This document provides an annotated outline for a prospectus on developing a staff education manual to improve medication adherence among adult African Americans with hypertension. Key elements of the prospectus include establishing the problem statement by citing evidence of non-adherence rates and its impacts. The document outlines practice-focused questions, describes how the project aims to promote positive social change, and establishes the feasibility of conducting the project in a medical facility setting. Potential sources of evidence are identified to support addressing non-adherence through patient education programs.

1. An Annotated Outline
The Prospectus document includes a title page (page 1)
followed by pages containing the required elements. Please use
the Prospectus template on the Writing Center website.
Title Page
The recommended title length is 12 words or less to include the
topic and the most critical keywords from the project. Double-
space the title if it is more than one line of type, and center it
under the word “Prospectus.” Please note that your doctoral
project title will likely change as the project evolves, so allow
yourself the flexibility to adapt your title, as necessary.
Include your name, your program (Doctor of Nursing Practice),
and your Banner ID
number—double spaced and centered under the title.
Title
Start with “Prospectus” and a colon, and then include the title
as it appears on the title page. Double-space if it is more than
line of type, and center it at the top of the page.
Problem Statement
Provide a one- to two-paragraph statement that establishes the
relevance of this problem:
1. Summarize preliminary, supporting evidence that provides
justification that this problem is meaningful and relevant to the
local setting as well as the broader field of nursing practice,
citing key scholarly sources.
2. Explicitly state the gap in nursing practice or problem that
will be your focus of this doctoral project
Practice-Focused Question(s)
List the guiding practice-focused question(s) that will address
the identified nursing problem or gap in nursing practice.
Social Change
How this will impact social change? Does this project support
the mission of Walden University to promote positive social
change?

2. Context for the Doctoral Project
Briefly describe the intended setting for the doctoral project. Is
it feasible to accomplish this project in the identified setting or
context?
Page 4
Sources of Evidence
Include relevant evidence that supports the need to address the
identified problem. Describe how the evidence justifies that this
problem is important to the nursing profession.
Approach or Procedural Steps
Identify your possible approach/procedural steps, summarize
possible strategies to obtain the data and resources needed to
complete the doctoral project. Is this project from among the
acceptable types listed on page 1?
Note: Evidence or data cannot be collected prior to approval of
the doctoral project proposal.
Ethical
Will this project provide protection for human subjects? Are
there potential ethical issues that may present problems for the
completion of this project?
Alignment
Do the various aspects of the prospectus align overall? The
problem should be supported by sources of evidence and should
align with the practice-focused question, and the approach or
procedural steps.
References
Use APA format for this prospectus. Include a minimum of five
APA-formatted peer-reviewed references for all citations in the
Doctoral Project Prospectus.
NURS 8000 Week 1 Announcement C-PIICOT Question
Template
Dear NURS Students,
Please use the following template for writing your PIICOT

3. question in upcoming assignments
PIICOT OUTLINE
· P= Patient group/Population
· I= Issue
· I= Intervention
· intervention should be based on high level evidence and a
specific national guideline (look at the National Guideline
Clearinghouse, Registered Nurses Association of Ontario
Guidelines,Joanna Briggs Institute, Cochrane Library, CDC,
Healthy People 2020, NIH, ADA, AHA, etc.)
· C= Comparison
· O= Outcomes that will be measured
· T= Time
PIICOT QUESTION NARRATIVE FORMAT:
· In ________ (customize this with your patient
group/population) within an urban/rural X (acute
care/ambulatory care/long-term care) agency in X (northern,
eastern, Midwestern) United States, how does X protocol
adoption (as recommended by X national guideline -give title
of specific guideline…not just something vague like National
Guideline Clearinghouse) impact ____________ (customize this
with the main, high-level outcomes you want this project to
achieve) as measured X months post-implementation when
compared to the current standard of care (list the current
standard-no X protocol)?
1
15
“Prospectus”
Medication Adherence among Adult African Americans with

