An Educational Intervention on the Use of Acupuncture for Chronic Pelvic Pain

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..................................................................................................................................11 Implementation Model ................................................................................................................14 Purpose..........................................................................................................................................15

.........................................................................................................................................15 Site .....................................................................................................................................17 Participants and Recruitment .........................................................................................18 Intervention ......................................................................................................................18 Evaluation Measures .......................................................................................................20 Analysis .............................................................................................................................20 Ethical Considerations.....................................................................................................21 IRB Review and Approval ..............................................................................................21

...........................................................................................................................................22 Pre-Survey Results ...........................................................................................................22 Post-Intervention Survey Question Results ...................................................................25 Discussion......................................................................................................................................26 Alignment With DNP Essentials .....................................................................................29 Essential I: Scientific Underpinnings for Practice ..............................................29 Essential II: Organizational and Systems Leadership for Quality Improvement and Systems Thinking ...........................................................................................29 Essential III: Clinical Scholarship and Analytical Methods for Evidence-Based Practice ..................................................................................................................29 Essential IV: Information Systems/Technology and Patient Care Technology for the Improvement and Transformation of Health Care .................................30 Essential V: Health Care Policy for Advocacy in Health Care...........................30 6 Table of Contents – Continued Essential VI: Interprofessional Collaboration for Improving Patient and Population Health Outcomes................................................................................30 Essential VII: Clinical Prevention and Population Health for Improving the Nation’s Health .....................................................................................................30 Essential VIII: Advanced Nursing Practice ........................................................30 Sustainability ....................................................................................................................31

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....................................................................................................................................33 Implications for Future Practice ....................................................................................33 Funding .........................................................................................................................................34 Appendix A: Site Authorization Letter......................................................................................35 Appendix B: Evidence Table.......................................................................................................37 Appendix C: Consent Document (Disclosure Letter) ...............................................................48 Appendix D: Recruitment Materials ..........................................................................................50 Appendix E: Evaluation Instruments ........................................................................................52 Appendix F: Participant Materials (Acupuncture Media Works Pamphlet) ........................55 Appendix G: IRB Approval ........................................................................................................58

.....................................................................................................................................61 7 List of Figures Figure 1 Project Application of the Iowa Model ........................................................................16 8 List of Tables Table 1 Pre-Intervention Perceptions of Acupuncture Questions 1-3 ......................................23 Table 2 Pre-Intervention Perceptions of Acupuncture Questions 4-5 ......................................24 Table 3 Survey Findings on Participant Demographics ...........................................................24 Table 4 Age Groups and Duration of Chronic Pelvic Pain ......................................................25 Table 5 Post-Survey Likert Scale Summary ..............................................................................26 Table 6 Project Budget Table ...................................................................................................34 9

Background: Chronic pelvic pain (CPP) is a complex and under-researched condition affecting approximately one in seven women in the U.S. (Dydyk & Gupta, 2023). Despite its multifactorial nature, treatment often relies on pharmaceutical and surgical interventions, many of which have limited long-term efficacy and significant side effects (Gallagher et al., 2018; Mardon et al., 2021). Acupuncture, a low-risk and cost-effective alternative, has gained recognition in chronic pain management and is now recommended by American College of Obstetricians and Gynecologists for CPP (Lin et al., 2023; ACOG, 2025). Increasing patient awareness of such non-pharmacologic options may help address gaps in women’s health care. Purpose: This quality improvement project evaluated whether women with CPP are receptive to acupuncture as part of treatment plan, either alongside or instead of traditional pain medications. Project aimed to determine if educational materials should be routinely implemented in clinical practice to diversify therapeutic options.

Pre-existing educational pamphlet on acupuncture for CPP (Acupuncture Media Works) was distributed to women presenting with CPP during three high-volume clinic days. After reviewing pamphlet, participants completed post-pre survey assessing knowledge, attitudes, and willingness to integrate acupuncture into care. Demographic data and survey responses were securely recorded by Project Lead. Descriptive statistics summarized receptivity and guided recommendations for integrating acupuncture education into routine practice.

Twenty-one women participated. Pre-survey data showed limited awareness, 81% reporting acupuncture had never been presented as treatment option. Post-intervention, participants reported significantly improved perceptions. On five-point Likert scale, participants 10 strongly agreed acupuncture is a valid treatment (M = 4.81), felt well-informed (M = 4.76), supported wider availability (M = 4.67), and were open to trying themselves (M = 4.67). Provider encouragement remained low (M = 1.67). Overall mean score (M = 4.20) indicates brochure effectively increased awareness and positive attitudes.

Brief educational intervention improved patient perceptions of acupuncture for CPP. Integrating education into routine care may expand safe, non-pharmacologic options. Sustained implementation requires greater provider engagement and institutional support. 11

