Why More Patients Finished, and What Should Change: Discussion and Implications of a Capstone on Preventive Tuberculosis Therapy
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Master of Science in Nursing Program, Aspen University
N599: Nursing Capstone
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Month Day, Year
Why More Patients Finished, and What Should Change: Discussion and Implications of a Capstone on Preventive Tuberculosis Therapy
In the capstone project, the county's tuberculosis clinic moved patients with latent infection onto a once-a-week, three-month regimen and let them prove each dose by phone video that a nurse watched. Across six months the finishing rate went from 57.9% to 78.6%, reaching 87.8% among those who used video, and the gain was both significant on testing and steady across every month charted. This section interprets those findings, compares them with the literature, examines the project's limitations and sets out implications for nursing practice, clinic policy and further work.
Interpreting the Findings
The size of the improvement is consistent with what the literature would predict from combining a shorter regimen with observation. Moving patients off daily rifampin onto the weekly combination, without observation, was associated with higher completion in a large U.S. cohort, 79% compared with 68% among adults under 50 and 87% compared with 64% among those 50 and older (Haas et al., 2021). Observation adds further benefit: in a randomized trial, completion of the weekly regimen was 87.2% with direct observation and 74.0% with self-administration (Belknap et al., 2017). The project's completion rates, 87.8% with video observation and 71.4% without it, are strikingly close to those trial figures, which suggests that video observation delivered much of the benefit of in-person observation without requiring patients to travel.
The high rate of on-time videos, 91%, echoes a London trial in active disease, where far more scheduled doses were seen by video than were seen in person (Story et al., 2019). In the framework used for the project, the Health Belief Model, the results fit the prediction that reducing barriers, fewer doses and no travel, and supporting self-efficacy through weekly contact would have more effect than emphasizing the threat of disease.
The survey responses support the same interpretation. Patients most often said that staying away from the clinic and getting a nurse's message back each week helped them finish, which corresponds to the constructs of perceived barriers and cues to action. Side effects in the first weeks were the most common reason patients considered stopping, a reminder that the project reduced barriers but did not remove the main physical cost of treatment. That finding points to an improvement the clinic can make: a planned phone check early in the course, at the point when flu-like reactions usually show up, to explain what is expected and when to seek care.
Limitations
Several limitations affect how confidently the improvement can be attributed to the intervention. The pre-post design cannot exclude other changes over time, such as differences in referral sources or staff, though none was documented and the patient populations were similar. Patients chose their option, so the higher completion among video users partly reflects who chose it, likely patients with smartphones and more predictable lives. The comparison of regimens is therefore not a fair test of video observation alone. The implementation period was six months and the sample 84 patients, too short and small to measure the outcome that matters most, fewer cases of active tuberculosis. Nursing time was self-recorded and may be imprecise. Finally, this capstone reports composite data constructed for teaching; a real project would face the same limitations and should report them in the same way.
Despite these limits, the improvement was large, consistent with prior evidence and sustained across all six months, which makes it unlikely to be due to chance alone.
Implications for Nursing Practice
For public health nurses, the project shows that the nurse's role in latent tuberculosis treatment can shift from monitoring monthly visits to maintaining brief, frequent contact that fits patients' lives. Reviewing a short video and replying took about five minutes per dose, and the weekly contact appeared to support adherence more effectively than monthly visits. Nurses in similar clinics can adopt the approach with modest training, a secure video platform and interpreter support for the first visit. Teaching should focus on concrete benefits and on what to do after a missed dose, since the framework and the evidence both suggest these matter more than frightening patients about the disease.
The project also has implications for nursing education and for the nurse's professional role. Public health nurses at the clinic reported that reviewing videos gave them a clearer picture of each patient's week than monthly visits had, including early warning of side effects and life changes such as new jobs or moves. Nurse educators preparing students for public health practice can use the approach as an example of how digital tools extend, rather than replace, the relationship between nurse and patient, and of how a nurse-led quality improvement project can change a clinic's standard of care using the nurse's own data.
