Please can you rewrite this paper below
This DNP project had some strength for a QI project. The chosen clinic has a strong deprescribing in the elderly ethics but still lacks a simple and standardized tool to identify polypharmacy in the elderly. The use of an ARMOR assessment tool is an effort to approach polypharmacy in a systemic and organized fashion (Haque, 2009). The data collected during the literature review provided important guidelines and produced the best practice recommendation regarding the importance of using an assessment tool for reducing polypharmacy in the elderly. The creation and the implementation of ARMOR assessment tool may prove to be the missing link in reducing elderly polypharmacy in the primary care settings. Another strength was the ability to download the ARMOR tool online for easy access and used by clinicians. A bonus is that the clinic has a director who is a medical professor with whom the DNP student has previously worked with and who had full support and trust in the DNP student in conducting the project. Easy access to these resources made it simpler for the clinicians to incorporate ARMOR assessment tool into their clinical practice.
A major weakness to the project was lack of polypharmacy guideline that is nationally accepted in the United States: Hence, guidance developed by NHS Highland/NHS Scotland was used for data collection and staff education. Another challenge was the unwillingness of some clinicians to accept the ARMOR tool as a measure to reduce polypharmacy. The time constraint poses another challenge for this project as some clinicians took some time off and were not able to fully participate in the whole process; some clinicians reported of not having enough time for each patient on every visit to complete medication reconciliation. Some difficult elderly patients’ refusal to have clinicians titrate or discontinued their medication was daily challenge.
Opportunities for the DNP project to take root were the many governmental and health related trends and initiatives created to increase the safety and health education of patients, like the Healthy People 2020 initiative mentioned earlier. The rise in the aging population in combination with the local community demographics of CDOA was another opportunity for the project to succeed and played an important role for both institutions to accept and support this DNP project. Implementation of this project helps standardize and provide quality tool in screening, management, and reducing polypharmacy in the primary care setting. The opportunity to reach more clinicians on how to reduce polypharmacy in the elderly presented itself during the project. In addition, as clinicians learned of the project, many have requested ARMOR assessment tool to be implemented in their private practices.
A threat to the project was an unfamiliarity and a reliance on technology during the ARMOR assessment tool implementation by the IT team. A different tool was uploaded for the clinicians to use for the ARMOR assessment tool training. The IT manager had to be emailed and called on a couple of occasions to streamline access to the tool. After the correct tool was downloaded, clinicians experienced some technical errors messages to access the tool during patient assessment, which caused delay care; clinicians were frustrated in the process. Patients threatening to switch providers was a challenge to most of the clinicians as none of the clinicians wanted to get any grievance from the patients. See Appendix I for the SWOT analysis table.
Responsibility and Communication Matrix
The DNP student was the primarily responsible in the execution and communication of this DNP project. This included synthesizing evidence, designing the project matrix, developing the didactic content, creating the questionnaire and data collection, delivering training, and developing and analyzing project metrics. The DNP chair and committee provided advice and support for the project.
The polypharmacy QI project did not incur any significant expenses. The associated expenditures of designing, implementing, and evaluating this DNP project was mainly related to human resource costs. This includes the expense of utilizing the time for staff education and understand the ARMOR assessment tool and the guidelines in prescribing in the elderly was estimated to be about $350 ($84 x 4 hours). The cost of the project manager’s cost is about $128 ($32 x 4 hours). The time spent by the DNP student to design, implement, and analyze the project were volunteer hours and did to accrue any costs. It is unknown what the clinicians cost were for approximately an hour of in-service for seven physicians, five nurse practitioners, and three physician assistants. See Appendix K for budget and expense details.
Study of the Intervention
The quality metrics used for evaluation of the project were measurements related to outcomes, participant/provider experience, and process. Outcomes metrics was utilized to measure the knowledge base of the clinician’s participants before and after the ARMOR tool training session and to assess performance improvements after project implementation in reducing polypharmacy. Another measurement of outcomes was assessing the likelihood of each clinician’s intention to reduce polypharmacy in screening all patients who are 65 years and older utilizing the drug review process adopted from the guidelines for prescribing in the elderly and the ARMOR assessment tool. Analyzing the participants experience in utilizing the ARMOR tool during the implementation phase determined the efficiency and effectiveness of the assessment tool. Process outcome was measured through an evaluation of participant feedback regarding the exercise of accessing and utilizing the ARMOR tool and identifying barriers to using the tool during the educational seminar.