Research in women’s health continues to be one of the most underfunded areas in medicine (Mirin, 2021). Historically, healthcare research has predominantly focused on male subjects or on conditions affecting both sexes, with limited emphasis on diseases that primarily impact women (Mirin, 2021). Consequently, many women report feeling unheard and overlooked in the diagnosis and treatment of female-specific conditions. Chronic pelvic pain (CPP) remains among the most complex conditions to treat due to its multifactorial etiology and poses a significant personal and socioeconomic burden. CPP is a complex and under-researched condition, affecting approximately one in seven women in the United States, and is defined as noncyclical pelvic pain lasting longer than six months. (Dydyk & Gupta, 2023; Meisenheimer & Carnevale, 2025). In the United States, the cost of CPP was estimated at $2.8 billion in 1996 and rose to $5.8 billion by 2020 (Lamvu et al., 2021). With increasing health disparities patients with CPP are often subjected to disproportionately high rates of gynecological surgeries and increased medication use—estimated to be three to four times higher than in individuals without CPP (Chang et al., 2024). In addition, 80% of CPP cases do not have a gynecologic origin, however, the condition accounts for 40% of laparoscopies and 12% of hysterectomies (Lamvu et al., 2021). Thus, the condition remains difficult to manage effectively because of persistent challenges in accurately identifying its underlying cause. Understanding the etiology of chronic pain is essential for effective treatment. CPP can be triggered by a range of conditions, including irritable bowel syndrome, major depressive disorder, chronic cystitis, endometriosis, adhesions, a history of traumatic events, and pelvic inflammatory disease (Dydyk & Gupta, 2023). CPP can be either a primary or secondary 12 condition, depending on the patient’s comorbidities. CPP is frequently associated with comorbidities that lead to nervous system hypersensitivity, necessitating a multidisciplinary management approach with a comprehensive history and physical examination to determine etiology (Meisenheimer & Carnevale, 2025). Recent studies show that women with a history of psychiatric illness experience more severe CPP and have higher rates of depression, anxiety, and insomnia (Dydyk & Gupta, 2023). With a higher prevalence of underlying psychiatric illness, CPP treatment for women who have been physically or emotionally abused is complex due to pelvic exams being traumatic, invasive, and triggering past events of trauma (Lamvu et al., 2021). Endometriosis, adhesions, and chronic cystitis can also contribute to secondary CPP (Dydyk & Gupta, 2023). A recent analysis of 270 evidence-based guidelines related to CPP revealed that the majority of recommendations emphasized surgical and pharmaceutical interventions (Mardon et al., 2021). Moreover, over 35% of these recommendations were based on expert opinion rather than empirical evidence (Mardon et al., 2021). These findings underscore a critical need for more rigorous, evidence-based research on pelvic pain to reduce the health disparities associated with this condition. Traditional therapy for pelvic pain often involves a variety of pharmacological interventions. Current evidence-based treatments for CPP include over-the-counter analgesics, pelvic floor therapy, cognitive behavioral therapy, SSRIs/SNRIs (anti-depressants) for mood disruption, cyclobenzaprine (muscle relaxer) administration, and hormonal suppression (Dydyk & Gupta, 2023). One commonly used medication for treating CPP is Leuprolide acetate, a gonadotropin-releasing hormone (GnRH) agonist. This medication induces a hypoestrogenic state, which helps relieve pelvic pain and incites amenorrhea (Gallagher et al., 2018). However, 13 side effects of Leuprolide acetate include depression, memory loss, bone density loss, hot flashes, and night sweats (Gallagher et al., 2018). While patients may experience these long-term side effects, pharmaceutical companies conducting drug trials tend to focus more on potential future fertility outcomes than on the long-term effects of the drug (Gallagher et al., 2018). In a recent study including twenty-five women taking Leuprolide acetate for CPP 80% of the women reported lasting side-effects greater than six months after discontinuing the medication, and only 63% reported adequate pain control during administration (Gallagher et al., 2018). Another form of treatment includes MyFembree the newly FDA-approved GnRH antagonist with a small percentage of add-back hormones to offset the hormonal suppression side effects (Myovant Sciences & Pfizer, 2022). Reported side effects from Pzifer and Myovant pharmaceuticals include suicidal ideation, hepatic impairment, bone loss, thrombolytic events, hypertension, and alopecia (Myovant Sciences & Pfizer, 2022). In addition, MyFembree can only be taken for up to two years, which further encourages alternative modalities of treatment. (Myovant Sciences & Pfizer, 2022). Various forms of medicine are practiced worldwide today. Western medicine is typically defined as conventional and follows a disease-centered approach (Kisling & Stiegmann, 2024). In contrast, Eastern medicine—often referred to as alternative medicine—adopts a holistic view, considering disease as a manifestation of dysfunction within the entire body (Kisling & Stiegmann, 2024). One common example of alternative medicine is acupuncture, which involves the insertion of fine needles into specific points on the body to promote healing and balance. The popularity of alternative medicine is steadily increasing in today’s healthcare landscape (Mortada, 2024). Over the past two decades, the prevalence and availability of alternative 14 therapies have risen significantly, with usage rates climbing from 9.8% to 76% (Tangkiatkumjai et al., 2020). Acupuncture, a traditional Chinese medicine approach, is used to treat both acute and chronic pain. Its benefits include being cost-effective, widely available, and having minimal to no side effects. Additionally, acupuncture improves quality of life, alleviates psychological distress, and is often used for patients who have not found relief through traditional medical therapies (Lin et al., 2023). It is believed that acupuncture enhances blood flow and circulation by increasing vascularization in the affected areas. In Chinese medicine, chronic illness is thought to result from a blockage of energy, with practitioners viewing conditions as systemic issues rather than localized problems (Van Hal, 2023). Furthermore, acupuncture is recommended as a modality for the management of chronic pelvic pain by the American College of Obstetricians and Gynecologists (2025). Recent reviews of clinical data show that acupuncture, even without adjunct therapy, has been effective in relieving chronic pelvic pain (Lin et al., 2023). Therefore, women seeking treatment for CPP should be educated on the efficacy of acupuncture and provided with a range of treatment options. Implementation Model This quality improvement (QI) project employed The Iowa Model Revised: Evidence- Based Practice to Promote Excellence in Health Care. The Iowa Model was chosen because it provides a clear, systematic framework for identifying problems, recognizing the need for change, and integrating improved practices into healthcare systems. The Iowa Model outlines several key steps in implementing change: identifying the issue, articulating the purpose, assembling a team, synthesizing evidence related to the topic, piloting the intervention, 15 integrating the changes into practice, and sustaining the improvement (Cullen et al., 2022). For the QI project to be put into practice establishing the need for improvement is imperative. Applying the Iowa Model flowchart, Figure 1 below depicts an overview of the steps taken in this QI project. Incorporation included identifying the area for improvement, researching what current literature states on the topic, and analyzing if participants are open to new treatment modalities. Purpose The purpose of this project is to educate women on the benefits of using acupuncture as a non-pharmacological option for pelvic pain. The project question hopes to answer, “are women with chronic pelvic pain open to receiving acupuncture as an adjunct or alternative approach to pain management, in comparison to the traditional pharmaceutical approach, for reducing chronic pelvic pain?” The main outcomes include understanding whether women are open to alternative modalities for CPP. The goal is for the site to incorporate pamphlets on CPP into practice after the QI project is completed.

