- Email: [email protected]
Using Implementation Science as the Core of the Doctor of Nursing Practice Inquiry Project
USING IMPLEMENTATION SCIENCE AS THE CORE OF THE DOCTOR OF NURSING PRACTICE INQUIRY PROJECT MARY E. RINER, PHD, RN, FAAN New knowledge in health care needs to be implemented for continuous practice improvement. Doctor of nursing practice (DNP) programs are designed to increase clinical practice knowledge and leadership skills of graduates. This article describes an implementation science course developed in a DNP program focused on advancing graduates' capacity for health systems leadership. Curriculum and course development are presented, and the course is mapped to depict how the course objectives and assignments were aligned with DNP Essentials. Course modules with rational are described, and examples of how students implemented assignments are provided. The challenges of integrating this course into the life of the school are discussed as well as steps taken to develop faculty for this capstone learning experience. This article describes a model of using implementation science to provide DNP students an experience in designing and managing an evidence-based practice change project. (Index words: Implementation science; DNP) J Prof Nurs 31:200–207, 2015. © 2015 Elsevier Inc. All rights reserved.
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VIDENCE-BASED PRACTICES (EBPs) that improve patient outcomes are available but are underused (Newhouse, Bobay, Dykes, Stevens, & Titler;, 2013), which adds to the proliferation of substantial unjustified variations in practices (Institute of Medicine, 2001; McGlynn, Asch, Adams, et al., 2003; Ward, Evans, Spies, et al., 2006). Preparing practice leaders for integrating EBPs into standard practice is an important challenge that doctor of nursing practice (DNP) programs are in the position to address. Health care agencies and the people they serve stand to benefit when DNP programs provide opportunities for students to find and apply current science through conducting practice improvement studies. A wide range of scholarly projects are completed by DNP students in meeting the eight Essentials established by the American Association of Colleges of Nursing. A Web search of DNP programs found, for example, that projects have included developing a portfolio based on course and practicum experiences, conducting project development work such as a business plan for a home Advanced Practice Associate Professor of Community and Health Systems, Associate Dean for Global Affairs, Indiana University Purdue University Indianapolis (IUPUI), Indianapolis, IN. Address correspondence to Dr. Riner: Associate Professor of Community and Health Systems, Associate Dean for Global Affairs, Indiana University School of Nursing (IUSON), 1111 Middle Drive, Indianapolis, IN 46202. E-mail: [email protected] 8755-7223
http://dx.doi.org/10.1016/j.profnurs.2014.11.002
Register Nurse business (Brown & Crabtree, 2013), and dissertation-type studies. DNP scholarly projects are increasingly being published in the professional literature. In a recent review of this literature, the manuscript categories included the following: designing informatics solutions in primary care and acute care settings, using evidence-based education solutions for academic and clinical learning, studies on how evidence-based research was implemented to address a specific concern, and conducting traditional research studies designed to generate clinical knowledge (Broome, Riner, & Allam, 2013). This wide range of DNP projects occurring in programs across the country suggests that further dialogue would be beneficial to identify best educational practices for practice doctorate scholarship. When developing our DNP Program in 2008-2009, there was little published information by or about DNP graduates or programs. As program faculty, we wanted to stay close to our clinical agency partners' needs for clinical practice improvement. The question that challenged our faculty as we developed the curriculum and inquiry project was, “What knowledge and skills do the clinical agencies need from nurses with a practice doctorate to address the complex clinical and regulatory environments they are facing?” Chief nursing officers and primary care nurse administrators stated that they needed nurses with practice doctorates to develop and manage solutions to patient population problems, department-level problems such as purchasing decisions, and reimbursement issues such as
Journal of Professional Nursing, Vol 31, No. 3 (May/June), 2015: pp 200–207 © 2015 Elsevier Inc. All rights reserved.
IMPLEMENTATION SCIENCE AS CORE OF DNP INQUIRY PROJECT
those related to 30-day readmission rates. To address these identified needs, we determined that the graduate would need experience in the following: advanced literature searching and synthesizing to identify the evidence for an intervention; developing a plan to implement the solution; and carrying it out, evaluating it, and disseminating the findings. The faculty believed it was important for graduates to demonstrate leadership and accountability for the full practice improvement process. We selected implementation science as the framework for structuring the experience.
