric caregivers. With the assistance of the project site and site champion, the American Academy of Pediatrics, the faculty mentor, and the project team, the DNP project aimed to positively impact the health literacy of pediatric caregivers. Increasing the health literacy of pediatric caregivers will indirectly improve the health and well-being of their children (Buhr & Tannen, 2020). Description of the Setting The setting for this DNP project was an emergency department in rural eastern North Carolina serving the pediatric and adult populations. The emergency department has 29 individual rooms with six rooms designated as the Green Zone for patients with minor illnesses or injuries. The patients that visit the Green Zone are categorized with acuity levels 4 or 5 which constitutes as needing no more than one resource for their illness or injury. These patients most often present with minor issues such as extremity injuries, common cold symptoms, or skin irritations. Most of these patients could be seen by their primary doctors due to their illness’s non-urgent status. The Green Zone provided an opportunity to implement a health literacy improvement project for pediatric caregivers, because the clients were not facing a life or death situation, were not in a high stressed environment, and were separated from the chaos of the main emergency department. HEALTH LITERACY IMPROVEMENT PROJECT 20 Description of the Population This not-for-profit hospital serves a county with a total population of 55,949 (United States Census Bureau, 2019). The health literacy improvement project’s target population was pediatric caregivers responsible for the health and well-being of children under the age of 17. The segment of the county’s population under the age of 18 is 22.4% which is the population that would be most impacted with better health outcomes due to the health literacy improvement project (United States Census Bureau, 2019). According to the administration of the emergency department at the project site, during the month of November 2018, 448 patients under the age of 17 with acuity levels 4 & 5 were seen in the emergency department and discharged (K. Eubanks, personal communication, March 11th, 2019). During the first phase of the project, 76 pediatric caregivers were invited to volunteer to participate. Inclusion criteria for volunteer participation were English or Spanish-speaking caregivers of children under the age of 17 that visited the emergency department with an acuity level of 4 or 5. Project Team The project team consisted of the site champion, the Spanish interpreter, the faculty mentor, and the DNP student who served as project lead. The project lead planned, developed, and implemented the project, as well as, analyzed the data, and disseminated the project findings. The site champion, the Director of Emergency and Ambulatory Care Services, advised the project lead and monitored the project with the organization’s interest in mind. The site champion has 35 years of experience in nursing and extensive knowledge of administrative and clinical operations. The Spanish interpreter was available when interacting with the Hispanic participants to translate conversations and assisted with inquiries about the project. The Spanish interpreter is a nationally certified medical interpreter that has been a translator for the hospital HEALTH LITERACY IMPROVEMENT PROJECT 21 for over ten years. The faculty mentor advised the student in all aspects of the DNP project. With 43 years of nursing experience and five years of experience working with DNP students and projects, the faculty mentor has vast knowledge to share with the student. Project Goals and Outcome Measures The goal of the DNP project was to improve the health literacy of pediatric caregivers to impact the health outcomes of their children. The strategy for accomplishing the goal was to introduce a reliable, trusted educational tool to the target population during a healthcare visit to the emergency department. Data collection included tracking the number of patients that entered the Green Zone during the recruitment phase and how many patients met the criteria for participation, the number of pediatric caregivers presented with the opportunity to participate and how many accepted, the number of English and Spanish-speaking participants, and the number of participants that received the mobile app, the website information, or the book. The project’s outcome measures included tracking the utilization of the educational tool, the knowledge obtained about childhood illnesses or injuries, and first aid techniques learned using the resource. Description of the Methods and Measurement The DNP quality improvement project provided participating pediatric caregivers with a reliable resource to be used as an educational tool to improve health literacy. The American Academy of Pediatrics’ mobile app, KidsDoc, and the KidsDoc symptom checker interactive tool on the HealthyChildren.org website was used as educational tools to promote health literacy for childhood illnesses and injuries. Dr. Barton Schmitt, a Professor of Pediatrics at the University of Colorado School of Medicine and Medical Director of the Pediatric After-Hours Call Center at the Children’s Hospital Colorado, designed the mobile app and web-based software. The information provided in the KidsDoc app and the KidsDoc symptom checker HEALTH LITERACY IMPROVEMENT PROJECT 22 interactive tool, available in English and Spanish, is based on triage protocols of 10,000 practices and 400 nurse advice call centers and reviewed by respected professionals listed within the app (Carey, 2016). The American Academy of Pediatrics and their licensing company, Self-Care Decisions, supplied 100 coupons for either iPhones and Androids in English and Spanish to incentivize participation. An English book written by Dr. Barton Schmitt or a Spanish book written by Gloria Mayer and Ann Kuklierus was provided as the educational resource for the participants without mobile devices or internet access. The intervention consisted of introducing the mobile or web-based app on a newly, purchased iPad dedicated solely for the project during a healthcare visit. The project lead made available an educational resource (KidsDoc app, website, or book) to participating pediatric caregivers and educated the participants on how to use the resource. Lastly, the project lead evaluated the participants’ utilization of the educational resource and the knowledge gained using the resource. A follow-up survey tool was used to evaluate the pediatric caregivers’ perception of the utilization of the educational resource (KidsDoc app, website, or book) and if utilization of the resource led to increased knowledge of childhood illnesses and first aid techniques (See Appendix E). Participants responded to a telephone survey that consisted of five questions using a four-point Likert scale and one open-ended question. Discussion of the Data Collection Process Pediatric caregivers were informed of the health literacy project and invited to participate. Participants volunteering to participate were asked to provide a phone number. The project lead contacted the participants four weeks and eight weeks after the review of educational resource materials. During the telephone follow-up, the project lead asked each participant questions on the follow-up survey. The Spanish interpreter agreed to be available to assist with HEALTH LITERACY IMPROVEMENT PROJECT 23 the Spanish-speaking participants. The project lead recorded the responses on an Excel survey worksheet with no identifying data (See Appendix G). The survey results were uploaded to a secure password-protected computer only accessible by the project lead in a locked office. IBM SPSS Statistics software was used to analyze the collected data and results were displayed using tables and bar charts for presentation. At the conclusion of the project, the data stored on the computer was deleted according to the project site policy, and the participation forms were shredded. Implementation Plan Education The first step in the implementation plan was to educate the staff about the health literacy improvement project. The project lead sent an email containing a project PowerPoint presentation to all registered nurses and certified nurse assistants working in the Green Zone prior to the January staff meeting. The project lead attended the January staff meeting to answer questions and clarify any concerns. Recruitment Phase The second step of the implementation plan was the recruitment phase. Supplies needed for the recruitment phase were participation forms, a script for presentation, an iPad, mobile app coupon redemption codes, instructions for accessing the website, and educational books. The project lead implemented the recruitment phase on Tuesdays and Wednesdays in the Green Zone during the months of January and February. As patients with acuity levels 4 or 5 entered the emergency department’s Green Zone, they were guided to their assigned room. The nurse on duty assessed the patient and prepared them for the provider. If the patient was a pediatric caregiver, the nurse invited them to participate in a pediatric caregiver health literacy project. HEALTH LITERACY IMPROVEMENT PROJECT 24 After the nurse exited the room and identified a potential participant, the project lead entered the room, identified herself as the project lead. The project lead explained the health literacy improvement project and demonstrated the KidsDoc symptom checker on the iPad. After the demonstration, the project lead asked the pediatric caregiver if they were interested in participating. See Appendix H for the script for presentation of educational resources. If there was interest in the project, the project lead reviewed the participation form and obtained consent for participation (See Appendix I). After the participation form was completed, inquiries were made concerning their cell phone model and access to the internet. If the participant had an iPhone or Android, a coupon was presented with a redemption code to download the mobile app. Once the mobile app’s download was completed, the project lead helped the participant set up the app on their phone. If the participant did not have a compatible cell phone but had a device with reliable internet access, the project lead demonstrated the process of accessing the KidsDoc symptom checker on the HealthyChildren.org website and provided navigational instructions for the software. See Appendix J for navigational instructions. If the participant did not have a compatible mobile device or reliable internet access, the participant was presented with an educational book. With the Spanish interpreter’s assistance, the Spanish-speaking population downloaded a Spanish version of the educational tools or received a book written in Spanish. If the nurse, provider, or other medical personnel entered the room at any time, all presentations ceased, so there was no disruption in the provision of care. The presentation did not last longer than 15 minutes and did not lengthen the time of the visit. The recruitment presentations were repeated with eligible pediatric caregivers on Tuesdays and Wednesdays from January 19th to February 17th, 2021, with 75 participants volunteering. The project lead tracked the data during the recruitment phase in an HEALTH LITERACY IMPROVEMENT PROJECT 25 Excel worksheet. The review of the recruitment phase using the PDSA rapid cycle model was completed after the first week of participant recruitment to evaluate and improve the process. Follow-up Phase At week four and week eight, the project lead contacted each participant by telephone for the follow-up survey (See Appendix K for Telephone Interview Script). The Spanish interpreter assisted with interviewing the Spanish speaking participants. A second PDSA cycle was completed after one week of telephone interviews to evaluate