Several variations in patient education handouts educate the patient on their disease, etiology, treatment options, and prognosis (Bhattad & Pacifico, 2022). For this project, determining the best education tool was determined by patient population, geographical location, and demographics. A pre-existing educational pamphlet by Acupuncture Media Works (Appendix F) was chosen for this QI project that details the benefits of acupuncture for CPP. 16 Figure 1 Project Application of the Iowa Model Note. Adapted from The Iowa Method of Implementation (Cullen et al., 2022). Identifying Triggering Issues/Opportunities: CPP is one of the hardest disease processes to treat that requires a multidisciplinary approach for treatment. Women's Health research is one of the most underfunded areas of research with inconsistant,and outdated guidelines. Purpose: Are women with CPP open to receiving acupuncture as an adjunct or alternative approach to pain management, in comparison to the traditional pharmaceutical approach, for reducing chronic pelvic pain? Team Formation: Include pelvic pain specialist and gynecologist, office staff including Medical Assistants, front office assistants, and Project Lead. The Evidence in Supporting Literature: A peer-reviewed, literature search was conductied using PubMed, NIH, and ACOG using terms "acupuncture", "chronic pelvic pain", and "alternative modalities for chronic pain".The evidence table is presented in Appendix C. Design and Pilot Process: Advanced Women's Care educates patients with pamphlets. A pamphlet was created educating women on the benefits of acupuncture. The outcome and data was gathered by verbal surveys and documented on a password-protected computer if women are interested in adding a secondary approach to treating CPP. Integration to Practice: The Project Lead educates consenting, and informed patients about the effects of acupuncture in CPP. The patients are informed this is voluntary and may request to not be apart of the QI project at any time. Preliminary data is gathered at this time and based upon statistical analysis. Dissemination: After successful integration, and statistical analysis has been completed the data is interpreted. Based upon interpretation, if women are interested in adding a secondary approach to chronic pain, the QI project can be incorporated. 17 The pamphlet educates women on the effectiveness, safety, and indications that acupuncture can be implemented in. Chinese medicine utilizes a total body approach to healing that is outlined in the pamphlet educating women on the multimodal indications for acupuncture treatment. The project design involves the systematic distribution of these pamphlets to women presenting with CPP to enhance their understanding of acupuncture as a complementary, non- pharmacological treatment option. The project ran for three days during the month of August. Data collected over this period was analyzed, and the sample size consisted of patients who agreed to participate in the QI project. Since patient allocation is random within the clinic, there was no predetermined sample size as scheduled patients for a given day vary. Site This QI project is situated in Phoenix, Arizona, an urban area within Maricopa County. The clinical site, Advanced Women’s Care, serves a diverse population of women encompassing all ages, ethnicities, and socioeconomic backgrounds. The clinic accepts a broad range of insurance types, including Medicare, Medicaid, Marketplace plans, and private insurance, and accommodates self-pay patients, ensuring that no individual is denied care due to financial constraints. The clinic shares office space with an obstetrics provider; however, the two practices operate independently, with separate patient rosters and staffing. The Advanced Women’s Care provider specializes in pelvic pain management and minimally invasive gynecological surgery seeing an average of twenty to thirty patients daily. Key stakeholders involved in this project include the clinic’s staff, patient population, and the primary physician who has endorsed the implementation of this quality improvement initiative. 18 Participants and Recruitment The target population for this quality improvement project included biologically female women presenting with a primary complaint of CPP. Due to the clinical setting, where patients seek care for a variety of reasons, a formal recruitment process was not utilized. Instead, potential participants were identified through a collaborative review of the weekly clinic schedule by the Project Lead and the attending physician. To maximize participant identification, the Project Lead and physician jointly determined the clinic days with the highest volume of patients presenting with CPP. Based on this analysis, three clinic days were selected for project implementation. This selection aimed to capture a diverse patient sample reflective of the clinic’s heterogeneous population and varied reasons for visits. As this is not research, no predetermined sample size was established. Participation was entirely voluntary, and all eligible patients were informed of the potential benefits of acupuncture as a complementary approach in managing chronic pelvic pain. See Appendix C for disclosure letter and Participation Consent. Intervention Guided by the Iowa Model of Evidence-Based Practice as the evidence-based framework, the project was initiated in response to a clinical trigger: the desire to explore patient interest in alternative therapeutic modalities beyond conventional pharmaceutical approaches. As part of the QI project, the Project Lead supplied the educational pamphlets at no cost to the clinic as noted in Table 6. This contribution is mutually beneficial, as it enhances patient education while supporting the physician’s objective to expand therapeutic options. Pamphlet education included education on the benefits of acupuncture, its cost-effectiveness, and the disease processes it treats. 19 A critical factor in implementing the intervention involved its potential impact on clinic workflow. Given that most patient appointments range from fifteen to thirty minutes, strict adherence to these time constraints is essential to respect both patient and provider schedules. The clinic’s waiting area features a prominently displayed wall of educational pamphlets covering topics such as contraception, pharmaceutical therapies, and surgical interventions. It is common practice for the physician to distribute these materials during treatment discussions. Based on these observations of existing clinic flow and patient education methods, the use of an educational pamphlet was determined to be the most feasible and minimally disruptive approach for delivering the intervention within the constraints of routine clinical practice. Moreover, evidence-based practice indicates that providing patients with written educational materials, such as pamphlets, can effectively reduce anxiety related to their health condition by improving knowledge and empowering patients in their care decisions (Alvis et al., 2019). During patient visits, the medical assistants first inquired whether patients presenting with CPP were willing to have a student present for their appointment. If the patient agreed, the Project Lead then entered the exam room to observe the appointment with the physician. After the physician concluded the appointment, the Project Lead stayed to explain the QI project and ask their consent to participating in the project. The Project Lead was the only stakeholder providing education and recruitment. Once participant consent was obtained, the physician left the room to maintain efficiency and minimize disruption to clinic workflow. At this stage, the Project Lead took responsibility for introducing the QI project, explaining the pre-post survey questions, and provide education using the pamphlet. This ensured that participants fully understood the project’s objectives while allowing for smooth data collection. If the patient 20 declined participation, the Project Lead did not include them in the project and thanked them for allowing observation of their appointment for learning purposes. Evaluation Measures At the end of the pamphlet education, the Project Lead evaluated if women agree or disagree with adding acupuncture as part of their CPP treatment plan. To assess the effectiveness of the project, a post-pre survey was conducted after the intervention to collect data, allowing for a comparative analysis of participant responses before and after the intervention. The evaluation included both pre and post-surveys. The pre-survey consisted of seven questions focused on demographic information (ethnicity, age), clinical history (duration of CPP), prior exposure to alternative medicine, and openness to acupuncture prior to receiving the educational pamphlet (see Appendix E). The post-survey included seven statements measured by using a 5-point Likert scale, where 1 indicated "strongly disagree" and 5 indicated "strongly agree," to assess participants’ comfort level and willingness to incorporate acupuncture following the pamphlet intervention. See Appendix E for detailed participation methods and the post-pre survey framework. Demographic questions included in the pre-survey were specifically designed for statistical analysis. Age, ethnicity, and education on their disease are important factors to consider when analyzing the data for trends. The greater the number of affirmative responses collected, the more effectively the QI project will advocate for the incorporation of acupuncture as an adjunctive therapeutic intervention. Analysis Descriptive statistics were used to analyze patient receptivity to acupuncture as an adjunct treatment for chronic pelvic pain. Summarizing the pre-post survey responses provided 21 insights into feasibility, guiding clinical decisions on service integration or referral pathways. All data collected from the pre-post surveys was securely stored on a password-protected computer accessible only to the Project Lead. Additionally, statistical analysis was used to determine whether project outcomes were met, ensuring data-driven recommendations for enhancing patient-centered care. Ethical Considerations The implementation of acupuncture for managing chronic pelvic pain is designed with careful adherence to the core principles of medical ethics: beneficence, nonmaleficence, justice, and autonomy. The project aimed to provide a therapeutic option that may relieve persistent pain, thereby promoting patient well-being, while ensuring that the intervention is low-risk and minimally invasive, aligning with the principle of nonmaleficence. To support justice, participant recruitment was equitable and inclusive, ensuring fair access to all eligible individuals regardless of demographic background. Autonomy was respected by emphasizing that participation is entirely voluntary, and participants were free to withdraw at any time without consequence. A disclosure letter (see Appendix C), outlines that no identifiable data was collected. This transparency ensured participants were fully informed, further reinforcing ethical standards throughout the project. IRB Review and Approval Following the successful defense of the project proposal, this initiative was submitted to the University of Arizona Institutional Review Board (IRB) for review (see Appendix G). The submission request deemed the project "not research" under IRB guidelines, as it is intended for quality improvement and not conducting new research. The Project Lead completed the required 22 Collaborative Institutional Training Initiative (CITI) training before IRB submission, ensuring compliance with ethical and regulatory standards. Upon receiving IRB approval, the implementation phase of the acupuncture intervention for chronic pelvic pain began, by adhering to institutional protocols.

Pre-Survey Results A total of 21 women experiencing chronic pelvic pain participated in the pre-survey. Participant ethnicity was diverse: 47.62% identified as Non-Hispanic White, 23.81% as Hispanic, 19.05% as Black or African American, 4.76% as Asian, and 4.76% as Other. Familiarity with acupuncture varied, with 38.10% reporting they were “slightly familiar” and another 38.10% “very familiar”. Smaller proportions were “not at all familiar” (14.29%) or “moderately familiar” (9.52%). Duration of chronic pelvic pain ranged from 0–5 years (33.33%), 6–10 years (38.10%), 11–19 years (19.05%), to over 20 years (9.52%). When examined by age group, most participants were between 26–49 years old (85.71%), with chronic pelvic pain durations ranging from 0–5 years (n=6), 6–10 years (n=7), 11–19 years (n=4), and 20+ years (n=1). Participants aged 18–25 accounted for 4.76% (n=1) and reported pain for 0–5 years, while those aged 50–65 made up 9.52% (n=2), all reporting durations of CPP for 20+ years. Openness to acupuncture was generally positive, with 42.86% reporting they were “very open”, 38.10% “somewhat open”, and 19.05% “slightly open”. Most participants (80.95%) indicated that alternative medicine had never been presented to them as a treatment for chronic 23 pelvic pain, and the same percentage (80.95%) had never heard of acupuncture being used for this condition. Table 1 Pre-Intervention Perceptions of Acupuncture Questions 1-3 7 8 4 2 4 8 9 2 3 8 8 0 1 2 3 4 5 6 7 8 9 10 0--5 6--10 11--19 20+ Slightly open Somewhat open Very open Moderately familiar Not at all familiar Slightly familiar Very familiar 1 2 3 4 How long have you been expieriencing Chronic Pelvic Pain? (Y) How open are you to trying acupuncture? How familiar are you with acupuncture? Number of Participants Pre-Intervention Perceptions Questions 1-3 24 Table 2 Pre-Intervention Perceptions of Acupuncture Questions 4-5 Table 3 Survey Findings on Participant Demographics 17 4 17 4 0 2 4 6 8 10 12 14 16 18 N Y N Y Has alternative medicine ever been presented as a treatment for CPP? Have you ever heard of acupuncture as a treatment for CPP? Number of Participants Pre-Intervention Perceptions Questions 4-5 4.76% 19.05% 23.81% 47.62% 4.76% Ethnicity Asian Black or African American Hispanic Non-Hispanic White Other 25 Table 4 Age Groups and Duration of Chronic Pelvic Pain Post-Intervention Survey Question Results Following the distribution of an educational brochure on the benefits of acupuncture for CPP, 21 women completed a post-intervention using a 5-point Likert scale where 1 = “strongly disagree”, 2 = “disagree”, 3 = “neutral”, 4 = “agree”, 5 = “strongly agree”. Overall, participants reported highly positive perceptions of acupuncture. They strongly believed acupuncture is a valid treatment for CPP (M = 4.81) and felt well-informed about how it works (M = 4.76). Participants expressed strong support for wider availability of acupuncture (M = 4.67) and openness to trying it themselves for pelvic pain (M = 4.67). Trust in acupuncture practitioners was moderately high (M = 4.57), and participants were somewhat willing to recommend acupuncture to others (M = 4.29). Despite these positive attitudes, very few reported that their healthcare providers had encouraged alternative treatments such as acupuncture (M = 1.67). The 1 6 4 1 2 7 0 1 2 3 4 5 6 7 8 18-25 26-49 50-65 Number of Patients Patient Age Range Duration of Chronic Pelvic Pain 0-5 11-19 20+ 6-10 Years of Chronic Pelvic Pain 26 overall mean response across all items was 4.20, indicating that the educational brochure effectively increased awareness and positive attitudes toward acupuncture among women with CPP as referenced in Table 5. Table 5 Post-Survey Likert Scale Summary

