November 21, 2008 — Last Friday was a groundbreaking day for Amy Drake Boitnott and the University of Virginia School of Nursing. On that day, friends and supporters from the school gathered in the Rotunda as Boitnott successfully presented and defended her capstone project and was awarded U.Va.'s first Doctor of Nursing Practice.
"This is truly an historic moment, as we award the first Doctor of Nursing Practice degree in the Commonwealth," Nursing School Dean Dorrie Fontaine said. "The DNP represents the highest level of nursing practice. Studies have shown better patient outcomes when nurses are more highly educated. We also know how important it is to have cohesive teams treating patients."
Boitnott has been an instructor at the School of Nursing since 2004, teaching first in the undergraduate pediatric clinical program and now in the nurse practitioner program.
The DNP differs from a Ph.D. mainly in the focus of the research. A Ph.D.'s primary interest is in pure research, said John Kirchgessner, assistant professor of nursing and chairman of Boitnott's review committee. A DNP is a clinical scholar who uses evidence-based research to develop interventions that may improve clinical practice.
"I am very proud to be a nurse today and represent the importance of nursing practice in such a way," Boitnott said. "The DNP is important for nurses and nursing practice."
In her defense, Boitnott presented her capstone project on childhood obesity, an issue that has risen to epidemic proportions worldwide. One in five children in the United States is overweight or obese with the highest incidence among 6- to 11-year-olds.
She created an intervention that targets parents and primary caregivers to improve quality of life, family physical activity and nutritional knowledge, with the aim of reducing body mass index in obese children. The program focuses on nutrition, environment and the complexity of households with working mothers.
Kirchgessner praised Boitnott's work and its potential impact. "All the co-morbidity health issues that go along with obese children impact their health much earlier," he said. "We are seeing adult-onset diabetes in 9-year-olds."
Boitnott reviewed research on healthy lifestyle programs that focus on increasing physical activity, improving diet and nutrition and modifying behaviors that contribute to excessive weight gain and obesity.
She decided to concentrate on reaching parents in a one-on-one setting after discovering that most of the literature focused on group approaches.
Boitnott worked with other health care professionals in the U.Va. Children's Fitness Clinic to test her intervention in a randomized controlled study that is ongoing.
After a child is identified as obese, Boitnott's intervention involves one-on-one interaction with parents as the exclusive agent of change in the modification of three areas — activity, nutrition and behavior — with the goal of altering the family's lifestyle. She applied social cognitive theory, which stresses creating awareness of emotional and behavior aspects for understanding behavioral change in order to provide new insights and understanding, in developing the interventions.
Over six sessions, parents are praised for participating in the plan, learn to identify their parenting style, create realistic expectations by learning to recognize current behavior, and work collaboratively to devise ways to achieve desired changes. They also learn to identify readiness to implement change and look at stressors that hinder success.
Other change factors emphasized during the sessions are the impact of increased physical activity and adherence to an eating plan in which family members dine together, rather than eat in shifts or on the run.
Ways to deal with teasing are also discussed as part of a session on body and self-esteem.
In the final session, barriers to successful implementation are discussed and ways to negotiate those barriers explored. Throughout the sessions, it is stressed that the child has not done anything wrong and that successes should be rewarded, but failure never punished.
Printed educational materials supplement each encounter with the interventionist.
Boitnott said the hardest part for the interventionists is engaging the parents and helping them move from a passive posture to active engagement in problem-solving that addresses their individual family dynamics and lifestyles.
Twenty-five families have signed up to participate since early September, with one family close to completing the sessions.
After 100 families complete the study, Boitnott's plans to modify and adapt the intervention to the primary care setting, to be incorporated in preventive care education.
The Academy of Pediatrics has approached her to collaborate in an initiative to develop a toolkit to assess, prevent and treat childhood obesity, Boitnott said.
In the question-and-answer session following the presentation, Boitnott said she feels strongly that prevention is the key to getting a handle on childhood obesity, and the home environment is critical to achieving that goal.
"The home environment is where children acquire their eating and exercise habits," she said.
Twenty-six nursing students entered the DNP program in 2007 and 15 in 2008. Other candidates are addressing topics that include national clinical guidelines that are culturally sensitive to Hispanics Americans, asthma management in children, a new diabetes education study on Virginia's Eastern Shore and a pediatric oncology project.
"DNP nurses are prepared to provide excellence in patient care in both community and acute care settings, to lead teams of care providers and to help educate the next generation of nurses," Fontaine said. "With a nursing shortage worsened by a nursing faculty shortage, it is more important than ever to better prepare those who will educate, mentor and serve as models for future nurse clinicians.
"For more than 100 years, the U.Va. School of Nursing has been committed to providing the best possible health care for patients and their families here in Virginia and worldwide. This is another important milestone in our history."