Implementation Science as a Branch of Translational Science Translational science is a widely used term referring to moving knowledge discovery along the continuum from “bench to bedside to curbside.” According to the National Center for Advancing Translational Science, it “comprises the process of turning observations in the laboratory and clinic into effective interventions that improve the health of individuals and the public—from diagnostics and therapeutics to medical procedures and behavioral changes.” Translational science involves a wide range of experimental and quasi-experimental studies along the research continuum from bench science to wide-scale dissemination and adoption. A number of terms are associated with translational science, including knowledge translation, adoption of innovation, quality improvement, improvement science, implementation science, and dissemination (Newhouse et al., 2013). Implementing new knowledge, at each stage of the discovery process, requires investigations conducted under controlled conditions. Once this efficacy is established, the intervention is ready to be tested in less controlled environments and requires a process of tailoring the intervention to the local context. Implementation science is a form of applied research that has been linked to practice-based quality and safety improvement studies (May, 2013). Applied research is often thought of as a systematic inquiry into solving practical problems. For DNP education, this emerging field provides the conceptual link between scientific knowledge and implementing this knowledge in practice. Implementation science provides a structure and tools for increasing the rigor of studies on how evidence can be adopted into new practice settings. Implementation science can assist in identifying, describing, and explaining elements of implementation processes and their outcomes (May, 2013). Another way to think about implementation science is that it is the study of the processes used to make a practice change. Consensus is growing around a workable definition of implementation science as “the study of methods, interventions, and variables that promote the uptake and use of research findings and other EBPs by individuals and organizations to improve clinical and operational decision-making in health care with the goal of improving health care quality” (Newhouse et al., 2013, p. S32). This emerging field of science provided the basis for developing the “Inquiry Project” in our DNP program focused on health systems leadership.
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Curriculum Development and Course Mapping Our school of nursing is located on an urban, researchintensive academic health campus in the Midwest. The program has a health systems leadership focus, is 37 credits, and is open to students with a nursing master's degree, including nurse practitioners, clinical nurse specialists, nurse administrators, and nursing educators. Students work in both primary and acute care roles in a wide range of facilities. The curriculum includes nine courses: Relationship-Centered Leadership in Complex Systems, Knowledge Complexity, Influencing Public Health Policy, Introduction to Nursing Informatics, Health Care Outcomes and Decision-Making, Clinical Epidemiology/Statistics in Nursing, Strategic Resource Management in Nursing and Health Systems, Inquiry I: Evidence-Based Research and Translation Science, and Inquiry II: Evidence-Based Research and Translational Science; an elective; and seven practicum credits. During the Inquiry courses, a detailed plan for an intervention targeting a problem in the students' own organization is developed, with the plan being implemented during the practicum experiences. The Inquiry Project core was developed using strengths of our academic health science campus and faculty. It involves three components: two didactic courses and seven practicum credits. In the Inquiry I: Evidence-Based Research and Translational Science course, students do a comprehensive literature searching and synthesis assignment. They identify an important problem from their own clinical agency, conduct a literature review using the Joanna Briggs Institute resources for evaluating and synthesizing the evidence, and develop a recommended course of action to address the clinical problem. This is followed by the Inquiry II: Evidence-Based Research and Translational Science course, which is discussed in detail in this paper. Here, students progressively develop a plan to implement the best practice he or she identified in the Inquiry I course. Specific coursework that prepares students for their practice improvement project includes a combined epidemiology and statistics course, a graduate-level statistics course (a pre-requisite for program admission), and a course focusing on data for decision making in which students use data, conduct analyses, and make decisions for clinical care. In the Inquiry I course, students critique a large number of studies related to their issue and identify a design that fits their project. In addition to the course faculty, students are each assigned a faculty mentor and a clinical agency mentor to support them in developing their proposal and in collecting, analyzing, and interpreting the data. The seven practicum credits provide the framework for the Inquiry Project and are taken progressively throughout the program under the supervision of a faculty advisor and agency mentor. The faculty advisor has major responsibility for supporting the student in developing, implementing, and evaluating the project and in writing the final paper. In addition, the faculty advisor works with the