A 21–item questionnaire using a 5-point Likert scale titled ARMOR/Polypharmacy Knowledge Evaluation (APKE) instrument was used to measure project outcomes. A copy of the questionnaire can be seen in Appendix J. Comparing pre- and post- interventional tests scores is a reliable method of measuring knowledge gained and intervention outcomes. The same questionnaire was used for the post intervention evaluation. Also, the pre and post chart review outcomes were assessed to evaluate a reduction in the polypharmacy for the 30 retrospective charts. All 15 clinicians completed the APKE questionnaires who participated in the project pre and post training on polypharmacy reduction in the elderly to assess both pre and post intervention outcomes. According to Colosi (2006), questionnaires are a commonly used method to collect information when evaluating educational programs, which often capture information related to knowledge, attitudes, and behavior which are defined as: knowledge refers to what participants understand about program content; attitude is the participant’s perceptions, feelings, and judgments regarding the topic; and behavior is what people do, will do, or have done related to the area of focus. The APKE questionnaire is an instrument that was composed by the DNP student to measure all three of those concepts. The first five questions are not graded. It’s for identification and screening purposes. Four out of the nine test questions were constructed to measure clinician’s knowledge regarding polypharmacy reduction in the elderly and ARMOR assessment tool.
• Identify your discipline
• About how many years have you been in your current position?
• Have you worked in a previous clinic that utilized polypharmacy assessment tool?
• Do you see patients 65 years and older?
• Do your elderly patients have more than five medications including multivitamins and supplements?
The next five questions check about the clinician’s knowledge on tools/resources available to deprescribe medications in the elderly patients who are 65+.
• Before today’s presentation, I was aware of ARMOR tool to screen all elderly who are =/>65 years on each visit to reduce possible polypharmacy
• Before today’s presentation, I had knowledge of ARMOR tool and guidelines for prescribing in the elderly.
• After today’s presentation, I know how to access and use ARMOR’s assessment tool in reducing polypharmacy in the elderly
• I feel confident in using the ARMOR assessment tool
• The following barriers may prevent me from deprescribing in the elderly: time constraints, competing healthcare demands/problems, and knowledge of how to assess/screen for falls and/or risk factors.
The next four questions measured behaviors related to participant’s intent to change their practice for reducing polypharmacy in the elderly by utilizing the ARMOR tool.
• How likely are you to complete medication reconciliation for my patients on each visit?
• How likely are you to screen the elderly who are 65 years and over for possible polypharmacy?
• How likely are you to have sufficient time for each elderly patient who are 65+ on each visit to assess the risks for polypharmacy?
• How likely are you to ask the elderly patient 65+ if they are taking any supplements and multivitamins on each visit?
The following four questions check for medication safety knowledge in the elderly.
• I check for appropriate dosage for patients based on age
• I check for drug to drug interactions on each patient’s visit
• I titrate medications without withdrawals to less than five medications
• I deprescribed medications based on patient’s assessment and medication reconciliation on each visit
The last three questions measure communication among providers in reducing polypharmacy
• I communicate with other clinicians about risk reduction/prevention of polypharmacy in the elderly
• I communicate with other prescribing clinicians immediately if polypharmacy is identified in a patient
• I am likely to discontinue a medication I did not prescribe and communicate that to the prescribing clinician if polypharmacy is identified or possible drug-to-drug interaction is imminent.
• A final open-ended response question was available for participants to provide general feedback.
DNP Project: Reducing Polypharmacy in the Elderly
The questionnaire for both the pre and post analysis were the same using a 5-point Likert scale, in which participants rated their degree of agreement with each response: strongly agree, agree, undecided, disagree, or strongly disagree for questions #1and 2 are for identification purposes, #3 – #5 are for screening purposes with no, no uncertain, and yes options. Questions #6 – 10 are strongly disagree, disagree, neutral, agree, and strongly agree. Question #11 – 14 are extremely unlikely, unlikely, neutral, likely, and extremely likely. The last but not the least, questions # 15 – 21 are never, almost never, occasionally, almost every time, every time. According to Nemoto & Beglar (2014), Likert scale is a psychometric scale that has multiple categories from which respondents choose to indicate their opinions, attitudes, or feelings about an issue. Likert scale is easy to use, popular, and reliable in which most researchers have used in the past. Since participants are accustomed to the process of filling out Likert-type scales, it was a quick and easy way to assess outcomes. In addition, using a Likert scales provided a quantitative approach of measuring results. The purpose of using the single open-ended question was to elicit qualitative responses regarding participant views on the QI project using ARMOR assessment tool as a measure of reducing polypharmacy in the elderly.
