Tuberculosis Prevention and the Effect of Correctional Staff Education on Practice Outcomes

Submitted by

Tremaine Grady

A Direct Practice Improvement Project Presented in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Nursing Practice

Grand Canyon University

Phoenix, Arizona

October 1, 2018




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 ii

© by Tremaine Grady 2018

All rights reserved.

 GRAND CANYON UNIVERSITY

Tuberculosis Prevention and the Effect of Correctional Staff Education on Practice Outcomes

by

Tremaine Grady

has been approved

October 1, 2018

APPROVED:

Pamela Love, PhD, MSN, RN, CNE, DPI Project Chairperson

Bonnie Elias, MSN, RN, Committee Member

ACCEPTED AND SIGNED:

________________________________________
Lisa G. Smith, PhD, RN, CNE
Dean, College of Nursing and Healthcare Professions

________________________________________
10/5/2018
Date
 Abstract

Prisons are high-risk environments for the transmission of disease because of the crowded living

spaces. Correctional facility staff play a significant role in preventing tuberculosis (TB) but have

inadequate knowledge about its transmission. The clinical question was, how effective was the use

of evidence-based education in increasing the correctional facility staff’s knowledge about the

transmission and prevention of TB? A quantitative method was used with a pre-test post-test

design to evaluate the level of correctional staffs’ knowledge in a central North Carolina prison.

The sample (N=50) included correctional officers, administrators, dentists, nurses, certified

nursing assistants, medical providers, and maintenance staff from different areas of the prison, all

of whom have varied levels of education. The adult learning theory, andragogy, and constructivism

were used as the theoretical foundation. The participants were administered a pre-test to assess

their initial knowledge about the transmission and prevention of TB. An evidence-based

intervention was used which included a review of pamphlets and interactive real-life scenarios

about TB transmission and prevention. Participants were given an opportunity to ask questions.

Thereafter, participants took a post-test and the data were analyzed with a t-test. The results

showed an increased knowledge of TB transmission and prevention (t42 = 0.77, p = 0.000). The

findings suggest that an evidence-based educational intervention can attain improved knowledge

about the transmission and prevention of TB and impact practice by decreasing the incidence of

TB in correctional facilities. The recommendation for the future includes increasing educational

opportunities available for staff members and better methods of prevention that can be

implemented to decrease TB spread to inmates and the community.

Keywords: tuberculosis, education, prison, transmission, prevention

 i

Dedication

I would like to dedicate this project to the memory of my husband, Gregory Jones.

Without his constant support and encouragement, I would not have reached this point in my

educational journey. He was always there for me and assisted in all my endeavors, and all the

adventures we had to take to get me through this journey. Regardless of what I needed, he was

my backbone, and when I was ready to give up, he would remind me that I could do it. He is the

primary reason I was able to complete this project, and I thank him for all of his support and

unconditional love. I hope he is proud of what we accomplished together.

 ii

Acknowledgments

I could not have completed this project without my family, whose support and

encouragement helped me throughout the process of conducting this project. I also wish to thank

my mentor and content expert, Bonnie Elias, MSN, RN, who has stood by me from the

beginning to end. Her expertise has been a major asset in helping me reach my goal, and she

always has been available for any advice or assistance I needed. I also would like to

acknowledge the support and encouragement of all of my co-workers and family, as they also

have been there on those days when the work became overwhelming and thank God for faith,

strength and endurance.

 iii

Table of Contents

List of Tables……………………………………………………………………………...vi

List of Figures……………………………………………………………………………vii

Chapter 1: Introduction to the Project ..................................................................................1

Background of the Project ............................................................................................4

Problem Statement .........................................................................................................8

Purpose of the Project…………………………………………………………………9

Clinical Question .........................................................................................................11

Advancing Scientific Knowledge ................................................................................12

Significance of the Project ...........................................................................................13

Rationale for Methodology ..........................................................................................15

Nature of the Project Design ........................................................................................16

Definition of Terms......................................................................................................19

Assumptions, Limitations, Delimitations ....................................................................21

Summary and Organization of the Remainder of the Project ......................................23

Chapter 2: Literature Review ……………………………………………………………25

Theoretical Foundations and/or Conceptual Framework .............................................28

Review of the Literature ……………………………………………………………31

Correctional Facilities and TB Risks………………………………………....32

Identifying the cause of TB and mode of transmission………………………36

Prevention…………………………………………………………………….43

Education……………………………………………………………………..51

Summary .................................................................................................................….58
 iv

Chapter 3: Methodology ....................................................................................................61

Statement of the Problem ............................................................................................62

Clinical Question .........................................................................................................63

Project Methodology....................................................................................................64

Project Design ..............................................................................................................65

Population and Sample Selection.................................................................................65

Instrumentation ............................................................................................................67

Validity ........................................................................................................................68

Reliability.....................................................................................................................69

Data Collection Procedures..........................................................................................69

Data Analysis Procedures ............................................................................................70

Ethical Considerations .................................................................................................71

Limitations ...................................................................................................................72

Summary ……………………………………………………………………………..73

Chapter 4: Data Analysis and Results..……….…………………………………………..75

Descriptive Data.. ………………………………………………………………….....75

Data Analysis Procedures.………………………………………………………….....83

Results……………………………………………………………………………........83

Summary…………………………………….………………………………………...89

Chapter 5: Summary Conclusions and Recommendations ……………………………....92

Summary of the Project………………….………………………………………….....93

Summary of Findings and Conclusions………………………………………………..94

Implications…………………………………………………………………................95
 v

Theoretical implications………………………………………………………….....96

Practical implications……………………………………………………………....96

Future implications………………………………………………………………...96

Recommendations …………………………………………………………….……......97

Recommendation for future projects…………………………………….…...........97

Recommendations for practice…………………………………………….……....99

Appendix A. Pre-test-Post-test/Supplemental Questions………………………………....112

Appendix B. IRB Approval…………...………………………………………………......116

Appendix C. Tuberculosis (TB) Facts/TB Elimination……….………………….….…....118

 vi

List of Tables

Table 1. Sample Size…………………………………………………………………..78

Table 2. Pre-and Post-test results……………………………………………………...79

Table 3. Descriptive Statistics of Demographic Variables…………………………….85

Table 4. Paired Sample Descriptive Statistics................................................................87

Table 5. Paired Samples Correlations.............................................................................87

Table 6. Paired Sample Test...........................................................................................87

 vii

List of Figures

Figure 1. Supplemental Questions: Post-test........................................................................88

 1

Chapter 1: Introduction to the Project

The crackdown on crime has resulted in an overwhelming number of incarcerations in the

correctional system. There are more than 2.4 million inmates in 1,719 state prisons, 102 federal

prisons, 2,259 juvenile correctional facilities, 3,283 local jails, 79 Indian Country jails, including

military prisons, and Immigration and customs enforcement (ICE) facilities (Wagner & Sakala,

2014). The average annual cost per inmate was $31,286 in 2013 (Williams, 2014). At the end of

2016, there were 2,162,400 people incarcerated in the U.S. in either state, federal prisons or local

jails (Kaeble & Cowhig, 2018). In North Carolina (NC), the total percentage of tuberculosis (TB)

cases reported in correctional settings in 2014 was 76%, 13% in local jails, 38% in state prisons,

and 25% in federal prisons (NC DHHS, 2017). It has been noted that living conditions in

correctional settings are crowded, with poor air circulation that increases the risk for the spread

of TB (Bergstrand, 2012). The absence of proper education regarding the prevention of TB puts

the correctional staff at an unfair disadvantage. The staff are a major key in TB prevention in

inmate populations. The correctional staff address the inmates’ concerns, observe their daily

activities, and are one of the inmates’ resources for care. In the project a pre-test was used prior

to the intervention for a review of the participants knowledge about TB. It was apparent that it

was important to have initial TB screening, proper annual follow-up with tuberculin skin test

(TST), and preventive measures to decrease the transmission of the disease. The TB germ is

spread to others by airborne transmission through coughing and sneezing in areas confined

closely (Centers for Disease Control and Prevention [CDC], 2005). Without prompt and proper

care, other staff members, inmates, and the community are all at risk of contracting the disease

(CDC, 2014). Thus, it is necessary to increase correctional staff’s knowledge about TB. To

intensify TB control in prison-based facilities raising awareness and knowledge among

 2

correctional staff, through continued education was recommended (Dara et al., 2013). A pre-test

tool obtained from the CDC’s self-study modules on TB was used to evaluate the information

about TB the correctional staff needed (CDC, 2016).

There are various forms of TB, each of which affects the body differently, and these

variations should be considered when providing preventative education and care. Immuno-

compromised people with diagnoses such as Human Immunodeficiency Virus/Acquired

Immunodeficiency Syndrome (HIV/AIDS), cancer, chronic kidney disease, and diabetes are

more susceptible to contracting TB (CDC, 2014). Literature from the CDC (2012) indicated that

TB in correctional facilities was a key public concern, and approximately 4-6% of TB cases in

the U.S. were attributable to incarceration. The early identification and detection of persons with

TB must be made a priority. Early detection can help to decrease the risk of spreading the disease

within a facility, to the inmate population, and into the community (Barbour, Clark, Jones, &

Veitch, 2010).

The focus of this DPI project was to evaluate the effect of educating correctional staff

about the prevention and transmission of TB to the inmate population in a correctional setting. It

was not known whether an evidence-based educational intervention would increase a

correctional facility’s staffs’ knowledge about TB transmission and prevention. Early detection

reduces inmates’, staff members’, and the community’s risk of exposure to TB (CDC, 204). The

use of pamphlets, real-life scenario implementation, and review constituted the evidence-based

educational intervention in the project. The participants pre- and post-test results were compared

to evaluate improvement in scores after the educational intervention was distributed. The validity

of the instrument was established because it fit the constructs for the project identified

conceptually. The reading level was appropriate and the time required for testing allowed the
 3

questions to be completed. Reliability was established by the stability of measures administered

to the same individuals at different times and by using the same standard test-retest reliability.

Additional information was needed to assess the level of staff knowledge, and the

education that was needed in these high-risk environments to help prevent the transmission of

TB to the inmate population (CDC, 2017). Hence, the participants’ initial pre-test scores were

recorded. The evidence-based educational intervention used consisted of pamphlets about TB

obtained from the CDC website that describes TB, the routes of exposure, and testing for the

disease (CDC, 2016). The pamphlets also contained information about TB medications,

elimination of TB, and skin testing to detect whether a person was infected with the disease.

Information about TB transmission was discussed, and real-life interactive scenarios used for

additional education, with a review. The participants were given the opportunity to ask questions

and discuss the disease and its process. The review included preventive measures noted in the

pamphlets. The data were collected using a pre- and post-tests design, and the scores were

compared after the educational intervention was implemented. The staff’s knowledge was tested

using questions about TB, its transmission, and methods used to prevent its spread. Quantitative

variables were described using the mean and median as measures of centrality, and standard

deviations and nonparametric tests were used for univariate analysis. The pre-test results were

evaluated and assisted in the development of an evidence-based education program that was used

as the intervention. Subsequent to receipt and review of the pamphlets, a post-test was

administered to the participants. All of the materials were reviewed after the pre-testing and the

participants returned to take the post-test one week later. This chapter discussed the background

of the project, the problem statement, the purpose of the project, clinical question, advancing

scientific knowledge, and significance of the project, rationale for methodology, nature of the
 4

project design, assumptions, limitations, delimitations, and the summary and organization of the

remainder of the DPI project.

Background of the Project

From Hippocrates to the 18th century, TB was known as phthisis and consumption, and

was referred to as the great white plague during the 19th century (Frith, 2014). In 1882, the

scientist Robert Koch discovered the organism Tubercle bacillus, Mycobacterium tuberculosis

(MTB), which is a rod–shaped bacterium also referred to as Koch’s bacillus and its contagious

nature. One of the risk factors for TB infection was recognized as incarceration (Cernat &

Brojboiu, 2011).

In 2013, North Carolina (NC) ranked the 25th highest state in the U.S. for TB cases,

which was an improvement from being the 3rd highest state in 1980 (Wos & Cummings, 2014).

Correctional facilities have been identified as having an increased occurrence of TB (CDC,

2014). The body systems the disease affected most in 2013 were pulmonary, followed by pleural,

lymphatic, and cervical (Wos & Cummings, 2014). Prisons have a higher risk of TB disease and

reports have shown an ongoing problem in that the occurrence is much higher than in the general

public (Dara, Chorgoliani, & DeColombani, 2014).

At the NC correctional facility site where the project was conducted, the participants’

pre-test score results demonstrated that there was a deficit in their knowledge about TB. There

were staff members within the facility who did not know the way TB spreads and how

contagious the disease is. Some staff members did not know exactly what TB was or that it does

spread. Further, they did not know the signs and symptoms of the disease and were unaware that

prisons are considered high-risk environments for the transmission of TB (Dara, Acosta,
 5

Melchers, Al-Darraji, Chorgoliani, & Reyes, 2013). In adequate knowledge levels could be the

result of a lack of education and training.

Some of the individuals who entered prison come from different cultural, ethnic, and

economic backgrounds, and different parts of the U.S. and other countries; all of which increased

the risk of TB transmission. TB is a highly prevalent disease in certain countries, and their

natives are more susceptible to the disease than are others (World Health Organization [WHO],

2013). TB is a top priority among transmittable diseases in corrections because they constitute an

extremely high-risk environment. NC prison systems also housed individuals who were referred

to as Health law violators. A health law violator is a person who lived in the community, was

diagnosed with active TB, and did not comply with medication prescribed and/or an isolation

order (NC Health and Human Services, Epidemiology Section, 2017). These violations lead to

their arrest and they were jailed and ordered by the court to continue TB drug treatment within

the correctional environment.

Because the literature demonstrated that all correctional facilities are environments that

are at high risk for the spread of TB and are a public concern (CDC, 2014). The staff were

provided additional education and training with the expected outcome of making them more

cognizant of the importance of preventive measures within correctional facilities. The increased

knowledge about the transmission and prevention of TB would impact practice by decreasing the

incidence of TB in correctional facilities. This was particularly important because the facility’s

policies and procedures manual provides guidelines for the prevention and treatment of

tuberculosis that were not followed consistently. A TB control plan was established to complete

initial and annual screenings of all staff and inmates (NC Tuberculosis Control Manual, 2017).

The policies stated that early identification and successful treatment of persons with TB are the
 6

most effective ways of preventing transmission of the disease (NC Health Services Policy &

Procedure Manual Subject: Tuberculosis Control Plan, 2017).

The improper placement of a tuberculin skin test (TST) increased the likelihood of

exposing others to an inmate or staff member who may be positive, but was not detected with

proper screening (WHO, 2014). This put many people within the facility and the community at

risk. In corrections, the inmates’ health and wellbeing would be improved by prevention of TB

and educating the staff, helped in this process (Rechtine, 2014). The medical providers,

physician assistants, administrative office and maintenance staff, nurses, certified nursing

assistants, dentists, and correctional officers were educated in the prevention and transmission of

TB within the inmate population. They received education about the necessary respiratory

precautions that must be maintained for the inmates’ safety. The importance of the initial and

annual screening of all inmates and newly employed staff was reviewed. Individuals who have

had a positive TST in the past were required to complete a health screening was included as a

part of the education. The health screening identified whether the person had any of the signs or

symptoms of TB and what steps should be taken if so. The staff were informed about the risk

factors for infection of TB following an exposure. The risk of infection may be determined by

exogenous factors, and a combination of the source and proximity to the infected individual in

the correctional setting, as overcrowding increases transmission (Norseman, Wood, Macintyre,

& Mathai, 2013). The staff were educated about offenders with medical conditions that

decreased their immune response and reduced their ability to fight infections and diseases. This,

in turn, puts them at an increased risk of developing TB (Norseman et al., 2013).

Therefore, a strategy must be established with respect to releasing an inmate on

medication for active TB or latent TB treatment back into the community and for follow-up care
 7

to decrease the spread of the disease. To ensure compliance with medication, the WHO

established the use of directly observed treatment (DOT) in the 1990s (Rodrigo et al., 2012).

This was an important plan to confirm treatment compliance through a quantitative bivariate

analysis involving variables used to identify the risk factors associated with subjects who did not

return for scheduled follow-up appointments, and assessed the factors that predict poor

adherence to TB treatment (Rodrigo et al., 2012).

Rodrigo et al, (2012) found that individuals who were on dialysis refused to receive TB

treatment and did not return for treatment follow-ups. A patient who is noncompliant with

treatment and has not completed the medication regime within nine months after it was

prescribed as a six-month regimen may develop resistance to medication. These prison inmates

put their population at higher risk of contracting TB and the criminal justice system poses

barriers to battling TB in prisons (Rodrigo et al., 2012; Dara et al., 2014). The correctional

setting requires enforcement of interventional screening to control the transmission of TB

because prisons are increasingly becoming a breeding ground for TB. Further, the released

inmates are transmitting the disease to the general population, which accounts for up to 25% of a

country’s TB burden (Nyasula, Mogoere, Umanah, & Setswe, 2015). Preventive treatment must

be expanded among those in high-risk groups congregated in settings such as prisons and

workplaces (WHO, 2015).

The assertion of universal access to early and accurate diagnosis of TB requires increased

diligence by diagnostic facilities with access to information and education of symptoms (WHO,
 8

2015). The use of systematic screening in high-risk groups helps reduced the burden of

undetected TB and the risks of transmission (WHO, 2015).

Problem Statement

It was not known whether an evidence-based educational intervention would increase a

correctional facility’s staffs’ knowledge about TB. Correctional facilities have been reported to

have up to 100 times higher levels of TB than the civilian population (WHO, 2015). It has been

established that the use of educational materials promotes empowerment and competency among

employees to undertake their work better (Chaghari, Saffari, Ebadi, & Ameryoun, 2017). This

project evaluated the effect of an evidence-based educational interventions on increasing the

correctional staff’s knowledge. Knowledge about TB transmission and prevention has been

found necessary to yield the best health outcomes among both inmate and general populations

(Morbidity and Mortality Weekly Report, 2006). TB control can be heightened in prison by

raising awareness of the disease throughout prison facilities, and including inmates, and prison

medical, and non-medical staff in continuous educational activities (Dara et al., 2014).

The staff was educated about the early identification of persons with TB and that entry

and periodic follow-up screenings should be conducted (CDC, 2014). Thorough and efficient

contact investigations should be performed after a positive TB case is identified (CDC, 2014).

The Tuberculosis Coalition for Technical Assistance (2013), has identified the importance of

follow-up care, which was included in the education intervention because most inmates return to

their communities after release. According to the Tuberculosis Coalition for Technical

Assistance (2013), it is important to know which individuals have been treated for active TB, as

it must be confirmed that these individuals have completed all medications before their release.

If their medication treatment regimen has not been completed, it is necessary to have a contact
 9

person or facility where they can continue to receive medication and follow-up treatment.

Inmates also are transferred to other facilities within the correctional system, and without proper

care, follow-up, and identification, others were at risk of contracting TB (Rodrigo et al., 2012).

