Digital Repository Masters Projects Spring 2023 Provider Education for Intervention in STI Acquisition Prevention Matthew Harris Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Harris, M. 2023. Provider education for intervention in STI acquisition prevention. Weber State University Masters Projects. https://dc.weber.edu/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact scua@weber.edu. WSU REPOSITORY MSN/DNP Provider Education for Intervention in STI Acquisition Prevention Project Title by Matthew Harris Student’s Name A project submitted in partial fulfillment of the requirements for the degree of MASTERS OF NURSING Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, UT 03/27/2023 Date 03/27/2023 Student Name, Credentials (electronic signature) Date 04/21/2023 MSN Project Faculty (electronic signature) Date Melissa NeVille Norton (electronic signature) Date DNP, APRN, CPNP-PC, CNE Graduate Programs Director Note: The program director must submit this form and paper. 1 Provider Education for Intervention in STI Acquisition Prevention Matthew Harris, BSN, RN, MSN Student Weber State University Annie Taylor Dee School of Nursing February 28, 2023 2 Abstract Gaps in provider knowledge adversely affect the successful prevention of sexually transmitted infection (STI) acquisition in sexually active adults. The assessment of these gaps concerns screening, pre-exposure prophylaxis (PrEP) uptake for high-risk clients, treatment, and prevention strategies, which are fundamental for provider growth and educational attainment. This project aims to reduce STI prevalence, improve outcomes in sexual health, improve provider education, and produce a culture conducive to acceptance and trust. This project will include resources to help public health registered nurses appropriately assess and re-evaluate current practices that will improve performance based on evidence-based practice findings. Provider education can be accomplished by attending sexual health training, conferences, and one-on-one consultations with sexual health and STI subject matter experts. The implications for this project are two-fold as providers gain invaluable knowledge and delineate this knowledge to clients resulting in decreased prevalence, increased screening, and increased treatment. The prevalence of STIs in the U.S. and the straining and failing of existing resources reiterate the importance of and need for education by providers to provide quality care, promote continuous quality improvement, and improve sexual health in the public health sector. Keywords: Sexually transmitted infections, STI, provider interventions, provider education, resources, teaching, prevention, practice guidelines, PrEP. 3 Provider Education for Intervention in STI Acquisition Prevention Sexually transmitted infections (STIs) are a significant concern to public health. These preventable infections are common, costly, and highly prevalent, with about 26 million STIs occurring yearly in the United States (Curry et al., 2022). The prevalence of STIs may be a possible reflection of a gap in provider education, influenced by a lack of understanding and internal biases. To better understand the relationship between STIs, a sense of syndemics, or the way diseases interact with the potential to increase or cause more harm (Jungkunz, 2021), is needed to ensure that intervention programs reflect the complex social processes and realities within which outbreaks can occur (Yu et al., 2017). While STIs are preventable through screening measures and educational awareness, there are an estimated 20 million new cases of STIs in the United States each year (The Office of Disease Prevention and Health Promotion, n.d.). The increased prevalence of STIs in the United States is a significant health outcome that must be assessed. The multitude of positive cases can be impacted by the integral role that providers play in the treatment and prevention of the acquisition of STIs, being fundamental to creating a culture of health. Providers in the health department setting primarily consist of nursing staff; therefore, the providers discussed in this project will be registered nurses. Curry et al. (2022) express how prevention, management, and treatment rapidly evolve, requiring providers to remain updated on guidelines and best practices for screening, preventing, and treating STIs. For best practices to be implemented accordingly and educational attainment to be effective, providers must be aware of and participate in understanding and decreasing the stigma surrounding STIs, including internal and external biases. Yu et al. and Bonett et al. (2017; 2020) express the importance of reducing the stigma surrounding STI acquisition, revealing a need for education supported by a co-production of 4 inferred knowledge and a lack of accuracy. Unaddressed stigma and reliance on inferred knowledge attend to the notion of prejudice and biases surrounding STIs shaped by social constructs. By giving providers the appropriate knowledge and the ability to reflect on their preconceived notions of STIs, their screening abilities can be impacted. In conjunction with promoting health, the continued goal of health departments is to create an improved culture of health in the United States. Curry et al. (2022) show how providers play essential roles in addressing STI rates through testing, treatment, and the delivery of preventative services. Provider educational attainment is a fundamental factor in achieving this essential role. Providers practicing in private sectors must ask open-ended sexual history questions as part of routine medical history at clients’ annual and ER/urgent care visits. A lack of sexual history taking among private providers dramatically contributes to the stigma surrounding STIs and missed opportunities for correctly diagnosing and treating clients with approved CDCrecommended regimens. One way to improve this standard of care is by equipping providers with the education necessary to impact client understanding. In return, this will make possible improvements in incidence rates. This MSN project aims to educate registered nurse providers in public health departments on STI prevention strategies to increase client screening rates. Statement of Problem While the research and statistics on the prevalence of STIs support increased provider education to decrease prevalence rates, incidence rates are still growing. Of the 325,719,178 residents in the United States in 2021, 1,758,668 tested positive for chlamydia; 583,405 tested positive for gonorrhea; 1,023,832 tested positive for HIV/AIDS (Bach & Heavey, 2021; SparkMap, 2022). Additionally, between