the telephone interview process. The participants received a second telephone interview at eight weeks after volunteering for the project in which the same follow-up survey questions were asked and answers recorded. Implementing two follow-up telephone interviews allowed the project lead to address any issues the participant may have experienced with the resource and re-evaluate the participant’s responses. A third PDSA cycle was completed after one week of the second telephone interviews to evaluate the interview process. Timeline The DNP project timeline began May of 2020 with identifying and researching the problem, and developing a plan considering the Healthy People 2020 goals and objectives. August of 2020 marked the second phase of the project which included project design, identification of the process and outcomes, collaboration with faculty and stakeholders, and the approval process. In January of 2021, the third phase started with the organization’s letter of support, implementation, revisions, and was completed with data analysis in April of 2021 (See Appendix L for the project implementation timeline). Results and findings, interpretations and implications, and conclusions began May of 2021 with the fourth phase of the project. Lastly, the fifth phase of the project consisted of project completion, final approval, dissemination of the HEALTH LITERACY IMPROVEMENT PROJECT 26 findings, and the podium presentation that took place in June and July of 2021 (See Appendix M). HEALTH LITERACY IMPROVEMENT PROJECT 27 Section IV. Results and Findings The purpose of the project was to introduce a reliable resource with trusted health information to pediatric caregivers to improve health literacy. Data collected during the Doctor of Nursing Practice (DNP) project consisted of both quantitative and qualitative results used to measure the outcomes and impact on pediatric caregiver’s health literacy. Quantitative data included data collected during the recruitment phase as well as during the telephone surveys. Qualitative data was collected during the telephone surveys with specific themes emerging from the participant’s comments. Findings, analyzed by SPSS statistical software, will be discussed and compared to the evidence found in the literature. Results During the recruitment phase, the green zone saw 229 patients of which 80 (35%) patients met the criteria for project presentation. The criteria for participation were pediatric caregivers above the age of 18 who care for children less than the age of 17, who speak either English or Spanish. There were 76 out of 80 (95%) potential participants who agreed to the project presentation, and 75 out of 76 (98.7%) volunteered to participate of which 73 (97.3%) spoke English and 2 (2.7%) spoke Spanish. Educational resources distributed to participants included 72 mobile app download codes, two website navigational instructions, and six books. Some participants did not know their password to download the mobile app during recruitment, so the download code was provided for home download as well as either a book or website navigational instructions (See Appendix N for Recruitment Data). During the follow-up phase, telephone interviews were conducted at four and eight weeks of educational resource utilization. At four weeks, 53 out of the 75 participants responded to the telephone interviews yielding a response rate of 70.7%. At the eight week telephone interviews, HEALTH LITERACY IMPROVEMENT PROJECT 28 36 out of 53 participants responded to the telephone interviews yielding a response rate of 67.9%. The project lead did not attempt to contact the participants that did not respond to the first telephone interview. Data collected from the survey questions included the occurrence of childhood illnesses or injuries, the amount of educational tool utilization, and if they obtained knowledge from the educational resource as well as any additional comments participants wanted to add. Eighteen participants out of 53 (34%) stated their child or children experienced childhood illnesses or injuries during the first four weeks of participation with a range of zero to four illnesses or injuries. Of the 53 participants, 35 (66%) participants indicated their children did not experience any illnesses or injuries. The second follow-up interview at eight weeks yielded a decrease in childhood illnesses or injuries. Of the 36 participants, 29 (80.6%) participants indicated their children did not experience any illnesses or injuries (See Appendix O for the Number of Illness Reported in the Telephone Survey). The four weeks follow up telephone interview surveyed the amount of resource utilization to seek health information. The data varied among participants with two (3.8%) participants indicating they always used the resource, 26 (49.1%) participants stated they often used the resource, 14 (26.4%) participants rarely used the resource, and 11 (20.8%) participants never used the resource. The eight week follow-up telephone survey yielded a reduction in utilization with only one (2.8%) stating they always use the educational resource to find health information for their child, 13 (36.1%) participants often used the resource, 14 (38.9%) participants rarely used the resource, and eight (22.2%) never used the resource (See Appendix P for Educational Tool Usage). During the four weeks telephone interview, participants were asked the four-point Likert scale with statements relating to learning at least two facts about childhood illnesses, 20 (37.7%) HEALTH LITERACY IMPROVEMENT PROJECT 29 strongly agreed, 22 (41.5%) agreed, 11 (20.8%) disagreed, and no one strongly disagreed. In response to the survey statement regarding the obtainment of at least one first aid technique, 17 (32.1%) strongly agreed, 23 (43.4%) agreed, 13 (24.5%) disagreed, and no one strongly disagreed. Lastly, in response to the statement that the educational resource assisted them in deciding what level of care to seek, 22 (41.5%) strongly agreed, 21 (39.6%) agreed, ten (18.9%) disagreed, and no one strongly disagreed (See Appendix Q). The eight weeks telephone interview revealed similar findings in regard to learning at least two facts about childhood illnesses or injuries from using the educational resource, eight (22.2%) participants strongly agreed, 19 (52.8%) agreed, nine (25.0%) disagreed and no one strongly disagreed. Eight (22.2%) participants strongly agreed they had learned at least one first aid technique, whereas 18 (50.0%) agreed, 10 (27.8%) disagreed, and no one strongly disagreed. In answer to the last survey question of whether the educational resource helped them decide where to seek care, seven (19.4%) strongly agreed, 20 (55.6%) agreed, nine (25.0%) disagreed, and no one strongly disagreed (See Appendix Q). The two follow-up telephone surveys at four and eight weeks of utilization asked the participants for any additional comments. During the first telephone survey, three themes identified through thematic analysis included 1) the mobile app was useful, helpful, and easy to use 2) participants enjoyed the app and were glad to have the mobile app on their cellphone, and 3) the educational resource was not used because there was not a childhood illness or injury. The thematic analysis of the comments during the second telephone interview yielded an additional theme of the desire to keep the mobile application in case of a childhood illness or injury. HEALTH LITERACY IMPROVEMENT PROJECT 30 Discussion of Major Findings The major findings in this DNP project indicate an increase in mobile device utilization, suggest mobile apps are the preferred educational tool, and demonstrates an increase in health knowledge of pediatric caregivers by introducing the KidsDoc mobile app. Furthermore, this health literacy-related intervention could lead to a possible reduction in non-urgent emergency department use due to the increase in health knowledge and the advice of when and where to seek care. The evidence presented in the Healthy People 2020 Mid-Course Review earlier in the paper stated that between 2007 and 2014, the number of people aged 18 and over who used their mobile devices to access the internet increased from 6.7% to 56.8% (National Center for Health Statistics, 2016). When comparing these figures with the results of this project, of the 75 participants, 72 patients had mobile devices with internet access yielding a percentage of 96% mobile device users. Although this project has a small sample size and the population was pediatric caregivers (younger generation), the difference in statistics was 39.2% which implied a vast increase in mobile device utilization with internet access. Furthermore, most participants chose the KidsDoc mobile app over a book or navigational instructions which aligns with Ohns’ (2019) focus group study results identifying the KidsDoc app as a preferred method of education. The SMART objectives outlined at the beginning of the project provide specific, measurable outcomes that contribute to achieving the project goals (See Appendix R for a Comparison of SMART Objectives and Results). The first goal of the SMART objectives was by the end of the 2-month period, the proportion of participants that report they used the app or website often or always to seek childhood illness information during their child’s illness or injury will be 50%. During the first four weeks, 52.9% of the participants often or always used the HEALTH LITERACY IMPROVEMENT PROJECT 31 mobile app to seek childhood illness information, but during the second telephone survey at eight weeks, only 38.9% reported they often or always use the app to seek childhood information. When comparing these figures with the number of childhood illnesses during the first four weeks, 66% of the participants encountered no childhood illnesses or injuries whereas during the second four weeks, 80.6% of the participants had no childhood illnesses or injuries. Additional comments made by 13 (36%) of the 36 participants during the second survey indicated that their child had not been sick, so they did not need to use the app. The second SMART objective was by end of the 2-month period, the proportion of participants that report they strongly agree or agree they learned at least two facts about childhood illnesses from the app or website will be 25%. During the first telephone interview, 79.2% participants reported they strongly agree or agree they learned at least two facts about childhood illnesses and during the second survey, 75% of participants reported they learned at least two facts about childhood illnesses. These findings exceeded the goal indicating an improvement in health knowledge in 75% of the participants. The third SMART objective was by the end of the 2-month period, the proportion of participants that report they strongly agree or agree they learned at least one first aid technique during their child’s illness or injury from the app or website will be 25%. Responses from the first survey indicated that 75.5% of the participants reported they strongly agree or agree they learned at least one first aid technique compared to 72.2% of the participants at week eight. Again, these findings exceeded the goal indicating an improvement in health knowledge in at least 70% of the participants. Although not a SMART objective, a survey question was posed to the participants about whether they felt the educational resource assisted them in deciding what level of care to seek HEALTH LITERACY IMPROVEMENT PROJECT 32 during a childhood illness or injury. During the first interview, 81% of the participants reported the resource assisted them to decide when and where to seek care compared to 77% in the second interview. These findings correlate with May et al.’s 2017 study conclusion suggesting a possible reduction in non-urgent emergency department use due to the mobile app improving parents’ understanding of mild acute illnesses, the severity