4. hypertension in South Central US
Beatrice Ekechukwu
Nursing – DNP General
A00464476:
Medication adherence among Adult African Americans with
hypertension in South Central US
Problem Statement
In the United States, it has been recognized that one of every
four medical visits results from patients not following the
advice they were given, and non-adherence constitutes 33% -
69% of medication-related hospital admissions each year (Scott
& McClure, 2010). Similarly, annual deaths due to non-
adherence to medication in the United States are estimated at
125,000, and non-adherence to medication also costs an
estimated $100 billion annually in both direct and indirect
healthcare costs (Scott, & McClure, 2010). These facts are
substantiated by Elliot (2003) who identified that non-adherence
to prescribed medication and insufficiently intensive treatment
as the two challenging obstacles to control high blood pressure.
Existing literature cites non-adherence to prescribed medication
and insufficiently intensive treatment (treatment that is not
enough to remediate or control a condition) as the two
challenging obstacles to controlling high blood pressure
(Solomon et al. 2015). Even though African Americans (AAs)
constitute about 12.8% of the entire United States population,
AAs have the highest rate of hypertension (over 38%) compared
to other ethnic groups (Ferdinand & Saunders, 2006; Flávio,
2011). According to Rigsby (2011), African Americans have an
earlier age of onset of hypertension increased incidence and
prevalence of hypertension; and high hypertension-related
morbidity, including mortality rates. Based on the existing
facts that AAs are susceptible to high incidences of

5. hypertension due to their genetic heritage, low literacy, and
socioeconomic status which are associated to medication
adherence, it becomes imperative to develop a staff education
manual. The staff education training module guided by the
Walden University staff education manual will thus assist the
facility to provide quality health education programs to help
improve hypertension medication adherence among AAs. The
DNP student will adopt the Walden staff education manual in
developing training that includes medication adherence
evidence-based materials. This approach will in turn expected
to reduce the incidence of hypertension within the AA
population. Staff education manuals which emphasize
behavioral interventions and increased adherence to
recommended pharmacological treatments and lifestyle changes
have been proposed as intervention strategies (Gross, Anderson,
Busby, Erith, & Panco 2013).
According to Healthy Paso Del Notre (2017), the percentage of
Medicare beneficiaries who were treated for hypertension in
2015 for El Paso County, Texas was 53.7%. African Americans
constitute 3.97% of the entire El Paso County (Healthy Paso Del
Notre, 2017). El Paso County has the highest percentage (24%)
of adults not taking hypertension medication as prescribed
compared to Texas (22%) and the US (21%) respectively (City
of El Paso Department of Public Health, 2013). The purpose of
this
capstone project is to utilize evidence-based clinical practice to
develop a staff education manual which can properly guide staff
of the facility to educate AA patients with hypertension. The
objective is to cultivate the culture of adhering to their
medications among the AAs and thereby increasing the goal of
achieving improved hypertension medication adherence (HMA)
among AA population.
Practice-Focused Question(s)
“Does the literature support the use of a staff education manual

6. in developing education module that can improve medication
adherence in AAs patients 21 to 85 years of age with
uncontrolled hypertension (HTN, BP > 140/90)?”
“Is literacy a hindrance and
associated to medication adherence among AA patients with
hypertension”?
“Will patient hypertension medication adherence education
provided through staff education training module and guided by
Walden’s staff education manual be more effective in achieving
intervention outcomes”?
“Does socioeconomic status affect hypertension medication
adherence”?
Social Change
AAs are known to suffer a disproportionately large burden of
cardiovascular morbidity and mortality in the United States
compared to other ethnic groups (Bosworth et al. 2008). Based
on this, it is indicated that half of the cardiovascular mortality
disparity between AAs and other ethnic groups is directly
attributable to hypertension (Bosworth et al. 2008). In this
regard, medication nonadherence is of particular interest
because it is recognized as a potentially modifiable factor that
might be used to reduce this unusual disparity in hypertension
control among AAs. Most evidence-based research literature of
hypertension treatment cite nonadherence to prescribed
medication and insufficiently intensive treatment as the two
challenging obstacles to controlling high blood pressure
(Elliott, 2003). According to Gross et al. (2013), evidence-
based research literature emphasized that educational
program that focused on behavioral interventions increased
adherence to recommended pharmacological treatments and
lifestyle changes.
The United States population has become cosmopolitan and
diversified to the extent that any intervention to address a