This project’s findings depict the critical role of education in enhancing the long-term viability of acupuncture within women’s health. Acupuncture has been shown to provide lasting relief for CPP. However, this project revealed a significant gap in patient education: prior to intervention, most participants lacked awareness of acupuncture as a viable treatment option. Following the distribution of an educational brochure, 21 women completed a post-survey using a 5-point Likert scale. Results showed overwhelmingly positive shifts in perception— participants strongly agreed that acupuncture is a valid treatment for CPP (M = 4.81) and felt 4.81 4.76 4.67 4.67 4.57 4.29 1.67 0.00 1.00 2.00 3.00 4.00 5.00 I believe acupuncture is a valid treatment for CPP. I feel well- informed about how acupuncture works. Acupuncture should be more widely offered as a treatment option for pelvic pain. I am open to trying acupuncture to help with my pelvic pain. I trust acupuncture practitioners to provide safe treatment. I would recommend acupuncture to others experiencing CPP. My healthcare providers have encouraged or supported alt. treatments like acupuncture. Likert Scale Averages Perceptions and Opennes Toward Acupuncture for Chronic Pelvic Pain 27 well-informed about how it works (M = 4.76). These findings suggest that educational outreach is a sustainable strategy for increasing acceptance and utilization of acupuncture. The pre-intervention data indicates that, prior to receiving the educational brochure, most participants had limited familiarity with acupuncture as a treatment for CPP. Across racial and ethnic groups, only a small proportion reported being very familiar with acupuncture, and the majority had never been presented with alternative medicine as a treatment for CPP. Awareness of acupuncture specifically for CPP was low, with most participants reporting they had not previously heard of it. Despite limited knowledge, many participants expressed some degree of openness to trying acupuncture, with several reporting being very open or somewhat open to the intervention. Duration of chronic pelvic pain varied widely, from less than 5 years to over 20 years, indicating that participants were at different stages in their pain experiences. Overall, the pre-intervention survey data suggests a general lack of prior exposure and education regarding acupuncture. The post-intervention survey results indicate that the educational brochure effectively increased positive perceptions of acupuncture among women with CPP. Participants strongly believed that acupuncture is a valid treatment for CPP and reported feeling well-informed about how it works, suggesting that the brochure successfully conveyed relevant and understandable information. There was notable openness to trying acupuncture for personal pain management and strong support for making it more widely available, reflecting a willingness to engage with non-pharmacological interventions. Trust in acupuncture practitioners was moderately high, and participants were somewhat likely to recommend acupuncture to others, indicating a generally favorable view but some residual hesitancy. Notably, participants reported minimal 28 encouragement from their conventional healthcare providers to explore alternative treatments, highlighting a gap in provider-driven support. Overall, the mean response across all items (4.20) demonstrates a broadly positive attitude toward acupuncture following the educational intervention, emphasizing the potential value of educational materials in promoting awareness and acceptance of complementary therapies for CPP. Acupuncture is relatively low-cost compared to long-term pharmacologic or surgical interventions. By increasing patient openness to acupuncture (M = 4.67) and trust in practitioners (M = 4.57), educational efforts may reduce reliance on more expensive or invasive treatments. However, the low mean score (M = 1.67) regarding provider encouragement of alternative therapies highlights a systemic barrier. For acupuncture to be sustainable at scale, healthcare providers must be educated and incentivized to discuss integrative options with patients. In hindsight, one of the most impactful revisions would be to expand the educational component to include healthcare providers alongside patients. While participants responded positively to the educational brochure, reporting increased awareness, trust, and openness toward acupuncture, the data revealed a significant gap in provider engagement (M = 1.67). This suggests that even when patients are informed and willing, the lack of provider support may hinder actual implementation of alternative therapies like acupuncture. Lastly, clinic costs are a crucial consideration in dissemination. Table 6 outlines the expenses required to sustain the project post-dissemination. If costs are deemed excessive, an alternative pamphlet on acupuncture may be developed. 29 Alignment With DNP Essentials The Essentials of Doctoral Education for Advanced Nursing Practice (American Association of Colleges of Nursing [AACN], 2006) established eight foundational competencies for all Doctor of Nursing Practice candidates. These essentials are relevant to this project because integrating acupuncture for CPP requires a strong scientific evidence base, interprofessional teamwork, patient-centered policy advocacy, and advanced clinical expertise. Essential I: Scientific Underpinnings for Practice This project applies foundational nursing science and current research to support acupuncture as a safe, evidence-based adjunct therapy for CPP, translating theory into practice to improve patient outcomes. Essential II: Organizational and Systems Leadership for Quality Improvement and Systems Thinking Implementation planning incorporated stakeholder engagement, resource allocation, and workflow integration to ensure feasibility and promote sustainable adoption within the clinical system. Engaging the stakeholders during this project is critical for sustainability. Incorporating evidence-based integrative treatments, such as acupuncture, can also potentially lower health care costs by reducing the use of high-priced pharmaceuticals. Essential III: Clinical Scholarship and Analytical Methods for Evidence-Based Practice A rigorous literature review and synthesis of acupuncture and CPP informed the practice change in this QI project, while data collection and evaluation methods assessed effectiveness in the target population. 30 Essential IV: Information Systems/Technology and Patient Care Technology for the Improvement and Transformation of Health Care In this QI project, electronic health records were utilized to access patient records, duration of patients’ CPP symptoms as noted by survey results, and previous treatments. Documentation on previous treatments is noted in the EMR. Essential V: Health Care Policy for Advocacy in Health Care The project promotes policy awareness by advocating for increased education and wider acceptance of non-pharmacological pain management options. Essential VI: Interprofessional Collaboration for Improving Patient and Population Health Outcomes Care delivery is coordinated among physicians, acupuncturists, nurses, and allied health professionals to enhance holistic, patient-centered outcomes. To implement quality improvement and promote project sustainability, stakeholder collaboration and input from various roles and perspectives are imperative. Essential VII: Clinical Prevention and Population Health for Improving the Nation’s Health By reducing reliance on opioids, pharmaceutical, and invasive interventions this project supports safer pain management and can contribute to improved public health outcomes. Essential VIII: Advanced Nursing Practice The advanced practice nurse serves as a clinical leader in the development and implementation of an evidence-based intervention aimed at improving the assessment and management of CPP. This role involves applying specialized clinical expertise, incorporating 31 interdisciplinary collaboration, and utilizing systems-level thinking to enhance care delivery and outcomes for a population frequently underserved in conventional healthcare settings. Sustainability To ensure the continued integration of acupuncture as a sustainable treatment for CPP at this practice site, several practical strategies should be considered. First, embedding patient education materials such as pamphlets and handouts into the electronic health record (EHR) system would streamline provider workflow and ensure consistent delivery of information. Adding a checkbox within the EHR to prompt providers to offer acupuncture education or referrals could further normalize its use. While hiring an in-house acupuncturist may offer convenience and continuity of care, partnering with a local acupuncture clinic could be a more cost-effective solution, especially in early implementation phases. This collaboration could include shared referral protocols, patient feedback loops, and co-hosted educational events. In hindsight, improving feasibility might involve earlier stakeholder engagement, clearer documentation pathways, and a larger sample size. These steps not only support sustainable care delivery but also reinforce acupuncture’s role as a low-resource, high-impact modality in chronic pain management. The project will be formally presented to the public and the project committee during the final defense. This presentation will include a summary of the methodology, results, and implications for practice. The final paper will also be submitted into the University of Arizona ProQuest DNP Project Repository. An executive summary will be shared with stakeholders at the project site, including clinical leadership and staff. This summary will highlight key findings, and recommendations for sustainability. A poster presentation may be developed for submission 32 to regional or national nursing conferences, such as the American Holistic Nurses Association (AHNA) or the American Association of Nurse Practitioners (AANP) annual conference. A manuscript may be prepared for publication in a peer-reviewed journal focused on women's health, integrative medicine, or nursing practices such as Journal of Holistic Nursing or Pain Management Nursing. Consideration will be given to submitting an abstract to interdisciplinary forums that promote alternative modalities in chronic pain treatment, thereby reaching a broader audience including acupuncturists, physical therapists, and other public health professionals.