the years 2017-2018, the prevalence of syphilis in the United States had a substantial increase in cases, with more than 35,000 positive cases 5 discovered. Change in knowledge starts with educating providers on evidence-based clinical practice changes that, as reflected by Kteily-Hawa et al. (2020), will help promote behavioral change and reduce stigma. However, gaps remain in designing interventions that encourage knowledge change and reduce stigma. Closing these gaps starts with increasing provider education so they are better suited to educate their clients. A proactive intervention that can impact and improve rates of HIV acquisition is the implementation of Pre-exposure prophylaxis medication (PrEP). Several studies discuss PrEP implementation as an important connection in the prophylactic prevention of HIV (Bonett et al., 2020; Bonner et al., 2022; Currey et al., 2022; Yu et al., 2017). Providers must understand the implications of using PrEP and how to succinctly relay this information to clients. The uptake of PrEP-eligible individuals and proper condom use can impact the transmission and acquisition of HIV while promoting awareness of other STIs that can aid in decreasing prevalence rates among high-risk individuals. Bonner et al. (2022) point out how, while PrEP is an effective tool in preventing HIV acquisition, providers inadequately utilize it. While PrEP is not new, its use to promote prophylactic prevention of HIV is a new concept that providers must be aware of to discuss with clients at risk for HIV acquisition and implement accordingly. Ways Project Contributes to Intended Recipients Improvements in provider education equip them with the tools and resources necessary to implement a change in practice to improve health outcomes. Client education starts at the source, with the providers acquiring knowledge to help them confidently treat and educate their clients. When providers are confident in their understanding of materials, their clients will be more receptive to what is being taught. Educational interventions are pivotal to improving provider screenings (Romo et al., 2019), with the implementation of dyadic interventions holding 6 promises for improvements in education, counseling, and access (Trent et al., 2022). When providers have the necessary and proper education, they can more readily pass down their knowledge to clients in an easily understandable way. By doing so, providers will be better able to advocate for their client’s needs due to this knowledge. Rationale for Importance of Project The implications of this project are two-fold. Providers gain invaluable knowledge by improving their understanding of STIs and how they can impact the rising rates in their communities. This new information is then passed on to clients, which will, in turn, aid in decreasing prevalence rates, increasing screening, and increasing treatment rates. Curry et al. (2022) discuss how providers are essential in addressing the increasing STI rates in the U.S. through screening, treatment, and prevention strategies. Addressing the gaps in knowledge concerning screening, treatment, and prevention strategies is fundamental for provider growth and educational attainment. These also correlate to gaps in care, such as PrEP referral, treatment education, obtaining a client’s sexual history, and the importance of screening, all of which start with provider education. This project will assist in decreasing these gaps in knowledge and care by reducing the prevalence rates of STIs, improving sexual health outcomes, improving provider education, and creating a culture of trust and acceptance. The review of literature reflects how some clients do not seek out STI education related to a lack of fear, which can be generalized to mean a lack of understanding concerning the severity of the impact that STIs have (Bonett et al., 2020; Bonner et al., 2022; Romo et al., 2019; Yu et al., 2017). Decreased provider understanding and stigma contribute to the lack of understanding by clients; therefore, educating providers can help to close this gap in knowledge and care. 7 Enhancing provider education on sexual health topics and open-ended communication can strengthen the provider-patient rapport, helping to reduce STI morbidity and improve sexual health outcomes. Bach and Heavey (2021) mention that current processes are falling behind, and the resources utilized to identify, treat, and prevent STIs are strained. The straining and failing of existing resources reiterate the importance of and need for education by providers and why it is crucial to stay on top of the ever-changing field of nursing to provide the best care possible. This project will improve registered nurse processes in county health departments by providing the tools necessary to support nursing efforts in building client rapport. In return, these steps will enhance client compliance with appointments and treatment, decreasing rates of STI transmission. Literature Review and Framework There is a rise in preventable STIs in the United States related to providers' need for more provisions in education and prevention strategies and non-compliance by clients. The following sections will address the review of the literature that took place that was accumulated to form the background and support of this project. The framework guiding the flow and implementation of this project will also be discussed. Framework The framework/EBP model chosen to guide this project is the Rosswurm and Larrabee model. This model focuses on an organizational process with these key steps: (1) assess the need for change in practice; (2) link problem interventions and outcomes; (3) synthesize best evidence; (4) design a practice change; (5) implement and evaluate the change in practice; and (6) integrate and maintain the changes (White, 2021). This model is further discussed by LibGuides: Nurses’ Guide to Evidence-based Practice: Models/Frameworks (n.d.) as a model 8 that supports evidence-based practice changes by combining quantitative and qualitative data, clinical expertise, and contextual evidence. With the basis of this project being a quality improvement project aimed at improving nursing processes, this framework flows well with and supports the project’s intent. The application of this model for a quality improvement project is further supported by Jie et al. (2017) in their review of how the model assists in providing a clear and smooth guiding framework for providers. This review includes how to carry out evidencebased practice changes, identify problems, obtain evidence, and promote the transformation and application of their