Document Type

Final Project

Graduation Date

Spring 5-7-2026

Degree Name

Doctor of Nursing Practice

First Advisor

Dr. Stephanie Burge

Second Advisor

Dr. Cathrin Carithers

Abstract

Background: Colorectal cancer (CRC) is the second leading cause of cancer-related mortality in the United States and disproportionately affects rural populations. Although more than 90% of cases occur in adults older than 50 years, increasing incidence among younger adults prompted an update to national guidelines recommending screening beginning at age 45. Rural residents face multiple barriers to colorectal cancer screening (CRCS), including limited access to care, transportation challenges, lack of insurance, and absence of standardized screening processes in primary care. These barriers contribute to lower screening rates, delayed diagnosis, and poorer outcomes. Evidence demonstrates that CRCS reduces CRC morbidity and mortality through early detection and removal of precancerous lesions; however, adherence remains suboptimal in underserved rural communities.

Purpose: The purpose of this Doctor of Nursing Practice (DNP) quality improvement project was to develop, implement, and evaluate evidence-based CRCS and follow-up algorithm to increase screening referrals among adults aged 45 years and older and assess provider and nurse satisfaction with the tool.

Methods: This quantitative quality improvement project used a pre–post design with retrospective and concurrent chart review and a provider and nurse satisfaction survey. The project was implemented in a rural Midwestern family practice clinic affiliated with a critical access hospital. Participants included three primary care providers (MD, APRN, PA) and four nurses (two RNs and two LPNs). The evidence-based CRCS and follow-up algorithm was developed using current national guidelines. Data was collected three months before and three months after implementation. Chart reviews captured CRCS referrals and key CRC risk indicators, including gastrointestinal symptoms and family history. A post-implementation survey assessed satisfaction, usability, barriers, and sustainability.

Results: A total of 112 patient charts were reviewed, including 68 pre-implementation and 44 post-implementation charts. Charts lacking documentation of CRC screening discussions or outcomes decreased from 61.4% pre-implementation to 29.4% post-implementation. Although this represented a substantial reduction in missed documentation opportunities, the difference did not reach statistical significance, χ² (1) = 2.91, p = .088, Cramér’s V = 0.16. Fidelity to the screening algorithm improved throughout implementation. Documented screening outcomes (Cologuard referral, colonoscopy referral, or patient refusal) increased significantly following implementation, χ² (2) = 9.16, p = .010, Cramér’s V = 0.35, indicating a moderate association between algorithm implementation and increased screening-related clinical actions. When no documentation/missed opportunities were included as an additional category, there was also a significant shift in outcome distribution after implementation, χ² (3) = 13.00, p = .005, Cramér’s V = 0.34, indicating a moderate association between algorithm use and improved documentation of screening decisions.

Implications for Practice: Implementation of a standardized, evidence-based CRCS and follow-up algorithm may improve screening consistency, enhance interprofessional collaboration, and reduce CRC disparities in rural primary care. Integration into the electronic health record may support sustainability and guideline adherence. This nurse-led quality improvement initiative demonstrated the potential to strengthen preventive care delivery and address health disparities in underserved rural populations.

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