It has been found that with the evolution of the current use of the TST and a test for latent

MTB infection over the last century, the incidence of TB has declined, as the use of preventive

measures and early detection have shown to decrease the cases of TB and latent TB (Lee &

Holzman, 2012). Educating staff has been shown to be an important component of preventive

measures that should be taken to decrease the risk of exposure to TB among the inmate/patient

population. The project provided information that established the need for additional research

about the use of an evidence-based educational interventions to increase knowledge about TB in

a high-risk environment. More education offered to staff can contribute to the critical knowledge

gaps in understanding about the way TB is caused and prevented. The reduction of TB

transmission in an inmate population in such high-risk environments requires prompt detection

through a combination of screening methods (Dara et al., 2014).

Purpose of the Project

The purpose of the DPI project was to examine the effectiveness of utilizing a pre-

posttest design of education about the spread and prevention of TB provided to a target

population of correctional staff in a correctional facility in central North Carolina. The project

methodology used was quantitative with a pre-posttest design. The pre-posttest was taken by

correctional staff members including physicians, nurses, office, maintenance and correctional

staff. The independent variable was the educational intervention and was measured using the

participants’ pre- and post-test results. The project’s dependent variable was the correctional

staff members. The change in the staff’s knowledge was evaluated with the post-test after the
 10

intervention. The project included the relevance of evidence-based practices that evaluated the

intervention’s effect on the correctional staff. The literature has shown that by analysis and

evaluation, training is a method offered to employees to fulfil organizational goals (Kunche, Puli,

Guniganti, & Puli, 2011). The evidence-based education was provided to increase the staff’s

knowledge of the ways to prevent the spread of TB to inmates, other staff members, and the

public. The outcome desired was that the evidence-based education would increase the

correctional staff’s knowledge about TB transmission, prevention and precaution practices to

take and impact practice by decreasing the incidence of TB in correctional facilities.

The varied educational levels of the staff members and background of the project had an

influence on the pre-test results. The degree of medical knowledge the participants had was an

additional variable. The lack of knowledge and practice gaps included, staff unaware of the signs

and symptoms of TB and did not comply with isolation precautions. The use of N95 mask for

isolation were single-use and should be disposed of after use. The staff were reminded to wear

proper masks and supply the patients with respiratory masks during any type of transport.

The correctional facility was located in an urban city in the central region of North

Carolina. The facility has housed inmates since 1884 and has a capacity of 752 inmates at

different custody levels. The majority of the inmates have a sentence of 20 years or more (NC

DPS, 2015). On an annual basis, the number of positive TSTs was 157, with 5-7 active TB cases,

and latent TB treatment in which 19 were ruled out for TB (NC Department Public Safety,

Infection Control, 2017). The facility also houses regular population, death row and safekeepers,

inmates who have been arrested for a crime but have not gone to trial and not been convicted of

the crime of which they are accused. They are housed in the maximum-security facility because

of health reasons that cannot be managed in a county jail or because they are under age 21. The
 11

prison also housed inmates who have acute or chronic illnesses, or are postoperative and require

hospitalization.

Clinical Question

The problem statement was generated because it was not known whether an evidence-

based educational intervention would increase the correctional facility’s staffs’ knowledge about

TB transmission and prevention. The clinical question in this project focused on the use of

educational resources to increase the correctional staff’s knowledge about the transmission and

prevention of TB. The following clinical question was used to guide the project and address the

educational needs of the correctional staff in this environment:

Q1: How effective was the use of evidence-based education in increasing the correctional

facility staff’s knowledge about the transmission and prevention of TB? As components of this

education, the need for strict respiratory precautions and isolation of patients are essential for

disease containment.

The reduced number of correctional facilities had caused overcrowding of inmates in

small, poorly ventilated living spaces that put them at an increased risk for TB infection (Federal

Bureau of Prisons Clinical Practice Guidelines, 2010). The containment of TB was identified as a

task that must be assumed by all correctional staff. The evaluation of this training and continued

education provided about TB was used to increase consistency, and the understanding of staff. A

large majority of the staff who worked in the correctional setting, supervise the inmates and

provide them with direct care. The project results focused on the staff’s future educational needs

to impact practice to decrease the incidence of TB in correctional facilities. The evidence-based

educational intervention provided was beneficial in this high-risk correctional setting to assist

with preventive methods. The inmate population transfers among facilities, including other
 12

prisons, county jails, and outside hospitals and other physicians’ offices. The early prevention

methods and knowledge of the signs and symptoms of TB would benefit prison staff, inmates,

and the community at large to decrease its transmission. The next area of the project discussed

the advancing scientific knowledge about the use of an evidence-based educational intervention

about TB transmission and prevention.

Advancing Scientific Knowledge

This DPI project has the scientific possibilities to increase and advance the knowledge

about TB transmission and prevention with the use of educational interventions. An essential

component of the project being prevention of TB, it can impact the overall health of the staff,

inmates and community. Ritchie et al., (2016) reported that TB remains an important cause of

global mortality and morbidity in low and middle-income countries, even though effective

treatment is available, and stated that additional knowledge is required to improve, refine,

implement, and evaluate educational interventions in TB prevention and transmission. According

to Dara et al., (2015) TB was found to be a highly infectious disease, and staff in the field of

corrections need more education to help them protect the patients and reduce the transmission of

the disease. Prisons were considered a reservoir for TB and have an extensive history of

infection. Thus, it is necessary for all involved to understand that the disease is highly contagious

and the risk factors in its transmission (Dara et al., 2015). The project was based on the pre-and

post-test results and applied the constructivist strategies theory (Eddy, 2016). The adult learning

theory is based on the education’s relevance, learners’ engagement, and active learning and

involvement, and focuses on the learner (Cox, 2015). This project focused on the primary
 13

investigator who supplied the learners with the new information needed to increase their

knowledge.

Only a limited number of articles had addressed healthcare in U.S. prisons and focused

on TB research. Education had been one of the methods used to increase the knowledge of the

people who protect the population within the correctional system and to produce the best

outcomes for both the inmates and the public. Effective training is thought to be important in

improving an organization’s efficiency, which depends upon the staff’s abilities (Kunche et al.,

2011). This outcome depended on the preventive measures taken by the correctional staff. The

project was based on theoretical principles that focused on learning using the constructivism

method. Constructivism is a theory based on the concept of the way people learn and construct

their own understanding of ways to create more knowledge (Bhutto & Chhapra, 2013). In

quantitative research methods, the information obtained was numerically based, and the

mathematical measurement tool used may influence the validity and reliability of the data

obtained.

Educating the correctional staff about TB increased the knowledge they need to protect

the health of the inmates who are admitted to the prison hospital for care, surgical procedures,

and recovery. The inmates processed in the facility for housing were monitored and screened for

TB. There was considerable inmate movement within the facility, as inmates were seen in the

clinics, radiology department, dental area, dialysis, and physical and occupational therapy. Many

inmates came from different prisons during the facility’s daily functions, which provided

multiple opportunities for transmission of TB. There also was movement from the correctional

facilities to the local communities, for various reasons, including medical care, work projects,

and release after incarceration and could expose the public to TB transmission. Increased
 14

knowledge about the transmission and prevention of TB provided the potential to decrease

infection rates and helped decrease medication treatment and resistance (CDC, 2015).

Significance of the Project

The project had clinical significance as it contributed to the current nursing knowledge in

the literature about education and TB transmission and prevention in corrections. The outcome of

the project was to show the importance of education for staff in the transmission and prevention

of TB. Identifying the areas where there are knowledge gaps can make a significance in the

interventions provided for staff. In extremely high-risk environments, emphasis must be placed

on disease prevention. Additional knowledge can support the necessary awareness of the

transmission and ways to help prevent diseases like TB. Some of the education identified that

staff needed was determined to be the ability to identify signs and symptoms of TB, to facilitate

early detection and treatment if necessary (CDC, 2012). The staff was provided with information

about the different methods to prevent TB that can be used daily while remaining diligent in the

surveillance and prevention of the disease. The CDC pamphlets and interactive scenarios

provided were discussed and reviewed with the project participants (See Appendices A and B for

pamphlet content). The improved understanding of the way TB spreads helped the staff

understand the importance of screening compliance.

Constructivist strategies provide learners with information to develop their own mental

models of information and process unique information actively and profoundly (Vogel-Walcutt,

Gebrim, Bowers, Carper, & Nicholson, 2011). This allows the learner to integrate the

information with their prior knowledge contextually and thus promotes deeper learning (Vogel-
 15

Walcutt et al., 2011). Accordingly, the investigator provided the learners with skills and support

to encourage them to construct their own personal learning experience actively.

The WHO (2013) TB goals and plan were parts of a 20-year strategy to end the global

TB epidemic, and to achieve a 95% reduction in deaths and 90% decrease in TB cases.

Policymakers and the WHO have obtained the evidence to rethink the work necessary to focus

on TB in prisons, with the guidance of the best methods to control and prevent TB. Future

research has been recommended to measure the effect of prison conditions on TB transmission

(WHO, 2013). The staff members were taught the potentially high risk of transmitting the

disease to others within a correctional facility and in the community. There are other high-risk

people who may not have the information or education to protect themselves and others properly

from contracting TB. There also may be other prison systems within the U.S. that acknowledge

the importance of the early detection of TB and educate their staff members about the preventive

measures to use and the signs and symptoms to look for. Alves, Silva, and Costa’s (2007) found

a number of cases of interruption of treatment and drug-resistant TB within their prison system

and the community. To protect the prison population, staff, and the population at large, it is

important to assess staff members’ level of knowledge because they are the first step in

preventing the transmission of TB. There also is a global aspect in the transmission of the disease

and an increased need for education within prison systems to detect and control TB early (Alves

et al., 2007).

Rationale for Methodology

The quantitative approach is an organized scientific method of investigation used to

examine the relations between variables with numerical data and evaluate them to obtain

statistical evidence of effects (Eddy, 2016). The quantitative method has been shown to be an
 16

important technique to investigate the way healthcare setting can be improved to generate new

knowledge and increase the availability of evidence-based healthcare data (Maldonado, 2014).

The quantitative methodology was chosen for this project to evaluate the independent variable of

evidence-based education as it related to knowledge level by comparing data obtained from

participants’ pre- and post-test scores. The quantitative process allowed for the deductive cause

and effect process with generalizations leading to prediction (Maldonado, 2014). The clinical

question was best addressed with the collection of numerical data and analysis using

mathematically based methods and was found to be the most effective (Eddy, 2016). The

outcome and goals of the project were to evaluate the use of education and training to improve

correctional staffs’ gaps in knowledge about TB. The qualitative method was not chosen because

it is most used to comprehend, understand, describe different phenomena by individuals, groups,

and cultures not numerical data (Maldonado, 2014). The quantitative methodology guided the

problem statement it was not known whether an educational intervention would increase a

correctional facility’s staffs’ knowledge about TB transmission and prevention. The project

focused on the clinical question on how effective was the use of evidence-based education in

increasing the correctional facility staffs’ knowledge about the transmission and prevention of

TB? The quantitative methodology was used and best to analysis the data obtained from pre- and

post-test focused on the implementation of the evidence-based educational intervention. The use

of the pre- and post-testing design was a viable method to assess the extent to which the

evidence-based educational intervention affected learning (Dimitrov & Rumrill, 2003). The

choice of the quantitative methodology was the most appropriate for this project, as it allowed

the association between the variables to be examined by comparing the pre-and post-intervention

test scores (Fain, 2015). The participants completed the pre-testing to analysis and describe the
 17

level of their knowledge about transmission and prevention of TB, prior to the evidence-based

educational intervention. The numerical data obtained were analyzed and evaluated to present

statistical evidence to address the project questions. The post-test was taken to evaluate the effect

of the training by comparing the pre- and post-test results that were included in the analysis

(N=50). The educational materials supplied to the participants after pre-testing were reviewed

and participants were given the opportunity to provide input and ask questions. The comparison

focused on their increased knowledge about the transmission and prevention of TB in a high-risk

correctional facility. The numerical data obtained were analyzed and evaluated and established

the extent to which the evidence-based educational intervention affected learning (Fain, 2015).

Nature of the Project Design

Choosing a project design depends on many factors, prior data of the topic, location and

setting of projects, feasibility, accessibility of subjects and ethics related to the project and

participants (Melnyk & Fineout-Overholt, 2015). The design was one needed to answer the

clinical question, how effective was the use of education in increasing the correctional facility

staff’s knowledge about the transmission and prevention of TB? The descriptive pre- and post-

test design selected was based on the ability to determine the relation between two or more

variables with the use of statistical tests. The descriptive design identifies trends and patterns to

interpret the results and explain the data analyzed. The use of the quantitative method to show

the intervention made a difference and caused a change (Dimitrov & Rumrill, 2003). The pre-

posttest design was chosen to answer the clinical question, and been shown to be widely used for

the purpose of comparing groups or measuring change (Dimitrov & Rumrill, 2003).

The project involved participants chosen randomly from different departments of the

correctional facility, and included medical providers, physician assistants, administrative office
 18

and maintenance staff, nurses, certified nursing assistants, dentists, and correctional officers who

volunteered to participate. Participants were assigned randomly to control systematic differences

and eliminate bias. When a total of 50 participants was reached, recruitment was concluded. The

total number of participants was chosen based on the percentage of staff in the facility to achieve

10% of the staff members in different departments for the t-test analysis. They were identified

and assigned a number that was used for identification throughout the project testing and on their

test sheets.

The project participant’s contact with the inmates ranged from frequent to minimal. The

15 correctional officers, custody staff, and 15 nurses spent the greatest amount of time with the

inmates, averaging 8-10 hours during a 12-hour shift. The staff who assisted with dialysis

treatment spent approximately 3-5 hours daily with the inmates receiving treatment. The doctors

and dentists spent an average of two hours on a daily basis. The 10-office staff and medical

records processing assistants spent the least amount of time with the inmates, approximately 15-

30 minutes periodically during the week. Because some of the participants have daily close

contact with inmates, their awareness of the signs and symptoms of TB can be beneficial for both

the staff members and inmate population (NC Department of Health and Human Services, 2017).

By knowing the signs and symptoms to look for, the staff members can be aware of who/what

may put the facility at risk for transmission of TB. The medical staff would know when to alert

the inmate’s provider about the symptoms noted and the correctional staff when to alert medical

staff. The 50 participants were given the pre-and post-tests about the transmission and prevention

of TB with a review of the information and opportunity for questions. No monetary remuneration

was offered and no restrictions were placed on the selection of the participants, who included a

variety of correctional staff; no participants dropped out or were eliminated. There were some
 19

participants who did not return to take the post-test.

The participants answered the same pre-and post-test questions and all were given the

same evidence-based educational material to review. The staff’s knowledge was evaluated with

the pre-test before they received evidence-based education about TB, and the post-test was given

to evaluate the knowledge acquired. The pre-test included a total of 20 questions: six were

multiple choice, two yes or no, five true or false, six fill in the blanks and one was a “what would

you do” scenerio. The participants were allowed one hour to take the test. They returned the tests

to the primary investigator to review and score. The evidence-based educational information

included handouts, evidence-based practice pamphlets, and active scenarios. The participants

returned the next day for the evidence-based educational intervention material and interactive

scenarios, and the education was completed with a review by the primary investigator. The

participants returned in seven days to take the post-test, after which the pre- and post-test scores

were analyzed. Adequate knowledge of TB epidemiology and control are critically important for

this population, and several studies have documented inadequate knowledge of the disease and

compliance with TB treatment guidelines among practicing physicians (Zhao et al., 2013). The

following section reviews and defines the terms used in the project.

Definition of Terms

The Definition of Terms section provides the technical terms and terminology related to

TB and abbreviations used in this project.

Bacilli Calmette-Guerin (BCG). This is an attenuated vaccine used in countries with a

large population of TB infected individuals. BCG is used in many countries with a high

prevalence of TB to prevent childhood tuberculous meningitis and miliary disease (CDC, 2016).

Custody level classification. The procedure used to assess inmate risks to establish their
 20

security requirements and program needs. There are five custody levels: close; medium;

minimum I; minimum II, and minimum III. Close custody is the highest and minimum III is the

lowest risk (NC DPS, 2013).

Direct Observation Therapy (DOT). The patient is given TB medication, is watched

while taking the medicine, and checked to ensure ingestion (Zhao et al., 2013).

Fast mask. This is a loose-fitting, disposable single-use item used as a barrier to different

substances. They are made in different thicknesses and cannot block small particles; therefore,

they have limited ability to protect against germs (FDA, 2015).

Fit test. This test is conducted to evaluate the fit of a respirator trained personnel use. A

scented substance is used to determine whether the employee can smell the odor. The test is

performed prior to the use of a respirator and annually thereafter (FDA, 2015).

N95 mask. This protective respiratory mask is worn after a proper fitting and excludes at

least 95% of micro-test particles (0.3 microns). If fitted properly, the N95 mask filters much

more than a standard face mask (FDA, 2015).

Tuberculosis (TB). This disease is caused by the bacterium Mycobacterium tuberculosis

and mycobacterium (M. bovis). Typically, it is airborne and transmitted by inhalation. It affects

the lungs primarily and may spread to other areas of the body (CDC, 2014).

TB control measures. These measures decrease the likelihood of transmitting TB (CDC,

2014).

Mantoux Tuberculin Skin Test (TST). This is the standard method of determining

whether a person is infected with MTB (CDC, 2014).

Tuberculin skin test (TST). The TST refers to the test and administration of the

Mantoux TB skin test performed by injecting 0.1 ml of tuberculin purified protein derivative
 21

(PPD) for testing and results in 48 to 72 hours (CDC, 2014).

QuantiFERON-TB Gold test (QFT). This blood test is used to identify Mycobacterium

tuberculosis (CDC, 2005).

Mycobacterium tuberculosis (M. tuberculosis). The germ is the causative agent of TB

(CDC, 2014).

Sputum specimen. This is the lab specimen obtained to rule out active TB in the patient.

Initially, 3 specimens are obtained and sent to the laboratory to be tested for MTB (CDC, 2014).

Health Law Violator (HLV). This is an individual diagnosed with active TB who is

prescribed medication for treatment and given an isolation order. The isolation order states that

the individual is to stay in his/her home at all times until the order is discontinued. The individual

violates the order of isolation or does not take the medication prescribed as ordered. Thereafter,

the Health Department notifies the county court that the individual has not complied with the

orders, and the court then orders the individual to be incarcerated until the end of treatment for

active TB (NC DHHS, 2017).

Assumptions, Limitations, and Delimitations

The assumptions of the project were that the participants would begin with an understanding

of the materials and the expectations of the project. The participants signed an informed consent

to take part in the project. The participants had no expectations for their own advancement or

monetary gain from the outcome of the project.

The following assumptions were made in this project:

1. The participants would be aware that the project focused on educating them about the

transmission and prevention of the communicable disease TB.

2. The participants would understand all of the expectations required to complete the
 22

review of the evidence-based educational information and return for post-testing.

3. The participants would read all of the evidence-based educational information

thoroughly.

4. The participants would answer all of the test questions accurately and truthfully.

5. None of the participants had contact with inmates or knowledge about TB before the

project was initiated.