In hindsight, several factors limited the potential for even more successful outcomes in this project. The most notable constraint was time. The short timeline limited opportunities for deeper engagement with healthcare providers, which could have strengthened the impact of the intervention. Feasibility also played a role. While the educational brochure was effective in shifting perceptions, logistical limitations prevented the inclusion of hands-on components, such as acupuncture demonstrations or facilitated referrals. These additions could have enhanced participant confidence and uptake. Planning was generally strong, but for future consideration, more emphasis could be placed on stakeholder engagement early in the process, particularly with organizational leadership and clinical staff. Their involvement could help align the project with broader quality improvement goals and facilitate integration into existing workflows. Potential bias in the project includes response bias, as participants may have felt inclined to provide favorable answers after receiving educational materials. The use of a single post- survey without a pre-survey limits the ability to measure true change in perception. Lastly, many 33 of the participants have been long-term patients of the provider and may have felt pressured into agreeing to participate.

This project highlights the critical gap in patient education regarding acupuncture as a treatment for chronic pelvic pain. Despite limited prior awareness, participants demonstrated strong receptivity and positive attitudes following a brief educational intervention. These findings suggest that integrating acupuncture education into routine clinical practice may empower patients with more diverse, low-risk treatment options. However, the lack of provider engagement underscores the need for broader systemic efforts, including provider education and institutional support, to fully realize the benefits of integrative pain management in women’s health. Implications for Future Practice This project demonstrated a clear need for increased patient education regarding acupuncture as a treatment for chronic pelvic pain. The strong positive shift in perceptions following a simple educational intervention highlights the value of integrating such materials into routine care. Sustaining this initiative at the clinical site could empower patients with more diverse, low-risk options and improve satisfaction with pain management. On a broader scale, implementing similar educational strategies across healthcare systems could lead to improved health outcomes, reduced reliance on pharmaceuticals, and significant cost savings. To support widespread adoption, organizational leadership should prioritize provider education and policy development that encourages integrative approaches. Health policy reforms, including insurance coverage for acupuncture and funding for alternative pain management research, are essential to 34 address existing gaps. Future efforts should also explore population health strategies and specialty training to ensure both patients and providers are equipped to consider acupuncture as a viable, evidence-based option for chronic pelvic pain. Funding This QI project incurred the cost of the brochures distributed during the intervention. The cost was self-funded by the Project Lead. See Table 6 for cost breakdown. There was no external funding. Table 6 Project Budget Table Item Description Quantity Unit Cost (USD) Total Cost (USD) Women’s Health and Acupuncture-Brochure Pamphlet 25 $19.99 + $10.50 Shipping $30.49 TOTAL $30.49 35 Appendix A: Site Authorization Letter 36 List of Appendices (required and optional) (Use APA 7th ed. appendix format; decide on your appendices [required listed below] in the order in which you mention the materials in your paper. . . .) Site Authorization Approval Letter (Required) Consent Document (Required) Recruitment Materials (Required) Evaluation Instruments (Required) Participant Materials (Required?) Chart Audit Forms (Optional?) Project Timeline (Optional? This seems more like something for them to create in 922-201 but not necessarily include in final paper.) Evidence Table (Required—was “Literature Review Grid”) Other Documents/Materials as Applicable, such as Budget (Optional) 37 Appendix B: Evidence Table 38 Author’s Last Name & Publication Year Title of Publication Type of Study Participants Major Strengths and Weaknesses of the Study Main Outcomes of Findings Relevance to Project 1. Alvis, M. L., Morris, C. E., Garrard, T. L., Hughes, A. G., Hunt, L., Koester, M. M., Yocum, I. C., & Tinius, R. A. (2019) Educational brochures influence beliefs and knowledge regarding exercise during pregnancy: A pilot study Quasi- experimental pre-post Women who are pregnant Strengths: -Advocates the need for brochures and patient teaching for the overall well- being of the patient Weaknesses: -The QI project is not focused on pregnant women After exposure to educational brochures, survey scores were significantly higher than baseline survey scores Current literature that supports the use of pamphlets and power of education in patients 2. American Association of Colleges of Nursing. (2006) The Essentials of Doctoral Education for Advanced Nursing Practice [PDF] Guideline Publication NA NA -list of guidelines to help DNP students and guide them in their project -DNP essentials handbook for DNP students preparing their final project 3. American College of Obstetricians and Gynecologists. (2025) Chronic pelvic pain Quantitative Women with Pelvic Pain Strengths: -ACOG is the guideline for treating women’s health issues -Standard of care -Provider based resource Weaknesses: -Not a research study -Not a quality improvement study -Does not include a literature review -Data based approach and standard of care versus finding new evidence -Lifestyle changes, medications, physical therapy, acupuncture, nutrition counseling, and surgery are all current treatment options for CPP. -Tests to diagnose CPP include transvaginal ultrasound, laparoscopy with biopsy findings, cystoscopy, colonoscopy, and sigmoidoscopy. -Pelvic pain is difficult to diagnose and treat due to a plethora of -The quality improvement project needs ACOG data to back up the validity of acupuncture and current evidence-based treatments. 39 Author’s Last Name & Publication Year Title of Publication Type of Study Participants Major Strengths and Weaknesses of the Study Main Outcomes of Findings Relevance to Project disease processes that could be the culprit. 4. Bhattad, P. B., & Pacifico, L. (2022). Empowering Patients: Promoting Patient Education and Health Literacy Mixed