found evidence into practice. The Rosswurm and Larrabee model applies to the MSN project by establishing key steps for implementation. The problem to be addressed lies within a gap in the knowledge of providers and the prevention of the acquisition of sexually transmitted infections in sexually active adults. Linked interventions, such as increasing provider education to outcomes that will improve the identified problem, question, or gap, are then identified. Information is gathered and synthesized to support the need for improvements in provider education. This data is then pieced together to form the foundation for a change in provider practice, with the backing of evidence-based practice solutions to be presented. Changes by providers, such as increased comfort in obtaining sexual health histories, decreased internal biases and stigma, increased open-ended questionnaires, and increased PrEP education, are then implemented into practice and undergo a series of evaluations to ensure the transition is smooth and has the intended effect. If these steps are implemented successfully, the final step in maintaining the integrated practice change can be accomplished and is a necessary process that must be continuously evaluated to improve health outcomes. Following the steps outlined in this model makes this project's successful completion and implementation possible. 9 Strengths and Limitations The Rosswurm and Larrabee model is well-constructed and outlines the steps to complete an evidence-based practice change. The strengths of this model are highlighted by Jie et al. (2017) in their review of how the model assists in providing a clear and smooth guiding framework for providers to carry out evidence-based practice change, identify problems, obtain evidence, and promote the transformation and application of their found evidence into practice. Due to the complexity and tedious nature of the model, limitations regarding time barriers can pose obstacles. In addition, the model’s inclusion of maintaining the proposed change may pose barriers in facilities with limited provider engagement or resources for continuance. Analysis of Literature Three major themes were identified during the literature search. Education is needed towards implementing pre-exposure prophylaxis (PrEP) therapy in patients at risk for HIV or those who test positive for other STIs, especially syphilis. Improving provider understanding and conscious effort to decrease provider biases and stigma related to STI acquisition is essential in improving screening and treatment rates. This will also assist in educating clients, aiding in decreasing biases and stigma they experience. Enhancing provider capabilities in screening techniques and their ability to relay information in a way that is understood without sounding judgmental is necessary to decrease the prevalence rates of STIs while also building rapport with clients. Search Strategies The databases utilized to acquire articles were CINAHL, MEDLINE, and Health Source: Nursing/Academic Edition. To ensure the gathered information was current and up-to-date, resources for the literature review were used only between 2017 and 2022. To further assist in 10 collecting articles, keywords such as sexually transmitted infections, intervention, education, resources, teaching, prevention, qualitative, quantitative, systematic review, practice guidelines, case studies, PrEP, success, and EBP were used. In addition, various Boolean phrases such as “PrEP AND quantitative research” were used to broaden the search for information. Pre-Exposure Prophylaxis Education Several studies found that pre-exposure prophylaxis (PrEP) is an important connection in the prophylactic prevention of HIV. In July 2012, the FDA approved tenofovir disoproxil fumarate/emtricitabine (Truvada) for use as PrEP medication, marking a new chapter in the history of the HIV epidemic. More recently, a second medication for PrEP, emtricitabine/tenofovir alafenamide (Descovy), was approved for cis-gendered men and transgender women (Bonett et al., 2020). Cis-gendered, as defined by Merriam-Webster (2022), is the sex corresponding to the sex assigned at birth; transgender is defined as a person whose gender identity differs from the sex the person was assigned at birth. The development of these prophylactic medications is important due to their impact on the HIV epidemic. Their development and dispersal helped to change the lives of multitudes of individuals affected by HIV. PrEP marked the turning point for safer sex practices, improved sexual health, and hope for high-risk people. Bonner et al. (2022) performed a retrospective, quantitative study (n=146) among general internal medicine (GIM) patients with a positive syphilis test from 8/1/2018 (preintervention) and 1/1/2019 (post-intervention). The authors found no statistical significance between rates of PrEP prescriptions between the pre-and post-intervention groups (p = 0.72). This absence of significance can possibly be attributed to a lack of understanding by participants on the importance or impact of PrEP – a reflection of inadequate teaching by providers, further emphasizing the importance of improved provider education. 11 Despite the research supporting the implementation of PrEP, its use has still met resistance from clients and providers. The qualitative studies completed by Yu et al. and Auerbach and Hoppe (2017; 2015) found a negative correlation between the willingness to use PrEP and having condomless sex. This finding poses a growing concern that PrEP will erode condom use programs and increase acquisition vulnerability. In addition, Curry et al. (2022) report how PrEP, if taken daily, is recommended for HIV prevention in high-risk individuals. Bonner et al. (2022) review several approaches that promise to increase PrEP uptake for highrisk populations. These approaches include direct patient outreach, peer outreach, home-based services (i.e., home visits for PrEP distribution and counseling), leveraging local health department services, and utilizing a PrEP coordinator. Providers must be educated and collaborate with a multidisciplinary care team for these approaches to be viable and successful. PrEP lowers the risk of HIV transmission and acquisition. Provider education about PrEP implementation is essential. Increasing awareness of the importance of PrEP uptake, advancements can be made toward implementing primary intervention measures in preventing STI acquisition. Mayer et al. (2015) expressed how one of the most significant barriers to providing PrEP is the reticence of healthcare providers due to concerns surrounding behavioral