of illnesses and where and when to seek care. A reduction in educational tool utilization was noted from week 4 to week 8, and an explanation for the reduction can be considered from the thematic analysis. The number of childhood illnesses or injuries decreased from 34% of participants reporting illnesses or injuries in the first 4 weeks to only 19.4% participants reporting childhood illnesses or injuries at 8 weeks. Participants expressed the lack of necessity of the mobile app due to their child’s wellness which affected their utilization. HEALTH LITERACY IMPROVEMENT PROJECT 33 Section V. Interpretation and Implications Costs and Resource Management In order to fully assess the feasibility and sustainability of this DNP project, the costs and resource management must be evaluated and weighed against the benefits. The total monetary costs associated with this DNP project was $893.13 (See Appendix S). The iPad and accessories were purchased for $488.40. The majority of the remaining costs were associated with the book purchases ($386.73). Lastly, the paper supplies ($18) were used for the participation forms and navigational instructions. For the purpose of the project, download codes were donated by the American Academy of Pediatrics and their licensing company, Self-Care Decisions with an expiration date of 30 days from the date of issue. Normally, the cost to download the KidsDoc mobile app is $1.99 per download. The labor resource for this project includes the labor of the project lead and the Spanish interpreter. The project lead spent 108 hours at the facility during the recruitment phase (nine days for 12 hours) as well as 14 hours interviewing participants. Given the labor cost for a registered nurse, this figure could be over $3000. The Spanish interpreter was present with the patient during the recruitment, so no extra cost was accumulated for her assistance with the project, and the interview time with the Spanish participants was under ten minutes, so no labor cost was attributed for her participation. Benefits When it comes to healthcare, estimating the monetary benefits of a project can be challenging. Data used for this analysis were provided by the administration of the emergency department in order to evaluate the benefits of the project. As noted earlier, during a one-month period (November 2018), 448 patients under 17 years old with acuity levels 4 & 5 were seen in the emergency department and discharged. The aggregate dollar amount billed for services HEALTH LITERACY IMPROVEMENT PROJECT 34 minus physician compensation equaled $402,743. Out of the 448 patients, 354 were Medicaid patients with a total of $317,056 in charges. According to a statistical brief #504 from the Agency Healthcare Research and Quality, in 2015 Medicaid was paying primary physicians a mean total payment of $126 per office-based visit for common illnesses such as ear infections and sore throats (Muhuri & Machlin, 2017). If 25% of the 354 Medicaid caregivers seen in the emergency department in November had sought advice using the KidsDoc app and decided to go to their primary physician’s office instead of the emergency department, then 88 caregivers would have gone to the primary office totaling $11,088 (88 x $126) in Medicaid payments to primary physicians’ offices reducing the Medicaid payments to the hospital by an astounding $78,848 in just one month. This calculation is centered around the assumption that the average charge for emergency department visits in November for this particular facility was $896 based on total Medicaid charges divided by total pediatric Medicaid patients ($317,056/354=$896 x 88). As seen with this one example, the minimal cost for this DNP project could have vast possibilities for increases in the rate of return for this small investment in the long run. Implications of the Findings Implications for Patients Empowering patients by improving health literacy has been proven to promote health and well-being, plus it helps patients make informed healthcare decisions (Paterick et al., 2017). Pediatric caregivers who download and use the KidsDoc symptom checker will have a reliable resource at their fingertips that will enhance parenting skills by increasing knowledge of childhood illnesses, suggesting first aid treatments, and providing care guides to assist in healthcare decision-making. The true beneficiary of the health literacy-related intervention will be the children of the pediatric caregiver. The Buhr and Tannen’s study concluded that HEALTH LITERACY IMPROVEMENT PROJECT 35 strengthening the health literacy of pediatric caregivers contributes to improved health outcomes of their children (2020). Visiting the primary physician in lieu of a non-urgent visit to the emergency department aids with continuity of care, delivery of preventive care, and improved patient outcomes (Pourat et al., 2015). Additionally, Healthy People 2030 HC/HIT-R01 objective is to increase the health literacy of the population with an emphasis in developing evidence-based interventions. This DNP project health literacy intervention can serve to address this objective by using the findings as evidence of improving the health literacy of the pediatric caregivers. Implications for Nursing Practice Knowledge gleaned from the DNP project could influence nursing practice by heightening awareness of technology based education. Findings from this DNP project implies the use of technology based education can not only improve health literacy but is the preferred method to seek healthcare information. Moreover, results and findings may encourage nurses to offer reliable web-based resources in addition to written instructions at discharge. Nurse Practitioners, especially in primary pediatric care settings, could promote using reliable healthcare information for their patients. The findings imply improvement in health literacy attributed to the use of the KidsDoc symptom checker and thus, they could promote its use at well-child visits. In fact, the American Academy of Pediatrics offers the web tool KidsDoc symptom checker to be installed on pediatric office’s webpage making the resource even more available. Nurse practitioners could advocate for the installation at their place of work. With interprofessional collaboration, providers, interpreters, and information technologists could forward this initiative to improve health literacy by advocating for technology based educational resources. HEALTH LITERACY IMPROVEMENT PROJECT 36 Impact for Healthcare Systems In addition to addressing the objective in Healthy People 2030, this DNP project addressed the three arms of the Institute of Healthcare Improvement’s Triple Aim Initiative by improving the health of the population, improving the patient experience, and reducing the healthcare costs. Partnering with the interprofessional team to suggest reliable technological based health information could positively impact the healthcare system. Investment in educational technology such as mobile applications could supply a vast number of people with reliable information to assist them with managing their healthcare thereby improving population health and the patient experience. An improvement in health literacy could reduce healthcare cost as shown in the cost-benefit analysis. Reductions in non-urgent emergency department visits could be seen by empowering pediatric caregivers with knowledge that affects their care-seeking behavior. The potential benefits from a reduction in non-urgent emergency department visits translates into reduced wait times and reduced stress related to overcrowding emergency departments. Sustainability Given the positive feedback from participants concerning the mobile app KidsDoc symptom checker, continuing to inform pediatric caregivers of the availability and usefulness of the app would be beneficial to the pediatric caregivers in the community. Posters advertising the HealthyChildren.org website and the mobile app purchased from the American Academy of Pediatrics at $.20 each can be displayed in the Green Zone patient rooms and the Family Birthing Center. Nurses could encourage pediatric caregivers to download the KidsDoc mobile app during discharge instructions by presenting a flyer ($.02 each) included in the discharge paperwork. Flyers and posters have been purchased by the project lead and presented to the Project HEALTH LITERACY IMPROVEMENT PROJECT 37 Champion. Approval for their use is pending finalization of project data and presentation to the Chief Nursing Officer. Although the download codes for the mobile app have expired, there are 21 English books and eight Spanish books available that could be dispersed to pediatric caregivers. The findings of this DNP project indicate that providing the mobile app KidsDoc symptom checker can improve the health literacy of pediatric caregivers and possibly reduces non-urgent emergency department use, therefore, every effort should be made to continue this health literacy-related intervention. Dissemination Plan The project site presentation will be presented in July of 2021 at a meeting with the chief nursing officer and the project champion. The organization supported this project and deserves a full presentation of findings and outcomes as well as recommendations for sustainability. Further presentations may be available as the organization explores opportunities for implementation in the family birthing center or the emergency department. Presentations at the local level include the pediatrician offices and the community health center with plans underway in establishing dates for presentations. This project was designed with the long term goal to improve the health literacy of the community. Reaching out to the community in efforts to promote a health literacy would not only heighten awareness but offer an intervention to improve health literacy. A poster presentation of the project will be presented at the University College of Nursing on July 13th, 2021. This DNP project will also be submitted to The Scholarship, the University’s institutional repository. Furthermore, publication in Pediatrics, the official journal of the American Academy of Pediatrics may be pursued pending advice from the faculty mentor as well as publications in the ANA’s American Nurse or the NC Board of Nursing’s Nursing HEALTH LITERACY IMPROVEMENT PROJECT 38 Bulletin. The NC Pediatric Society virtual annual meeting on August 28, 2021 is a possible forum for a presentation as well. HEALTH LITERACY IMPROVEMENT PROJECT 39 Section VI. Conclusion Limitations and Facilitators Limitations The DNP project had several limitations. Recruitment for participation was conducted on specific days and was implemented during the COVID pandemic when the census at the hospital was lower than normal contributing to the small number of participants. The response rate to the surveys was 70% (53 out of 75 participants) for the first survey at four weeks and 68.6% (36 out of 53 participants) for the second survey at eight weeks. The participants that did not respond to the first survey were not surveyed during week eight. The results could have been impacted if all participants had responded or were surveyed at week eight. Lastly, the time frame in which the DNP was completed was a limitation. Continued utilization of the mobile app could not be assessed past two months due the time constraint. The utilization of the educational tool decreased from four weeks to eight weeks partly due to the decrease in childhood illnesses or injuries but could also be attributed to the decreases in the number of participants surveyed. Facilitators The facilitators for the project came in the form of people and resources. The organization and the project team supported the project making it possible to conduct the project in the Green Zone of the emergency department. Staff within the Green Zone encouraged the project lead and helped identify possible participants by