Study- which included both qualitative and quantitative research Healthcare providers were educated through pre- and post-lecture surveys, which included both qualitative and quantitative questions regarding patient education pamphlets and their likelihood of incorporating them into practice. Strengths: -Quality improvement technique using PSDA -Incorporation of both qualitative and quantitative research to ensure quality data -20 pie chart diagrams stating clear, concise questions identifying areas for improvement with compliance from providers Weaknesses: -Number of participants was not clearly stated -How evidence was picked and sorted through was also not clearly stated -Bias and risk for bias was not addressed or mentioned -Patient education tools such as pamphlets, posters, and patient teaching exercises improve patient satisfaction, health literacy, and shared decision making. -There is limited time during patient appointments to set aside time for educational teaching due to provider turnover, staffing, and demands to see a certain number of patients each day. -Out of 47 responses 46.8% said they would “definitely” and 53.2% said they would “likely” provide patients with printed educational tools if they were organized well. 0/47 providers stated they would not hand out educational tools. -The DNP project will be implemented by passing out pamphlets educating women on the benefits of acupuncture. I wanted to see the effects of educational tools and compliance with providers for implementation long term. -Patient education is vital to compliance, and patient outcomes. -Organized, time- efficient educational tools can change the outcomes of patient satisfaction. 40 Author’s Last Name & Publication Year Title of Publication Type of Study Participants Major Strengths and Weaknesses of the Study Main Outcomes of Findings Relevance to Project 5. Chang, W. H., Chou, F. W., & Wang, P. H. (2024). Chronic pelvic pain and Chinese medicine body constitution deviation Systematic Review Women with CPP Strengths: -analyzing clinical data on CPP, which is already a weak area which indicated the need for the paper Weaknesses: -not giving any current clinical data Power of acupuncture in women suffering with CPP and evaluating current guidelines synthesizes evidence from multiple practice guidelines. -evaluates the quality of the guidelines 6. Cullen, L., Hanrahan, K., Edmonds, S. W., Reisinger, H. S., & Wagner, M. (2022). Iowa Implementation for Sustainability Framework Mixed-methods formative evaluation Mixed groups of people that use the Iowa Method of Implementation Strengths: -Excellent data showing the relevance of the Iowa Method, the diversity it can be implemented in, and how it brings forward organization through implementation Weaknesses: -Does not give examples of the changes it has brought forward into evidence-based practice Strengthen the education of clinician (s) and propose its usefulness in implementation research -This is the method used for implementation and data to prove its effectiveness is needed 7. Dydyk, A. M., & Gupta, N. (2023). Chronic Pelvic Pain Quantitative Women with chronic pelvic pain >3-6 months of pain Strengths: -Strong evidence- based data regarding the treatment of CPP -Advocating for a strong -Chronic pelvic pain is associated with IBS, depression, and pelvic 40edication40y disorder -CPP is seen in 4-16% of women - 50% of endometriosis Identification and underlying etiology of pelvic pain -Give examples of how to treat and evaluate chronic pelvic pain 41 Author’s Last Name & Publication Year Title of Publication Type of Study Participants Major Strengths and Weaknesses of the Study Main Outcomes of Findings Relevance to Project interprofessional team Weaknesses: -Not a clinical trial -Not a quality improvement study -No recent, new data being presented patients suffer with pelvic pain -Managing CPP can be a lifelong condition that requires a multidisciplinary approach -The team consists of physical therapy, cognitive behavioral therapist, gynecologic surgeon, and pain management specialist depending on disease process CPP is secondary to -Education for future providers on how to improve outcomes of chronic pelvic pain 8. Gallagher, J. S., Missmer, S. A., Hornstein, M. D., Laufer, M. R., Gordon, C. M., & DiVasta, A. D. (2018). Long-Term Effects of Gonadotropin- Releasing Hormone Agonists and Add- Back in Adolescent Endometriosis Longitudinal, observational follow-up study 51 subjects aged 15– 22 years enrolled in a 12-month longitudinal treatment trial of leuprolide depot. All subjects had surgically confirmed endometriosis treated with ablation Strengths: -Excellent data encompassing the negative side effects of medications -Multiple tables comparing Gonadotropin- Releasing Hormone Agonists and Gonadotropin- Releasing Hormone Agonists PLUS add back hormone treatment Weaknesses: -Ideally, I wanted all my research to stay within 5 years (2020- -All women reported side effects during treatment - 80% of women reported side effects lasting longer than 6 months after stopping treatment - Almost half (9 of 20) reported side effects they considered irreversible, including memory loss, insomnia, and hot flashes - Subjects believed that GnRHa used with add-back was effective and would recommend -I wanted to focus on a study that talks about the side-effects of some of the 41edication on the market for pelvic pain. This article speaks volumes in my opinion because even though most of the women said they had side-effects; women still were willing to put their bodies through it to have lasting relief from pelvic pain. -This article gives me ample opportunity to prove my point that there needs to be 42 Author’s Last Name & Publication Year Title of Publication Type of Study Participants Major Strengths and Weaknesses of the Study Main Outcomes of Findings Relevance to Project 2025) for the most accurate results it to others, despite significant side effects alternative treatment options for CPP 9. Kisling, L. A., & Stiegmann, R. A. (2024). Alternative Medicine Narrative review Educational resource that does not include participants Strengths: -Data has been curated within the last year -Strong data that shows the need for alternative medicine Weaknesses: -Not a clinical trial, or evidence that is showing us new data There is an increase in evidence around alternative medicine and more providers are willing to implement alternative medicine for their patients -The QI project needs data that pushes the need for alternative medicine in patients that have not been healed in Western medicine 10. Lamvu, G., Carrillo, J., Ouyang, C., & Rapkin, A. (2021) Chronic Pelvic Pain in Women: A Review Systemic Review Women with Chronic Pelvic Pain Strengths: -Quality information for patient education on CPP -Recent statistical analysis of current evidence regarding CPP -Financial data of the costs of surgery regarding CPP which is an important aspect regarding push for alternative therapies Weaknesses: -Exploring already known evidence versus finding new clinical data -Does not include any new research for a quality -CPP is mostly caused by endometriosis, cystitis, irritable bowel syndrome, and myalgia -There is a significant history of CPP with women who have experienced abuse, trauma, and mental health diseases - Psychosocial advocation and intervention is critical in CPP treatment -This is important to tie into my project because I want to address the mental health aspect in CPP -Mental health advocation is critical for the well-being of women, and overall quality of life -If women are feeling hopeless because of this condition, it therefore, creates more of a push for the integration of supplemental therapy to address this condition 43 Author’s Last Name & Publication Year Title of Publication Type of Study Participants Major Strengths and Weaknesses of the Study Main Outcomes of Findings Relevance to Project improvement intervention 11. Lin, K. Y., Chang, Y. C., Lu, W. C., Kotha, P., Chen, Y. H., & Tu, C. H. (2023). Analgesic Efficacy of Acupuncture on Chronic Pelvic Pain: A Systemic Review and Meta-Analysis Study Systemic Review and Meta-Analysis Study A total of 1455 CPP patients (867 females and 588 males) were included into this meta-analysis. Strengths: -Large group of patients to gather ample amount of evidence –Studied monotherapy versus adjunct therapy to diversify the results -Lists specific acupressure points to incorporate into the study Weaknesses: -Study also includes men which is not relevant to project proposal Acupuncture used in monotherapy or in adjunct to western medicine treatment have both been shown to treat CPP Acupuncture is practiced worldwide for a myriad of chronic pain issues and widely recognized as a modality for treatment -The treatment for CPP often doesn’t focus on the etiology but rather just treating the pain -CPP requires a multidisciplinary approach for proper treatment, and management Acupuncture even as monotherapy has beneficial, analgesia effects -Abdominal acupuncture, and ear acupuncture have a higher treatment efficacy than western medicine treatment -This trial is critical for my defense that there are other alternative treatments for pain -I want to make the argument that people are interested in other modalities than western medicine therapy 12. Mardon, A. K., Leake, H. B., Szeto, K., Astill, T., Hilton, S., Moseley, G. L., & Chalmers, K. J. (2022). Treatment recommendations for the management of persistent pelvic pain: a systematic review of international clinical practice guidelines Systemic Review Females with persistent pelvic pain and clinical practice guidelines regarding treatment Strengths: -The evidence reviews 270 clinical practice guidelines that evaluate the best practice for CPP -Captures subsequent high-quality guidelines Weaknesses: -Data suggests many of the recommendations for CPP are not evidence- based and purely expert opinion -Data suggested psychological support yet did not suggest what that looks like long term -This piece of evidence is fascinating for the quality improvement project because there is such limited data on guidelines for CPP. For example, we know the guidelines for HTN, diet, and lifestyle, and first-line pharmacology treatment. However, 44 Author’s Last Name & Publication Year Title of Publication Type of Study Participants Major Strengths and Weaknesses of the Study Main Outcomes of Findings Relevance to Project -Not all 270 reviews were broken down by condition meaning there was multiple etiologies for CPP -Two reviewers were used to evaluate data which leaves room for bias -35% of recommendations were supported only by expert opinion not evidence-grade data -None of the data was based on low-income countries and focused more on wealth- centered developed countries -There is much room for improvement in the guidelines for CPP so there can be a standard of care in patient treatment and outcomes there is no such guideline for treating CPP and each provider could be developing their own plan. It has been noted multiple times how difficult of a disease it is to treat. Thus, a guideline is essential. 