disinhibition, risk compensation, costs, and potential toxicities. Beyond adherence to PrEP implementation, Auerbach and Hoppe (2015) discuss how implementation will require understanding how individuals and communities comprehend it. The study posed several questions: “Will those taught believe in Prep’s effectiveness? Will they trust the agencies and individuals promoting its use? Will they have access to financial support? Perhaps most important, will those at risk recognize themselves to be at risk, and if so, will the risk be significant enough to engage in prevention?” (Auerbach & Hoppe, 2015, p.32). To answer these 12 questions effectively, providers must engage in the appropriate knowledge attainment to pass along information in a way that is easy to understand. This education can be accomplished through attending sexual health training, conferences, and one-on-one consultations with sexual health and STI subject matter experts. Tackling Biases and Stigma A relationship between provider stigma and the ability of a provider to provide proper screening measures for at-risk clients was identified in the literature (Bonett et al., 2020; Bonner et al., 2022; Kteily-Hawa et al., 2020; Romo et al., 2019). Improving understanding and decreasing biases and stigma in providers related to STI acquisition is essential in improving screening and treatment rates. Kteily-Hawa et al. (2020) developed a community-based, peerfacilitated, mixed methods interventional research study (n=78) among South Asian women. Statistical significance was found (p = 0.03) regarding knowledge after implementing and comparing the utilization of story-based versus fact-based questionnaires. The implementation of story-based questionnaires was found to have contributed to increases in HIV/STI knowledge, comfort in the discussion of sexual history, and reduced stigma towards HIV/STI topics. Adversely, fact-based questionnaires could lead to increased stigmatization and apathy toward the relevancy of sexual health information. Nursing, physician, and staff discomfort directly impact obtaining a brief sexual health history (Romo et al., 2019), and stigma further affects the delivery of health services (Bonner et al., 2022). Physicians also report time restraints and discomfort as personal barriers affecting STI testing. The impact included issues in reporting, fractured sexual health care systems, and the stigmas surrounding disclosure of risk behaviors that continue to challenge providers and health systems. Additionally, in a qualitative study completed by Yu et al. (2017) (n=18), a need for education is supported as evidenced by a co- 13 production of inferred knowledge and lack of true knowledge that attends to the notion of uncleanliness and stigma shaped by the social construct of perceived understanding in communities. The importance is shown in how decreasing provider stigma facilitates an environment conducive to growth and health improvement. Improving Provider Screening and Understanding Providers play an integral role in the treatment and prevention of the acquisition of STIs. Trained providers must employ essential skills to prevent STIs (Shi & Singh, 2022), use educational interventions to improve screening rates (Rome et al., 2019), and implement the collection of a sexual health history into practice (Jones & Barton, 2004). These skills include good communication skills that encompass an establishment of rapport with clients and the ability to ask open-ended questions and listen—using open-ended communication by providers assists in initiating and completing a thorough sexual history assessment. Furthermore, these skills encompass positive attitudes that reflect respect, empowerment, trust, and an approach that incorporates the principles of holistic care. Jones and Barton (2004) examine the provision of a sexual history by providers and how doing so is thought to hold the key to the practice of sexual health medicine. Their discussion reflects on how a brief sexual health history can form the basis for treatment, prevention, education, and sexual health promotion and how a lack of doing so contributes to the fragmentation of our nation’s sexual health (Jones & Barton, 2004). Additionally, facilities can benefit by increasing client retention when providers show sound knowledge and genuine concern for best practices in STI screening, treatment, and prevention. This starts with improving provider education (Curry et al., 2020; Trent et al., 2022) to decrease prevalence rates and increase client compliance and understanding. To implement these practices, providers must address time constraints and perceived discomforts to provide 14 quality care (Romo, 2019) while utilizing the knowledge they have gained to implement a change in their behavioral practice (Kteily-Hawa et al., 2020). To assist in implementing this change in practice, a dyadic approach for behavioral change regarding improving sexual health education and counseling and enhancing access to sexual health services holds promise (Trent et al., 2022). Providers' implementation of dyadic interventions holds promise for instituting communal coping within relationship dynamics to enhance sexual decision-making, communication, and behavior changes to reduce the future risk of STIs. Equipping providers with the tools necessary to make informed and evidence-based changes in their practice can improve sexual health outcomes for clients. Summary of Literature Review Findings and Application to the Project The literature review reflects a need for providers to address internal biases and stigma associated with screenings and treatment of STIs. The inclusion of PrEP education and implementation by providers is pivotal to creating a culture that assists in preventing individuals deemed high risk from procuring HIV. For this to become a reality, eligibility for PrEP must be determined by completing a thorough sexual health history assessment (Bonner et al., 2022). Providers play a critical role in preventing, managing, and treating STIs; therefore, it is imperative for providers to be versed in current guidance to diagnose and treat STIs and incorporate this guidance into routine practice. Literature review findings support the goal of implementing educational opportunities for providers regarding the importance of sexual history taking, open-ended communication, and training to reduce stigma and biases. Project Methodology This MSN project aims to educate Registered Nurses (RNs) in public health departments on STI prevention strategies to increase client screening rates. Four deliverables have been 15 created to promote this