6. The primary investigator (PI) assumed that the test results were fair and the data were

accurate.

7. The primary investigator assumed that all participants would answer all questions

accurately and review the evidence-based educational information supplied to them.

8. It was assumed that when beginning the project, the participants would understand all

the expectations to complete all review of evidence-based educational information

and return for post-testing. They were made aware that the project was focused on

educating the staff about the transmission and prevention of a communicable disease

TB.

9. The evidence-based educational materials were distributed with the assumption that

the participants would read them.

10. The primary investigator assumed that none of the participants had contact with

inmates or knowledge about TB prior to the initiation of the project and that the test

results were fair and the data were accurate.

The limitations in the project were as follows:

1. The participants’ levels of medical knowledge and of TB varied which may have

influenced the test results.

 23

2. Some of the participants had a history of latent TB disease, and thus had more

detailed knowledge of the disease and its transmission.

3. The participants who did not return for the post-testing decreased the sample size for

the data analysis and constituted a limitation to the project results.

4. The small sample of participants was attributable to scheduling issues or conflicts and

the amount of time available for participation and limited the ability to obtained

statistically significant findings.

5. The time constraints and ability to provide all data required to complete the project

posed some limitations.

6. The length of time required for data collection was identified as a limitation.

7. The results might have been stronger with a larger sample size.

The delimitations in the project were as follows:

1. This project’s design focused largely on one area and made no comparison with a

control group of participants who did not receive the evidence-based educational

intervention. The project could have identified specific areas of the facility to

evaluate the educational needs in different areas and departments.

2. The project focused on the education and knowledge of staff members in all

departments to help them implement preventive methods within the correctional

facility.

3. The project involved only the correctional staff and excluded the prisoners.

Summary and Organization of the Remainder of the Project

The descriptive quantitative project examined the effectiveness of an educational

 24

intervention to educate the correctional staff about the way TB is transmitted and methods to

prevent the spread of the disease by comparing their scores on pre- and post-tests. The

intervention included a review of materials and testing before changes in the participants’

knowledge level was assessed in the post-test. According to the WHO (2015), TB is more than

100 times more prevalent in prisons than in the general population because the overcrowded

living environment often resulted in the contraction of TB. Correctional staff play an essential

role in the prevention of TB infection among prisoners. The project discussed the problem of the

staff’s inadequate knowledge about the spread and prevention of TB and the project’s objective

of educating them about the disease.

According to the WHO (2013), risk groups should be prioritized for screening based on

careful assessment of local TB epidemiology and use interventions to improve its early detection.

These groups included inmates in prisons and other penal institutions and prison staff. This

screening can help identify TB carriers and cases and improve infection control (IC) and

interventions in prisons by using IC for inmates. Chapter 2 provided the literature review of

previous and current research with scientific information that supported the project. Chapter 3

discussed the methodology, project design, and procedures used in the improvement project.

Chapter 4 details the data analysis and provided graphics and a written summary of the results.

Chapter 5 interprets and discussed the results of the data obtained from the DPI project.
 25

Chapter 2: Literature Review and Theoretical Framework

This chapter discussed the theoretical framework for the project, and reviewed literature

that addressed the problem of the facility’s correctional staff’s inadequate knowledge about TB

and the way it spreads. The literature review was conducted to establish the framework that

clarified why this project was significant and used the following databases: Cumulative Index of

Nursing and Allied Health Literature (CINAHL); Cochrane Library; PubMed; ProQuest Nursing,

and Allied Health Source. Medical Support Headings (MeSH) terms included tuberculosis,

education, training, employee training, prison, transmission, prevention.

The problem statement was based on the fact that, it was not known whether an evidence-

based educational intervention would increase a correctional facility’s staffs’ knowledge about

TB transmission and prevention. The evidence-based educational intervention included

pamphlets, interactive scenarios, and review related to the transmission and prevention of TB.

The project main focus involved the education and prevention of the transmission of TB in the

high-risk environment of a correctional facility (CDC, 2012).

The project methodology was quantitative, and used a pre- and post-test design to

compare the participants’ test scores after an intervention. The data were collected with a formal,

objective method to obtain systematic numerical information to use in statistical analyses. The

literature review focused on correctional facilities and TB risks, and the ways to identify its

cause and mode of transmission. The review also focused on prevention and education about the

transmission of TB, the methods available to prevent TB, and the high risk of the spread of TB in
 26

correctional facilities worldwide (CDC, 2012). The project evaluated the use of evidence-based

education to increase individuals’ knowledge to help achieve positive health outcomes.

The chapter was organized in sections that included correctional facilities and TB risk,

identifying the cause of TB and mode of transmission, prevention and education. It identified the

cause of TB and mode of transmission by overcrowding and poor ventilation, as well as infection

control methods. The chapter discussed TB transmission interventions, symptom screening and

other preventive methods. The pre-test scores revealed a gap in the correctional staff’s

knowledge about TB, prior to receiving the interventional educational tools. The educational

tools were distributed and reviewed with participants with an opportunity to ask questions. A

comparison of TB outbreaks in the prison population was made with the general population. The

knowledge acquired, with the evidence-based educational intervention was assessed with the

post-test about the spread of TB among inmates and the community also were discussed.

The theoretical foundation of the project included the adult learning theory, andragogy, as

defined by Knowles (1973). The project also used the constructivism theory to supply the

participants with skills and help them construct their own learning styles and objectives. The

literature review included information about education and its effect on learning, disease

prevention, the scale of TB in the community, as well as recommendations and collaboration in

the care of TB. The information above was used in the project to support the topic of the use of

education to increase the understanding of TB among staff at correctional facilities. The

theoretical framework was based on the adult learning theory and focused on andragogy to

produce the maximum in learning. The adult learning theory’s concepts helped in the guidance

of the problem statement, it was not known whether an evidence-based educational intervention

would increase a correctional facility’s staffs’ knowledge about TB transmission and prevention.
 27

The constructivism theory was also used in the project. Renewed interest has emerged in the

potential interventions for early detection following systematic TB screening.

This section of the project discussed the background and history of TB. The number of

cases of active and latent TB in the prisons system in comparison to the general public. The

factors that made correctional facilities a high-risk environment for the spread of TB. The

importance of the project would contribute to the gaps of information related to evidence-based

educational interventions and improved knowledge of staff members about TB were addressed.

Prisoners have been identified as being among one of the highest groups in jeopardy of

acquiring latent TB infections that can become TB in comparison to the general population

(Shah, Ali, Ahmad, & Hamadan, 2013). Shah et al. (2013) found with male inmates between the

ages of 15 and 64 years old at a correctional facility, the percentage of TB cases reported while

incarcerated was 9.2% for the US born inmates. An additional 48% of 376 inmates had a latent

TB infection. Inmates were exposed to high-risk factors and behaviors that increased their

susceptibility to develop TB. These high-risk factors supported the need for education for the

correctional staff. The article provided no references on the use of education to improve

knowledge about disease processes and prevention. Correctional staff are an essential element in

inmates’ care and are necessary to prevent transmission of communicable diseases like TB in a

correctional facility.

There also was a limited amount of data in reference to the prevention of TB in

correctional facilities in the U.S. It is necessary to evaluate the use of evidence-based educational

interventions to enhance the knowledge of communicable diseases in high-risk environments.

The inmate population came from various areas of the world, and included those with chronic

diseases and older inmates, which increased the probability of transmission of this highly
 28

contagious disease (Dara et al., 2013). There have been breakthroughs in the treatment of TB,

but the incidence of the disease in prisons is five to 70 times more than in the general population,

and includes inmates with drug-resistant TB that is difficult to contain (Dara et al., 2013). The

next section discussed the theoretical foundations of the project. The use of the adult learning

theory, andragogy, and the constructivist model to guide the project was discussed.

Theoretical Foundations.

This section focused on the theoretical foundations of the project and discussed the adult

theory and different steps used in the theory for learning. The constructivist model and different

methods of learning and how it was incorporated in the project was included in the chapter.

Inadequate knowledge levels could be the result of a lack of education afforded to staff. In adult

learning it has been established that change can be difficult and may require extra efforts for

positive outcome.

The theoretical foundations of the project incorporated Knowles’ adult learning theory

and focused on andragogy that develops the link between adult learning theory and coaching the

learner (Cox, 2015). The adult learning theory incorporates life experiences and theory to

produce the maximum learning outcomes (American Institutes for Research, [AIR], 2011). It

was found that acknowledging the experience of learning and its value can evolve into an

individual’s practice of activities, such that the learner’s knowledge and experiences affect

subsequent actions (Cox, 2015). Behavior variables affect an individual’s motivation and the

constructivist model is referred to as the learning theory because it focuses on the way people

learn. Andragogy is based on: 1) the learner’s need to know why s/he needs to learn something;

2) the learner and his/her self-concept; 3) the learner’s previous experiences; 4) the learner’s

readiness to learn, and 5) the orientation of learning the learner establishes (Blondy, 2007). The
 29

theoretical foundation used was based on building on knowledge effectively and guided the

process (Cox, 2015). In Knowles andragogy theory he discovered that instructors needed to care

about the actual interests of the learners instead of their own interests (Blondy, 2007). The

andragogy approach assisted in answering the clinical question, how effective was the use of

evidence-based education in increasing the correctional facility staffs’ knowledge about the

transmission and prevention of TB?

It was found there was an ongoing problem of disregard for the importance of compliance

with the Department of Public Safety’s policy for TB testing and screening is a significant

problem (NC DPS Health Services Policy & Procedure Manual, 2011). The absence of

continuous TB monitoring and the treatment necessary within a correctional center is detrimental

to the staff, inmate population, and the community being exposed to an infected person. The staff

completed the pre-testing to assess their current understanding of TB and the transmission of the

disease. The TB evidence-based educational intervention was given to the participants, after

which the primary investigator conducted a review of the material. The participants in the project

worked in different areas in the correctional facility. Some worked with inmates in outside

rounds (OSR) where many of the inmates live. Additional staff, both medical and non-medical,

worked in the hospital in-patient area that houses acute and chronically ill patients. The time

taken to prepare for data collection and analysis can be extensive. The methods of collecting data

included preparation and scheduling the pre-testing for participants. The evidence-based

educational materials were distributed and reviewed with the participants. Statistical analysis of

the data was conducted after the project was completed. Pre- and post-test results were compared

after the evidence-based educational intervention was reviewed by participants. A series of

 30

strategies and methods were applied for the learning process to guide in the employee education

(Aliakbari, Parvin, Heidari, & Haghani, 2015).

Adult learning theory the theoretical foundation used for this project was based on the

concept of learning, readiness, and motivation, and focused on Knowles’ theory of andragogy

adult learning theory. Because it was not known whether an educational intervention would

increase correctional staff’s knowledge about TB, this theory was appropriate because it

examines the readiness to learn that is based on the need to know or do something different,

practical reasons to learn, and internal motivation. According to Knowles, adults are self-

directed and control the content and process of their learning (Palis & Quiros, 2014). This project

focused on the staff’s learning and their increased knowledge about TB to assist in applying

preventive measures for inmates to reduce the transmission of the disease. The project measured

the use of an evidence-based educational intervention for increasing the knowledge of

correctional staff’s knowledge of TB transmission and prevention of the disease. The adult

learning theory was used because adults need to know why the information they are taught is

necessary (AIR, 2011). Thus, it was important to evaluate the participants’ educational needs,

which was accomplished with the pre-test about TB (Palis & Quiros, 2014). The assessment

helped direct the educational intervention used in the project. In the 1984 edition of The Adult

Learner, Knowles added seven process design elements: (1) Setting an appropriate climate; (2)

mutual planning involving the learner; (3) learners diagnose their learning needs; (4) learners

help set learning objectives; (5) learners help design learning plans, (6) learners support the

implementation of learning plans, and (7) learners are involved in evaluating their learning.

Using Knowles’ theory of adult learning allowed the participants’ specific skills and
 31

knowledge to be assessed to develop learning objectives based on their needs. The adult learning

theory also gave the opportunity to evaluate the quality of the experience of learning the materials

supplied to the participants and their needs for future learning (AIR, 2011). Change is

sometimes difficult to implement, but may be necessary to achieve the best outcome for all

parties involved.

Constructivist theory strategies provide learners with information that they incorporate

into their mental models to process novel information actively and profoundly and integrate it

contextually with their prior knowledge, which promotes deeper learning (Vogel-Walcutt et al.,

2011). The clinical question that guided the project, led to an evaluation of the use of an

evidence-based educational intervention about TB prevention and transmission. The educator

supplied the learners with skills or support and encouraged them to construct their personal

learning experience actively (Vogel-Walcutt et al., 2011). Learning theory created an interactive

environment in which to present the evidence-based educational intervention. The theory

allowed active engagement in the learning process, as interactive scenarios were used to present

real life situations to educate the participants about the cause and transmission of TB. This model

was chosen to allow the participants the opportunity to create meaningful experiences by playing

an active role in their education. The participants were given scenarios about the transmission of

TB and, asked what the best outcome would be in the situation. Constructivism also allowed

group discussions in the process of learning new information, in which the primary investigator

coordinated the discussion to keep it focused and elicit the best information for the learner

(Aliakbari et al., 2015). The interaction occurred during the review process when the pamphlets

and handouts were distributed to the participants. Constructivism allows the learner to develop

increasingly strong abilities to integrate new information. This theory proved useful in allowing
 32

the participants to be involved actively in the learning process and in discussions, in which they

offered different perspectives on the subject they were learning (Aliakbari et al., 2015).

Review of the Literature

A systematic review of the literature was conducted to assess the evidence that screening

for TB increases the number of people placed in treatment, identifies cases earlier in the disease

process, reduces mortality and morbidity, and influences TB epidemiology. The clinical question

for the DPI project was, how effective was the use of evidence-based education in increasing the

correctional facility staff’s knowledge about the transmission and prevention of TB? In many of

the articles reviewed the authors indicated prison as a high-risk environment for the transmission

of TB. The themes discussed were correctional facilities and TB risk, identifying the cause and

mode of transmission of TB, prevention and education.

Correctional facilities and TB risks. This section of the project discussed the risk of TB

within a correctional facility and risk factors that increase incidence of the disease. The risk of

TB in this environment puts the inmates, staff members and community at risk of contracting the

disease. Shah et al. (2013) found that screened inmates for HIV and TB were among the groups

in greatest jeopardy of acquiring a TB infection because of the confined environments in which

they live (CDC, 2012). Prisoners usually entered the system with poor nutrition, financial

problems, and lack of healthcare. The authors studied a sample of 1,027 jail inmates. Their

research evaluated the high incidence of TB in comparison to the public and compared inmates

vs. non-inmates to identify which group was more likely to have a significant number of risk

factors for infection with Mycobacterium tuberculosis (MTB), which may progress to advanced

TB (Shah et al., 2013). The concentration of a mass population in a small area has caused major

outbreaks of TB, as shown in a North Carolina outbreak that involved 25 homeless patients, 72%
 33

of whom had a history of incarceration in the local county jail. These findings indicated that,

because of the environment in which they live, incarcerated people are at higher risk for

contracting TB compared to the general public (Shah et al., 2013).

TB is an infectious disease that infects one third of the global population each year, and

approximately 8 to 10 million people develop active TB (CDC, 2014). According to Cernat and

Brojboiu (2011), who studied 260 patients with TB admitted to a prison hospital between 2006

and 2009, a large proportion of TB cases (19.61%) was identified prior to entering prison. The

authors confirmed that, despite incarceration or the subjects’ socioeconomic status, these people

had a greater risk of developing active TB compared to the general population. According to

Cernat and Brojboiu (2011), the risk of contracting TB was 2.5 times higher among the groups of

persons incarcerated. According to Dara et al., (2013) a study that consisted of prisoners

diagnosed with pulmonary and or extra-pulmonary TB of 20 large city and county jails was

completed to evaluate the results of anti-TB treatment and identify the risk factors. According to

Dara et al., (2013) it was found with limitations in the current data, 9.2% of anti-TB cases were

reported among those incarcerated who were born in the U.S. An additional 48% of 376 inmates

had a latent TB infection and a known HIV status (Dara et al., 2013). The study identified

continued outbreaks and transmissions of TB even after inmates were screened for the disease,

which were thought to be attributable to incomplete treatments of inmates known to have latent

TB (Dara et al., 2013). These studies were initiated and built on the assumption that jail inmates

are exposed to risk factors that predispose them to develop TB (Dara et al., 2013). This

information further supported the need for correctional staff to be educated to aid in prevention

of TB. The authors discussed the time to act to prevent and control TB among inmates and the

different methods for prevention, as their research involved the increased spread of TB in
 34

correctional facilities (Dara et al., 2013). In the project, correctional healthcare workers were

asked questions related to the spread of TB. The questions asked were whether the participants

knew the way the disease was spread, and the necessary precautions to prevent its transmission.

The new intake inmates were given a skin test, and all results were recorded. This information

supported the need for ongoing screening and keeping the staff aware of the questions that

needed to be asked to be aware of risk factors for transmission of TB within a correctional

facility (Dara et al., 2013).

More than 9.8 million people are detained in penitentiaries and the incidence of TB

among imprisoned individuals differs from that of the general population and ranges from five to

70 times higher (Dara et al., 2013). Monitoring the TB situation in penitentiary services includes

standard recording of results and screenings. The continuum of care of inmates who are released

while being treated for TB infection or disease should be performed before they are discharged

from prison (Dara et al., 2013). Information also supported the need for additional research and

implementation of education for both inmates/offenders and correctional staff (Al-Darraji, Tan,

Kamarulzaman, & Altice, 2015).

Nogueira, Abrahoa, and Galesi (2011), research was based on active and latent TB

among prison inmates. Their observational study was conducted between March and December

of 2011 and estimated the prevalence of TB and latent TB among inmates in one prison and jail.

Questionnaires were given to the study participants that asked about their sociodemographic and

the epidemiological data that were used for various laboratory tests. The following information

was gathered: the prisoner’s name; parents’ ages; marital status; ethnic group; birthplace and

nationality; schooling; previous prison sentences, if any; length of stay in the prison unit; any

history of TB or contact with someone who was infected with TB (Nogueira et al., 2011). They
 35

were asked whether they smoked, or had a cough or lung disease. The study emphasized that

staff should be aware of inmates’ lifestyles prior to incarceration, their health issues, and history

of any chronic disease that may make them at greater risk for TB (Nogueira et al., 2011).

The authors interviewed 2,435 inmates and 2,237 (91.9%) consented to a TST. The

interview questions included health and family history, and living environment prior to

incarceration and lifestyle behaviors that may contribute to the risk of exposure to TB (Nogueira

et al., 2011). Among those interviewed and tested, 73.0% had positive reactions, for a prevalence

of TB of 830.6 per 100,000 inmates. The coefficients of prevalence were 1029.5/100,000 for the

prison inmates and 525.7/100,000 for the jail inmates, which indicated the high percentage of

positive TST reactions (Nogueira et al., 2011). The absence of the testing and screening

completed could have ill effects for all staff, other inmates, and the community (Nogueira et al.,

2011). The obstacles in this study that hindered the implementation of control strategies in the

facilities included the following: the prisoners hide their symptoms because of the violence in

prisons and the priority on security (Nogueira et al., 2011). The study supported the fact that

continued education about TB in high-risk correctional facilities was essential in changing the

staff’s understanding about transmission and prevention.