7. chronic medical issue, such as hypertension medication
adherence, requires an individualized, culturally sensitive
approach that aligns with the assessment of patients’ beliefs,
knowledge, and health habits (Lakshman et al. 2014). The
MAAAA
project is designed to promote patients’ awareness of their
adherence patterns, which can change their behavior and remain
the key elements to changing patients’ behavior such as
education, motivation, and measurement (Vrijens et al. 2017)
In the South Central United States, it has been recognized that
one of every four medical visits results in patients not following
the advice they were given, and nonadherence contributes
between 33% and 69% of medication-related hospital
admissions each year (Scott, & McClure, 2010). Similarly,
annual deaths due to nonadherence to medication in the United
States are estimated at 125,000 deaths, and nonadherence to
medication also costs an estimated $100 billion annually in both
direct and indirect healthcare costs (Scott, & McClure, 2010)
and AAs
particularly those in South Central United States bear huge
chunk
of these adverse impacts. The implication is that these factors
impose a substantial burden on the healthcare system and,
therefore, call for the identification of viable alternatives to our
society’s heavy reliance on medications (Lauzière et al. 2013).
Previous studies on the use of education programs for
hypertension medication
suggested that the implementation of educational programs
included benefits due to the reduction of costs related to
treatments
. Also, Lauzière et al. (2013) reported the effects of
educational programs on HTN that demonstrated the reduction
in BP among participants from previous studies. The beauty of
the staff education manual is that the facility will use a
structured educational program that will be more efficient to
increase patients’ knowledge on HTN medication adherence

8. compared to the usual approaches of counseling at the bedside
or in the office
Diligent implementation of patient-centered education proposed
by the staff education manual for this project should enhance
medication adherence to hypertension disease prevention and
management programs in low-income populations such as the
AAs and may be replicated to other vulnerable ethnic
populations.
Context for the Doctoral Project
The MAAAs
project will take place at a middle-sized, privately owned
medical facility in the South-Central US,
which has documented high incidences of hypertension
especially among AAs and primarily attributed to medication
non-adherence. The management of the facility sees the DNP
project’s staff education manual as a window of opportunity in
finding a long-term solution to hypertension medication
adherence. Also, the facility sees increasing medication
adherence across a population is vital to improving its
potentials for achieving CMS
Five-Star ratings,
and to the success of chronic care management programs. It
recognizes that medication non-adherence, particularly among
AA patients, causes poor clinical outcomes, which then
increases the use of expensive and potentially avoidable
healthcare services
The DNP student
develops
a staff education training module, which is
guided by Walden University staff education manual
that the facility can use in providing quality evidence-based
hypertension medication adherence education to AA patients.

9. The DNP student will train staffs
of the facility to provide medication adherence patient
education based
on the Walden University staff education manual and
encourages t
he facility to use it
as the platform for the patient education. The facility has the
entire set
of infrastructure and the required resources to implement the
project but, its organizational structure and human resources
wills
are lacking. The beauty of staff education
training module that is guided by the Walden staff education
manual is that it will provide the facility the opportunity
potentially
evaluate implementation successes or failures of medication
adherence. According to Brown et al. (2017), this
approach is essential in examining changes that occur inside
the facility, the target population, community, or system.
It is pertinent to note that the facility does not offer staff
training on how to access and provide quality patient
medication adherence education services to AA patients. Most
importantly, the facility does have an incoheren
t patient education platform, especially one sufficient enough to
provide effective patient education services to AA patients
. Furthermore, the staff is not trained in how to utilize
evidence-based written documents, such as education handouts
in providing programs to improve hypertension medication
adherence.
Possible Sources of Evidence
Apart from the US territories with higher Medicare medication
non-adherence, the greatest hypertension medication non-
adherence in the US mainland occurs in the South Central
United States (Ritchey et al. 2016). Higher prevalence of
hypertension medication nonadherence in the South Central

10. United States is substantiated with data provided by the US
Census Bureau which stated n
ational medication nonadherence rate in the United States as
follows;, 28.9% for the South, 26.7% for the West, 24.1% for
the Northeast, and 22.8% for the Midwest (Ritchey et al. 2016).
Also, the same data stated
that the South Central United States has a hypertension non-
adherence rate of 30.8%, and is second to the highest in the
south compared to the south-east and south-wes
t (Ritchey et al. 2016). Also, evidence to date indicates that
patient education is one of the most successful interventions to
improve adherence and patient self-management of chronic
diseases
such as hypertension (Odusola et al. 2011). Medication
adherence is a complex healthcare problem and described as the
process by which patients take their medication as agreed upon
with their prescriber (van der Laan et al. 2017).
Social/economic, condition-, treatment- or health care system-
related norms have been identified as causes of non-adherence
by patients (van der Laan et al. 2017). Non-adherence to
medication has become an alarming problem in the United
States healthcare system causing an
excess cost of over $170 billion annually (Bazargan et al.
2017). Despite medication nonadherence being a major cause of
morbidity and mortality among the AA population, medication
non-adherence among underserved minority
populations receives inadequate attention (Bazargan et al.
2017).
It is equally important to note that all available evidence-based
research literature points in the same direction are showing that
nationally
and statewide, the incidence of hypertension is higher in the AA
patients compared to other ethnic groups (Ferdinand &
Saunders, 2006; Flávio, 2011). According to Gross et al. (2013),
evidence-based research literature emphasized that educational