project’s introduction and implementation within the district’s county health departments. The deliverables include (a) an RN presentation on screening strategies and PrEP use, which will include an outline of teaching points and assessment strategies, (b) a provider and client handout that encompasses STI information such as signs and symptoms and frequently asked questions, (c) the development of a QR code that is easily accessible and takes users to the state’s website for sexual health and harm reduction and (d) printable signage that can be hung in clinics in the form of posters or flyers. To assess caregiver understanding of the education being implemented, sexual health training, conferences, and one-on-one consultations with a sexual health and STI subject matter expert can be utilized. Description and Development of Project Deliverables Four items were created to aid in the implementation of this project. In this section, the deliverables are described in detail. In addition, a brief explanation of the rationale for the use of each deliverable is also included. PrEP Implementation PowerPoint The first deliverable is a PowerPoint presentation (see Appendix A). The exhibition aims to educate providers on the important implications of using PrEP. The exhibit includes a detailed description of what PrEP is and the benefits of its use derived from current literature (Bonner et al., 2022; Bonnett et al., 2020; Currey et al., 2022; Yu et al., 2017). The presentation will help caregivers understand the importance of PrEP’s use, how to appropriately refer clients for its use, and the implications behind PrEP utilization and uptake. Additionally, after reviewing with RNs showing understanding, this deliverable will allow for opportunities to assess understanding of the information using the teach-back method or facilitating open-ended questions. 16 Provider and Client Handouts Educational handouts were developed to be utilized by providers and clients (see Appendix B). The handout will contain information gathered from current health department resources and literature about STIs, their prevalence, signs, and symptoms, and frequently asked questions. (Bach & Heavey, 2021; Romo et al., 2019; SparkMap, 2022). Public Health RNs will utilize the handout to teach clients about the prevalence of STIs, signs, and symptoms, and how to answer frequently asked questions through open communication and improved sexual history taking. This deliverable will benefit providers and clients by creating an intermediary for active engagement. Informational QR Code The third deliverable is the development of a QR code that is easily accessible and takes users to the state’s website for sexual health and harm reduction. The rationale for utilizing a QR code lies within societal reliance on technology in their everyday lives. The QR code (see Appendix C) will be implemented by incorporating it on handouts, and informational posters, displaying it at clerical windows, and making it accessible in clinic rooms and around the community. Public Health nurses can promote using the QR code at STI visits and utilize it as a quick reference should a question arise. Utilizing this deliverable can be helpful when the nurse or clerical staff are unsure of an answer, assisting in passing down information as a collective effort (Kteily-Hawa et al., 2020). The ease of use and direct reference to materials makes this deliverable ideal for quick and easy educational guidance. Posters and Fliers The final item created for this project is clinic posters and fliers (See Appendix D). The use of these resources can not only be utilized in clinics but also distributed around the community for access and quick reference. The rationale for using posters and fliers lies within 17 the advertisement of services these resources offer, being fundamental to spreading the word in the community about the services clinics offer and aiding in answering clients’ questions. Utilizing the information provided by the posters and fliers fosters an environment and opportunities to utilize the information to implement a change in a provider’s practice (KteilyHawa et al., 2020). Further utilization offers the multidisciplinary care team more opportunities for education and the promotion of services. Plan and Implementation Process This MSN project will be implemented after officials of the Oklahoma State Department of Health (OSDH) have conducted a review process to ensure validity and reliability. Once the review process is completed, and utilization and implementation have been cleared, the next step will be to roll out the changes to the coordinating nurses in county health departments and gain support while delineating the information to their staff. Coordinating nurses can relay the information and proposed changes to their team by utilizing time during their weekly morning meetings. These meetings will take place in the conference rooms already used in each health department. Each session will provide an opportunity to gain support for changes from the staff to improve their understanding of changes and create allotted time for any questions staff may have. The meetings will allow for the utilization of the presentation and explain the project deliverables. The project will be introduced to the health department team, including nurses, leadership, and clerical staff, with the objective, emphasized to gain their support. At this point in the meeting, deliverables will be distributed to staff in attendance to have a hard copy for reference. The presentation will include the rationale for providing the RNs with teaching points and assessment strategies. 