This article examined the prevalence and correlation of latent TB among employees of a

Malaysian correctional facility over a six-month period (Melchers, Elsland, Lange, Borgdorff, &

Hombergh, 2013). Melchers et al. (2013) conducted interviews previously with full-time

employees using a structured questionnaire that asked about sociodemographic data, correctional

system work history, and TB-related risk factors. The total number of employees recruited was

445 and 420 (94.4%) provided complete data. Their average age was 30 years old, and 88.8%

were men, 76.4% of whom had worked at the prison an average of 60 months. The employees
 36

who consented had a TST and returned for a reading after 48 to 72 hours (Melchers et al., 2013).

The individuals who had positive results (81%) had worked at the prison longer than 12 months.

This information was used for comparison to the correctional facilities in the U.S. There may be

gaps in the research because of the differences in the lifestyles and living environments of

inmates in the U.S. and those in Malaysia (Melchers et al., 2013).

The information in this section described the factors that increased the risk of

transmission of TB in the correctional setting. The lifestyles, crowded living conditions within

the facility and absence of testing and screening completion having ill effects for staff, inmates

and the community. The benefits of education for the staff members to increase their knowledge

about the disease transmission and prevention was established.

Identifying the cause of TB and mode of transmission. The identification of TB, its

mode of transmission and cause are discussed in this section. The increased cause of

transmission of TB within the correctional setting was also discussed in the project. The

importance of infection control and management of TB in the prisons. There were occurrences of

TB outbreaks and continuous transmission despite inmate screening in prisons (Shah, et al.,

2013). The continued need for established policies, guidelines and updates were included in this

section.

Bergstrand’s (2012) revealed that the incidence of TB is five to 70 greater in prisons than

in communities. Clearly, TB has become a major problem in correctional settings, including

jails, prisons, and detention centers. Prisons serve as a reservoir for TB, pumping the disease into

the civilian community through staff, visitors, and former inmates treated inadequately

(Bergstrand, 2012). Therefore, managing TB in prisons must be an integral part of any public

health policy designed to control and ultimately eradicate the disease. Improving TB control
 37

among prisoners can be a benefit to society. The U.S. Agency for International Development

(USAID) has addressed the growing public health problem of TB in correctional settings. The

agency developed policy guidelines and recommendations that included screening inmates,

strengthening health services in prisons, improving Infection control (IC) measures. The training

of medical and non-medical penitentiary staff, and establishing community collaborations for

post-release follow-up and treatment was also included (Bergstrand, 2012). The education

available to correctional staff in the prevention of TB was beneficial to offenders, other staff

members, and the community.

Per Koch’s original discovery, the National Institutes of Allergy and Infectious Diseases

of the National Institutes of Health (NIH, 2012) reported that TB is caused by the infectious

bacterium (MTB). One of the most important ways to decrease the spread of infectious diseases

is with strict IC. In an article “TB control in prison: Current situation and research,” Dara et al.

(2015) reported the number of reasons why TB remains a major infectious disease in prison

systems: insufficient laboratory capacity and diagnostic tools; interrupted supply of medicines;

lack of assimilation of care between civilian and prison TB services, and inadequate IC

measures. They reported that the low priority of policy updates and changes in prison healthcare

are some of the reasons why there is a need for strict preventive and screening methods (Dara,
 38

2015). The discussion was about the need to maintain monitored, updated policy and guidelines

for cause of TB transmission. The importance of management and control of the spread of TB.

The high rate of transmission in the prison and undiagnosed cases due to improper follow-up of

screening and treatment. The fact that TB affects vulnerable populations which the prison was

included in that group. TB has remained a major infectious disease in the prison systems.

Barbour et al. (2010) indicated that the health crisis of TB in prisons extends beyond their

walls, although again, their findings supported the fact that the rate of TB is higher in prisons

than in the community. Numerous factors contribute to the spread and transmission of TB, and

these risks predispose imprisoned people to an even higher risk of the disease. The study noted

inadequate standards in IC measures (Barbour et al., 2010). There also were conflicts about what

the best methods were to decrease the spread of the disease, and such conflict is hazardous for

everyone at the facility. Additional problems were prisoner segregation depending on their

crimes and lengths of sentences, and the lack of medical facilities and resources, which included

prison staff, as well as the low priority policymakers assigned to providing the best healthcare

within the prison system (Barbour et al., 2010).

Kranzer et al. (2013) conducted a systematic review to assess the evidence that initial

screening for TB increased the number of TB patients given anti-tuberculosis treatment,

identifies cases earlier in the disease process, reduces mortality and morbidity, and affects TB

epidemiology, and found that screening increased the number of cases found in a shorter period

of time. This recent systematic review provided the evidence necessary for policymakers,

including the WHO, to continue their efforts to address TB in prisons (Kranzer et al., 2013).

There were guidelines and assistance available on ways to control and prevent TB in

prisons best. Many academics, healthcare workers, and campaigners have called for intensive
 39

screening of high-risk populations, which include inmates, as part of an interim integrated

strategy to decrease the global incidence of TB. Barbour et al., (2010) review included

recommendations for future investigation to measure the effect of prison conditions on TB

transmission, and assess the risk for transmission of TB from prisons to the community. In

October 2010, the Global plan to stop TB 2011-2015 was launched by the Stop TB partnership,

which is a coalition of a number of different organizations worldwide (Barbour et al., 2010).

Their goal was to reduce TB by 50% or as much as possible and reduce prevalence rates

compared to the 1990 baseline by 2015. The Stop TB strategy was in its final year and has

extended the goal to end the TB epidemic by 2035. The primary objective in achieving this goal

was to ensure early diagnosis of all TB cases, including those in high-risk inmate populations.

TB affects vulnerable populations around the world, and the prison population is one of

those with the highest risk for TB (Gegia et al., 2011). According to these authors, an estimated

nine million people are held in prisons worldwide, and an estimated 8.5% have TB infections

(Gegia et al., 2011). Their research found that, in addition to being infected with the bacteria that

causes TB, prisoners also are less likely to be diagnosed, receive treatment, and complete the

treatment necessary (Gegia et al., 2011). The authors used a combination of qualitative methods

to describe the problem of TB control in Georgian prisons (Gegia et al., 2011). Qualitative

methods are useful in providing valid data on healthcare problems. The study used participant

observations, ethnographic interviews, and interviews with key informant. Data were obtained

from a total of 23 participants in a variety of prisons, including health officials, physicians,

nurses, and prisoners. The study revealed a lack of coordinated screening efforts, delays in

initiating proper treatment, and a limited number of human resources to manage TB in the

prisons (Gegia et al., 2011). Together with TB, most prisoners suffer from co-morbid conditions
 40

that decrease the likelihood that they will recover or be cured of TB (Gegia et al., 2011). There

also were insufficient laboratory resources, poor infrastructure, and poor follow-up of TB

patients who are released from prison (Gegia et al., 2011). The Georgian prison system would

like to initiate a number of reforms, and those that have been implemented have made progress,

but there are limitations in the plans, including funding, implementation, monitoring, and

ensuring the human rights of the prison population (Gegia et al., 2011).

In the last two decades, TB has continued to be a social issue that affects the world’s

most disadvantaged communities, including prisoners, and TB is a leading cause of their

mortality and morbidity (Lee et al., 2012). The Global Fund grant database, which approved the

investment of 21.7 billion in 150 countries by the end of 2010 was reviewed to identify the funds

allocated for TB and HIV/TB grants, and activities that monitor treatment of TB and support

activity in prisons settings. The distribution and number of countries with TB support programs

in the prisons were mapped by year, geographic region, TB or the multidrug-resistant TB

problem, and the prison population. The study also identified the type of services offered,

management of the program, their performance and types of services offered. (Lee et al., 2012).

Approximately 50% of the 105 countries with Global Fund programs with TB services were

within the prison setting. Thirty-two percent (73 of 228) of TB grants represented $558 million

of all disbursements of Global Fund TB support by the end of 2010. The range of services

tracked was limited in scope and scale, and 69% offered only 1 type of service, while less than

one-fifth offered 2 types of service. Based on the study it was concluded that there has been an

increase in the funding investments available for the fight against TB in prison settings, but
 41

continued research is needed to determine the funding levels and areas in which services were

lacking in prisons (Lee et al., 2012).

A study Bryant et al., (2016) conducted in North Carolina concluded that effective TB

investigation is critical in continued progress in TB elimination. As the cases of TB decline, this

decreased TB staff’s involvement in contact investigation. Multivariable models were used to

study the association between staff familiarity and the quality, time, and results obtained from

investigations of TB cases. The study found that a total of 501 cases and 3,230 contacts met the

inclusion criteria. Data were stratified by the number of cases in the county and whether the case

involved smear-positive or -negative results (Bryant et al., 2016). More staff involvement and

rapid contact identification were noted in the smear-positive cases. The authors also noted that

the speed of identification and the number of contacts is a major aspect of contact investigations,

the prevention of the spread of TB, and necessary treatment, and that it is important to retain

experienced, educated, knowledgeable staff to mentor other staff.

According to Sequera et al. (2015), from the first day of incarceration, prisoners are

exposed, and expose others to, a multitude of communicable diseases, many of which can be

prevented with vaccines. In 2013, TB had a prevalence overall of 159 cases per 100,000, for an

incidence of 126/100,000 and a mortality of 16/100,000. More than one million incident cases

had HIV. In some countries, the incidence in prisons is 100 times that in the general population.

Currently, the Bacilli Calmette-Gurein (BCG) vaccine is recommended only for children born in

countries with high disease burdens and medical personnel in close contact with persons infected
 42

with TB. The vaccine is not indicated in prison prevention programs because of its lack of ability

to prevent TB in adults (Sequera et al., 2015).

The Agency for Healthcare Research and Quality (AHRQ) is a resource for all staff for

systematic screening, active TB principles, and recommendations (AHRQ, 2011). This article

provides guidelines for clinical diagnosis and management of TB and measures for its prevention

and control. Preventive guidelines in specific settings have been established by a variety of

agencies for reference and are useful in the high-risk correctional environment. The need for

employees to be aware of the signs and symptoms of TB and other important information is vital

in prevention. Inmates transferred to medical services must be evaluated and proper interventions

taken as needed. The guidelines state that the patient follow-up necessary must be monitored and

completed. The evidence supporting the recommendations established that appropriate diagnosis

of primary cases of TB and identification of secondary cases helps prevent further cases.

According to Foster, Bell, and Jayasinghe (2013), care control and collaboration in a

prison hospital is important to decrease infection. The inmates’ healthcare is balanced with the

priority to maintain the security and safety of all in the prison and the outside community.

Typically, nurses learn about prison healthcare after qualification. The academics of nursing in

this environment has pointed out that the prevailing philosophy in the prison culture is security

rather than healthcare. Collaboration and cohesive teamwork are necessary and were associated

with a greater sense of both safety and healthcare security for both the prison and the community

Foster et al., 2013).

Monitoring the TB situation in penitentiary services includes standard recording of

results and screenings (Dara et al., 2013). The study of participant correctional healthcare

workers asked questions about whether they knew the way TB spread and the necessary
 43

precautions to be taken; none provided correct answers. Yet it is critical that continuation of the

care of released inmates who are being treated for TB infection is ensured before

discharge/release from prison (Dara et al., 2013).

The importance of the identification and cause of transmission of TB, was the topic in

this section. The bacteria that causes the disease and the ways to decrease its spread and the

prevalence in prisons were included in the literature review. The information indicated the

importance of identification of TB, importance of screening, surveillance and control. The modes

of transmission and the increased occurrences in correctional facilities. The measures taken in

care control and collaboration in prison to decrease TB infection.

Prevention. This section discussed the methods and necessity for prevention of TB in a

high-risk environment. The different methods of prevention of the disease and early detection.

The necessity of knowledge about the signs and symptoms of TB. The CDC recommendations

for the prison, a high-risk environment. Preventing the spread of the infection from the prison to

the community through intensified TB screening of new and transferred prisoners and supplying

special quarantine areas or cells for both is a necessary intervention. To prevent TB infection

among prisoners, prison staff contact investigations may be conducted (CDC, 2014). This can

help identify those suspected to have TB and TB cases and improve IC and interventions in

prisons. The WHO recommended screening individuals with HIV as part of its three I’s policy

initiative (Kranzer et al., 2013). The three I’s policy involved intensified case finding, isoniazid

therapy and infection control (Kranzer et al., 2013). The three I’s policy also focuses on the risk

of active TB disease among risk groups as well as population-wide screening interventions

(Kranzer et al., 2013). The review assessed four potential benefits of screening for TB disease in

a study in the U.S. that evaluated mandatory screening, as well as prophylaxis and treatment, for
 44

those who want to use homeless shelters. According to Kranzer et al., 2013 the trends in TB in

that district fell by nearly 90% over 10 years.

The prison population in the U.S. is one of the highest, with 2.1 million incarcerated

individuals, that contributes to overcrowding and prison populations have an extremely high

prevalence of TB compared to civilian communities (Bureau of Justice, 2011; Awofeso, 2010).

According to Awofeso (2010), TB ranks number 10 in the world as a principal cause of death

and disability. In 2007, an estimated 9.3 million cases of TB and 1.8 million deaths from TB

occurred worldwide. Globally, prisons have been shown to have a higher prevalence of TB

morbidity and mortality compared to the general population (Awofeso, 2010). The total number

of TB patients in 2014 was 8,961 and 8,935 (99.7%) of those were in the U.S. 376 (4.2%)

patients were reported to be residents of correctional facilities at the time of TB diagnosis (CDC,

2015). The increased number of inmates with TB can be attributed to the architecture of prisons

and the fact that TB is an airborne disease. According to Awofeso, (2010) South African prisons

have a total capacity of 115,327 inmates, but in 2007, the average number was 163,049, 42%

excess capacity.

TB surveillance and treatment plans continue to be inadequate in some prisons, as they

do not consistently complete skin testing of new inmates and test the correctional health staff

annually, although evidence has shown that this surveillance method is a practice that is able to

detect new cases early well (Awofeso, 2010). The consequences of improper surveillance

activities or failure to complete them led to a TB outbreak in a New York prison and a study

related to this outbreak found that only nine (23%) of 39 inmates with Mycobacterium Drug

Resistant-TB (MDR-TB) received treatment prior to a surveillance. A systematic review was

conducted to identify the risk of latent infection and TB in prisons in comparison to the local
 45

public and to estimate the fraction of TB in the general public that is attributable to transmission

from those in prison (Baussano et al., 2010). The results established that much better TB control

in prisons potentially could protect prisoners and staff from spreading TB within and outside the

prison and reduce TB’s cost and burden on society.

According to Herrera, Bosch, and Aguilera (2013), the risk of TB is very high due to the

dynamics of close contact between prisoners and the transmission through prison staff, visitors

and the public. The prison system represents an area for TB transmission to the population at

large and should be a source of public concern (Herrera et al., 2013bnm,).

Hollenbeak, Schaefer, Penrod, Loeb, and Smith’s (2015) article discussed the efficiency

of healthcare in state correctional institutions, and reviewed studies of estimates of the efficiency

of healthcare in the prison setting. The increased population and the number of infirmary beds

for care of the population were evaluated to see whether the inmate could be accommodated in

the space available. The paper discussed the increased healthcare needed for inmates who

contract TB, and found that older, white inmates, and inmates with parole violations received

less efficient care. Without the proper care necessary in this environment major transmissions of

the bacteria can occur.

The CDC (2012) reported that TB can be difficult to control in correctional facilities.

Effective TB prevention and control within these facilities must include early identification of

individuals with the disease, which can be accomplished by screenings at initial entry and

periodic follow-up screenings. Another prevention method would be successful treatment of TB

and latent TB infection. There is a great need for the appropriate use of airborne precautions,

such as environmental controls and respiratory protection with proper equipment. The facilities

also should maintain effective and properly functioning isolation rooms. The correctional facility
 46

must have proper discharge planning for inmates who have been diagnosed with TB and are

receiving treatment to ensure proper follow-up and care as needed. There must be thorough and

efficient contact investigations when a TB case has been identified, with necessary care

thereafter for all individuals affected (CDC, 2012). Continued education of inmates and

correctional facility staff should be implemented as a requirement and put into policy. These

measures helped protect the inmate population, correctional staff, visitors, and the community.

Upon implementation of all preventive measures to help decrease the transmission of TB, there

should be periodic surveys and evaluations that proper procedures and policies are being

followed.

According to Dara et al. (2013), millions of people are detained in penitentiary services

who subsequently are at greater risk of infection with MTB and then develop TB. TB prevention

in the penal system is recommended strongly to include psychological counseling and support

for inmates to improve their adherence to medications. The promotion of operational research

continues to build evidence to enhance TB prevention in correctional facilities. With respect to

monitoring the diagnosed and treated cases of TB found in these facilities, complete treatment is

recommended as a topic for further research.

Melchers et al.’s (2013) study identified screening tools and asked whether screening

and TSTs are sufficient to help decrease the spread of TB in high-risk populations. Their

systematic review considered the screening practices and diagnostic tools for TB detection.

Screening tools used were identification of signs and symptoms of unrecognized TB in

asymptomatic individuals by use of examinations, questionnaires, and chest x-rays, as well as the

TST with the proper follow-up. They reported further that the treatment of active TB cases

necessary involves Isoniazid preventive therapy (IPT) and isolation of TB suspects. An overview
 47

of airborne TB and the preventive methods that should be taken are made available for staff. The

necessary treatment prescribed for active and latent TB disease was discussed and requires

consistent screening (National Institute of Allergy and Infectious Disease, NIH, 2012).

TB transmission has been documented from inmates to other inmates, employees,

visitors, and volunteers (Bick, 2007). Overcrowding, poor ventilation, delayed diagnosis, and

failure to adhere to standards for prevention, screening, and containment have all contributed to

the transmission of MTB within jails and prisons and then into the non-incarcerated population.

Proper isolation and masking of staff and inmates is needed when MTB is suspected and the

testing necessary to rule out TB must be performed, all of which must be conveyed in education

(Bick, 2007).

Dara et al. (2013) discussed TB prevention and control care in prisons. Their article

“Time to act to prevent and control tuberculosis among inmates” focused on the importance of

the prompt detection of TB using a combination of screening methods, such as screening during

initial processing, mass screening at regular intervals (annually for all inmates and staff), contact

screening based on medical clinical questionnaires, chest x- rays, smear microscopy, and self-

referrals. The foundation of strengthening TB control in prison programs is educating both the

inmates and all staff members on a continuous basis.

Baussano et al.’s (2010) article, “The Tuberculosis incidence in prisons: A systematic

review,” investigated the risk of latent TB and TB in prisons compared to the public. Overall,

they found that prisons represent an area of society with a high rate of disease transmission.