asking permission for the project lead to present the project. The project team not only supported the project but advised throughout the entire process. The administrators made available a password protected laptop with a secured nickel drive to store the participants information, as well as an office to secure the laptop. The American Academy of Pediatrics and their licensing company, Self-Care Decisions, supported HEALTH LITERACY IMPROVEMENT PROJECT 40 the project and donated download codes for the mobile app. The Emergency Medical Director, the Chief Nursing Officer, and the local pediatrician supported and approved the DNP project. Without these facilitators, the DNP project would not have been possible. Recommendations for Others Recommendations for others that may want to replicate this DNP project would include eliminating the iPad due to the cost. The mobile app can be shown on a personal mobile device or, if available, the electronic medical record handheld device during the discharge instructions educational session. Another recommendation would be to reduce the number of books purchased, because only two Spanish books and four English books were distributed. A recommendation would be to send the survey via text message instead of telephone interviews in order to save time and possibly improve the response rate. Standardizing the discharge process to include the demonstration of the KidsDoc mobile app as an available resource, providing flyers in the education discharge paperwork, and displaying posters advertising the HealhyChildren.org website within patient rooms could promote sustainability within the organization. Recommendations Further Study Further study by the technology industry should focus on similar apps specific for adult health as well as specialized apps targeted to assist with a particular diagnosis such as diabetes management or heart disease. While incorporating a 5th grade reading level and making the app easy to use, the apps can broaden the understanding of a particular disease or health concern, and help patients improve their health outcome by improving their health literacy. Continued study of preferences and trends with the growing technology use in the healthcare system is essential to provide the most effective and efficient use of technology as an educational resource. HEALTH LITERACY IMPROVEMENT PROJECT 41 Future projects focused on reducing limited health literacy are necessary to create a toolbox of evidence-based interventions that address health literacy. Additional studies in the use of the KidsDoc app or other health informational apps related to emergency department visits and primary care offices is recommended. Studies focused on the effects of technological-based health literacy interventions have on the costs and continuity of care have potential to further evidenced-based practices. Evaluations to determine the improvement of patient outcomes due to technological-based health literacy interventions could be valuable. Final Thoughts The purpose of this DNP project was to introduce a reliable resource with trusted health information to pediatric caregivers visiting the emergency department for a non-urgent illness. At least 72% of the participants indicated this health literacy improvement intervention enhanced parenting skills by increasing knowledge of childhood illnesses, suggesting first aid treatments, and providing care guides to assist in healthcare decision-making. In addition, participants preferred the mobile app as their educational resource. Results and findings from this project suggest the use of technology as an educational resource shows promise for future health literacy improvement interventions. While improvements in health literacy aligns with the objectives of Healthy People 2030 and supports the three arms of the Institute of Healthcare Improvement’s Triple Aim Initiative, it can also have positive implications for patient outcomes, nursing practice, and healthcare systems. HEALTH LITERACY IMPROVEMENT PROJECT 42 References Brega, A., Barnard, J., Mabachi, N., Weiss, B., DeWalt, D., Brach, C., Cifuentes, M., Albright, K., & West, D. (2015). AHRQ health literacy universal precautions toolkit (2nd ed.). Agency for Healthcare Research and Quality. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient- safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2.pdf Buhr, E. & Tannen, A. (2020). Parental health literacy and health knowledge, behaviors and outcomes in children: A cross-sectional survey. BMC Public Health 20(1096), p.1-9. https://doi.org/10.1186/s12889-020-08881-5 Carey, J. (2016). KidsDoc app is a useful resource you can recommend to parents with some caveats. iMedicalApps.com. https://www.imedicalapps.com/2016/03/kidsdoc-app- pediatrics-app-review/ Donovan, E., Wilcox, C. R., Patel, S., Hay, A. D., Little, P., & Willcox, M. L. (2020). Digital interventions for parents of acutely ill children and their treatment-seeking behavior: A systematic review. British Journal of General Practice, 70(692), e172–e178. https://doi.org/10.3399/bjgp20X708209 Drent, A. M., Brousseau, D. C., & Morrison, A. K. (2018). Health information preferences of parents in a pediatric emergency department. Clinical Pediatrics, 57(5), p. 519-527. https://doi.org/10.1177/0009922817730346 Heath, S. (2017, February 7). Five best practices for improving patient health literacy. Patient Engagement HIT. https://patientengagementhit.com/news/five-best-practices-for- improving-patient-health-literacy HEALTH LITERACY IMPROVEMENT PROJECT 43 Heijmans, M., Waverijn, G., Rademakers, J., Vaart, R., & Rijken, M. (2015). Functional, communicative and critical health literacy of chronic disease patients and their importance for self-management. Patient Education and Counseling, 98(1), 41-48. https://doi.org/10.1016/j.pec.2014.10.006 Hennekens, C. & Drowos, J. (2017). Ethical issues in public health research. CITI Program. https://www.citiprogram.org/members/index.cfm?pageID=665&ce=1#view Institute for Healthcare Improvement. (2020a). How to improve. http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx Institute for Healthcare Improvement. (2020b). IHI triple aim initiative. http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx Ladley, A., Hieger, A. W., Arthur, J., & Broom, M. (2018). Educational text messages decreased emergency department utilization among infant caregivers: A randomized trial. Academic Pediatrics, 18(6), 636-641. https://doi.org/10.1016/j.acap.2018.02.003 Lenoir County Health Department. (2018). 2018 Lenoir county community health assessment. https://lenoirmemorial.thehcn.net/content/sites/lenoirmemorial/2018_Lenoir_County_CH NA_-_Final_Version.pdf Lenoir UNC Health Care. (2020). Our mission, vision, & values. Unclenoir.org. https://www.unclenoir.org/about-us/mission-vision-values/ Lepley, B. E. & Brousseau, D. C., May, M. F., & Morrison, A. K. (2019). Randomized controlled trial of acute illness educational intervention in the pediatric emergency department. Pediatric Emergency Care, 36(4), 192-198. https://doi.org/10.1097/PEC.0000000000001719 HEALTH LITERACY IMPROVEMENT PROJECT 44 May, M., Brousseau, D., Nelson, D., Flynn, K., Wolf, M., Lepley, B., & Morrison, A. (2017). Why parents seek care for acute illness in the clinic or the ED: The role of health literacy. Academic Pediatrics, 18(3), 289-296. https//doi.org/10.1016/j.acap.2017.06.01 Muhuri, P. & Machlin, S. (2017). Differences in payments for child visits to office-based physicians: Private versus Medicaid insurance, 2010 to 2015. Statistical Brief #504. Agency for Healthcare Research and Quality. U.S. Department of Health & Human Services. https://meps.ahrq.gov/data_files/publications/st504/stat504.shtml National Center for Health Statistics. (2016). Health communication and health information technology. Healthy People 2020 Midcourse Review. Hyattsville, MD. https://www.cdc.gov/nchs/data/hpdata2020/HP2020MCR-C17-HC-HIT.pdf Office of Disease Prevention and Health Promotion. (2020a). HealthyPeople 2020. HealthyPeople.gov. https://www.healthypeople.gov/2020/topics-objectives/topic/health- communication-and-health-information-technology/objectives Office of Disease Prevention and Health Promotion. (2020b). HealthyPeople 2030. Health.gov. https://health.gov/our-work/healthy-people-2030/about-healthy-people-2030/health- literacy-healthy-people Office of Disease Prevention and Health Promotion. (2010). National action plan to improve health literacy. U.S. Department of Health and Human Services. https://health.gov/sites/default/files/2019-09/Health_Literacy_Action_Plan.pdf Office of Disease Prevention and Health Promotion. (2017). Quick guide to health literacy. U.S. Department of Health and Human Services. https://health.gov/our-work/health- literacy/health-literacy-online HEALTH LITERACY IMPROVEMENT PROJECT 45 Ohns, M. J. (2019). Identifying the preferred method to educate low income caregivers about common childhood illnesses: A step toward health literacy through a focus group study. Journal of Pediatric Nursing, 47, 131-135. https://doi.org/10.1016/j.pedn.2019.05.003 Paterick, T., Patel, N., Tajik, J., & Chandrasekaran, K. (2017). Improving health outcomes through patient education and partnerships with patients. Baylor University Medical, 30(1), 112-113. https://doi.org/10.1080/08998280.2017.11929552 Pourat, N., Davis, A., Chen, X., Vrungos, S., & Kominski, G., (2015). In California, primary care continuity was associated with reduced emergency department use and few hospitalizations. Health Affairs, 34(7), 1113-1120. https://doi: 10.1377/hlthaff.2014.1165 United States Census Bureau. (2019). QuickFacts: North Carolina; Lenoir county. https://www.census.gov/quickfacts/fact/table/nc,lenoircountynorthcarolina/PST045217 HEALTH LITERACY IMPROVEMENT PROJECT 46 Appendix A Demographics Comparison Chart DNP Project Age NC Community Under age 18 22.4% 21.9% 65 years and older 20.2% 16.7% Race White 55.4% 70.6% African American 41.4% 22.2% Hispanic 7.9% 9.8% Poverty levels 22.1% 13.6% Median Household Income $38,387 $52,413 Education High School Diploma 80.4% 87.4% Bachelor’s Degree or higher 14.5% 30.5% High School Dropouts 2.8% 2.3% (United States Census Bureau, 2019) HEALTH LITERACY IMPROVEMENT PROJECT 47 Appendix B Literature Review Matrix Authors Year Article Title Theory Journal Purpose and take home Design/Analysis/ IV DV or Themes Pub message Level of Evidence concepts and categories Peetoom, 2016 Does well-child care None Stated BMJ Education of parents in Systematic Review Concept: The effect of K., Smits, education improve Journals regards to fever and common of Literature providing education in J., Ploun, consultations and Archives of childhood infections prior to (RCT) well child clinics prior to L., medication management Disease in episode of childhood illness Level of episode of illness on Verbakel, J., for childhood fever and Childhood showed potential to improve Evidence: II parental healthcare Dinant, G., common infections? A parental health care seeking seeking behavior and & Cals, J. systematic review. and medication management. medication management. IV: Education intervention prior to childhood illness DV: "Parental practices of health seeking behavior (frequency of physician consultations, appropriateness of consultations) and medication management" (Peetoom et al., 2016) Morrison, 2013 The relationship between None Stated Academics 1) Review of literature Systematic Review Concept in 7 articles: A., Myrvik, parent health literacy Pediatrics pertaining to health literacy of of Literature Low health M., and pediatric emergency parents in pediatric ED and Level of literacy(LHL) in parents Brousseau, department utilization: the relationship between Evidence: II of pediatric patients in D., A systematic review literacy and ED utilization 2) ED. Hoffmann, assessed effectiveness of Concept in 4 articles: R., & education interventions and The relationships Stanley, R. reduction in ED utilization between LHL and ED (Morrison et al., 2013, p. utilization 422). 