18 Next, a discussion will occur, including how to present the handouts, utilization of QR codes, and a questionnaire that reflects retained knowledge over the presentation. The RNs will then use what they have learned to distribute the handouts, QR codes, and other deliverables for public use. Finally, the nurses will educate staff on using each of the deliverables; this will occur during regular staff meetings after the initial training should additional questions or understanding arise. Ideally, morning meetings will allow open communication to address concerns and collaboration, free of noise and distractions. Interdisciplinary Teamwork The success of this project requires a collaborative effort among providers and the multidisciplinary care team. Collaboration enables members of the health department team to succeed by improving provider screenings and client outcomes. Each team member will have a part in the implementation of this program. For the implementation of this project to be successful, it will require an understanding of how individuals and communities comprehend it (Auerbach & Hoppe, 2015). The coordinating and project lead will collaborate on the assembly and distribution of deliverables. The district nurse manager and assistant district nurse manager will aid in distributing the information to district health departments so that they can implement the proposed changes district-wide. The community outreach coordinator will work with the health planning coordinator to provide outreach and distribute resources more readily in the district’s communities. The social media officer will be best suited to disseminate information among the state’s social media platforms. Collaboration with the state’s Rapid Start Supervisor and Sexual Health and Harm Reduction team will assist in implementing this project into state training. Lastly, incorporating a combined effort will help complete follow-up analyses to ensure a thorough and complete data assessment for evaluation. 19 Coordinating Nurse. Coordinating nurses at county health departments hold a BSN degree or higher. Each coordinating nurse is responsible for ensuring that any changes to protocols or practices are communicated to staff, making them a key factor in rolling out the proposed changes from this project. In addition to sharing and passing on information, the coordinating nurse must also allow time during working hours for their team to receive training on new processes and review new deliverables for staff and clients. Coordinating nurses are pivotal to their health department’s success, as they act as mediators for new information and encourage team members to promote the implementation of this project. Once the information is passed down, health department RNs can implement the information they have learned into practice and assist in reinforcement teaching to other staff. District Nurse Manager (DNM) and Assistant District Nurse Manager (ADNM). Once the project implementation is approved, the DNM and ADNM will aid in distributing the information to district health departments so that they can implement the proposed changes district-wide. The DNM and ADNM act as mediators for the district, communicating any changes in practice or protocols. Their role is essential for district-wide communication and collaboration. Community Outreach Coordinator and Health Planning Coordinator. The community outreach coordinator will work with the health planning coordinator to provide outreach and distribute resources more readily in the district’s communities. Community outreach coordinators are responsible for developing and executing programs that engage the community in meaningful ways and promote positive relationships between these groups and their communities (CLIMB, 2022). The role of the health planning coordinator lies in synchronizing the planning, development, implementation, and evaluation of health improvement plans, 20 systems, and initiatives on a district-wide level (Oklahoma State Department of Health, 2023). Both roles are necessary for the district-wide implementation of this project. Social Media Officer. The state’s social media officer plays a significant role in distributing information among the state’s social media platforms. This officer is uniquely suited to distribute information due to their access to and upkeep of the state’s social media platforms. Due to society’s reliance on technology, especially the younger generations, using social media to communicate information is practical and necessary. Rapid Start Supervisor and Sexual Health and Harm Reduction Team. The rapid start supervisor and team collaboration are pivotal to implementing this project into state training. The Rapid Start Supervisor can utilize the information, specifically over PrEP, to assist in further implementing educational materials from the project. Collaboration with the Sexual Health and Harm Reduction Team will allow the project’s intent to be implemented in state training to further educate providers, especially new employees. Timeline Including a detailed timeline will assist the project lead in organizing the implementation of this project. Implementation will require coordination among interdisciplinary care team members to ensure that all aspects of the project are reviewed and delineated appropriately. Health department teams must schedule an education meeting to deliver a presentation of the project and its deliverables. Depending on the size of the county health department, a thirtyminute to a one-hour session should be adequate, allotting more time as needed. The deliverables will be produced and ready for distribution prior to the scheduled meeting. The implementation of this project will begin as soon as there has been review and clearance from state officials. The goal for implementation into practice will be within one month of the initial presentation. 21 Allocation of time will be implemented to review proposed changes so that questions and concerns may be addressed. Coordinating nurses will present the handouts and copies of the presentation to staff at the initially scheduled meeting. Staff will begin implementing and distributing new materials as soon as they receive instruction on these materials and their questions are answered. Health Department RNs and Coordinating Nurses will act as mediators to answer questions, offer support during this interval, and produce a checkoff sheet to evaluate staff on understanding and implementation. Health department RNs will collaborate with their respective Coordinating Nurses to complete a review of charts and client attendance rates to review the effectiveness of implementation. The suggested timeframe for planning, implementing, and evaluating this MSN project will span approximately two months (see Appendix E). Plan for Evaluation of Project The success of this project will be determined by comparing the results from the pre-and post-education implementation by review of client attendance rates for screening and treatment through auditing their charts and reviewing the electronic health record (EHR). An increase in attendance rates post-education will indicate if the provider’s education was successful. Provider understanding can be assessed by implementing a checkoff sheet to utilize in observing staff teaching, with implications to be incorporated into current skills checkoffs. In addition to the implementation review discussed in the provided timeline, a quarterly and annual review will assist in gaining insight into the effectiveness of implementing the improvement program for provider education for the intervention