Prisoners’ spread of this disease to the public has been hypothesized to play a major role in

increasing the level of TB incidence, prevalence, and mortality rates (Baussano et al., 2010).
 48

Ignoring the importance of TB prevention and control in prisons can cause serious consequences

for the inmates and the general public in nearby communities (Barbour et al., 2010).

According to Viney et al. (2014), inmates and correctional staff may transfer TB to

different facilities in the penal systems and medical facilities in the community through contact

with visitors. Those inmates released without a diagnosis or before completing therapy can cause

widespread infections in local communities (Viney, 2014). This research was a descriptive study

that used qualitative and quantitative methods with open-ended questions to allow for expanded

answers. The study was conducted to assess the knowledge, attitudes, attention to, and practices

pertaining to active TB patients (Viney, 2014). After an assessment of interviews with 35

patients, 22 (63%) of whom were male, the authors concluded there was a large knowledge gap

about TB transmission.

During the interviews, the participants attributed TB to cigarettes, kava, alcohol,

contaminated foods, sharing eating utensils contaminated with TB, and sorcery. The large

majority (94%) did not believe that bacteria caused TB. Almost all the TB patients (89%) stated

that their disease was treated best at a hospital with antibiotics. However, three-quarters (74%) of

them were stigmatized because of their diagnosis of TB. The study concluded that better

information about TB is required to correct the common misconceptions about the disease

(Viney, 2014). The limitations in the study were the use of a convenience sample, which may not

result in generalizable findings. All interviewers were TB nurses employed by the Ministry of

Health, and they may have wanted to please the other nurses (Viney, 2014).

In a survey that assessed knowledge about TB and health information using a

questionnaire in a medical school in Southwest China, found that there was an inadequate

amount of knowledge overall and the need to rethink the approach to TB health and promotion
 49

(Zhao, Ehiri, Li, Luo and Li, 2013). The poor knowledge of TB on the part of medical students,

the study documented underscored the need to increase TB health promotion and target efforts at

educating people about TB. This study focused on the participants’ core knowledge of TB. Low

scores were obtained in knowledge about the signs/symptoms of TB, its transmission, treatment,

and policies. Approximately 261 respondents (18%) had no knowledge of TB symptoms, and

fewer than 132 (10%) could identify all the symptoms. The results showed that 119 (10.8%) men

and 13 (3.4%) women had a knowledge of TB symptoms overall and knew all of its normal

symptoms. Overall, the authors concluded that health professionals’ awareness of TB is very

limited among future clinical leaders in China (Zhao et al., 2013).

The purpose of Ferreira, De Oliveria, and Marin-Leon’s (2013) study was to analyze the

attitudes and practices related to TB in a prison and public health services. The study used a

cross-sectional questionnaire with 141 prisoners, 115 prison employees, and 158 public health

workers to evaluate the knowledge about TB on the part of prisoners, prison unit employees, and

public health workers. The results showed that three groups had misconceptions about TB and

the public health services employees showed basic errors in TB knowledge that demonstrated the

deficits in their training. The study showed increased clinical competence after a 3-week core

course with persistent improvement for 24 weeks. There were practices and attitudes that limited

this tool’s usefulness in data collection. Other limitations were related to obtaining statistically

valid samples of inmates because of the prison conditions and security requirements. Random

selection of the inmates was made using the prison’s criteria for security measures for movement

to a meeting area. The prison employees and public healthcare workers all participated based on

their own interest in the study (Ferreira et al., 2013). The study indicated that with respect to

access to training programs, public health and prison workers, should have adequate knowledge
 50

about TB after an assessment of their knowledge. They concluded that considering the high

prevalence of TB in prisons, supervision is required for educational activities in the prison

system (Ferreira et al., 2013).

Early detection should be implemented to assist in prevention. According to the WHO,

(2013) the burden of undiagnosed TB is high in many settings, especially in some risk groups.

However, many people do not experience typical TB symptoms in the early stages of the disease,

and thus, these individuals are unlikely to seek care early and may not be diagnosed properly

even when they do seek care eventually. This behavior of neglect is a barrier that results in

missed or delayed TB diagnosis. Unless targeted properly to a relevant risk factor, TB screening

requires many resources for the number of persons identified with TB and can lead to spurious

diagnoses of TB because of a high number of false-positive tests (WHO, 2013).

The Alabama Department of Corrections (DOC) recently faced its worst TB outbreak in

five years. Prison officials reported nine cases in 2016, a significant increase from the fewer than

five infections documented annually (Collins, 2014). This unprecedented public health crisis

followed on the heels of a major court case stemming from the poor medical treatment of

prisoners in Alabama’s DOC and overcrowding of its correctional institutions, including St. Clair

Correctional Facility, which holds 300 more inmates than space allows. Two advocacy groups

filed a lawsuit on June 17, 2014, claiming the state fails to provide inmates basic medical and

mental healthcare. The lack of nursing and correctional staff who are educated properly about

TB can be a major problem that can be avoided with proper interventions. Inmates in such
 51

situations have attempted to file lawsuits against the state DOC, and the initiation of lawsuits

exerts a burden on state budgets.

Prevention, early detection and screening processes were discussed in this section of the

project. The knowledge of the signs and symptoms, proper follow-up was identified as vital

aspects of prevention of TB in a high-risk environment. The next section discussed the use of

education and training for increasing staff knowledge about the disease. The section discussed

the variety of available resources for information on the transmission and prevention of TB. The

different methods that can be used to educate staff and articles supporting particular methods that

are implemented with positive outcomes. The benefits established from educating the staff about

the disease transmission and prevention.

Education. The literature review in this section discussed practices for training methods

used to educate the staff to obtain the best patient outcome and increase their knowledge. The

articles were support of the use of education to answer the project’s clinical question. How

effective was the use of evidence-based education in increasing the correctional facility’s staffs’

knowledge about the transmission and prevention of TB? The studies involved training methods

to increase knowledge about methods of prevention of TB in a high-risk environment. This

section discussed the different methods of teaching that can be used to educate the staff. The

effectiveness of particular methods of educational interventions were included in this section.

Based on their study, Dara et al. (2014) believe that TB control in prison is a major health

problem. Barriers to tackling TB in prisons are complicated and co-exist with other aspects of

both the health and criminal justice systems, as well as the cultural, historical, and economic

situations in each country. In their study, health education and training were provided for

correctional staff. The initial classes and in-services were conducted with timely follow-ups to
 52

test skills and knowledge of both. Further, they initiated effective plans for resource development

that covered the entire process, such as basic education, pre-service, retraining and on-the-job

training, supervision, and career development (Dara et al., 2014).

According to Awofeso, Schelokova, and Dalhatu’s (2008) article, “Training of front-line

health workers for tuberculosis control” appropriate training of front-line health workers is

needed to improve offenders’ health. Training resources were made available for staff to review

in class and at their leisure. The training information included the completion of a pre-test and

other activities related to the spread of TB. The authors conducted a review of the number of TB

cases in jails and prisons in comparison to the number in the public. TST should be performed

unless a history of a positive TST is noted for either new staff or an inmate (Bick, 2007). The

prevalence of newly-incarcerated inmates with HIV and other viruses, including Hepatitis B and

C, Syphilis, Gonorrhea, and Chlamydia, as well as TB are increasing. This study found that 25%

of U.S. inmates have a latent TB infection and the number with active TB is 6-10 times greater

than in the non-incarcerated population Awofeso et al., 2008).

The Education-Service Partnership to Promote Best Practices in a Latent Tuberculosis

Infection program addressed the challenges in follow-up in latent TB programs. The objectives

of the program were to gain knowledge and improve surveillance and compliance with follow-up

and treatment. The project involved 193 latent tuberculosis infected (LTBI) individuals who

were contacted by phone or mail (Belcher et al., 2011). The education opportunity applied to

competencies in epidemiology and prevention. The project used telephone scripts for encounters

with clients who had positive TSTs and those who also had a positive TST and a negative chest

x-ray. The telephone scripts were used to solicit information and answer general questions about

follow-up treatment. There were limitations and challenges in this process, including incorrect
 53

information, and telephone contact was very limited; there also were language barriers in some

cases. The program outcomes showed that the process of assessment designed and implemented

allowed for service learning and evaluation and resulted in improved practices.

Weaver et al., (2014) demonstrated a method to evaluate best practices for training mid-

level practitioners to improve global health services. A pre-post-test design and on-sight support

(OSS) yielded additional improvements as tested with a clustered-randomized trial. There were

12 written case scenarios used to assess clinical competencies in HIV/AIDS, TB, Malaria, and

other infectious diseases. Each participant completed different blocks of four scenarios assigned

randomly before IMID and after a 3-week course and a second refresher course at 36 Uganda

health facilities (Weaver et al., 2014).

Critical research on simulation-based mastery learning (SBML) has been used to evaluate

the effectiveness of simulation learning and information retention (McGaghie et al., 2014). The

use of medical education and evaluation of its implementation and immediate results with

documentation of translational outcomes, was found to be related to improved patient care

practices. The method addressed the science of learning, and the importance of innovations in

medical education and healthcare. Evidence proved that the SBML outcomes obtained in the

educational lab transferred to downstream patient care and patient outcome. The research was

conducted over a seven-year period and included a qualitative synthesis of SBML with a critical

review approach to synthesize the findings. The population in the study was 23 medical

education students.

According to Trossman (2016), experts say it is critical that nurses choose and use the

correct Personal Protective Equipment (PPE). The use of a procedure mask can help protect

healthcare workers from common colds and seasonal influenza that are spread in large droplets
 54

through coughing and sneezing. Respirators, on the other hand, are needed against airborne

diseases, such as TB, measles, and chickenpox. Protection from droplet-spread illnesses also is

important because the droplets are invisible. Based on the study’s findings, it appears that many

hospital care workers are unclear about when and how to use respiratory protection .

Each individual’s method of learning varies. Bhutto & Chhapra’s (2013) study of

constructivism demonstrated that it is important to build a meaningful understanding appropriate

for all learners and situations, and this can occur with different educational and non-educational

methods in which instructors have a tendency to generalize this concept. Constructivists

emphasize the focus on the learner and the depth of his/her progression in understanding their

learning, and assistance. That allows the learner an opportunity to provide input in the learning-

teaching encounter. Research on constructivism has shown that it is a concept in which students

establish their own understanding as they build knowledge on their own (Bhutto & Chhapra,

2013). This was an exploratory study intended to understand the constructivism approach. The

research used a quantitative research design with a sample of 26 different private and

government schools selected from among more than 60 schools. The schools were chosen by the

completion of a questionnaire by the heads of the schools’ departments and principals.

According to the authors, the results suggested that there were different areas of development in

the learning environment that encourage learning and emphasize sociocultural elements, as they

have a direct influence on the learning process (Bhutto & Chhapra, 2013).

According to Loos and Fowler (2001), the effectiveness and influence of training

intervention research can be used to identify major variables that affect the learning process and

optimize resources available for training. Their research helped identify the critical elements that

affect training effectiveness and efficiency. It established training goals and objectives, drafted
 55

instructional materials, held interviews, produced curriculum, and low-cost simple tasks for staff

(Loos & Fowler, 2001). The research model described pertained to both educational needs, the

way they determined and what target populations the training would serve. Some OSHA

standards for control of workplace hazards include requirements for worker training to reduce

risks of injury and disease (Loos & Fowler, 2001). A uniform system of research was needed,

and the model recognized that real-world factors affect formal training interventions. Each year,

American corporations spend $55-$60 million to train approximately 60 million employees using

the model of integrated primary and secondary data collection with qualitative and quantitative

analysis. The benefits of each technique are applied to evaluate training effectiveness (Loos &

Fowler, 2001). It was established the standard of best practice to limit certain jobs to workers

who were considered competent by virtue of specialized training. The outcomes varied and the

wide variety of independent variables included—timing, format, and location of training

modification, as well as the rationale for the training content or educational approach—

minimized the effects, and made the results difficult to interpret. However, all of the variables in

the review influenced the effectiveness of the training and learning action continuum, and

suggested that additional capacities are needed and require developing personnel ,workplace

programs, and evaluating readiness (Loos & Fowler, 2001). The readiness professional workers

needed included: 1) a broad-based perspective on occupational and environmental health; 2) the

ability to be a lifelong learner; 3) the knowledge to develop and operate integrated controls

across multiple occupational settings, and 4) the capacity to convey health and safety information

in a manner meaningful to the learner (Loos, & Fowler, 2001).

Employee training is a vital part of any business and is essential to its success (Uma,

2013). This is especially true in healthcare. Training is helpful in enhancing new employees’
 56

competency, and also improves the business’ productivity. The purpose of this study was to

determine training’s effect on employees’ performance to understand the importance of training

and opportunities for employee performance and organizational development, and the training’s

purpose, need, and the benefits it offers in increasing employees’ competency in the organization

(Uma, 2013). The research revealed that every organization needs to have well-trained and

experienced people to complete job duties, and training plays an important role in improving a

business’ effectiveness (Uma, 2013).

Jansson, Syrjala, Ohtonen, Merilainen, Kyngas, and Ala-Kokko (2016) used a

randomized, controlled trial to test the effectiveness of simulation education in a 24-month

follow-up study in a clinical setting. The trial was conducted from February 2012 to March 2014

with 40 critical care nurses initially, ultimately 30, in a 22-bed adult mixed medical-surgical

intensive care unit. The study evaluated behavior and cognitive development through a validated

Ventilator Bundle Observation Schedule and Questionnaire during baseline that was repeated

three times in simulations and real-life clinical settings. The study was designed to identify the

effectiveness of simulation education for nurses in a high-risk environment. The authors’ goal

was to show that simulation education may enable learners to improve their skills and retain

more information (Jansson et al., 2016). It also was found to improve the participants’ cognitive,

behavioral, and psychomotor skills. The limitations also may be attributable to the participants

who dropped out of the study and the resulting lack of robust evidence. However, the original

question was answered. The authors found that the skills needed to maintain and follow
 57

evidence-based guidelines improved significantly in both study groups during the 24 months

(Jansson et. al, 2016).

O’Malley, Perdue, and Petracca (2013) established a framework for test results of an

outcome-level evaluation of in-service training of healthcare workers. The purpose of the study

was to attract widespread recognition to the number of healthcare workers trained inadequately

(O’Malley et al., 2013). In-service training is a key strategy to produce well-trained, well-

prepared healthcare workers that provides stronger healthcare systems and better patient

outcomes (O’Malley et al., 2013). The framework was based on an inductive approach that

identified themes and categories in qualitative data to develop a model about the underlying

structure of experiences or processes. The study indicated what types of results may reasonably

be expected from a training program, and the way to prioritize evaluation across a wide range of

training projects. The data collection was completed through interviews with a sample of 15

informants. The training evaluation framework provided conceptual and practical guidance to

help evaluate in-service training outcomes in the healthcare setting (O’Malley et al., 2013).

Validation of the framework using stakeholder feedback and pilot testing suggested that the

model and accompanying tools may support outcome evaluation planning usefully (O’Malley et

al., 2013). Employee training is an investment and a good way to improve the quality of services
 58

provided, and its effectiveness must be evaluated to establish the degree to which focused

outcomes have been met (O’Malley et al., 2013).

This section of the literature review discussed the different methods of education that can

be used and made available to staff members. The best methods of education used to increase the

knowledge of the staff members, used as a guideline and how it influenced prevention of TB.

Summary

The literature review discussed information about the transmission and prevention of TB

in high-risk prison environments. The problem statement was the foundation of the project, it

was not known whether an evidence-based educational intervention would increase a

correctional facility’s staffs’ knowledge about TB transmission and prevention. The quantitative

methodology was used to guide pre-posttest design of the project and evaluate the results. The

literature review was used to answer the clinical question, how effective was the use of evidence-

based education in increasing the correctional facility’s staffs’ knowledge about the transmission

and prevention of TB? The basis of the theories used were from the adult learning theory and the

constructivist theory and were incorporated in the project. The constructs of this environment

make disease prevention an important topic. The information focused on TB in correctional

facilities and the risks of its spread to correctional employees, prisoners, visitors, and the

community. The lack of education and knowledge about TB transmission and prevention in a

high-risk environment of the correctional staff established the need for the project. The project

and the process used was explained to the participants. There was recruitment for the project

amongst the staff within the correctional facility and participants volunteered after primary

investigator explained the informed consent and confidentiality. The target population was the

correctional staff of a maximum-security prison in an urban city of central North Carolina. The
 59

participants signed an informed consent form for any data collected during the project. The

chapter discussed the way the disease was transmitted and methods of TB prevention. Continued

research is needed to analyze the progress that has been made in preventive measures in

correctional settings through education of staff. The U.S. has one of the largest numbers of

incarcerated individuals, 2.2 million (Bureau of Justice, 2014). The project is needed to expand

the knowledge for educating staff on prevention and transmission of diseases within in high risk

environments. Providing education and training for correctional staff may help concentrate on

preventive methods and practices that must be implemented to decrease the transmission of TB

to the correctional population, staff, visitors, and the community.

This project consisted of pre-and post-testing correctional staff to ascertain their level of

knowledge about being employed in an environment at high risk for transmission of TB. The

pre- and post-test results were used to assess their knowledge of TB and the way it is spread to

others. The evidence-based educational intervention of pamphlets and scenarios reviewed what

should be done to prevent transmitting the disease to others. The test results were compared after

the staff members received the education and training about TB to assess the benefits and

outcome of the education provided. Chapter 3 discusses the objectives and methodology used in

the DPI project. The adult learning theory assisted in the guidance of education and learning

needs of the participants. Constructivism theory applies methods of learning, new knowledge and

self-reflection on the part of the learner (Yoders, 2014). A quantitative methodology was used to

determine whether an evidence-based educational intervention about TB would increase the

participants’ knowledge of the disease and its transmission. Pre- and post-testing were completed

with 20 questions and 60 minutes were allocated to complete the test. The participants also

answered post-test supplemental questions about the educational intervention that was used in
 60

the project. All of the data gathered were analyzed to determine the outcome of the project. As

there is a lack of literature on the use of evidence-based educational interventions in high-risk

environments to improve knowledge of the prevention and transmission of TB. There were gaps

in practices of TB prevention that would benefit with ongoing education. There is additional

information needed on the effectiveness of education and training to increase the knowledge

about the transmission and prevention of TB. In Chapter 3 the choice of the project methodology

approach was discussed. The quantitative analysis with a pretest-posttest design to evaluate the

effect of an educational intervention were addressed in line with the clinical question in the

chapter. The target population of correctional staff in a NC facility were used to answer the

clinical question. How effective was the use of evidence-based education in increasing the

correctional facility’s staffs’ knowledge about the transmission and prevention of TB? The

instrumentation, validity, reliability, data collection procedures were included in the chapter.

Data analysis procedures, ethical consideration and limitations were also addressed. Chapter 3

conclusion summarized the content of the chapter content.