8 Articles used IV and DV IV: educational intervention (booklets, home visits, courses) DV: outcome of ED use May, M., 2018 Why parents seek care for None stated Academic "To explore the decision to Qualitative study Themes of Care Brousseau, acute illness in the Pediatrics seek care and decision with grounded Seeking Behavior: D., Nelson, clinic or the ED: The role making regarding location of theory approach seeking answers, D., Flynn, of health literacy care among parents with low Level of seeking reassurance, K., Wolf, and adequate health literacy" Evidence: III prompt care, M., Lepley, (May, M., Brousseau, D., overestimate of severity B., & Nelson, D., Flynn, K., Wolf, of illness, perceived Morrison, M., Lepley, B., & Morrison, good care, beliefs about A. A., 2017, p. 289). health care facilities, timely care, identify urgent conditions, trust and rapport with facility, knowledge of health care navigation, first born or children under 2. HEALTH LITERACY IMPROVEMENT PROJECT 48 Instr. Used Sample Size Sample method Subject Comments/critique of the article/methods GAPS Charac. Literature Search with Search Literature search of Parents in well The authors found that…"educating parents in well child clinics prior to episodes screening by 3 authors only identified 4512 Medline, Embase, child clinics prior of childhood fever and common infections showed potential to improve parental including RCT. Data references, 43 CINAHL, to episode of practices in terms of healthcare-seeking behavior and medication management" organized in two main studies meeting PsycINFO, Cochrane childhood (Peetoom et al., 2016). outcome measures of criteria for full Library, Web of illness. frequency of physician text review, and Science Limitations: Articles published after 1980. Articles excluded that focused on consultation and medication 8 studies parental self reports, or when education was provided during a childhood illness. management. Quality eligible for data Articles could have been overlooked due to choice of keywords. Study restricted assessment performed extraction with to countries with organizational structure of well child clinics. There was a wide according to Cochrane risk population range difference in outcome measures in each of the studies. of bias tool. sample sizes ranging from 88- Synthesis: Literature review revealed potential of single or multicomponent 999 from total education intervention prior to childhood illness could change parent healthcare of 3154 seeking behavior. individual household members. Low Health Literacy 17 studies were Literature search of Studies reviewed The authors found that ….."Roughly 1 in 3 parents in the emergency department measures - REALM and chosen out of PubMed, CINAHL were restricted to with their children have low health literacy. Low health literacy may have a TOFHLA (long and short 483 that met from studies studies that used relationship with increased emergency department use in children. Targeted low versions) in 12 studies criteria for completed from 1980 - only parents of literacy interventions can reduce emergency department utilization" (Morrison et reviewed. Parent reports, review 2012 children 0-18 al., 2013, p. 421). Medicaid/medical/hospital years of age in Limitations: Review was limited to United States, limited to the quality and records, hospital database, the United States quantity of peer reviewed literature available, and studies varied in sample size, and chart reviews were used as subjects of population, and subject recruitment strategies (Morrison et al., 2013, p.427). to measure ED use 8 studies. study. Review Synthesis: Providers need to be aware of low health literacy when articles were communicating with parents of pediatric patients and incorporate literacy excluded. strategies. Interventions to improve health literacy in parents could have an impact on ED utilization but further research on this subject would be beneficial and valuable (Morrison, et al., 2013, p. 428). Newest Vital Sign (health 50 (44 female & Convenience English The authors found that….."caregiving skills in addition to physician-patient literacy screen), Children 6 males) parents sample/Purposive speaking, parents relationships and perception of care seem to influence the behavior of patients with Special Health Care of children < 8 sample of participants aged > 18 years managing their child's mild acute illness. These factors might be amenable to a Needs questionnaire, & years old old seeking care future health literacy intervention." (May et al., 2017, p.289) sociodemographic seeking care at for nonurgent or Limitations: Study was location specific for large urban clinics and hospitals, information survey clinic (20) or sick children < 8 included only English speaking subjects, and only interviewed 50 subjects. Rural emergency years of age. and small city clinics and hospitals with more diverse ethnic subjects may provide department (30) different reasons or viewpoints for seeking care in ED or clinics. An additional amount of interviews may also prove beneficial. Synthesis: Data obtained in this study may support the need for parental health literacy interventions that could lead to a reduction in nonurgent ED use. HEALTH LITERACY IMPROVEMENT PROJECT 49 Drent, A., 2018 Health information Hypothesis: 1) Clinical Purpose of study was to Mixed method Themes for semi Brousseau, preferences of Low health Pediatrics evaluate preferences for analysis with structured interview D., & parents in a pediatric literacy health education material for descriptive questions: current Morrison, emergency parents would childhood illness for parents statistics and media access and use, A. department have equal with low health literacy in qualitative educational preferences access to order to determine interviews such as educational media but use preferences in medium, Level of medium, location of media less distribution, content, and Evidence: III distribution, content, and often. 2) Low impact. In addition, this impact of health health literacy study aimed to discover information parents would media access and use in low have different health literacy parents of preferences children < 8 years old. than parents with adequate health literacy for educational material about childhood illnesses. Buhr, E. & 2020 Parental health literacy None stated BMC Public Low parental health literacy Cross sectional Theme: parental health Tannen, A. and health knowledge, Health negatively impact the health quantitative study literacy, socio-economic behaviours and outcomes and well-being of the Level of status, educational in children: a cross- children. Parents with low Evidence: V levels, vocational sectional survey health literacy less likely to training, current job, and meet the preventive and child health behaviors health care needs of their children. Strengthening health knowledge of parents may contribute to improved child outcomes Donovan, 2020 Digital interventions for None stated British Examine evidence of whether A systematic Theme: digital E., Wilcox, parents of acutely ill Journal of digital interventions facilitate review interventions to advise C., Patel, S., children and their General parents deciding to seek Level of parents on seeking care Hay, A.D., treatment-seeking Practice treatment for acute illnesses Evidence: I for acute illnesses Little, P., & behaviour: a systematic or self care. Little evidence Wilcox, M. review to support digital interventions to help parents caring for children with acute illnesses. Heijmans, 2015 Functional, none stated Patient Examine the associations Cross sectional Theme: Low health M., communicative and critical Education between health literacy and quantitative study literacy may contribute Waverijn, health literacy of chronic and self-management Level of Evidence: to poor self management G., disease patients and their Counseling V of chronic disease Rademakers importance for self- , J., Vaart, management R., & Rijkens, M. HEALTH LITERACY IMPROVEMENT PROJECT 50 Newest Vital Sign (health 92 recruited-71 Convenience English speaking The authors found that….It is likely parents with low health literacy would benefit literacy screen), Children completed sample/Purposive parents > 18 from a combination of print, internet, or app-based resources for health education with Special Health Care questionnaires sample of participants years old seeking and it has potential to reduce the number of nonurgent ED visits (Drent et al., Needs questionnaire, & 30 completed care for acute 2018). sociodemographic questionnaires illness for non Limitations: Study was performed in ED setting so findings may not apply to information survey, & in and interviews distressed other settings. Some parents had difficulty articulating preferences for preferred person semi structured <8years old child educational information and the use of convenience sampling could lead to interview with Emergency interpretative limitations of data. Severity Index of Synthesis: The study provides evidence that multiple information resources is 5 in Wisconsin preferred by parents and could possibly have an effect on nonurgent ED visits. Children's ED When developing educational information for the low health literacy population, during time this study could direct the modes of material development and disbursement of frame 12/2013- such material. 8/2014. cross-sectional survey 4217 parents, Convenience Sample, parents and Authors confirmed relationship between low parental health literacy, socio- questionnaires including 1518 children purposeful selection children at 28 economic status and some child health behaviors likely to negatively impact their European Health Literacy age 6-10, 2776 process public health and well being. Survey Questionnaire children age 11 elementary and Limitations: Sample not representative of the entire country, participants may and older secondary school have faced challenges with responding to the survey, self reporting on health in two states in literacy vulnerable to social desirability bias Synthesis: Strengthening health Germany, knowledge of parents may contribute to improved child outcomes. Brandenburg and Hessen Two studies used Likert 294, 4456,& 98 convenience caregivers Outcome: Lack of evidence to support using digital interventions to advise parents scale questions & one study in 3 studies, sampling/ purposive visiting ED, app on when to seek care or self treat at home. used qualitative analysis of caregivers of sample users (any age), Limitations: Literature search may have missed some articles open comments children <18 parents visiting Synthesis: Future research is needed in the development of apps collaborating with years of age pediatric office intended users making sure of ease of use and effective advice. self-report questionnaire, 3 1341 chronic nationwide random Patients >15 Outcome: communicative and critical health literacy play a role in successful self health literacy scales disease patients sampling of chronic with chronic management of chronic disease incorporated to assess health disease patients from disease, not Limitations: Questionnaires filled out at home so possibility of assistance in literacy and self management general practices institutionalized , completing questionnaire. Also, some patients were ill for a long time which (PCCHL, PIH, & PEPPI-5) not terminally ill, could influence the level of health literacy. and mentally able Synthesis: Health literacy skills are important for some aspects of self to participate management, but context is important as well. HEALTH LITERACY IMPROVEMENT PROJECT 51 Ladley, A., 2018 Educational text messages Text messages Academic To determine if text messages Randomized Trial IV: text messages Hieger, decreased emergency to caregivers Pediatrics to infant caregivers can study Level of DV: visits to ED A.W., department