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student in completing the institutional review board (IRB) process. Most projects are approved by IRB staff as quality improvement studies, but for projects with a more complex design, the faculty member works with the student to receive IRB approval. The student works with an agency mentor who serves as a “champion” and provides on-site support, helps solve problems, and participates in evaluating the final product. A second faculty member joins the committee when the student is ready to develop his or her proposal. As we planned the courses, we focused on identifying the most valuable and needed aspects of implementing evidence into practice. On the basis of our reflections, the two co-faculty course developers identified learning assignments we believed were essential for students to demonstrate competence in when planning, implementing, and evaluating their Inquiry Project. Although it may seem like a high bar, if the student pursuing a practice doctorate does not implement and evaluate an EBP during the education program, where will she or he get supervised experience to develop such knowledge and skills? The faculty conceptualized the Inquiry Project as a practice improvement project for the student within his or her work setting. This served to frame the Inquiry Project as a quality or safety project. For this reason, we decided to use the Standards for Quality Improvement Reporting Excellence (The SQUIRE Group, 2008) as the standard for writing the final paper. These guidelines were developed by an international group of journal editors to guide manuscript development of quality improvement studies. They are used in multiple ways within the Inquiry Project core as well as in other courses to guide learning experiences. Recent literature shows that the SQUIRE guidelines are becoming accepted practice within DNP programs and quality improvement studies (Riesenberg, Leitzsch, & Little, 2009; Stein, 2010).
Inquiry II: Evidence-Based Research and Translational Science Course We designed Inquiry II so student assignments would result in a completed proposal for their implementation intervention that included a data management and analysis component. A course map (Table 1) links assignments with course objectives, program outcomes, and DNP Essentials. Following is a description of the modules and assignments students complete that lead to development of their study proposal.
Module 1: Identifying an Implementation Science Framework Here, students are exposed to a variety of translational science models, primarily those focused on the elements and processes of translating evidence into practice. These include the Practical, Robust Implementation and Sustainability Model (PRISM; Fieldstein & Glasgow, 2008), the Promoting Action on Research Implementation in Health Services framework (Kitson et al., 2008),
the VA Quality Enhancement Research Initiative (Stetler, Mittman, & Francis, 2008), the Consolidated Framework For Implementation Research (Damschroder et al., 2009), and the Cycle of Change model (Carey, Buchan, & Sanson-Fisher, 2009). Early models tended to be conceptual, with minimal specificity relative to implementation strategies and measures for use. Recently, other models and beginning theories that are more detailed have emerged and been added to the readings list. In particular, May (2013) has made a significant contribution to this field with his general theory of implementation. An initial assignment requires the student to critique multiple implementation models and discuss them with peers in the discussion forum. The student does an in-depth critique of the model he or she selects to guide his or her Inquiry Project as a key learning assignment. In a second component of the module, the student critiques an article relevant to his or her Inquiry Project focus area using the SQUIRE Guidelines. This activity familiarizes the student with the standards faculty will use in judging the capstone paper. Example. One student used an experimental design to identify whether time to appointment for patients with dysuria could be reduced and patient satisfaction with care improved through use of an evidence-based protocol, as compared with a traditional appointment, at a Federally Qualifying Health Center. This student applied the PRISM model to plan for how the intervention would need to consider external factors, the implementation process, the sustainability of the infrastructure, and how particular characteristics of patients would likely influence program adoption, implementation, and maintenance.