13.Meisenheimer, E. S., & Carnevale, A. M. (2025). Chronic Pelvic Pain in Women: Evaluation and Treatment Qualitative Study Women suffering with CPP Strengths: -interviews women on their experience of CPP Weaknesses: -does not provide new clinical data like a RCT would provide -Main takeaway is that most women with CPP suffer psychosocial comorbidities -explores patient perspectives on managing CPP -analyzes data using interviews 14. Mirin A. A. (2021) Gender Disparity in the Funding of Diseases by the U.S. National Institutes of Health Retrospective cohort study with a longitudinal follow-up Analysis of funding by the U.S. National Institutes of Health (NIH) to identify possible gender disparity in funds regarding women’s health Strengths: -Ample amount of evidence regarding gender-based funding -Data collected was taken from >10 years of evidence-based medicine Weaknesses: -Some of the most underfunded diseases are female-dominant and some of the most overfunded are male- dominant - That is, 74% of the nongender-neutral diseases favor males, and 26% favor females. This pattern -For a long time, most women-based diseases were seen as women in hysteria, poor life decisions -This evidence shows the need for evidence- based research for CPP. Endometriosis is one of the lowest funded diseases that includes an 45 Author’s Last Name & Publication Year Title of Publication Type of Study Participants Major Strengths and Weaknesses of the Study Main Outcomes of Findings Relevance to Project -Large disparities upon funding for gender-based diseases -Data is mixed between men and women, versus just female was for all three budget years -Endometriosis is one of the most underfunded female- dominant diseases, was stereotyped as being brought on by women’s life choices etiology for CPP. Women need to be advocated for and the research for evidence- based practice 15. Mortada E. M. (2024) Evidence-Based Complementary and Alternative Medicine in Current Medical Practice Evidence- Based Review Complementary and Alternative medicine rates in the US increasing Strengths: -Systemic review searching the databases on people seeking alternative therapies -Data is all within five years Weaknesses: -Not a quality improvement study that is providing new data for the guideline of CPP -Does not consist of a trial showing which alternative therapies are the most helpful -Natural products or herbal drugs rank among the top 10 most popular remedies in IM that people in the US use most regularly, as many people believe that herbal therapies are natural, safer, and healthier than allopathic medications -Alternative therapies are not taught in medical schools and do not have backing from the FDA -With times changing, and suspicion surrounding the healthcare system more people are drawn to alternative therapy -In my clinical practice I see more people asking for alternative therapy, which is why we need to have alternative therapy options for chronic diseases (I want to present this narrative in my project) 16. Myovant Sciences, & Pfizer. (2022) Myovant Sciences and Pfizer Receive U.S. FDA Approval of MYFEMBREE®, a Once-Daily Treatment for the Management of Moderate to Severe Pfizer FDA approval notice Women diagnosed with Moderate to Severe Endometriosis Strengths: -Actual announcement from the pharmaceutical company and their disclosures of the medication Weaknesses: Myfembree is currently one of a few medications approved by the FDA for the treatment of Endometriosis. We know endometriosis is an estrogen sensitive -Evidence showing from the pharmaceutical that manufactures the drug shows significant side effects and can only be taken for two years maximum 46 Author’s Last Name & Publication Year Title of Publication Type of Study Participants Major Strengths and Weaknesses of the Study Main Outcomes of Findings Relevance to Project Pain Associated With Endometriosis -Not an evidence- based article. Just used for supporting evidence disease that pain analgesia can be managed by hormonal suppression 17. Tangkiatkumjai, M., Boardman, H., & Walker, D. M. (2020) Potential factors that influence usage of complementary and alternative medicine worldwide: A systematic review Systemic Review / Thematic Analysis Literature (231 publications) on the reasons for using or not using complementary and alternative medicine (CAM) Strengths: -231 pieces of evidence were analyzed -Countries outside of the US were also analyzed and showed the demand for alternative therapy steadily increasing Weaknesses: -This current review began in 2019 and has reviewed relevant sources published over a 15- year period from 2003 to 2018 (this is not as updated as I would like) -Alternative medicine is used because: expectation of benefits (84% of publications), (2) dissatisfaction with conventional medicine (37%) and (3) the perceived safety of it -Push for alternative medicine because of the lack of outcome of western medicine -This is another article that proves my quality improvement project purpose that the public is more interested in alternative therapies and perceives it is safe and works well -The availability of alternative therapies is more readily available than western medicine especially with technology in current times 18. Van Hal, M., Dydyk, A. M., & Green, M. S. (2023) Acupuncture Systemic/ Educational Overview Acupuncture Strengths: -Giving informational facts about acupuncture and the history behind how it works -Discusses the potential side effects of acupuncture which is important for patient education -However, despite numerous studies, the mechanism for how acupuncture might be functional physiologically is not yet known -Functional MRI has shown physiologic changes in the central nervous system while -Most amazing studies explaining the HOW of acupuncture are in Chinese and Oriental / Traditional Chinese medicine is a separate entity from western medicine that is difficult to compare when speaking about the disease process. This is 47 Author’s Last Name & Publication Year Title of Publication Type of Study Participants Major Strengths and Weaknesses of the Study Main Outcomes of Findings Relevance to Project Weaknesses: -Purely information providing no new evidence -Does not include guidelines or current practice guidelines -Finding studies that are in English regarding the pathophysiology of acupuncture is difficult to find undergoing acupuncture an important aspect to discuss in the project because they view systemic issues as a total body issue rather than a localized issue. 48 Appendix C: Consent Document (Disclosure Letter) 49 Consent Document (Disclosure Letter) Hello, my name is Montana Augustine, a DNP Student at the University of Arizona. I am leading a quality improvement project here at Advanced Women’s Care. I, the Project Lead, am seeking if patients have an interest in acupuncture as an option for managing chronic pelvic pain. Your participation is completely voluntary. If you choose to participate, I will ask you a few brief questions before and after you review an educational pamphlet about acupuncture. The goal is to see whether the information changes how you feel about acupuncture as part of your treatment. Here’s what participation involves: • You will answer a few questions before reading the pamphlet (pre-survey). • You will then read the educational pamphlet about acupuncture for pelvic pain. • Afterward, I will ask a couple more questions to gather my information (post-survey). • I will record your answers of the surveys on a password-protected computer only the I, the Project Lead have access to. • No personal or identifying information will be collected but generalities of ethnicity and age will be recorded. Important Information: • Participation is voluntary, and you may stop at any time. • Your decision will not affect the care you receive. • This project is a quality improvement initiative—not a research study—and is designed to enhance patient education and care. • All information gathered is collected on a password-protected computer only the Project Lead has access to. Thank you for your time and consideration. If you have any questions, please contact me any time. Montana Augustine, RN, BSN, DNP-FNP Student [email protected] 602-301-2145 50 Appendix D: Recruitment Materials 51 Recruitment Materials Eligibility Criteria: • Biologically female woman presenting with a chief complaint or clinical history of CPP. • Able to read and understand English. • Willing to participate in a brief pre- and post-survey related to acupuncture education. Recruitment Process: 1. Clinic Schedule Review: The Project Lead and attending physician collaboratively reviewed the weekly clinic schedule to identify patients likely to present with CPP. Three clinic days with a higher anticipated volume of CPP-related visits were selected for project implementation. 2. Verbal Consent and Enrollment: The Medical Assistant asks permission for a student to be present during examination during intake. If the patient agrees to having a student, the Project Lead enters the room with the physician for the clinical consultation and observes the appointment until completion. Upon conclusion of the appointment the Project Lead will explain the project’s purpose and obtain consent using a standardized script (see Appendix [C]). Patients who agree to participate will be enrolled in the project. 3. Initial Approach by the Student Lead: After conclusion of the appointment with the physician, the Project Lead briefly introduces the QI project and askes whether the patient would be open to learning about acupuncture as a potential option for managing chronic pelvic pain. If the patient expresses interest, the pre-post survey is conducted. 4. Survey Administration: Participants completes a brief pre-survey assessing their perceptions of acupuncture before being given an educational pamphlet to review. Following pamphlet review, a post-survey with additional questions will be administered by the Project Lead. Responses will be recorded in the password-protected computer only the Project Lead has access too. Voluntary Participation: Participation is entirely voluntary. Patients could decline or withdraw at any point without affecting the care they receive at the clinic. No incentives will be provided, and no identifiable data will be collected. 52 Appendix E: Evaluation Instruments 53 Pre-Survey Questions • What is your ethnicity? o Hispanic or Latino o Non-Hispanic White o Black or African American o Asian o Native American or Alaska Native o Native Hawaiian or Other Pacific Islander o Other (please specify): _________ • What is your age range? o 18-25 o 26-49 o 50-65 o >65 • How long have you been experiencing Chronic Pelvic Pain? o 0-5 years o 6-10 years o 11-19 years o 20+ years • Has alternative medicine ever been presented to you as an option for Chronic Pelvic Pain? o Yes / No / Unsure • Have you ever heard of acupuncture as a treatment for Chronic Pelvic Pain? o Yes / No • How familiar are you with acupuncture? o Not at all familiar / Slightly familiar / Moderately familiar / Very familiar • How open are you to trying acupuncture as a treatment option for your pelvic pain? o Not open / Slightly open / Somewhat open / Very open Post-Survey Questions Perceptions and Openness Toward Acupuncture for Chronic Pelvic Pain Statement Strongly Disagree Disagree Neutral Agree Strongly Agree I believe acupuncture is a valid treatment for chronic pelvic pain. 1 2 3 4 5 I feel well-informed about how acupuncture works. 1 2 3 4 5 I am open to trying acupuncture to help with my pelvic pain. 1 2 3 4 5 I trust acupuncture practitioners to provide safe treatment. 1 2 3 4 5 54 Statement Strongly Disagree Disagree Neutral Agree Strongly Agree Acupuncture should be more widely offered as a treatment option for pelvic pain patients. 1 2 3 4 5 My healthcare providers have encouraged or supported alternative treatments like acupuncture. 1 2 3 4 5 I would recommend acupuncture to others experiencing chronic pelvic pain. 1 2 3 4 5 55 Appendix F: Participant Materials (Acupuncture Media Works Pamphlet) 56 57 58 Appendix G: IRB Approval 59 List of Appendices (required and optional) (Use APA 7th ed. appendix format; decide on your appendices [required listed below] in the order in which you mention the materials in your paper. . . .) Site Authorization Approval Letter (Required) Consent Document (Required) Recruitment Materials (Required) Evaluation Instruments (Required) Participant Materials (Required?) Chart Audit Forms (Optional?) Project Timeline (Optional? This seems more like something for them to create in 922-201 but not necessarily include in final paper.) Evidence Table (Required—was “Literature Review Grid”) Other Documents/Materials as Applicable, such as Budget (Optional) 60 61