utilization of infants can reduce nonurgent visits to Evidence: I Arthur, J. & among infant caregivers: reduce ED and if text message are Broom, M. A randomized trial nonurgent ED feasible and effective. visits Lepley, 2019 Randomized controlled mHealth app Pediatric To determine feasibility, Randomized Trial Theme: educational B.E., trial of acute illness would be Emergency demand, acceptability, and study Level of resources to improve Brousseau, educational intervention in preferred by Care usefulness of mobile app Evidence: I health literacy of D.C., May, the pediatric emergency parents as an compared to written material pediatric caregivers M. F., & department educational Morrison, intervention to A. K. help care for child compared to written materials Ohns, M.J. 2019 Identifying the preferred Journal of To discover the preferred Qualitative Themes discovered in method to educate low Pediatric method of educational research focus qualitative analysis: income caregivers about Nursing resource for low income group study Level access of information common childhood caregivers in regards to of Evidence III and comprehensiveness illnesses: A step toward common childhood illnesses of information health literacy through a focus group study Paterick, T., 2017 Improving health none stated Baylor Physicians and patients form Expert opinion Theme: improved Patel, N., outcomes through patient University a partnership where the Level of Evidence physician-patient Tajik, J., & education and Medical physician provides V relationship can lead to Chandrasek partnerships with patients information and educating improved health aran, K. and the patient accepts and outcomes acts on the information. The partnership improves shared decision making. Meyers, N., 2020 Parents use of Academic to examine how health Cross sectional Theme: technology as a Glick, A., technologies for health Pediatrics literacy affects internet and analysis Level of form of communication Mendelsohn management: A health cell phone usage for health Evidence V and education , A., Parker, literacy perspective management R., Sanders, L., Wolf, M., Bailey, S., Dreyer, B., Velazquez, J., & Yin, S. HEALTH LITERACY IMPROVEMENT PROJECT 52 Newest Vital sign to assess 231 caregivers Convenience sample n=231 (84.2%- Outcome: Educational text messages is effective is reducing nonurgent visits to health literacy, of infants at pediatric office racial or ethnic ED minorities, Limitations: Results could be swayed due to text messages may have improved 69.7% yearly relationship between caregiver and pediatric office and this relationship income improvement could steer the caregiver to seek care at the office instead of the ED, <2$20,000, not necessarily the information provided caused the reduction 70.4% low Synthesis: RCT established the benefits of text messages to caregivers to reduce health literacy) ED visits and thereby reducing healthcare costs and improves continuity of care Newest Vital Sign to assess 98 parents of convenience sampling English speaking Outcome: low demand for mHealth app with parents that used the book and giving health literacy, 5-point Likert children <12 at ED caregivers of written information to pediatric caregivers has ability to empower parents with scale, additional qualitative years of age children <12 knowledge and reduce nonurgent visits to ED comments years of age that Limitations: no Spanish speaking population, inability to download the app due to health book with video, visited ED from internet problems within the facility, possibility that too much information on app mHealth app, car seat safety June 4, 2014- can be overwhelming, app had medical jargon and complex sentences, video and handout, and July 2, 2014 Synthesis: Only 1 in 3 parents chose to download the app, a low health literacy combination of book and app with nonurgent book was preferred by parents compared to mHealth app. Parents found the book complaint more understandable. Providing written health information with video has capacity to improve knowledge to care for sick child and potentially decreases nonurgent ED use Newest vital signs-health 30 participants Convenience/purposiv Individuals with Outcome: Preferred method of educational resource was KidsDoc mobile app with literacy screening tool, either expecting e sample/recruited low income and comments about ease of access and amount of information. ranking of preferred first child or from WIC services at least one child Limitations: small sample size, possible bias from PI educational resource parent of at least and a prenatal health <10 years of age Synthesis: Although the reasons for nonurgent ED use is multifactorial, low health one child education program for or expecting first literacy is one factor. The benefits of determining preferred educational resource low income pregnant child could help to improve health literacy of this vulnerable population and decrease women health care cost and improve continuity of care. no instrument used none none none Article of opinion discussing physician-patient relationship and how with improved health literacy by physician teaching could lead to improved shared decision making and patient engagement Newest vital sign to measure 858 convenience sample English and Outcome: Higher health literacy, higher income, and English speaking participants health literacy, questionnaire from 3 urban pediatric Spanish were associated with greater use of internet and cell phones. There is an overall and interview clinics speaking parents desire to use internet and cell phone as modalities of communication and education of children < 8 even among low health literate participants. years of age Limitations: Self reported responses might not reflect actual usage of technologies, recruited from 3 findings might not be generalized to the population due to sampling, and limited urban pediatric number of questions pertaining to technology usage clinics excluding Synthesis: Although the current usage of technology is higher in the higher health vision or hearing literacy group, there is a desire regardless of health literacy to use the cell phone impairments or and internet for health management. Continued studies of trends and preferences parents seeking are needed to avoid further disparities in healthcare. care for children with urgent issues. HEALTH LITERACY IMPROVEMENT PROJECT 53 Appendix C PDSA Worksheet TOOL: STEP: CYCLE: PLAN I plan to: I hope this produces: Steps to execute: 1. DO What did you observe? • STUDY What did you learn? Did you meet your measurement goal? ACT What did you conclude from this cycle? BB (Brega et al., 2015) HEALTH LITERACY IMPROVEMENT PROJECT 54 Appendix D SMART Objectives, Interventions, and Outcome Measures SMART Objectives Intervention Outcome Measure By the end of the 2-month Introduction to internet Utilization of app or website period from start of project, software (mobile app or to seek information about the proportion of participants website) to pediatric childhood illness that report they used the app caregivers in emergency or website often or always to department in rural NC seek childhood illness hospital information during their child’s illness or injury will be 50%. By end of the 2-month period Utilization of app or website Learned at least two facts from start of project, to learn about childhood about childhood illnesses proportion of participants that illnesses from app or website report they strongly agree or agree they learned at least two facts about childhood illnesses from app or website will be 25%. By the end of the 2-month Utilization of app or website Learned at least one first aid period from start of project, to get first aid advice during technique from the app or proportion of participants that their child’s injury. website. report they strongly agree or agree they learned at least one first aid technique during their child’s injury from app or website will be 25%. o-Study HEALTH LITERACY IMPROVEMENT PROJECT 55 Appendix E Telephone Follow-up Survey Survey Questions Available Answers Please answer what best describes your experience with the health literacy project. How many childhood illnesses or injuries did your child experience during the last 4 weeks 0 1 2 3 or more (or 8 weeks)? Did you use the educational resource to look Never Rarely Often Always up health information? I learned at least two facts about childhood Strongly Strongly Disagree Agree illnesses while using the educational resource. Disagree Agree I learned at least one first aid technique while Strongly Strongly Disagree Agree using the educational resource. Disagree Agree Using the educational resource assisted me in Strongly Strongly deciding what level of care to seek during my Disagree Agree Disagree Agree child’s illness or injury. Additional Comments or Suggestions: lank Wor HEALTH LITERACY IMPROVEMENT PROJECT 56 Appendix F Code Sheet HEALTH LITERACY IMPROVEMENT PROJECT 57 Appendix G Data Collection Tool DNP Health Literacy Improvement Project Survey Results Amount of Learned at least 2 Assisted me in Amount of Learned at least 2 Learned at least Assisted me in deciding Additional Reliable Learned at least Additional # of Numerical Educational # of educational tool facts about deciding what level of educational tool facts about one first aid what level of care to comments or Language interne t one first aid Comments or illnesses Identifier Tool illnesses usage d uring last 4 childhood care to seek during my usage d uring last 8 childhood illnesses technique (2 nd seek during my child’s suggestions (2nd access technique Suggestions 2nd call weeks illnesses child's illness weeks (2nd call) Call) illness (2nd call) Call) HEALTH LITERACY IMPROVEMENT PROJECT 58 Appendix H Script for Presentation of Educational Tools Hello, my name is Sissie Combs, and I am a student at East Carolina University in the Nurse Practitioner program. I am doing a project for the hospital to improve the health literacy of parents and caregivers of children under the age of 17. Do you have any children in that age category? Answer: No Well, I am sorry you are here, but I hope you get to feeling better. Thank you for your time. Answer: Yes I would like to tell you about the project and see if you are interested in participating. Is that ok? Answer: No Well, I am sorry you are here, but I hope you get to feeling better. Thank you for your time. Answer: Yes The American Academy of Pediatrics has developed an App and website tool to help you when your child is sick or injured. So many people are turning to google searches looking for information, and the Academy wanted to provide a reliable resource for parents, so they developed this app. The app is called KidsDoc Symptom Checker. You can get it on your phone if you have an iPhone or Android, or you can access it on a tablet or computer when you have internet access. I would like to demonstrate what this tool can do and how you can use it when your child is sick or injured. Do you have an iPhone or Android? Answer: Yes (Proceed to the app and demonstrate how to use it using ear pain as the symptom) Answer: No Do you have internet access in your home and a device to use such as a tablet or computer? Answer: Yes (Proceed to the website and demonstrate how to use it using ear pain as the symptom) Answer: No In that case, I would like to show you a book by the same doctor that designed the app. (Provide the book and demonstrate how to look up ear pain as a symptom) HEALTH LITERACY IMPROVEMENT PROJECT 59 (After demonstrating the app, website, or book, proceed to recruitment) Now that you have seen the resource, would you be interested in participating in the project and receiving (a coupon for the app, OR instructions to access the website, OR the book)? If you are willing to participate in the project, I will need for you to complete a participant form that will include you providing your first name and phone number. I will provide you