of STI acquisition prevention. With the information gathered from these reviews, providers can determine if the program’s learning objectives have 22 been met. Providers will be better suited to address obstacles toward outcome completion and make modifications as needed. Ethical Considerations Several ethical considerations must be considered and addressed for this project. Clients have a right to treatment regardless of age, sex, socioeconomic factors, or sexual identity. For best practices to be implemented accordingly and educational attainment to be effective, providers must be aware of and participate in understanding the stigma surrounding STIs, including internal and external biases (Bonett et al., 2020; Yu et al., 2017). Discussing STIs and obtaining a thorough sexual health history can be uncomfortable for providers and clients. Nurses, physicians, and additional staff may feel embarrassed when obtaining a brief sexual health history (Romo et al., 2019), with further stigma negatively affecting the delivery of health services (Bonner et al., 2022). Therefore, providers must address these feelings of unease and make every effort to ensure that clients remain comfortable – ensuring they understand that anything discussed is strictly confidential. This project is essential because the goal is to ensure caregivers receive training on recognizing stigmas and internal biases and proactively managing them to deliver quality care. Providers’ personal opinions must also be considered when preparing to implement new processes affecting their day-to-day operations. Participation is not necessarily mandatory, and providers may resist change, especially seasoned nurses who are used to doing things a certain way. Although the overall goal is to help providers improve their interventions for clients, providers must not feel pressured to do things they are unprepared to do. The importance of open communication to allow for questions and evaluations of understanding is seen here. Doing so will ensure that staff is comfortable implementing the proposed changes and that any concerns 23 may be addressed. Nurses must exercise patience and recognize that additional education may be needed to ensure that implementation and staff succeed. The final ethical consideration is the implications imposed by the Health Insurance Portability and Accountability Act (HIPAA). Due to the analysis of patient records to determine the effectiveness of education implementation, following these guidelines is of utmost importance. To do that, Wise (2020) has developed a HIPAA compliance checklist that illustrates the rule changes introduced over the last 25 years and will serve as a detailed but easy-to-understand HIPAA compliance guide. By following the guidelines outlined in this compliance checklist, we can be sure that we follow the proper guidelines to remain HIPAA compliant throughout the program intervention. Discussion In review, providers must tackle internal biases and stigma associated with screenings and treatment of STIs. Included during educational attainment by providers is PrEP implementation for high-risk individuals that will aid in preventing HIV acquisition. Providers play a crucial role in preventing, managing, and treating STIs. It is imperative for providers to be versed in current guidance to diagnose and treat STIs and to incorporate this guidance into routine practice. The factors’ impact extends to identifying eligible PrEP candidates, which challenges providers and health systems to complete thorough sexual health histories and identify those at risk (Bonner et al., 2022). Creating educational opportunities for providers on the importance of sexual history taking, open-ended communication, and training to reduce stigma and biases is critical to successfully addressing STI morbidity and improving sexual health outcomes in communities. This section will dive deeper into and address implications for this project, project dissemination, and recommendations. 24 Evidence-based Solutions for Dissemination The dissemination of this project will be completed through several avenues. Dissemination will begin through a poster presentation for peers and graduate faculty at Weber State University (WSU). The same poster presentation will be presented to clinic faculty and staff during staff meetings to ensure attendance and allow for questions. For disseminating information regarding PrEP education, the PrEP PowerPoint (Appendix A) will be used in conjunction with the poster presentation. At the end of month two, post-implementation, the project results will be further disseminated by comparing the pre-and post-education implementation results by reviewing client attendance rates for screening and treatment through chart auditing and EHR review. This data will be distributed to state leaders to assist in reflecting on the project’s success and allow for evaluation and incorporation of any needed changes. This time of evaluation and dissemination of data with leadership will assist in determining if this practice change is working or if there is a need to re-evaluate its implementation into practice. Significance to Advance Nursing Practice This project will benefit public health providers by assisting them in gaining invaluable knowledge to improve their practice by increasing their understanding of STIs and the resulting impact the education received can have on the community. The significance providers play in STI prevention is discussed by Curry et al. (2022), and how providers are essential in addressing the increasing STI rates in the U.S. through screening, treatment, and prevention strategies. This significance supports this project’s implications for advancing nursing practice in the public health sector. In addition, significance can be seen in how the implications of it can impact clients and assist in decreasing STI prevalence, increasing screening rates, and increasing rates of treatment. Several resources discuss the implications of a lack of provider education on a client’s 25 aptness concerning STIs and their impact (Bonett et al., 2020; Bonner et al., 2022; Romo et al., 2019; Yu et al., 2017). Therefore, enhancing provider education on sexual health topics and open-ended communication can strengthen the provider-patient rapport, reduce STI morbidity and improve sexual health outcomes. Implications The strengths of this project lie in how it prepares public health RNs to know how to conduct thorough sexual health histories, implement open-ended questions, and make a conscientious effort to improve their screening skills. The project also provides the tools to educate