Alvis, M. L., Morris, C. E., Garrard, T. L., Hughes, A. G., Hunt, L., Koester, M. M., Yocum, I. C., & Tinius, R. A. (2019). Educational brochures influence beliefs and knowledge regarding exercise during pregnancy: A pilot study. International Journal of Exercise Science, 12(3), 581–589. https://doi.org/10.70252/NGXF7418 American Association of Colleges of Nursing. (2006). The Essentials of Doctoral Education for Advanced Nursing Practice. https://www.aacnnursing.org/Portals/42/Publications/DNPEssentials.pdf American College of Obstetricians and Gynecologists. (2025). Chronic pelvic pain. https://www.acog.org/womens-health/faqs/chronic-pelvic-pain Bhattad, P. B., & Pacifico, L. (2022). Empowering patients: Promoting patient education and health literacy. Cureus, 14(7), e27336. https://doi.org/10.7759/cureus.27336 Chang, W. H., Chou, F. W., & Wang, P. H. (2024). Chronic pelvic pain and Chinese medicine body constitution deviation. Taiwanese Journal of Obstetrics & Gynecology, 63(1), 4–5. https://doi.org/10.1016/j.tjog.2023.11.002 Cullen, L., Hanrahan, K., Edmonds, S. W., Reisinger, H. S., & Wagner, M. (2022). Iowa implementation for sustainability framework. Implementation science: IS, 17(1), 1. https://doi.org/10.1186/s13012-021-01157-5 Dydyk, A. M., & Gupta, N. (2023). Chronic pelvic pain. In StatPearls [Internet]. StatPearls Publishing. Available from https://www.ncbi.nlm.nih.gov/books/NBK554585/ Gallagher, J. S., Missmer, S. A., Hornstein, M. D., Laufer, M. R., Gordon, C. M., & DiVasta, A. D. (2018). Long-term effects of gonadotropin-releasing hormone agonists and add-back in adolescent endometriosis. Journal of Pediatric and Adolescent Gynecology, 31(4), 376–381. https://doi.org/10.1016/j.jpag.2018.03.004 Kisling, L. A., & Stiegmann, R. A. (2024). Alternative medicine. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK538520/ Lamvu, G., Carrillo, J., Ouyang, C., & Rapkin, A. (2021). Chronic pelvic pain in women: A review. JAMA, 325(23), 2381–2391. https://doi.org/10.1001/jama.2021.2631 Lin, K. Y., Chang, Y. C., Lu, W. C., Kotha, P., Chen, Y. H., & Tu, C. H. (2023). Analgesic efficacy of acupuncture on chronic pelvic pain: A systematic review and meta-analysis. Healthcare (Basel, Switzerland), 11(6), 830. https://doi.org/10.3390/healthcare11060830 62 Mardon, A. K., Leake, H. B., Szeto, K., Astill, T., Hilton, S., Moseley, G. L., & Chalmers, K. J. (2022). Treatment recommendations for the management of persistent pelvic pain: A systematic review of international clinical practice guidelines. BJOG: An International Journal of Obstetrics and Gynaecology, 129(8), 1248–1260. https://doi.org/10.1111/1471-0528.17064 Meisenheimer, E. S., & Carnevale, A. M. (2025). Chronic pelvic pain in women: Evaluation and treatment. American Family Physician, 111(3), 218–229. https://pubmed.ncbi.nlm.nih.gov/40106288/ Mirin, A. A. (2021). Gender disparity in the funding of diseases by the U.S. National Institutes of Health. Journal of Women’s Health, 30(7), 956–963. https://doi.org/10.1089/jwh.2020.8682 Mortada, E. M. (2024). Evidence-based complementary and alternative medicine in current medical practice. Cureus, 16(1), e52041. https://doi.org/10.7759/cureus.52041 Myovant Sciences, & Pfizer. (2022). Myovant Sciences and Pfizer receive U.S. FDA approval of MYFEMBREE®, a once-daily treatment for the management of moderate to severe pain associated with endometriosis. Sumitomo Pharma America, Inc. https://www.us.sumitomo-pharma.com/newsroom/press-releases/myovant-sciences-and- pfizer-receive-us-fda-approval-myfembree/ Tangkiatkumjai, M., Boardman, H., & Walker, D. M. (2020). Potential factors that influence usage of complementary and alternative medicine worldwide: A systematic review. BMC Complementary Medicine and Therapies, 20(1), 363. https://doi.org/10.1186/s12906- 020-03157-2 Van Hal, M., Dydyk, A. M., & Green, M. S. (2023). Acupuncture. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532287/