free of charge (a coupon code for the app, OR instructions for accessing the website, OR a book). In one month, I will call you to see if you have used the resource and ask you about 6 questions concerning the resource. And then you will get another phone call after two months with the same questions. The app has no expiration, and you can use it as long as you like, OR the website is available as long as HealthyChildren.org is working, OR the book is yours to keep. The telephone call will be short and at your convenience. I will only need your first name and phone number; no other private information will be needed. Are you interested in participating? Answer: No Ok, well, thank you for your time and I hope you get to feeling better. Answer: Yes Wonderful, I will get the participation form for you to complete as well as (the coupon code so we can download the app, OR the instructions for the website, OR the book for you). (Provide resource: help to download app, OR give Navigational instructions handout, OR the book) I look forward to talking with you on the phone to see how things are going with the resource. I hope it provides you with information that you find is helpful. So, I will call you in a month, when is the best time to call? (Write down on the participation form) Thank you for your participation and enjoy the resource! HEALTH LITERACY IMPROVEMENT PROJECT 60 Appendix I Participation Form You are being invited to participate in a Health Literacy Improvement Project. The purpose of this project is to improve the health literacy of pediatric caregivers with the use of a reliable educational resource (a mobile app or web-based interactive tool designed by the American Academy of Pediatrics or an educational book). This project is led by Yvette Combs, a DNP student at East Carolina University. You will be provided an educational resource focused on childhood illnesses and injuries in your preferred language. You will be contacted twice via telephone by the project lead to answer survey questions about the educational tool provided to you after four and eight weeks of participation. You must be 18 years or older to participate, speak either English or Spanish, and provide care for an individual under the age of 17. No identifying private data will be needed except for your first name and telephone number. You have the right to refuse participation or withdraw participation at any time during this project. Your acceptance or rejection of participation will in no way affect your provision of care during this healthcare visit. If you would like to participate in this DNP project, please provide your name and telephone number in the space provided. First Name: ________________________________________________________ Date: __________________ Telephone Number: __________________________ Best Time to Call: _____________________________________________________ HEALTH LITERACY IMPROVEMENT PROJECT 61 Appendix J Instructions for KidsDoc Symptom Checker 1. Go to HealthyChildren.org on your device’s browser 2. Click on Tips & Tools 3. Scroll down to KidsDoc Symptom Checker and click on “View” 4. If you would like to view in the Spanish language, click on “en Espanol” icon at the right lower part of your screen 5. Once you are in the KidsDoc Symptom Checker, you can search for a child’s illness or injury by clicking on the body part or use the A-Z index. 6. Once you have the symptom selected, you have options to view the “definition” of the illness or injury, “when to call” your pediatrician for care, or “care advice” for suggestions for first aid or home treatments Instrucciones para KidsDoc Control de sνntomas 1. Ve a HealthyChildren.org en el navegador de tu dispositivo 2. Haga clic en Consejos y herramientas 3. Desplαcese hacia abajo hasta KidsDoc Symptom Checker y haga clic en "Ver" 4. Si desea ver en el idioma espaρol, haga clic en el icono "en Espaρol" en la parte inferior derecha de la pantalla 5. Una vez que estι en el Comprobador de sνntomas KidsDoc, puede buscar la enfermedad o lesiσn del niρo haciendo clic en la parte del cuerpo o utilizando el νndice A-Z. 6. Una vez que haya seleccionado el sνntoma, tiene opciones para ver la "definiciσn" de la enfermedad o lesiσn, "cuαndo llamar" a su pediatra para la atenciσn, o "consejos de cuidado" para sugerencias de primeros auxilios o tratamientos en el hogar HEALTH LITERACY IMPROVEMENT PROJECT 62 Appendix K Script for Follow-up Telephone Interview Hello, my name is Sissie Combs, and I am the ECU student that talked with you at the emergency department (4weeks ago OR 8 weeks ago). You provided your phone number so I could call you to ask about the educational resource you received. Do you have time to talk with me, or should I call you back at another time that is best for you? Answer: No. I don’t have time. I understand. When would be a better time to connect with you? Answer: _____ Wonderful, I will call you back (time specified) (make notes regarding call back date and time) Answer: I no longer want to participate OK, I apologize for any inconvenience, and thank you for allowing UNC Lenoir to serve you and your healthcare needs. Answer: Yes I understand you received the (mobile app download OR website instructions OR the book) during our last conversation. I have 5 survey questions I would like to ask you. Is that OK? Answer: No Have you decided not to participate in the survey? Answer: Yes Ok, I apologize for any inconvenience, and thank you for allowing UNC Lenoir to serve you and your healthcare needs. Answer: Yes Great. Thank you for your time. My first survey question is…. How many childhood illnesses or injuries did your child experience since you received the (mobile app OR website instructions OR book)? 0, 1, 2, or 3 or more The next survey question asks you to choose between never, rarely, often, and always. Did you use the (mobile app OR website instructions OR book) to look up health information? So you can choose between never, meaning you did not use the (mobile app OR website instructions OR book), rarely, meaning you used it but rarely, often meaning you used often, or always meaning you used it every time your child was experiencing a childhood illness symptom. The next three questions ask you to choose if you agree, strongly agree, disagree, or strongly disagree with the statements I provide. HEALTH LITERACY IMPROVEMENT PROJECT 63 The first statement is, “I learned at least two facts about childhood illnesses while using the educational resource.” Would you say you strongly agree, agree, disagree, or strongly disagree with that statement? The second statement is, “I learned at least one first aid technique while using the educational resource. Would you say you strongly agree, agree, disagree, or strongly disagree with that statement? The third statement is, “Using the educational resource assisted me in deciding what level of care to seek during my child’s illness or injury.” Would you say you strongly agree, agree, disagree, or strongly disagree with that statement? OK, that completes the survey, but do you have any additional comments about the (mobile app OR website instructions OR book) or your experience with the (mobile app OR website instructions OR book)? Thank you for participating in the survey. First Interview: Is it ok to call you again in 4 weeks to complete the survey again? Answer: Yes Well, I will look forward to our next conversation. Have a great day! Answer: No Thank you for your time and participation in my project. Second Interview: Thank you for participating in the survey. I hope you enjoy the (mobile app OR website instructions OR book). HEALTH LITERACY IMPROVEMENT PROJECT 64 Appendix L Timeline for Project Implementation Project Implementation January 19, 2021 Participation Recruitment January 19 – February 17, 2021 PDSA Rapid Cycle January 22, 2021 Project Champion Meeting-Face to Face February 2, 2021 Agenda: Data Collection Project Champion Meeting -Face to Face February 17, 2021 Agenda: Recruitment Completion 1st round of Telephone Interviews Feb 23 – March 17, 2021 Data Collection (4 weeks after recruitment for each participant) PSDA Rapid Cycle Feb 24, 2021 Project Champion Meeting-Face to Face March 2, 2021 Agenda: 1st Round of Interview Progress Project Champion Meeting-Face to Face March 17, 2021 Agenda: 1st Round of Interview Completion 2nd Round of Telephone Interviews March 19 – April 14, 2021 Data Collection (8 weeks after recruitment for each participant) Project Champion Meeting-Face to Face March 30, 2021 Agenda: 2nd Round Interview Progress Project Champion Meeting-Face to Face April 13, 2021 Agenda: 2nd Round Interview Completion Data Analysis and Reporting April 12 – April 22, 2021 Project Champion Meeting to share April 26, 2021 Results HEALTH LITERACY IMPROVEMENT PROJECT 65 Appendix M DNP Project Timeline • IDENITIFY A NEED DNP I • LITERATURE REVIEW MAY -AUG • DEVELOP A PLAN CONSIDERING HEALTHY PEOPLE 2020 GOALS AND OBJECTIVES 2020 • IDENTIFY ORGANZATION AND PROJECT CHAMPION • PROJECT DESIGN AND COLLABORATION DNP II • CITI MODULES AUG -NOV • PROCESS AND OUTCOME EVALUATION STRATEGIES • APPROVAL PROCESS 2020 • ORGANZATIONAL LETTER OF SUPPORT DNP III • IMPL EMENTATION (Detailed timeline available) JAN -APR • RE-EVALUATIONS AND REVISIONS 2021 DNP IV • RESULTS AND FINDINGS MAY -JUNE • INTERPRETATION AND IMPLICATIONS • PROJECT CONCLUSIONS 2021 • FINAL DNP PAPER SUBMISSION DNP V • FINAL APPROVAL JUNE -JULY • DISSEMINATIONS OF THE FINDINGS 2021 • PODIUM PRESENTATION • PROJECT COMPLETION HEALTH LITERACY IMPROVEMENT PROJECT 66 Appendix N Recruitment Data Patients Met Presented Accepted Rejected Mobile in Green English Spanish Website Book Criteria Project Participation Participation App Zone Totals 229 80 76 75 1 73 2 72* 2 6 *Participants that could not download mobile app while in the ED were supplied a download code and an additional educational resource. HEALTH LITERACY IMPROVEMENT PROJECT 67 Appendix O Number of Illnesses Reported in Telephone Survey Number of Illnesses Reported in Telephone Survey # of illnesses Four Weeks Eight Weeks Frequency % Frequency % 0 35 66.0 29 80.6 1 11 20.8 6 16.7 2 5 9.4 1 2.8 3 1 1.9 0 0 4 1 1.9 0 0 Totals n=53 n=36 22 of the 75 participants did not 17 of the 53 participants did not respond to the first follow up call respond to the second follow up call HEALTH LITERACY IMPROVEMENT PROJECT 68 Appendix P Educational Tool Usage Educational Tool Usage Likert Scale Four Weeks Eight Weeks Did you use the educational resource to look Frequency % Frequency % up health information? Always 2 3.8 1 2.8 Often 26 49.1 13 36.1 Rarely 14 26.4 14 38.9 Never 11 20.8 8 22.2 Totals n=53 n=36 HEALTH LITERACY IMPROVEMENT PROJECT 69 Appendix Q Telephone Survey Results 4 Week Survey (n=53) 37.70% Learned at least two facts about 41.50% childhood illnesses 20.80% 32.10% Learned at least one first aid 43.40% technique 24.50% 41.50% Assisted me in deciding what 39.60% care to seek 18.90% 8 Week Survey (n=36) 22.20% Learned at least two facts about 52.80% childhood illnesses 25.00% 22.20% Learned at least one first aid 50.00% technique 27.80% 19.40% Assisted me in deciding what 55.60% care to seek 25.00% Strongly Agree Agree Disagree Strongly Disagree HEALTH LITERACY IMPROVEMENT PROJECT 70 Appendix R Comparison of SMART Objectives and Results Comparison of SMART Objectives and Results Four Weeks Eight Weeks n=53 n=36 By the end of the 2-month period from start of project, the proportion of participants that report they used the app or 52.9% 38.9% website often or always to seek childhood illness information 2.9% above goal 11.1% below goal during their child’s illness or injury will be 50%. By end of the 2-month period from start of project, proportion of participants that report they strongly agree or agree they 79.2% 75% learned at least two facts about childhood illnesses from app 54.2% above goal 50% above goal or website will be 25%. By the end of the 2-month period from start of