11. program
that focused on behavioral interventions increase adherence to
recommended pharmacological treatments and lifestyle changes.
Also, empowering hypertensive patients using a health
education strategy with the necessary information and skills
required to maintain and improve their health has been
attributed to yielding positive outcomes (Leung, Ho, Ho, Lee, &
Mark, 2005). Evidence-based research also points out that
provider-patient interaction
using educational pamphlets will benefit patients with
hypertension by enabling them to actively participate in their
recovery and learn self-management skills they can use to
improve their overall health. In this regard, evidence-based
literature also postulates that patients who feel in control of
their health are more compliant in making healthy lifestyle
changes (Cleary et al. 2011).
On the other hand, Elliott (2003) identified other factors such
as lack of a consistent health care provider, inadequate
knowledge, or incorrect perceptions to be prevalent in cases of
non-adherence. Moreover, beliefs about hypertension; lack of
social support,
transportation; or control over dietary choices and complexity
of the treatment regimen such as inconvenient dosing,
undesirable drug-related effects, and difficulty integrating
therapeutic lifestyle changes as significant barriers to blood
pressure control that many patients face (Elliott 2003). Based
on the need to promote medication adherence, national
organizations, such as the National Committee for Quality
Assurance (NCQA), emphasize the importance of medication
adherence as a measure of the quality of health care system
performance. Maclean et al. (2012),
and Khanam et al. (2014) identified poor adherence as the main
cause of failure to control hypertension, including poor
adherence to antihypertensive treatment as a significant
cardiovascular risk factor. This MAAAA project will,
therefore, synthesize the information provided by evidence-

12. based literature including Miller (2016
) to provide evidence
-based staff education training module that can help address the
prevalence of hypertension medication adherence.
Approach or Procedural Steps
The MAAAA project is a
staff education training module guided by Walden University
staff education manual with an end product of brochure
and intended to provide medication adherence patient education
at an internal medicine facility in South Central United States
. The staff education training module will contain a series of
steps and approaches
the facility can use in providing effective evidence-based
patient education on hypertension medication adherence. The
staff of the facility after
being trained by the DNP student will use be able to apply the
staff education training module provide p
atient education programs to AAs
to improve hypertension
adherence. In this regard, the DNP student will plan and
implement a six-week teaching session consisting of one-hour
weekly power point presentations on how to use this app
roach to provide evidence-based information to AA
hypertension patients. This is very important
especially as the staff education manual will address patients’
beliefs and concerns about the condition and treatment,
identifies
social cultural and individual barriers to adherence
as well as enhances
patients’ confidence in their ability to overcome those barriers
(Odusola et al. 2011).
During the 14-minutes
patient wait-time of the outpatient primary care visits, the staff
of the facility can utilize and constitute
these

13. moments as teaching sessions. The step-by-step staff education
training module will
if properly used become a resource with improved
confidence and ability in providing effective patient medication
adherence education. Also, the staff education training teaching
module will be characterized by concentrated, yet integrated,
basic evidence-based medication adherence approach designed
to integrate all stakeholders in collaborative efforts to achieve
reasonable, measured outcomes.
Ethical
The DNP Student
will obtain Walden University IRB
approval and the facility’s institutional ethical approval as well
as maintain the confidentiality of the project process. In this
regard, the DNP student will seek IRB approval after the
prospectus has been approved. As with any scholarly project in
the healthcare arena, the MAAAA project will address ethics
and human subjects’ protection appropriately and per IRB
approval. If there is the need for the use of protected health
information (PHI), the health insurance and accountability act
(HIPPA) policy
, as well as the facility’s policy,
will be adhered to address the issue.
Alignment
It has been recognized that taking specific medications in
treating a chronic issue such as hypertension requires
motivating individuals/population to change their behavior such
that their inner urge is activated to move or prompt them to
action. This strategy influences medication behaviors as well as
to overcome barriers to adhere to planned prescriptions
(Resnick, Wehren, & Orwig, 2003). Factors identified to be
influential in promoting individuals’ willingness to adhere to
medications include; lack of knowledge about the benefits of