 61

Chapter 3: Methodology

This chapter provides a description of the methodology used in the project. It begins with

a focus on a review of the project. The project was designed to examine the relation between

an evidence-based educational intervention and increased knowledge of TB. The literature

review confirmed that correctional facilities are environments at high risk for the spread of TB,

which poses a public concern (CDC, 2014). The populations housed in these areas all contribute

to the risk factors (CDC, 2012). The project discussed how it was not known whether evidence

based educational intervention would increase a correctional facility’s staffs’ knowledge about

TB. This chapter discussed the question of how effective the use of education in increasing the

correctional facility’s staffs’ knowledge about the transmission and prevention of TB?

The project involved educating the staff about the disease, the way it spreads to others,

and the preventive measures that should be implemented at all times. Pre-testing was conducted

before the education program to evaluate the staff’s current knowledge, and post-testing was

completed to evaluate the outcomes of the evidence-based educational intervention. The

evidence-based educational intervention used questions related to the transmission of TB,

preventive measures, testing, and screening, and the education was provided to help change the

staff’s behaviors. The desired outcome of the intervention was to increase the correctional

staff’s knowledge of TB transmission and prevention, to impact the practices on screening,

testing, and to decrease the inmates’ risk of infection. The project was implemented using a

small sample size of fifty staff members who were recruited to participate in the project. The

DPI project evaluated the skills and knowledge about TB and the outcome of education by

comparing the participants’ pre- and post-test results. The data was helpful in evaluating the

results of the evidence-based educational intervention and the additional information needed
 62

about the prevention of TB in a high-risk population.

Statement of the Problem

It was not known whether an evidence-based educational intervention would increase a

correctional facility’s staffs’ knowledge about TB. The educational intervention of pamphlets,

interactive scenarios, and review were used to increase the staffs’ knowledge about the

transmission and prevention of TB. It was found there was a deficient amount of education,

knowledge, and adherence to preventive measures against the spread of TB in correctional

facilities.

Early identification of persons with TB through initial entry and periodic follow-up tests

and screening were established, and efficient contact investigations were conducted when a

positive TB case was identified (CDC, 2014). The Tuberculosis Coalition for Technical

Assistance (2013) had identified the importance of follow-up care, because most offenders were

released from, and they returned back to public communities. The TB-infected person’s return to

the community puts the public at risk if the disease is not detected and full treatment received.

According to the Tuberculosis Coalition for Technical Assistance (2013), the risk of an infected

person returning to the community without treatment makes it important to identify these people

and ensure that they have completed all medication prior to release. To ensure the proper care

and treatment of patients exposed to, or with active TB, follow-up is needed after transfer or

discharge. If the medication treatment regimen is not completed, information is needed about a

contact person or facility to continue medication and continuity of care (Rodrigo et al., 2012).

Inmates are transferred to other facilities within the correctional system, and without

proper care, follow-up, and identification, others are at risk of contracting TB (Rodrigo et al.,

2012). The literature demonstrated that the evolution of the use of the Tuberculin test over the
 63

last century has led to a decline in TB. Testing for latent MTB infection and the use of

preventive measures have been shown to decrease the cases of active and latent TB. (Lee &

Holzman, 2012).

Educating staff is an important component of making them aware of the preventive

measures necessary to decrease the risk of exposure to TB. Students’ have examined pre- and

post-tests to assess the effectiveness of evidence-based education, and found an increase of

undiagnosed cases of TB made the project important in using evidence-based education to

reduce the transmission of TB.

Clinical Question

The clinical question in this project was related to the knowledge deficit on the part of the

correctional staff about the transmission and prevention of TB in a high-risk environment. The

clinical question involved the importance of educating the staff about the prevention of TB.

Q1: How effective was the use of evidence-based education in increasing the correctional

facility’s staff’s knowledge about the transmission and prevention of TB? As components of this

education, the need for strict respiratory precautions and isolation of patients are essential for

disease containment.

A quantitative method was used to collect data and answer the clinical question. The staff

completed a pre-test to assess their initial knowledge about the transmission and prevention of

TB, and the results were scored. After the pre-test the participants were given evidence-based

educational materials to review before taking the post-test. After completion, the post-tests were

graded, and the test scores were compared using a t-test. The data were evaluated and the staff

members’ knowledge assessed, and the results demonstrated increased knowledge and awareness

about TB. The data collected and methodology used showed that the project tool can be
 64

replicated and implemented with other participants and obtain similar results. The test supplied

for the project also produced the same answers regardless of who completed the test. The

questions had either right or wrong answers. The answers were consistent and based on evidence

from CDC information and data. The test, evidence-based educational, and training materials

were obtained from the TB section of the CDC’s website about the transmission and prevention

of TB (CDC, 2014; 2016). The method was selected because of its numerical basis and ability to

analyze the data statistically.

Project Methodology

The use of a quantitative methodology for the project was the best method to measure the

outcomes of the test and education because of the way the data was analyzed. The method used a

formal, objective, systematic method to collect data for analysis. The quantitative method was

used for the evaluation of the testing and evidence-based educational materials supplied to the

correctional staff, as an intervention to increase their knowledge about TB transmission and

prevention. The project used the quantitative method to complete analysis of the evidence-based

educational intervention with pre and post-testing results comparison.

According to Hoare (2012), qualitative methodology is used to understand reasons,

opinions, or motivations, provides insight into a problem, and is used to identify trends in

thoughts and opinions and investigate a problem more deeply. Thus, the qualitative method

focused more on the thoughts and opinions of a sample group and what this project sought was a

numerical outcome with which to compare the data.

The quantitative method generated numerical data and translated them into information

amendable to statistical analysis. The quantitative method was flexible and the data collected

could be interpreted easily (Maldonado, 2014). The use of pre- and post-tests lent itself to the
 65

tasks of gathering data on program satisfaction, processing those data, and identifying the lessons

learned that can be used to modify and refine a specific program (Sewell, 2011). The quantitative

method uses measurable data to develop facts and reveal patterns, which helped answer the

project questions.

Project Design

The quantitative project was selected with a pre-posttest design used for assessment. The

quantitative approach was considered an important technique to investigate the way healthcare

settings can be improved and generated new knowledge and evidence-based healthcare design

and practices (Maldonado, 2014). A group of fifty volunteer participants were used in this

project. Their demographic information was obtained, including their work area, job title, and

gender. A pre-test was given followed by evidence-based education and training with handouts

and active scenarios. The use of the test and the ability to mail or email it made it easier to recruit

participants for the data collection and obtain useful results. After completion of the evidence-

based educational program, a post-test was given, and the test results were analyzed. As

mentioned previously, correlation analysis identifies trends, patterns, and helps interpret and

explain the data analyzed (Maldonado, 2014).

Population and Sample Selection

The target population of the project consisted of correctional staff. The project took place

within a correctional facility in an urban city of North Carolina. The facility consisted of a prison

housing area with and attached hospital. The facility included a hospital/mental health center that

cared for an incarcerated inmate population. The hospital included a 120-bed inpatient medical

area with eight negative pressure respiratory isolation rooms. The first and second floors of the

facility held the medical clinic, surgical suites, laboratory, physical/occupational therapy,
 66

dialysis, urgent care, a respiratory clinic, and radiology department that conducts x-rays,

ultrasounds, and CAT scans. The clinic and auxiliary departments had daily appointments with

inmates in the facility and outside camps. The Urgent Care department treated emergencies of

the prison inmates at the facility and those from the outside camps, and was the first department

in which inmates were seen. This department also conducts the intake and processes all new

inmates to the prison. The inmates were processed in when they came from county jails with

conditions that could not be cared for at those facilities. The Mental Health section of the

hospital included both acute and chronic care mental health services. There was a treatment

center that included several classrooms for daily programming and treatment. The inmates,

correctional staff, visitors both official and unofficial, congregated in all of the areas within the

prison. As a high-risk area, the prison placed all of the people who have contact with any

individual, in the system at risk of contracting TB. The correctional staff within the facility

lacked knowledge about TB and disregarded the facility’s policies and procedures and methods

of preventing the disease. The correctional staff were the first line of defense of prevention and

health care for the inmates.

The sample size was one of convenience in that the staff and the primary investigator

were employed at the same facility in which the pre-posttest and intervention were offered. The

sample size of 50 correctional staff was selected randomly from different departments of the

facility, of approximately 500. The 10% was estimated as adequate representation and best

because of availability and work schedules of the correctional staff. Flyers were distributed to

recruit participants for the project. The primary investigator acquired informed consent by each

participant that were signed and included confidentiality, anonymity, and that anyone could

decline to participate at any time. They were informed that the project included a pre- and post-
 67

test and compared the test scores to evaluate the outcome of the evidence-based educational

intervention about TB. The participants were also informed about the confidentiality measures

that were taken with the project information and documentation. The primary investigator

indicated that no personal information, such as name, profession, or test results, was disclosed

and the project was approved by the Grand Canyon University Institutional Review Board (IRB)

(see Appendix B). The participants took the pre-test to evaluate their knowledge about the

prevention and transmission of TB. The evidence-based educational information about TB, was

distributed for review, after which they were given the post-test. The requirements to participate

in the project included taking both the pre- and post-test. The participants were supplied with

evidence-based educational materials to review information about TB transmission and

prevention. If any of the participants withdrew from the project, it was indicated in the final

results of the project. The participants were assigned a number that coincided with their assigned

test. The tests were scored and saved for future evaluation. The test results were compared

statistically using a t-test.

During the education and testing, all project materials were stored securely in a locked

file cabinet and were accessible only by the primary investigator. At the completion of the

project, all documents used for analysis that were not required for future reference were

destroyed and those needed were stored securely.

Instrumentation

Tests. The test instrument included true and false, fill in the blank, and multiple-choice

questions. All questions were drawn from data and material about TB obtained from the CDC

website (2016). Supplemental post-test questions were included in the project and involved

whether the participants felt the educational intervention was effective, and if the information
 68

was beneficial for future use. The project questions tested the correctional staff’s knowledge

about TB and its transmission and prevention. There was a total of twenty questions, seven fill in

the blanks, six multiple choice, five true or false, two yes or no questions and post-test

supplemental questions. The test questions were worth 20 points each, and totaled 100 points.

The test questions were developed by the CDC and used as an educational resource on the site.

There were questions related to the TB policies and procedures of NC DPS incorporated in the

test. The test questions were used to evaluate the initial knowledge of the correctional staff prior

to the evidence-based educational intervention. The participants returned in one week for the

post testing. The post-test was given after the evidence-based educational intervention was

reviewed with the participants.

Handouts. The participants received handouts about the bacteria, transmission and the

prevention of TB. The information included the methods necessary to prevent transmission of the

disease. The handouts were developed by the CDC as an information resource. The handouts

identified, defined latent and active TB and the differences between the two. The signs and

symptoms of the disease, and the correct way to place, read, and document TST results were

included in the evidence-based education materials. The handouts also included the proper use of

respiratory PPE preventive measures for active TB patients. These documents were obtained

from the CDC website.

Validity

The measurement tool utilized in the DPI project indicated it was an excellent instrument

for the desired outcome of evaluating the relationship between two variables. The measurement

tool was obtained from the public website of the CDC and information of the primary

investigator. The validity of the data collected was confirmed because the test information was
 69

obtained from a reliable source, the CDC website, which includes educational information

related to the disease. The external validity was noted to be generalizable and would allow the

correctional staff to replicate the project using the educational intervention. The validity can

show an improved knowledge about TB in another setting (Melnyk & Fineout-Overholt, 2015).

Using the pre- and post-test validated the data by the statistical information gathered during

analysis of the test results. The data collection and methodology showed the validity and

reliability of the project information. The project was reproduced to implement with other

participants or test the same sample participants used originally and obtain similar results. The

valid conclusion reached was that there was a relation between the educational intervention and

the correctional staff’s behavior related to TB prevention. The validity was confirmed because

the test addressed the purpose intended (Center for Applied Linguistics, 2017). An independent

sample t-test to establish the effects of the intervention of the educational information which

indicates the need for education for correctional staff.

Reliability

The reliability of the project is related to the ability of the measurement to produce

reliable results that can be used successfully, and on a continuous basis. Reliability indicates the

degree to which the tool is bias free and allows for consistent measurement over time (Mohajan,

2017). Reliability is used to evaluate the stability of measures administered at different times the

more accurate the results and better the reliability of the tool. According to Mohajan, (2017) a

stable measure produced exactly the same scores repeatedly with two methods to test stability,

test-retest reliability, and parallel-form reliability. A numerical method was used in an Excel
 70

spreadsheet to document the data. The analysis completion was done by using descriptive

statistics in SPSS that identified the characteristics and variable results.

Data Collection Procedures

The primary investigator explained the project the informed consent form, confidentiality

and the expectations for participation to the staff members. The target population was the

correctional staff of the prison and 50 staff participants from the facility were assigned a number

and tested to assess their knowledge about the transmission of TB and preventive methods prior

to the evidence-based educational intervention. The pre-test was developed for data collection

which included specific questions about TB transmission and prevention and based on tools used

by the CDC. All participants signed the informed consent form for all data obtained for the

project. In addition to the CDC, the test information was obtained from policies in place at the

facility. After completion and a review of the evidence-based education, participants took a post-

test. The pre- and post-test results were analyzed with respect to the participants’ compliance

with policies and screening. After the pre-tests were given and test scores were recorded, the

participants returned the following day and were given the educational information to review.

They participated in a discussion about an interactive scenario, and had the opportunity to ask

questions or give input to the group. The participants returned in seven days and completed the

post-test to compare with the pre-test results after the evidence-based intervention was used. All

data collected was secured in a locked file cabinet in the locked office of the primary

investigator. The key was maintained by the primary investigator for the entire project.

Data Analysis Procedures

The primary investigator collected the data of the pre-testing documents and all scores of

tests were calculated. The scoring was done based on a 100- point scale with test question being
 71

worth five points each. After the testing was completed, the primary investigator transferred the

test scores on a Microsoft Excel spreadsheet. The evidence-based educational intervention was

given and reviewed with the participants. The scored test results were entered to an SPSS

program, the data was analyzed and established the means for both the pre- and post-tests.

Quantitative variables were described using mean and median as measures of centrality and

standard deviation. After which a t-test was performed to compare all test results and survey

questions to assess the effectiveness of the evidence-based educational intervention. The answers

to the post-test supplemental questions were analyzed to see if there was a correlation between

the educational intervention and the participants knowledge of TB prevention and transmission.

The descriptive data was analyzed and showed the mean of the test scores of the participants.

The clinical question focused on, how effective was the use of evidence-based education in

increasing the correctional facility’s staffs’ knowledge about the transmission and prevention of

TB?

The outcome desired was that the staff attained improved knowledge about the

transmission and preventive of TB in correctional facilities and impact practice by decreasing the

incidence of TB in correctional facilities. The primary investigator sent the data that was

obtained to a statistician, who utilized SPSS to obtain a simple t-test. The t-test compared the

pre- and post-test results and the findings suggest that an evidence-based educational

intervention can attain improved knowledge about the transmission and prevention of TB and

impact practice by decreasing the incidence of TB in correctional facilities. The post-test

 72

summary questions showed a positive effect on the educational intervention used after the pre-

test.

Ethical Considerations

The ethical issues associated with the project were considered by the primary

investigator. All the participants volunteered for the project. The participants were required to

complete consent forms that disclosed all information about the project. The participants were

told why the information was being obtained and the method in which it would be used. The

project data was stored in a secured locked cabinet in the primary investigator’s office. The

participants also were informed that they would receive no remuneration for participating in the

project. All participants’ privacy was ensured by withholding any personal identifiers, which

gave the participants trust in the primary investigator conducting the project. The data collected

was all confidential and all participants were kept anonymous. There was no coercion, use of

force, threats or intimidation used and all participants were willing participants, and not acting

under duress. The concerns of the participants well-being, respect, justice and beneficence were

considered by the primary investigator. The project design was followed and within the

theoretical framework initially established and followed throughout the project. The clinical

question and practice problem focused on the correctional staffs’ lack of knowledge about the

transmission and prevention of TB within a correctional facility in central NC. The project was

submitted to Grand Canyon University’s (IRB) for review and permission was granted to
 73

conduct the project. There were no known conflicts of interest by the primary investigator or the

participants. The principles of respect, justice, and beneficence were adhered to for the project.

Limitations

The participants’ levels of medical knowledge and of TB varied. Some had Doctoral

degrees, Masters of Business, Master’s and Bachelor’s or Associates of Science in Nursing, a

high school education or GEDs, while some were physicians, physician assistants, nurses,

dentists and administrative and maintenance staff, which influenced the test results, and was

considered a limitation. A limitation in this project was that it was conducted in only one NC

prison. Some of the participants had a history of latent TB disease, and thus had more detailed

knowledge of the disease and its transmission. Some had extensive medical backgrounds and

others had no formal medical background or knowledge about TB. There were nurses who

worked in a medical capacity but had limited knowledge about TB. The eight participants who

did not return for the post-testing decreased the sample size for the data analysis and constituted

a limitation to the project results, as did those who did not complete the post-test. The small

sample of participants was attributable to scheduling issues or conflicts and the amount of time

available for participation and limited the ability to obtain more statistically significant findings.

The time constraints and ability to provide all data required to complete the project posed some

limitations. An additional limitation of the DPI project was identified because of the length of

time required for data collection. The participants answered all of the DPI project questions to

the best of their ability. The limitations were unavoidable due to the time constraints and

availability of staff members but did not affect the results negatively. The results may have been
 74

stronger with a larger sample size. The sample size was used because of the scheduling and

availability of staff.

Summary

This chapter discussed the project methodology, which focused on whether educating

correctional staff would increase their knowledge about the transmission and prevention of TB.

The correctional staff’s initial inadequate knowledge about the transmission of TB and the fact

that the population were high-risk and put the inmates and community in jeopardy. Thus, there

was a significant need for staff education to increase their knowledge about TB transmission and

prevention to impact practice by decreasing the incidence of TB in correctional facilities. The

following clinical question was included in the chapter. How effective was the use of evidence-

based education in increasing the correctional facility staff’s knowledge about the transmission

and prevention of TB? Initially, a number of the correctional staff lacked knowledge about TB.

As components of this education, the need for strict respiratory precautions and isolation of

patients are essential for disease containment. The clinical question that guided the project was,

how effective was the use of evidence-based education in increasing the correctional facility

staff’s knowledge about the transmission and prevention of TB?

The chapter also discussed the project participants and data collection. The data analysis

was completed with pretest and posttest results to evaluate the effectiveness of the evidence-

based educational intervention about the transmission and prevention of TB. The goals of the

project were to analysis the data collected from the participants with positive results to impact

practice by decreasing the incidence of TB in correctional facilities. The data analysis calculated

the frequencies of variables, and differences between the variables to support the use of an

evidence-based educational intervention about TB disease. An additional goal was to help

 75

establish proper training and education for both new and current employees, and increase the

staff’s knowledge about TB transmission and prevention. Chapter 4 discussed and summarized

the data collection, descriptive information, analysis and presents the results. The problem

statement, methodology, clinical question with clarity of the findings are discussed in Chapter 4.
 76

Chapter 4: Data Analysis and Results

The purpose of the project was to examine the effectiveness of utilizing a pre-post-test

design of evidence-based education about the transmission and prevention of TB, provided to a

target population of correctional staff in a correctional facility in central NC. This chapter

explained, summarized, the collected data, and how it was analyzed in the project. The use of

evidence-based education and training and the effect on correctional staff’s practices in the high-

risk environment of the prison system. Thus, the quantitative descriptive project examined the

use of evidence-based education and training presented to the correctional staff. The problem

statement was, it was not known whether an evidence-based educational intervention would

increase a correctional facility’s staffs’ knowledge about TB transmission and prevention.