project, proportion of participants that report they strongly agree or 75.5% 72.2% agree they learned at least one first aid technique during their 50% above goal 47% above goal child’s injury from app or website will be 25%. Additional Survey Statement Proportion of participants that report they strongly agree or 81% 77% agree the educational resource assisted them in deciding what level of care to seek during a childhood illness or injury. HEALTH LITERACY IMPROVEMENT PROJECT 71 Appendix S DNP Project Budget Item Quantity Unit Cost Total Electronic Supplies Ipad 1 $329 $329.00 Taxes for Ipad $23.03 Apple Support and Damage Care 1 $69.00 $69.00 Ipad Case 1 $62.96 $62.96 Taxes for case $4.41 Office Supplies Paper 2 $4.00 $8.00 Printing 100 $0.10 $10.00 Educational Resources KidsDoc App Coupons 50 0 (Donated by Self Care, Inc) $0.00 English book (My Child is Sick ) 25 $10.17 $254.25 Spanish Book (Que Hacer Cuando Su Nino 10 $8.99 $89.90 Se Enferme ) Shipping $25.42 Taxes $17.16 TOTAL $893.13 HEALTH LITERACY IMPROVEMENT PROJECT 72 Appendix T Doctor of Nursing Practice Essentials Description Demonstration of Knowledge Essential I Competency – Analyzes and uses information to • Developed the health literacy Scientific develop practice improvement DNP project. Underpinning Competency -Integrates knowledge from humanities and • Searched literature for evidence for Practice science into context of nursing based practice regarding technology Competency -Translates research to improve practice and its use for health literacy Competency -Integrates research, theory, and practice to education. develop new approaches toward improved practice and • Developed a DNP project that outcomes furthered the objectives of Healthy People 2010, 2020, and 2030. • Developed a new approach to improve health literacy with the use of technology. Essential II Competency –Develops and evaluates practice based on • Analyzed literature to determine Organizational science and integrates policy and humanities best practice in health literacy & Systems Competency –Assumes and ensures accountability for improvement, for example, the Leadership for quality care and patient safety teach-back method. Quality Competency -Demonstrates critical and reflective • Assumed responsibility for the Improvement & thinking DNP project, researched the Systems Competency -Advocates for improved quality, access, evidenced based interventions, and Thinking and cost of health care; monitors costs and budgets analyzed the DNP project for ethical Competency -Develops and implements innovations concerns. incorporating principles of change • Evaluated project using Competency - Effectively communicates practice measurement tools to monitor the knowledge in writing and orally to improve quality Competency - Develops and evaluates strategies to outcome. manage ethical dilemmas in patient care and within • Discussed the quality improvement health care delivery systems with organization’s administration. • Evaluated costs and benefits of the project by comparing the current costs of a non-urgent ED visit and the costs of a primary care visit. • The DNP project strived to meet the three arms of the Triple Aim. • Developed a budget for the DNP project taking in account all costs associated with implementation. • Introduced the mobile app to improve health literacy of pediatric caregivers. • Wrote a scholarly paper using APA format and relaying the information to the organization’s leadership. • Reviewed the CITI modules, provided alternatives for participants without internet access or smartphones, and used an interpreter for the Spanish speaking population. HEALTH LITERACY IMPROVEMENT PROJECT 73 Essential III Competency - Critically analyzes literature to determine • Critically analyzed literature to Clinical best practices determine best practices in Scholarship & Competency - Implements evaluation processes to improving health literacy. Analytical measure process and patient outcomes • Compared SMART objectives with Methods for Competency - Designs and implements quality project findings. Evidence-Based improvement strategies to promote safety, efficiency, and • Designed and implemented a health Practice equitable quality care for patients literacy improvement strategy that Competency - Applies knowledge to develop practice was safe, efficient, and equitable. guidelines • Applied knowledge to develop a Competency - Uses informatics to identify, analyze, and DNP project that could lead to a predict best practice and patient outcomes change in practice guidelines by Competency - Collaborate in research and disseminate standardizing the discharge process findings to include a demonstration of the mobile app. • Used informatics to identify and analyze patient flow and the number of pediatric clients with acuity levels 4 & 5 that could be impacted with the health literacy intervention. • Collaborated with ED Nursing Director, Faculty mentor, Chief Nursing Officer, ED Medical Director, and local Pediatrician. • Disseminated the findings to nursing and pediatric organizations as well as the stakeholders. Essential IV Competency - Design/select and utilize software to • Selected and utilized software such Information analyze practice and consumer information systems that as SPSS to analyze data collected Systems – can improve the delivery & quality of care from DNP project in order to Technology & Competency - Analyze and operationalize patient care improve delivery and quality of care. Patient Care technologies • Utilized Excel software to data Technology for Competency - Evaluate technology regarding ethics, track the recruitment and survey the Improvement efficiency and accuracy results. & Competency - Evaluates systems of care using health • Selected a reliable health Transformation information technologies information mobile app to present to of Health Care participants to improve health literacy. • Evaluated technology selected to assess if efficient, ethical, and accurate. The mobile app was downloaded in both English and Spanish language. • Analyzed data for a period of a month to establish an average number of pediatric client visits and the costs associated with these visits. Description • Demonstration of Knowledge Essential V Competency- Analyzes health policy from the • Analyzed health policy from the Health Care perspective of patients, nursing and other stakeholders perspective of patients such as the Policy of Competency – Provides leadership in developing and “whys” associated with ED visits for Advocacy in implementing health policy non-acute illnesses. Health Care Competency –Influences policymakers, formally and • Analyzed the health policy informally, in local and global settings regarding long wait times in the ED Competency – Educates stakeholders regarding policy HEALTH LITERACY IMPROVEMENT PROJECT 74 Competency – Advocates for nursing within the policy and the effects on nurses and arena stakeholders within the organization. Competency- Participates in policy agendas that assist • Provided leadership when with finance, regulation and health care delivery recommending a policy Competency – Advocates for equitable and ethical (standardizing discharge process) to health care decrease the amount of non-urgent visits to the ED by improving health literacy. • Provided evidence of a strategy to improve health literacy. Healthy People 2030’s objective to improve the health literacy of the population is seeking evidence for strategies to improve health literacy. • Educated stakeholders regarding the findings and proposed sustainability by including mobile app demonstration at discharge and posting signage advertising the mobile app. • Advocated for nursing within the policy arena by proposing an intervention designed by an APRN that can improve health literacy. • Participated in project that led to a health literacy improvement strategy that could reduce cost and improve the health care delivery in the ED. • Addressed the gaps associated with limited health literacy in a rural underserved population. Essential VI Competency- Uses effective collaboration and • Used effective collaboration and Interprofessional communication to develop and implement practice, communication to develop and Collaboration policy, standards of care, and scholarship implement a DNP project to improve for Improving Competency – Provide leadership to interprofessional health literacy of pediatric Patient & care teams caregivers. Population Competency – Consult intraprofessionally and • Provided leadership in the green Health interprofessionally to develop systems of care in complex zone to nursing staff while Outcomes settings implementing DNP project. • Consulted with organization’s leaders, local pediatrician, and ED medical director to develop health literacy improvement intervention in the green zone of a busy ED in a rural community. • Collaborated with interpreters to communicate with the Spanish population. • Prepared abstract of project for submission for dissemination to influence practice, policy, standards of care, and scholarship. Essential VII Competency- Integrates epidemiology, biostatistics, and • Performed the community Clinical data to facilitate individual and population health care assessment for the DNP project and Prevention & delivery identified a practice issue based on HEALTH LITERACY IMPROVEMENT PROJECT 75 Population Competency – Synthesizes information & cultural research and considered national Health for competency to develop & use health promotion/disease goal and objectives set forth in Improving the prevention strategies to address gaps in care Healthy People 2010, 2020, and Nation’s Health Competency – Evaluates and implements change 2030. strategies of models of health care delivery to improve • Synthesized information & cultural quality and address diversity competency to develop & use health promotion when addressing the gaps of care associated with limited health literacy. • Evaluated and implemented a change strategy by addressing the limited health literacy using a mobile app to improve health literacy that is available to a diverse population. Essential VIII Competency- Melds diversity & cultural sensitivity to • Conducted systematic assessments Advanced conduct systematic assessment of health parameters in of limited health literacy within the Nursing Practice varied settings African American community and Competency – Design, implement & evaluate nursing Spanish speaking population. interventions to promote quality • Designed, implemented, and Competency – Develop & maintain patient relationships evaluated the nursing intervention to Competency –Demonstrate advanced clinical judgment improve health literacy by providing and systematic thoughts to improve patient outcomes a reliable health information mobile Competency – Mentor and support fellow nurses app to participants with measurable Competency- Provide support for individuals and outcomes. systems experiencing change and transitions • Developed patient relationships by Competency –Use systems analysis to evaluate practice interacting with the patients during efficiency, care delivery, fiscal responsibility, ethical the presentation of the project and responsibility, and quality outcomes measures maintained that relationship with follow up telephone surveys. • Demonstrated advanced clinical judgment and systematic thought in order to improve health literacy to improve patient outcomes. • Mentored and supported fellow nurses by conducting peer reviews of their DNP project, interacted with fellow nurses during immersion, and participated in social media groups. • Provided support for individuals and systems experiencing change and transitions while implementing the project. • Used system analysis (PDSA model) to evaluate practice efficiency, care delivery, fiscal responsibility, ethical responsibility, and quality outcomes measures during the implementing and evaluation stage of the DNP project.