Both quantitative and qualitative methods were used to draw inferences from the data. A comparison of the mean was the primary method used to analyze project data. Comparison of the means for the chart review and clinicians’ questionnaire were each calculated and analyzed separately. The goal of the analysis was to demonstrate a trend in positive changes to knowledge (i.e. Reducing polypharmacy/ARMOR tool), attitude (i.e. confidence and barriers) and behavior (i.e. intent to change practice) and served as an indication of project intervention success. This was accomplished by calculating and comparing the mean scores of similar test questions for each category. For instance, comparing the mean score of reducing polypharmacy knowledge/ARMOR tool prior to and following the educational intervention and then determining if the post intervention mean score exceeded the pre -intervention knowledge score. Using the Likert-type questions, the targeted goal was get a mean score greater than 3. A 3 (undecided) on a 5-point. Likert scale represents an unbiased score, and anything higher (4=agree/likely; 5=strongly agree/most likely) demonstrates greater agreement with the concept at hand. Thus, a score higher than a 3 indicates a positive interventional effect like increased knowledge, intent to change practice, and confidence levels. Mean scores lower than a 3 (2=disagree/somewhat likely; 1=strongly disagree/not likely) indicate a negative trend where goal attainment measures are not met. The qualitative method used to analyze the intervention was to scrutinize and categorize clinician’s responses to the open-ended test question and a reflective on elderly care as evidence in post chart review.
Dante Alighieri played a critical role in the literature world through his poem Divine Comedy that was written in the 14th century. The poem contains Inferno, Purgatorio, and Paradiso. The Inferno is a description of the nine circles of torment that are found on the earth. It depicts the realms of the people that have gone against the spiritual values and who, instead, have chosen bestial appetite, violence, or fraud and malice. The nine circles of hell are limbo, lust, gluttony, greed and wrath. Others are heresy, violence, fraud, and treachery. The purpose of this paper is to examine the Dante’s Inferno in the perspective of its portrayal of God’s image and the justification of hell.
In this epic poem, God is portrayed as a super being guilty of multiple weaknesses including being egotistic, unjust, and hypocritical. Dante, in this poem, depicts God as being more human than divine by challenging God’s omnipotence. Additionally, the manner in which Dante describes Hell is in full contradiction to the morals of God as written in the Bible. When god arranges Hell to flatter Himself, He commits egotism, a sin that is common among human beings (Cheney, 2016). The weakness is depicted in Limbo and on the Gate of Hell where, for instance, God sends those who do not worship Him to Hell. This implies that failure to worship Him is a sin.
God is also depicted as lacking justice in His actions thus removing the godly image. The injustice is portrayed by the manner in which the sodomites and opportunists are treated. The opportunists are subjected to banner chasing in their lives after death followed by being stung by insects and maggots. They are known to having done neither good nor bad during their lifetimes and, therefore, justice could have demanded that they be granted a neutral punishment having lived a neutral life. The sodomites are also punished unfairly by God when Brunetto Lattini is condemned to hell despite being a good leader (Babor, T. F., McGovern, T., & Robaina, K. (2017). While he commited sodomy, God chooses to ignore all the other good deeds that Brunetto did.
Finally, God is also portrayed as being hypocritical in His actions, a sin that further diminishes His godliness and makes Him more human. A case in point is when God condemns the sin of egotism and goes ahead to commit it repeatedly. Proverbs 29:23 states that “arrogance will bring your downfall, but if you are humble, you will be respected.” When Slattery condemns Dante’s human state as being weak, doubtful, and limited, he is proving God’s hypocrisy because He is also human (Verdicchio, 2015). The actions of God in Hell as portrayed by Dante are inconsistent with the Biblical literature. Both Dante and God are prone to making mistakes, something common among human beings thus making God more human.
To wrap it up, Dante portrays God is more human since He commits the same sins that humans commit: egotism, hypocrisy, and injustice. Hell is justified as being a destination for victims of the mistakes committed by God. The Hell is presented as being a totally different place as compared to what is written about it in the Bible. As a result, reading through the text gives an image of God who is prone to the very mistakes common to humans thus ripping Him off His lofty status of divine and, instead, making Him a mere human. Whether or not Dante did it intentionally is subject to debate but one thing is clear in the poem: the misconstrued notion of God is revealed to future generations.
Babor, T. F., McGovern, T., & Robaina, K. (2017). Dante’s inferno: Seven deadly sins in scientific publishing and how to avoid them. Addiction Science: A Guide for the Perplexed, 267.
Cheney, L. D. G. (2016). Illustrations for Dante’s Inferno: A Comparative Study of Sandro Botticelli, Giovanni Stradano, and Federico Zuccaro. Cultural and Religious Studies, 4(8), 487.
Verdicchio, M. (2015). Irony and Desire in Dante’s” Inferno” 27. Italica, 285-297.