staff and clients in identifying needs and addressing concerns appropriately. Additionally, training providers using sexual health training, conferences, and one-on-one consultations with sexual health and STI subject matter experts will assist providers in gaining confidence in completing screenings. The completion of accurate screenings and the resulting improvement in sexual health outcomes in clients will assist providers in gaining a sense of fulfillment in their practice. Limitations of this project are impacted by the small population size that can interfere with participation. In addition, maintaining the proposed change may pose barriers in facilities with limited provider engagement or resources for continuance. However, once the project is implemented and takes off, utilization of its teachings into practice district-wide can increase engagement and participation. Despite implementation on a large scale, lack of cooperation by providers can pose another limitation for this project. Many providers have a set way of doing this and may see this as another way of adding more work to an already abundant field of protocols. For there to be a collective understanding of the importance of this project, 26 communication efforts must be instituted to assist in understanding the implications of adding more work that comes with efforts to improve quality care and outcomes. Recommendations The literature review revealed a rise in preventable STIs in the United States related to providers’ need for more provisions in education and prevention strategies and non-compliance by clients. While there were many discussions on ways for improvement and factors that impede doing so, studies did not reflect a singular change for best practice. Reflection shows that each facility has different needs and capabilities; therefore, finding the best work should be the standard. The recommendations for this project reflect efforts that have the potential to be successful in a public health setting. Therefore, an abundance of possible solutions reflects the need for additional research to determine the most successful methods in improving provider education so that a more straightforward approach may be implemented. Conclusions Preventable STIs are common, costly, and highly prevalent, with about 26 million occurring yearly in the United States, 20 million of these cases being new (Curry et al., 2022; The Office of Disease Prevention and Health Promotion, n.d.). A gap in provider understanding contributes to the increased prevalence of STIs, influenced by a lack of understanding, confidence, stigma, and internal biases. Additionally, the decreased pursuit of STI education can be attributed to a lack of fear, generalized to mean a lack of understanding surrounding the severity that STIs have on health (Bonett et al., 2020; Bonner et al., 2022; Romo et al., 2019; Yu et al., 2017). As reviewed by Bach and Heavey (2021), current processes are falling behind, and the resources utilized to identify, treat, and prevent STIs are strained. The shortage of existing resources reiterates the importance of and need for education by providers and why it is crucial 27 to stay apprised of updates for best practice techniques to provide equitable care, promote continuous quality improvement, and improve sexual health outcomes in the public health sector. 28 References Auerbach, J. D., & Hoppe, T. A. (2015). Beyond “getting drugs into bodies”: Social Science Perspectives on pre-exposure prophylaxis for HIV. 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R., Reimer, J., & Lorway, R. (2018). “I'm more aware of my HIV risk than anything else": syndemics of syphilis and HIV among gay men in Winnipeg. Culture, Health & Sexuality, 20(9), 1036–1048. https://doi.org/10.1080/13691058.2017.1411975 32 Appendix A Presentation on PrEP Efforts in the US. https://d.docs.live.net/acbd81297eaf97b0/Documents/NRSG6802_HarrisM_PrEP_Presentation_ 01_22_23.ppsx Presentaon on PrEP Efforts in the U.S. Mahew Harris BSN, RN, MSN Student What is PrEP? Pre-exposure prophylaxis HIV prevenon 33 Prevalence Public Health Priority 37,881 Diagnoses Medicaons Truvada Descovy Racial/Ethnic minories 34 Implicaons of PrEP Substanal protecon from HIV infecon Partner knowledge/cooperaon not required Protecon from sexual transmission Protecon from shared needle use Safe and well tolerated Key Barriers Cost Access Sgma Adverse Effect Concerns 35 State Level Social Policies Civil Rights Act of 1964 & 1968 HIV Criminalizaon Laws Funding Affordable Care Act Ryan White Comprehensive AIDS Resources Emergency (CARE) Act 36 PrEP to Need Rao Non-Discriminaon Laws Employment Housing Public Accommodaon Credit State Employment 37 Analysis Descripve Stascs Least Squares Mulple Regression Model Regression Diagnoscs Limitaons Ecological analysis at state level Limited only to statutory criminalizaon laws Cross-seconal design 38 Study Results Median of 1,147 PrEP Users Median of 389 new diagnoses of HIV 36 states had criminal exposure laws 36 states had at least 1 non-discriminaon law 36 states implemented Medicaid expansion References Bonett, S., Meanley, S., Elsesser, S., & Bauermeister, J. (2020). State -level discrimination policies and HIV pre -exposure prophylaxis adoption efforts in the U.S. Health Affairs, 39(9), 1575 –1582. https://doi.org/10.1377/hlthaff.2020.00242 39 Appendix B Provider Handout 40 Appendix C Informational QR Code 41 Appendix D STI Clinic Poster 42 Appendix E Timelines Project Implementation Timeline Week 1 Meet with DNM, ADNM, and Coordinating Nurses to review the project and schedule implementation. (One hour.) Week 2 Produce and ready deliverables for distribution. (Two days.) End of Month 1 The program is introduced to providers in all Health Departments in the district. PowerPoint presentation to the health department team. (Approximately 30min to one hour.) End of Month 2 RNs complete the postimplementation review. Evaluate the program and make necessary improvements. Ongoing Continue to evaluate the program. Implement improvements as needed. Health Department RNs begin introducing the program to staff. Caregiver Timeline Within the first week of implementation Providers will implement a checkoff sheet to observe staff teaching in practice. RN will introduce the program, present the handouts, and educate staff on changes. Two weeks after the program introduction Providers will complete a post-implementation review to assess if changes are being implemented smoothly and address any barriers to implementation. Ongoing RNs will continue to assess provider understanding and provide support and additional education when needed.