Correctional facilities are a high-risk environment and it was not known whether an

evidence-based educational intervention, would increase a correctional staffs’ knowledge about

TB. The clinical question was the guide for the data analysis of information obtained, how

effective was the use of evidence-based education in increasing the correctional facility staff’s

knowledge about the transmission and prevention of TB? The independent variable was the

evidence-based educational intervention and was measured using the pre- and post-test results.

The projects dependent variable was the correctional staff members. The participants’ knowledge

about TB transmission and prevention was evaluated after the evidence-based educational

intervention was implemented, with the use of the post-test. The quantitative methodology was

used to guide the clinical question, how effective was the use of evidence-based education in

increasing the correctional staff’s knowledge about the transmission and prevention of TB?

Descriptive Data
 77

At the start of the DPI project, permission was granted from the CEO of the facility for

the primary investigator to display recruitment flyers for the project. The approval to proceed

with the project came from the Grand Canyon University, IRB. The population sample

comprised of staff members from a correctional facility in an urban city in central North Carolina

who volunteered to participate. The participants had a variety of educational backgrounds and

job titles.

The project methodology was quantitative with a pre-posttest design and problem

statement was, it was not known whether an evidence-based educational intervention would

increase a correctional facility’s staffs’ knowledge about TB transmission and prevention. The

focused clinical question in this project was how effective was the use of evidence-based

education in increasing the correctional facility staff’s knowledge about the transmission and

prevention of TB? The department of public safety housed many offenders who come from

different areas of the U.S. and foreign countries. Some of the inmates suffered from chronic

diseases or lifestyles that increased their susceptibility to communicable diseases. An estimated

44% of state inmates were reported as having current medical problems (CDC, 2012). Those

reported most often were arthritis (15%) and hypertension 14% (CDC, 2014). The purpose of the

quantitative DPI project was to examine the effectiveness of utilizing a pre-post test design of

evidence-based education about the transmission and prevention of TB, provided to a target

population of correctional staff in central North Carolina. The fact that many of the inmates

come from different countries and those that have a high incidence of TB puts all inmates, staff,

and the community at risk for TB (CDC, 2014). The participants in the project were correctional

staff from different areas of the facility. This included medical providers, physician assistants,
 78

certified nursing assistances, nurses, custody correctional staff, dental, administrative,

maintenance staff members.

The participants were chosen randomly, by recruitment. The project was explained by the

primary investigator and an informed consent was signed by the volunteers. The staff members

were all assigned a number that was used throughout the project. Participants were assigned

randomly to control systematic differences and eliminate bias. The total number of participants

was chosen based on the percentage of staff in the facility to achieve 10% of the staff members

in different departments for the t-test analysis.The amount of contact with inmates varied and

averaged between eight to ten hours out of a 12 hour shift. Some of the participants had close

contact with the inmates on a daily basis so being aware of the signs and symptoms of TB would

be beneficial for the staff members and inmate population for prevention. It was found that

continued information is needed to assess the level of staff knowledge and the education they

need in the high-risk environment of corrections, to help prevent the transmission of TB to the

inmate population and the community (CDC, 2015). Hence, the participants’ initial pre-test

scores were recorded. The evidence-based educational intervention used and consisted of

pamphlets about TB obtained from the CDC website that described TB, the routes of exposure,

and testing for the disease (CDC, 2016). The pamphlets also contained information about TB

medications, elimination of TB, and skin testing to detect whether a person is infected with TB.

The pamphlets also contained information about the way TB is spread. There were also real life

interactive scenarios used and a review of the information that was completed with the

participants. The participants were given the opportunity to ask questions and discuss the disease

process and transmission and prevention. The review included preventive measures noted in the

pamphlets, how the disease was spread. The use of TB skin test for prevention and medication
 79

treatment were included in the pamphlets. The data were collected using pre- and post-tests and

the scores were compared after the evidence-based educational intervention was implemented.

The staff’s knowledge was tested using questions about TB, its transmission, and

methods used to prevent its spread. Quantitative variables were described using the mean and

median as measures of centrality, and standard deviations and nonparametric tests were used for

univariate analysis. The pre-test results were evaluated and assisted in the development of an

education program that was used as the intervention. Subsequent to receipt and review of the

pamphlets, a post-test was administered to the participants. All of the materials were reviewed

after the pre-testing and the participants returned to take the post-test one week later. Continued

information is needed to assess the level of staff knowledge and the education required in these

high-risk environments to help prevent the transmission of TB, to the inmate population and the

community (CDC, 2015). Hence, the participants’ initial pre-test scores were recorded. The

evidence-based educational intervention used consisted of pamphlets about TB obtained from the

CDC website that describes TB, the routes of exposure, and testing for the disease (CDC, 2016).

The pamphlets also contain information about TB medications, elimination of TB, and skin

testing to detect whether a person is infected with TB, and the way it is spread and was

implemented with real life interactive scenarios and a review of the information. The participants

were given the opportunity to ask questions and discuss the disease and its process. The review

included preventive measures noted in the pamphlets. The data were collected using pre- and

post-tests and the scores were compared after the evidence-based educational intervention was

implemented. There were a total of 50 participants of 29 males and 21 females who took the pre-

test. This included 15 correctional staff 8 males and 7 female. The nursing department were 15

total 10 female and 5 males. There were 20 participants from miscellaneous departments of the
 80

facility 11 were male and 9 female. The post-test included 42 participants 14 male and 28

females and 8 who did not return. The sample size: staff member table also includes the

participants who were included in the education and training review completed by the primary

investigator. All of this information was kept in a secure location and participants identification

information was included in the secure storage. The participants had different levels of

education. There were participants who had high school degrees, associates, bachelor and

masters degrees. There were also medical physicians, family nurse practioners and physician’s

assistants. Table 1 lists the number of participants in the project by profession and gender.

Table 1

Sample Size: Staff Members

Profession Total Male Female

Correctional Staff 15 8 7

Nursing 15 10 5

Misc./Other 20 11 9

Pre-test (Step#1) 50 29 21

Education & Training 50 29 21

Post-test (Step#2) 42 14 28

Total Participants 50 29 31

Note. Study participant groups: Pre-and Post-Test results.

 81

Table 2 list the results of the pre- and post-tests. The project participants were all

assigned a number at the beginning of the project, identified in the middle of Table 2. The

number assigned was used for identification of test scores. The test scores are listed below

showing the participants who took pre-test and included the assigned number. The pre-test

results are listed individually, with scores that ranged from the highest of 95 to the lowest 45.

The post-test results are listed and those participants who did not return indicated. The test

results range from the highest of 100 to the lowest of 60. The scoring information for test results

out of 100 points for the 20 questions were listed below. The number of incorrect questions and

percentage score received in the test were also listed in Table 2.

Table 2
Participant pre-post test scores
Participant
Gender Pre-test scores Post-test scores
number

F 85 Participant 1 90
F 90 Participant 2 90
F 95 Participant 3 95
F 85 Participant 4 85
F 85 Participant 5 90
F 75 Participant 6 85
F 90 Participant 7 Did not return
F 60 Participant 8 75
F 95 Participant 9 90
F 80 Participant 10 80
F 85 Participant 11 85
M 65 Participant 12 Did not return
M 75 Participant 13 80
F 60 Participant 14 80
 82

F 90 Participant 15 85
M 85 Participant 16 Did not return
F 65 Participant 17 75
F 45 Participant 18 60
M 65 Participant 19 80
F 60 Participant 20 80
F 90 Participant 21 80
M 85 Participant 22 85
M 80 Participant 23 75
M 55 Participant 24 Did not return
F 85 Participant 25 85
M 50 Participant 26 Did not return
F 75 Participant 27 85
F 90 Participant 28 90
F 70 Participant 29 85
M 85 Participant 30 85
F 75 Participant 31 85
F 70 Participant 32 80
F 55 Participant 33 75
M 65 Participant 34 80
F 60 Participant 35 75
M 55 Participant 36 80
M 60 Participant 37 80
F 85 Participant 38 85
F 90 Participant 39 Did not return
M 95 Participant 40 95
F 80 Participant 41 100
F 70 Participant 42 80
M 75 Participant 43 85
F 75 Participant 44 Did not return
M 80 Participant 45 85
F 65 Participant 46 85
M 70 Participant 47 Did not return
 83

M 90 Participant 48 90
M 80 Participant 49 90
M 55 Participant 50 65

Data Analysis Procedures

The clinical question was used to guide the data analysis how effective was the use of

evidence-based education in increasing the correctional facility staff’s knowledge about the

transmission and prevention of TB? The pretest was taken by participants all variables were

coded prior to entering into statistical software. The participants’ post-tests were collected,

graded, and documented for statistical comparison to the pre-test results. The data was entered on

a Microsoft Excel spreadsheet numerically and transferred to SPSS for data analysis with a t-test.

Test results for the pre-test ranged from 55 to 95 with a mean of 75.80 and SD of 13.01. The

results provided by the 42 participants who returned for the post-test ranged from 60-100 with a

mean of 83.10 and SD of 7.40. The data obtained from both the pre- and post-tests were analyzed

using a t-test. Calculations of the pre- and post-test scores were made to obtain the mean of all 50

participants for each. The test results were entered in an Excel spreadsheet and the final

calculations were made of the mean of the pre- and post-test results to determine the degree of

improvement in the scores after the participants completed the evidence-based educational

training. The pretest and posttest questions were summed to establish scores and entered into an

Excel file. The scores were recorded into groups and comparisons made. The data were entered

manually and were analyzed using Statistical Package for Social Sciences (SPSS).

Results

The final clinical question was answered with the project data by determining the mean

of the test results and comparing the pre-and post-test results with a t-test. The findings
 84

supported the clinical question: How effective was the use of evidence-based education in

increasing the correctional facility staff’s knowledge about the transmission and prevention of

TB? The final outcome showed statistically significant improvement in the correctional staff’s

test scores after the evidence-based educational intervention (t42 = 0.77, p = 0.000). The findings

suggest that and educational intervention can attain improved knowledge about the transmission

and prevention of TB and impact practice by decreasing the incidence of TB in correctional

facilities.

This section discussed the summary and analysis of the data as they related to the clinical

question. Descriptive statistics were used to summarize the dataset using frequency distributions

and/or other descriptive methods. The results obtained were analyzed with descriptive and

inferential statistics to verify the relation between the variables (Folador et al., 2012). The data

obtained from the pre- and post-test scores the correctional staff participants completed were

analyzed using a t-test and the scores were listed in two columns. The scores were listed and

numbered one through fifty for both the pre- and post-test for each participant. The scores were

entered in each column of the dataset. The dependent t-test was obtained using the compare

means command or paired samples command in the analyze menu of the statistical program X v.

X. Descriptive statistics of the total sample (N=50) indicated that most of those in the pre-test

phase were female 31 (62%) and medical staff (25) (50%: Table 3). In the post-test phase, most

also were female 28 (66.67%) and medical staff (25) (59.52%: Table 1). The evaluations showed

that a certain percentage of nurses, certified nursing assistants, and medical providers obtained

the highest scores on the tests. The other participants, who included individuals from corrections,

housekeeping, and lab staff members with less medical knowledge had varied results.

The DPI project indicated that the evidence-based educational intervention was an
 85

effective tool that increased the correctional staff’s knowledge. The improved test scores many

of the participants achieved, measured the positive effect of the TB evidence-based educational

intervention they received. Early identification of persons with TB or who have been exposed to

the disease through entry and periodic follow-up screenings should be established (CDC, 2014).

The pre-test included questions related to the proper placement and amount of time required

before reading the TST. The number of correct and incorrect answers to these questions were

calculated and analyzed for comparison to the post-test results. The goal of the project was to

attain improved knowledge about the transmission and prevention of TB and impact practice by

decreasing the incidence of TB in correctional facilities.

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Table 3

Descriptive Statistics of Demographic Variables

Measure ƒ %

Group Sequence

Pre-test (total sample size) 50 100

Post-test 42 84

Did not return 8 16

Gender

Female 31 62

Did not return 3 10

Male 19 38

Did not return 5 26

Staff

Correctional Officers 15 30

Did not return 7 47

Medical Staff 25 50

Did not return 0 0

Other Staff 10 20

Did not return 1 10

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Table 4
Paired samples descriptive statistics
Mean N SD SEM
Pair 1 Pre-test 75.48 42 13.011 2.008
Post-test 83.10 42 7.404 1.142

Table 5
Paired Samples Correlation
Pre-test & Post-test N Correlation Sig.
42 0.77 0.000

Table 6
Paired sample test Paired Differences 95% Confidence Interval of the Difference
Mean SD SEM Lower Upper
Pair 1 Pre-test – Post-test -7.62 8.71 1.34 -10.33 -4.90

The tables above describe the pre-test results and a comparison was made with the post-test

results after the evidence-based educational intervention was reviewed by the participants. The

analysis was conducted using paired t-test. This analysis was used to obtain the best numerical

comparison of the test scores of the participants. In Table 4 a paired-samples t-test was

conducted to compare the pre-test results and post-test results after the evidence-based

educational intervention was administered to the participants. There was a significant difference

int the scores for post-test results (M=75.48, SD=13.01) and post-test after evidence-based

educational intervention (M=83.10, SD=7.40) conditions; t (42) =0.77, p=0.000. These findings

showed that the evidence-based educational intervention had a positive effect on the knowledge

and test scores of the participants. Specifically, the results suggest that when an evidence-based
 88

educational intervention is used their test scores increased about the transmission and prevention

of TB and impact practice by decreasing the incidence of TB in correctional facilities.

 89

Outcome of Increased Education

The increased education provided lead to changes in the level of knowledge about TB

between the pre- and post-test scores? The first information that was obtained was the mean of

all the pre- and post-tests. The median, the value at the midpoint, also was calculated by sorting

the test scores from smallest to largest (Infinity, 2013). The t-test then was used to compare the

means of the pre-and post-tests. According to Trochim (2006), the formula for the t-test is a

ratio, the top of which is the difference between the two means, while the bottom is the

variability in the scores (Trochim, 2006). The post-test supplemental questions were:

1. Has this education about tuberculosis increased your awareness about the disease and

how it can be spread to the inmate/patient population? Yes or No

2. Are you now aware of some of the signs and symptoms of tuberculosis that an inmate

or patient may exhibit or report to you? Yes or No

3. Do you now know the preventive measures that should be taken to decrease the

spread of tuberculosis to the inmate patient population? Yes or No

4. Was the educational information helpful for future care of patients with tuberculosis?

Yes or No

5. Would you recommend this education for other staff members and the inmate/patient

population? Yes or No

6. Should the inmates be included in the project?

The remaining participants which were 42 out of the original 50 answered the

supplemental post-test questions. The project participants answered the question and the data

were collected and analyzed. The information gathered is displayed in Figure 1. within the text.
 90

The results of supplemental question number one was 40 of the participants answered yes

and two answered no. Question number two all participants answered yes. The number three

question obtained 39 yes and three no answers. The fourth question received 36 yes and six no

answers with question number five obtaining 39 yes and three no answers. The final question had

33 yes and nine no answers. The results obtained from the supplemental questions listed above

were used in the project are shown in Figure 1 below.

42 42
40
39 39
39
36
36
33
33

30
Number: Yes and No

27

24

21

18

15

12
9
9
6
6
3 3
3 2
0
0
Yes No Yes No Yes No Yes No Yes No Yes No

Figure 1. Supplemental Questions: Post-test

Summary

The results of the analysis showed that evidence-based educational training led to an

increase in the participants’ test scores. The data analysis confirmed the importance of additional

training and education related to the prevention and transmission of TB. The participants’ post-

tests were collected, graded, and documented for statistical comparison to the pre-test results.

The analyzed data answered the clinical question, how effective was the use of evidence-based
 91

education in increasing the correctional facility staff’s knowledge about the transmission and

prevention of TB. Test results for the pre-test ranged from 55 to 95 with a mean of 75.80 and SD

of 13.01. The results provided by the 42 participants who returned for the post-test ranged from

60-100 with a mean of 83.10 and SD of 7.40. The evidence-based education and training

increased the correctional staff’s knowledge of the disease, which assisted in the prevention and

spread of TB among the inmates and to the community. The findings suggest that an evidence-

based intervention can attain increased knowledge about the transmission and prevention of TB.

The analysis of the data presented in this chapter was used to summarize the project in addition

to the previous three chapters. Chapter 5 explains the necessity of additional training and

education for correctional facility staff. The chapter summarizes the statistical data and results of

the statistical tests related to the clinical question. The increased knowledge and education

impacted practice by decreasing the incidence of TB in correctional facilities. The focus of this

DPI project was to evaluate the effect of educating correctional staff about the prevention of

transmission of TB to the inmate population in a correctional setting. It was not known whether

an evidence-based educational intervention would increase a correctional facility’s staff

knowledge about TB. Early detection reduces inmates’, staff members’, and the community’s

risk of exposure to TB. The use of pamphlets, scenario implementation, and review constituted

the evidence-based educational intervention in the project. The participants pre- and post-test

results were compared to evaluate improvement in scores after the evidence-based educational

intervention. The validity of the instrument was established because it fit the constructs for the

project identified conceptually. The reading level was appropriate and the time required for

testing allowed the questions to be complex. Reliability was established by the stability of

measures administered to the same individuals at different times and by using the same standard
 92

test-retest reliability. In Chapter 5, the primary investigator summarized the results of the project.

The analysis of the results regarding the possible variables affecting the outcomes of the project

are discussed. The recommendations for practice and future projects were explored, discussed

along with a final summary of the DPI project. It discussed the implication of the project and

gave an overview of the entire project and its contributions to future practice.
 93

Chapter 5: Summary and Conclusions and Recommendations

In this chapter a summary and conclusion of the project finding were discussed. A list of

recommendations for practice and future projects are included in the chapter. This DPI project

was conducted because of correctional institution staff’s apparent inadequate knowledge about

TB. In the correctional setting infectious disease is a health issue and TB is a main focus of the

project. In the literature review the primary investigator presented examples of important

contributions about TB in corrections. During the project, the intent was to add value to the

subject in current literature. The results of the evidence-based educational intervention showed

increased knowledge on the part of the correctional staff that made them more aware of the

symptoms of TB transmission and its prevention. This intervention decreased the likelihood of

exposure and facilitated early intervention, which reduced the degree to which inmates, staff

members, and the community were exposed to TB. The staff members’ previous disregard of the

necessary precautions that must be taken with patients who may be infected with TB to help

prevent further transmission of the disease imposes a higher risk on the population inside and

outside the correctional settings.