14. the treatment, drugs side effects or unpleasant sensations,
economic and social considerations, complexity
of the regimen, poor patient-provider communications as well as
providers’ beliefs in treatment effectiveness and motivation
(Resnick, Wehren, & Orwig, 2003).
Implications of the proposed MAAAA outcomes are that the
target population will be better informed and educated to be
comply with the prescribed medication regimen. The
accompanying change of attitudes and behaviors may then be
influenced by perceived efficacy expectations including self-
efficacy and the outcome expectations related to taking
medications as well as outcome of such behaviors. In this
regard, there will be individuals with strong self-efficacy and
outcome expectations about medication adherence. Based on
these, the effectiveness of the medications will be more
motivated and will persist longer in correctly following the
recommended medication treatment program. The hypertension
medication adherence project will promote enhanced personal
attributes such as emotions, perceived health status as well as
confidence in the physicians. Also, the project will promote
and enhance environmental factors such as routine, distractions,
costs and social support, including task-related and behavioral
factors such as medication aids, schedules, as well as
knowledge about medications, medication delivery system and
side effects. References
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(1), 3-12
�Remove quotation marks
�Name your project here and show the abbreviation you will
use for it in parentheses

19. �Omit and – how do you intend to show this? It reads like a
research question.
�These all read like research questions, you cannot do research
– and if you are doing staff education, none of these will be
answered; your first question is adequate – but you don’t need
quotation marks; and semi colon after HTN
�An educational
�You cannot use an abbreviation until you have defined it
�Commas to offset nonessential clause
�A huge chunk – but this isn’t a real scholarly term
�Medication or medication adherence?
�Need a citation for these studies
�Is this your social change statement? Need a stronger section
to support social change
�Your abbreviation must be the same each time you use it, and
relate to the project title

20. �No comma
�Have you defined CMS? If not, it must be defined before
using an abbreviation
�No comma
�What is “it”?
�Which DNP student
�Future tense
�Will be – past tense as this is before the project
�Comma to finish offsetting the nonessential clause
�The staff – no s
�Won’t it be based on the module you developed? It is the
module that is based on the manual, isn’t it?
�Check verb tense throughout this section

21. �Synthesis and clarity
�What entire set?
�what
�a staff education
�to potentially evaluate
�what approach?
�Incoherent?
�What is this section saying? Need clarification
�Comma to finish offsetting nonessential clause
�Reported would be a better verb here
�demonstrated – data doesn’t state
�clarity

22. �comma
�this doesn’t flow
�is underserved minority and AA population the same group?
�Sentence structure
�Plural
�Plural
�And not comma with only two elements
�No comma with two
�This has no purpose here
�An evidence based
�Isn’t your approach to develop a staff education module?
�Isn’t the project to develop the module?

23. �A brochure – your staff manual will have an end product of a
brochure? What does this mean?
�Need clarity here
�Steps and approached? What do you mean
�Comma around nonessential clause
�Able to apply… provide – look at your sentence structure
�Only to AAs?
�Hypertension adherence or medication adherence?
�Which approach ?
�comma
�keep verbs in agreement
�comma
�how can a staff education manual enhance patient confidence?

24. �No s
�Constitute these moments?
�What moments?
�Comma around nonessential clause
�A resource doesn’t have confidence, so can’t have improved
confidence or ability
�Need clarity here, I don’t know what you are saying
�APA and Walden say to use first person
�Need to define all abbreviations before using
�Reference needed
�No comma
�Look at your guideline and see what should be addressed in
this section.

25. �Period after date throughout
�List first six then THREE dots … and final author
�Italics for ALL volume numbers
�No capital for population
�Capital after colon – I told you that the last time
�Only capitalize first word, proper nouns, and words following
a colon in article titles. I told you that the last time
�List the first six authors and only use three dots (elipses)
�Italics