Implications for Policy and Next Steps
The clinic's leadership has agreed that video-verified weekly dosing will be what nurses propose first to every adult who can take it, keeping daily rifampin for contraindications or patient preference, consistent with national guidelines that list both among preferred regimens (Sterling et al., 2020). Keeping the model going means budgeting for the video software and protecting nurses' time, which the department will include in its tuberculosis program budget, and a plan for patients without smartphones, such as loaner devices. Next steps include extending monitoring to twelve months, tracking progression to active disease over the following years, and exploring whether the approach can be adapted for patients referred from contact investigations, a group at higher risk of progression. Sharing the results with other county clinics through the state tuberculosis program would allow a larger, multisite evaluation.
Conclusion
Weekly dosing checked by nurses over video was associated with a large, lasting rise in the share of clinic patients who completed preventive therapy, closely matching what published trials would predict for observed weekly therapy while removing the need for travel. The design's limitations mean the result should be confirmed over a longer period and in other settings, but the evidence is strong enough to justify making the approach the clinic's standard. For a clinic where nearly half of patients once left treatment unfinished, the project suggests that meeting patients where they are, on their phones and on their schedules, is how public health nursing can help them finish.
References
Belknap, R., Holland, D., Feng, P.-J., Millet, J.-P., Caylà, J. A., Martinson, N. A., Wright, A., Chen, M. P., Moro, R. N., Scott, N. A., Arevalo, B., Miró, J. M., Villarino, M. E., Weiner, M., & Borisov, A. S. (2017). Self-administered versus directly observed once-weekly isoniazid and rifapentine treatment of latent tuberculosis infection: A randomized trial. Annals of Internal Medicine, 167(10), 689-697. https://doi.org/10.7326/M17-1150
Haas, M. K., Aiona, K., Erlandson, K. M., & Belknap, R. W. (2021). Higher completion rates with self-administered once-weekly isoniazid-rifapentine versus daily rifampin in adults with latent tuberculosis. Clinical Infectious Diseases, 73(9), e3459-e3467. https://doi.org/10.1093/cid/ciaa1364
Sterling, T. R., Njie, G., Zenner, D., Cohn, D. L., Reves, R., Ahmed, A., Menzies, D., Horsburgh, C. R., Crane, C. M., Burgos, M., LoBue, P., Winston, C. A., & Belknap, R. (2020). Guidelines for the treatment of latent tuberculosis infection: Recommendations from the National Tuberculosis Controllers Association and CDC, 2020. MMWR Recommendations and Reports, 69(1), 1-11. https://doi.org/10.15585/mmwr.rr6901a1
Story, A., Aldridge, R. W., Smith, C. M., Garber, E., Hall, J., Ferenando, G., Possas, L., Hemming, S., Wurie, F., Luchenski, S., Abubakar, I., McHugh, T. D., White, P. J., Watson, J. M., Lipman, M., Garfein, R., & Hayward, A. C. (2019). Smartphone-enabled video-observed versus directly observed treatment for tuberculosis: A multicentre, analyst-blinded, randomised, controlled superiority trial. The Lancet, 393(10177), 1216-1224. https://doi.org/10.1016/S0140-6736(18)32993-3
How this N 599 Module 6 example is structured
Aspen does not publish N599 module prompts, so check your classroom and capstone guide for the exact instructions. This example restates the results, interprets them against the literature and the framework, examines specific limitations, draws implications for nursing practice and for policy with next steps, and concludes.
N599 Module 6 questions, answered
What does N599 Module 6 usually ask for?
After the results, Aspen's capstone typically requires a discussion that interprets findings, compares them with the literature, addresses limitations and draws implications for practice. Check your capstone guide.
How should limitations be written?
Specifically: name each feature of the design that limits the conclusions, explain how it could affect the result, and state what was done to reduce its influence or what future work could address it.
What are implications for practice?
Concrete changes that nurses, organizations or policymakers could make based on the findings, stated within the limits of the evidence and linked to the resources needed.
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