The project used the pre-testing scores that were an indication of the staffs’ knowledge

and practice gaps that exist about the prevention and transmission of TB. After the pre-test an

evidence-based educational intervention was provided for review by the participants. The post-

testing was completed in seven days for assessment of knowledge after the intervention. The

strength of this project was the improved test results the participants achieved and impact on

practice by decreasing the incidence of TB in correctional facilities. The goal of the DPI was to
 94

demonstrate how an evidence-based educational intervention impacts the level of knowledge of

the participants.

The weaknesses of the project were that without actual review by the primary

investigator, it was not possible to determine whether the participants read the evidence-based

educational information provided after the initial review. There are a limited number of articles

about TB in U.S. correctional facilities that include recent statistical information. An additional

weakness was the limited number of departments the staff represented, as there is a diverse

number of departments in the facility. Further, the exclusion of the inmates made it impossible to

evaluate their own knowledge of the methods of transmission and prevention of TB.

The purpose of the quantitative project was to examine the effectiveness of utilizing a

pre-posttest design on implemented evidence-based education about the spread and prevention of

TB provided to a target population of correctional staff in a correctional facility in central North

Carolina. The project discussed the need for additional education and training about TB and the

preventive practices they use with the inmates, other staff members, and the community. The risk

factors for TB infection following exposure may be determined by exogenous factors and a

combination of the source, proximity to the infected individual, and the correctional setting,

because transmission is high in overcrowded environments (Norseman et al., 2013).

Summary of the Project

The project focused on the clinical question, “How effective was the use of evidence-

based education in increasing the correctional facility staff’s knowledge about the transmission

and prevention of TB?” The primary investigator’s goal was to determine if an evidence-based

educational intervention would increase the participants’ knowledge about TB transmission and

prevention. The independent variable was the evidence-based educational intervention and the
 95

participants were the dependent variable in the project. There was a lack of compliance of staff

with prevention of TB. The importance of the screening procedures and TB transmission in a

high-risk environment were discussed in the project. The significance of the project was to

establish the importance of the evidence-based educational intervention for the staff knowledge

about TB and preventive measures. The literature has established that prisons, jails, and all

correctional facilities are environments that are at high-risk for the spread of TB, which poses a

serious public concern (CDC, 2014). The DPI project focused on the lack of information and

knowledge about TB in a high-risk environment within a correctional facility. The project was

initiated with a pre-test about TB to assess the staff’s knowledge. After the pre-test the evidence-

based educational intervention was implemented for the participants by the primary investigator.

There were also opportunities for them to ask questions. One week following the evidence-based

educational intervention a post-test and supplemental questions were administered. All test

scores were calculated and a comparison made to show the level of knowledge both before and

after the evidence-based educational intervention. The staff were educated and made aware that

they play a key role in preventing the spread of TB within the facility. Many of the correctional

staff had contact with the inmates the majority of their day. The project explored the different

areas of non-compliance and areas in which the correctional staff needed education and training.

The results from the literature on this health issue and education, had shown the association of

the need of ongoing education, and increased levels of knowledge about TB transmission and

prevention. This improvement can also extend to other correctional facilities, staff and benefit

other communities. The project can be replicated and adapted to other correctional facilities and

staff. The prevention of TB extends beyond the prison walls because the inmates are seen in
 96

outside hospitals and clinics, and some have jobs within the community which may expose many

people in the community.

In Chapter 5 the results and implications of the project were discussed. The possible

recommendations for future research and summarize the entire project.

Summary of Findings and Conclusions

The findings in this project suggested that an evidence-based educational intervention

could attain improved knowledge about the transmission and prevention of TB. In the post-test

summary question, “Are you now aware of some of the signs and symptoms of TB that an

inmate or patient may exhibit or report to you?” all of the participants answered yes to the

question. There were errors in placement and incorrect reading of the skin test within the facility.

Early identification of persons with TB or who have been exposed to the disease through entry

and periodic follow-up screenings should be established (CDC, 2014). It has been found that

after students’ pre- and post-tests were used to assess the effectiveness of such education and

noted increased compliance with TB policies (Harrell, 2011). These were issues on which the

project focused to establish the importance of educating and training the correctional staff about

TB and preventive tools. The DPI project involved the correctional staff and the outcome desired

was an improvement in their knowledge about TB transmission and prevention to impact

practice by decreasing the incidence of TB in correctional facilities. The project can be easily

replicated and adapted to the needs of a particular correctional setting. The significance of the

project was the implications on the nursing knowledge and education to assist in diagnosis and

treatment of TB. The need for diligent observation and evaluation of inmates suspected of being

exposed to TB was found to be very important in the literature. Working with the correctional

staff allows the primary investigator to find out what educational needs the staff members have.
 97

Each correctional facility may have a unique set of educational needs but can all benefit from the

evidence-based education interventions about TB transmission and prevention. The correctional

staff’s increased knowledge about TB was a benefit and positive contribution to both the

correctional inmate population and outside community. A positive outcome of the project would

be to show the importance of the need to keep updated training available for correctional staff

members. There were knowledge and practice gaps in the correctional setting which put the

community, the facility and people in it in jeopardy of TB transmission. There are interventions

needed to avoid the spread of the disease and monitor the patients who are being treated. From

the literature it has been established that prisons, jails and all correctional facilities, are areas that

TB can spread at an increased manner due to overcrowding and poor ventilation (CDC, 2014).

Implications

This project implications provided more consistency in the correctional staffs’ education.

The individual staff members stated where they might need additional help and assistance with

TB transmission and prevention. This project permitted evaluation of the staff’s knowledge

about a disease that is transmitted easily in the correctional setting. Because they worked in

extremely high-risk areas, the correctional staff must be made aware of the precautions that must

be taken at all times.

Theoretical implications. The teaching and evidence-based educational training were

based on the theoretical foundation of the constructivism method. This method was based on

learning and indicates that knowledge was constructed within the learner’s mind. The

constructivist strategies provided the information with which learners developed their own

mental models. The original information must be processed actively to be integrated contextually

with their prior knowledge and promoted deep learning (Vogel-Walcutt et al., 2011). The
 98

theoretical framework of the project included the use of the adult learning theory which provided

a standard for implementing the evidence-based educational intervention for the participants. The

theory also helped the focus remain on the best educational outcome for the correctional staff.

Practical implications. The DPI project initiated within the correctional facility can

benefit both the patients in the in-patient area, the prison inmates, all the correctional staff, and

the outside community because of prevention taken to reduce the spread of TB. The staff were

supplied with the interventional evidence-based education and methods that helped reduce the

spread of TB in the facility. The emphasis was on the potentially high risk of transmitting the

disease to others in the correctional facility and in the community.

Future implications. The WHO has a twenty-year strategy to end the global TB

epidemic with the goal to achieve a 95% reduction in deaths from TB and 90% decrease in TB

cases (WHO, 2013). Policymakers and the WHO were provided with evidence to rethink the

work necessary to focus on TB in prisons with guidance in using the best methods and practices

to control and prevent TB (WHO, 2013). A weakness of the project was the sample size, which

was a small number of participants. This caused a less than viable data result. There are other

high-risk areas that may not have the information or education to protect themselves and others

properly from contracting TB. Correctional staff need ongoing education and training to remain

up to date and knowledgeable about the disease. The strengths of the project were, it indicated

areas that the staff lacked knowledge about the transmission and prevention of TB. The project

gave staff members the opportunity to ask questions and voice concerns about needed education

about TB. The pre-test used in the project was beneficial in showing the areas the staff required

more education and lacked knowledge about TB transmission and prevention. The evidence

based educational intervention offered the staff the opportunity to ask questions and give input
 99

about TB in a high-risk environment. The data showed an increase in knowledge of TB with the

use of the evidence-based educational intervention of the project and impact practice by

decreasing the incidence of TB in correctional facilities. The increase of diagnosed cases of TB

substantiates the need for the use of the DPI project to evaluate where the education and training

is most needed to continue to impact practice.

Recommendations

This section of the project discussed the future project and practice recommendations.

Recommendations are needed to continue the validation and reliability of this and future

projects. Maintenance of ethical standards, confidentiality and informed consent would always

be the foundational rationale for all recommendations. of evaluation of the use of education for

staff members about the difference of latent TB and active TB and preventive methods. The

project can be used to evaluate and trace the effects of education on staff in other areas of

corrections. The project pre-test could assess the specific areas where training and education is

needed. The use of the DPI project is needed for future practice to maintain the validity and

reliability of this project and those in the future.

Recommendations for Future Projects. There are many cases of TB that affect the

prison system, including a number of latent TB cases and health law violators who come to the

prison for direct observation and treatment to maintain their medication regimen (CDC, 2013).

Future studies on TB detection and prevention should be conducted in prisons, such as a project

involving the number of latent and active TB cases in the prison on treatment medication who

complete treatment. One recommendation would be to make more educational opportunities

available for staff members based on the current results of the project. Another recommendation

included establishing staff to oversee and manage the duties and responsibilities of management
 100

of TB prevention techniques of the staff. There are many inmates treated for latent and active TB

within the correctional system who are transferred and released to different facilities and to the

community. The monitoring and tracing of completion treatment can be considered for a future

project. The completion of treatment for TB is vital in the reduction of medication resistant

treatment (WHO, 2015).

There is a limited number of studies in the U.S. involving TB in prisons. One study was

conducted to determine the number of inmates exposed to TB, where the disease was contracted,

and whether they were placed on a medication regimen for treatment. The data showed that the

risk of contracting TB was approximately 2.5% higher in incarcerated persons (Cernat &

Brojboiu, 2011). The quantitative methodology may be used to collect data in the prison system

to explore these issues further.

Many aspects of TB are unknown. Future projects could address other areas of the body

that can be affected by TB in addition to the lungs. A future project involving cases of TB of

individuals in the prison system who were infected in areas other than the lungs, as well as

pulmonary TB, is recommended. The different body parts affected by TB and the medical

treatment required for those conditions and their prognosis can be identified. It also is important

to evaluate the response to treatment in comparison to that on the part of inmates with active

pulmonary and extrapulmonary TB.

The next steps in future projects would be expansion to other NC correctional facilities to

evaluate the project for improved knowledge and training for staff and better methods of

prevention that can be implemented to decrease TB spread to inmates and the community. The

next steps in the continued work in this type of project, would have involved evaluation of

different departments of the prison, and other facilities to assess their needs for education. The
 101

ongoing education of staff members working in high-risk environments, would help determine

what kinds of training are most beneficial in achieving the best patient outcomes. The project

could identify particular departments that lack the knowledge about TB transmission and

prevention and continue to answer the clinical question. The project results assisted in the staff’s

future educational needs. The pre-test may identify the areas where additional education is

needed. The project can identify the lack of knowledge of individuals in particular preventive

measures required in decreasing the transmission of TB. This could be offered as an area of

education and learning, including the proper documentation of skin test readings and why they

must be administered correctly and read accurately. The quantitative methodology can be used to

determine the results of hands-on practice in administering TSTs and reading the results. Such a

project can be conducted with a pre-test to establish the number of staffs who lack the knowledge

of how to administer the test who require additional education. The pre-test also helped

determine who needed education and training, by determining if the practice of practitioners

were completed properly. The increased education about TB preventive methods can be used to

evaluate whether the proper documentation is kept and the TST are read correctly. The

significance of the project would assist in obtaining an evidence-based educational intervention

to attain improved knowledge about the transmission and prevention of TB. A project can be

conducted that involves the healthcare community in evaluating the number of patients who are

released and continue latent TB treatment and follow up with their local health department. The

more information that is known about TB, the better the methods of prevention that can be

implemented to decrease the spread to inmates and the community.

Recommendations for Future Practice. The recommendations for future practice are

discussed in this section of the project. An education program to improve TB prevention

 102

practices, would benefit the staff members, inmates, and the community to decrease the

transmission of the disease. The staff should have scheduled semi-annual training classes with

simulation activities, powerpoint presentations, and handouts for review. The project participants

were scheduled a time to review the evidence-based educational materials during a normal work

day. The allocated time could allow the staff to make suggestions about training and education

they need, and ask any questions about TB. Educating the inmate population to make them more

aware of TB in a high-risk environment and signs and symptoms to look for. The use of

evidence-based education about the necessity of treatment completion as a means to prevent

further infection for both staff and inmates. Educational programs for the nursing staff about the

transmission of TB to allow for the ability to educate other staff members about prevention. The

collaboration with the community health services for the follow-up care and monitoring of

inmates who are released to the community for education and treatment completion.

An investigation of screening, detection, and prevention methods of TB transmission in

the prisons is an area that can be implemented into future practice, including evaluating chest x-

rays and blood work of those patients who have tested positive. Monitoring blood work, weight,

and eye exams frequently while patients are receiving latent TB treatment should be future

practices. Individuals who are isolated to rule out TB should have their sputum specimens and

lab work monitored very closely. Recommendations for future practice also include the use of

new innovative methods available to identify TB in inmates and staff. The identification of

inadequate knowledge levels can result in additional training and eduation in particular areas.

This could benefit the inmate population, correctioanl staff members and the community. The

additional evidence-based education may contribute to knowledge about the prevention and
 103

precautions to be taken by the staff to decrease the transmission of TB to inmates and the

community.

There is a considerable amount of information about TB, which many people who live

and work in high-risk environments may not be aware. The continuous movement within and

between correctional and healthcare facilities without proper screening and testing for TB can

put other inmates, staff, and the communtiy in jeopardy of being exposed to undiagnosed TB.

The more information and increased educational opportunities about TB, the better the methods

of prevention that can be implemented to decrease TB spread to inmates and the community. The

increase of knowledge and education of the staff in the high-risk environments such as prisons,

allows improved care, early detection and survillence of the TB.

 104

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TB Prevention and the Need for Education and Training for Correctional Staff

Test Questions Pre-Post-Test and Supplemental Questions

Participant #_____________

1) After having a TST (Tuberculin Skin Test) placed, when does the patient (inmate)

have to have it read?

a. the next day

c. 48 to 72 hours

b. in one week

d. only if it turns red

2) When does Central Prison/Central Prison Healthcare Complex complete the

annual TB screenings for all staff? ___________________________.

3) Who can wear a surgical mask? ______________________________.

4) A patient is suspected of having Tuberculosis and must be placed on which type

of precaution?

a. Contact Precautions

b. Universal Precautions

c. Airborne Precautions
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5) Who can wear the respirator (N95) when isolation precautions are in place?

___________________________.

6) Prisons, jails and correctional facilities are at high risk for spread of tuberculosis?

True or False

7) If a patient (inmate) had a tuberculin skin test last year and the results were

negative, they do not have to return for testing. True or False

8) How is the Tuberculin germ spread?

a. by using the same glass, plate, or fork of a tuberculosis infected person

b. by touching a tuberculosis infected person

c. through the air by sneezing, coughing, speaking of a person infected with

tuberculosis

d. disease of the lungs or throat

9) One of the patients (inmates) has his TST read and the nurse says the reading is

17mm. What is the next step?

a. you need another test done

b. chest x-ray

c. come back in 4 days to see if it changes.

10) BCG is a vaccine used for tuberculosis and administered in countries where

tuberculosis is common. True or False

11) Can latent tuberculosis spread to others? Yes or No

12) An inmate (patient) reports having spinal tuberculosis (extrapulmonary

tuberculosis). Is this possible? Yes or No

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13) You are the nurse or correctional officer in the out-side rounds area of the prison. He

is a new processor who came for admission; he is a transfer from a county jail. He is

originally from Mexico and has been in the U.S. for just the last year. His TST was

placed and he had a reading of 20mm. He reports having a cough for the last 3-4

weeks, weight loss of 15 pounds in the last month, and occasional shortness of breath.
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His chest x-ray was ordered; the staff is waiting for the results. What would be your

plan of care for this patient? _____________________________________

14) QuantiFERON-TB Gold is a blood test for tuberculosis. True or False

15) Name 3 high-risk areas for transmission of Tuberculosis? 1)_________ 2)

_________ 3) ____________.

16) An inmate (patient) has a diagnosis of HIV and this makes him less likely to

contract tuberculosis. True or False

17) Name three (3) signs or symptoms of tuberculosis disease. 1)________2)

__________ 3) ___________.

18) A tuberculosis infection control plan is in place in high risk environments to

achieve?

a. prompt detection of infectious patients (inmate)

b. use of airborne precautions

c. treatment of patient (inmate) who has suspected or confirmed tuberculosis

disease

d. all the above

19) What does DOT stand for? D_____O______T______?

20) What additional test may be used to tell whether a patient (inmate) has active

tuberculosis disease?

a. chest x-ray

b. sputum samples

c. peak-flow

d. endoscopy
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e. c. and d.

f. a. and b.

g. all the above

Post-Test Supplemental Questions:

1. Has this education about tuberculosis increased your awareness about the disease and

how it can be spread to the inmate/patient population? Yes or No

2. Are you now aware of some of the signs and symptoms of tuberculosis that an inmate

or patient may exhibit or report to you? Yes or No

3. Do you now know the preventive measures that should be taken to decrease the

spread of tuberculosis to the inmate/patient population? Yes or No

4. Was the educational information helpful for future care of patients with tuberculosis?

Yes or No

5. Would you recommend this education for other staff members and the inmate/patient

population? Yes or No

6. Should the inmates be included in the project? Yes or No

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IRB Approval Letter

3300 West Camelback Road, Phoenix Arizona 85017 602.639.7500 Toll Free 800.800.9776 www.gcu.edu

DATE: December 3, 2016

TO: Tremaine Grady, MSN

FROM: Grand Canyon University Institutional Review Board

STUDY TITLE: [970042-1] Tuberculosis Prevention and the Need for Education and
Training of Correctional Staff
IRB REFERENCE #: 970042-1
SUBMISSION TYPE: New Project

ACTION: APPROVED with Conditions

APPROVAL DATE: December 3, 2016
EXPIRATION DATE: December 3, 2017
REVIEW TYPE: Expedited Review

REVIEW CATEGORY: Expedited review category # [enter category, or delete line]

Thank you for your submission of New Project materials for this research study. Grand Canyon
University Institutional Review Board has Conditionally Approved your submission. Conditional approval
has been granted based on the signed document by the DNP Learner and Chair stating that the research
has not collected data in advance of receiving this GCU IRB approval letter. This conditional approval is
also based on an appropriate risk/benefit ratio and a study design wherein the risks have been
minimized. All research must be conducted in accordance with this approved submission.

This submission has received Expedited Review based on the applicable federal regulation.

Please remember that informed consent is a process beginning with a description of the study and
insurance of participant understanding followed by a signed consent form. Informed consent must
continue throughout the study via a dialogue between the researcher and research participant.
Federal regulations require each participant receive a copy of the signed consent document.

Please note that any revision to previously approved materials must be approved by this office prior
to initiation. Please use the appropriate revision forms for this procedure.

All SERIOUS and UNEXPECTED adverse events must be reported to this office. Please use the
appropriate adverse event forms for this procedure. All FDA and sponsor reporting requirements
should also be followed.

Please report all NON-COMPLIANCE issues or COMPLAINTS regarding this study to this office.

Please note that all research records must be retained for a minimum of three years.

-1- Generated on IRBNet

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Tuberculosis (TB) Facts/TB Elimination

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