Module 2: Developing a Logic Model The intent of this module is to facilitate students' critical thinking about how they will implement their practice improvement project. The ability to visualize and articulate the rationale and logic underlying the intervention and the strategies selected for implementing it are essential in designing a tight study that links resources, actions, and outcomes in a linear fashion through the entire cycle-of-change process. Through a variety of logic model readings including Kellogg (2000), forum discussions, and assignments, the student develops a visual program logic model that shows the linkages among the situation, assumptions, activities, outcomes, and intended impact of the intervention and implementation strategies. This is accompanied by a narrative, integrative review of the literature that supports the visual model. Example. Nurse-sensitive indicators (NSIs) are extremely important in today's hospital environment. Decreasing nurse turnover is important to hospitals because such turnover affects the quality of nursing care provided and, in turn, patient outcomes such as complications. Financially, there is a significant cost associated with nursing turnover, and hospitals are financially penalized for the hospital-acquired conditions related to many of these NSI
Topic Implementation Science Theory
Artifact • Critique implementation science articles
Program logic model
• Critique an article using SQUIRE Guidelines Develop a visual program logic model and write an integrated review of the literature that addresses key components of the i ntervention and implementation.
Intervention Plan with Measurement and Evaluation Component
Describe your intervention including a measurement and evaluation component with timeline. See SQUIRE Guidelines (Steps 11 and 12)
Implementation Plan with Measurement and Evaluation Component
Describe how you will implement the intervention including a measurement and evaluation component with timeline.
Reflection on practice
Reflective journals 1,2,3,4 for D737 and D749.
IRB
Develops IRB proposal with Program Committee.
• CC 1. Students critique and apply theoretical, conceptual, and operational perspectives relative to implementation science as a basis for developing a project proposal. • PO 5. Translate knowledge for application to the delivery of advanced nursing practice. • E2. Organizational and systems leadership for quality improvement and systems thinking (#1 Develop and evaluate care delivery approaches…). • CC2. Write an integrated review of the literature that addresses key components of the project proposal. • PO3. Integrate the needs of diverse societies in the design, delivery, and evaluation of health services in complex systems. • E1. Scientific underpinnings for practice (#2 Use science… to describe the actions and advanced strategies to enhance, alleviate, and ameliorate health and health care delivery phenomena…). • CC4. Project how the evaluation results will be utilized and disseminated. • PO #7 Evaluate the impact of change on complex health systems including individuals and populations. • Essential 7: Clinical prevention and population health for improving the nation’s health (#1 analyze…scientific data…). • E 3: Clinical scholarship and analytical methods for EBP (#3 Design, direct, and evaluate quality improvement methodologies to promote safe, timely, effective, efficient, equitable, and patient-centered care). • CC3 Write an integrated review of the literature that addresses key components of the project proposal. • PO #6 Implement changes based on evaluation of health systems, health policy, and nursing science in response to social, political, economic, and ethical issues. • Essential 7: Clinical prevention and population health for improving the nation’s health (#2 synthesize concepts…to, improve health status/access patterns, and/or address gaps in care…). Essential 3: Clinical scholarship and analytical methods for EBP (#2 Design and implement processes to evaluate outcomes of practice, practice patterns, and systems of care…) AND (#5 Use information technology and research methods appropriately to design evidence-based interventions). • CC5. Utilize reflective practice concepts in understanding and implementing the role of change agent. • PO4. Transform clinical practice through reflection, action, inquiry, strategic resource management, information technology, and/or knowledge-based resources. • Essential VI: Interprofessional Collaboration for Improving Patient and Population Health Outcomes (#3 employ consultative and leadership skills with intraprofessional and interprofessional teams to create change in health care and complex health care delivery systems). • CC6. Project IRB application submitted to IUPUI IRB. • PO7. Evaluate the impact of change on complex health systems including individuals and populations. • E3. Clinical scholarship and analytical methods for EBP.
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Notes. PO = program outcome, CC = course competency, E = DNP Essential. Riner, M.E. Developed by.
Course competencies/PO/essential
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Table 1. Course Map
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Figure 1. Logic problem tracing (M. Lowder, 2013).
phenomena. Using Renger and Titcomb’s (2002) method of peeling back to the root of a problem, one of our DNP students analyzed this situation as follows (see Figure 1). She determined that the first “why” associated with the poor NSIs was the lack of autonomy, control, and accountability possessed by direct nursing caregivers. The second “why” was a bureaucratic, linear decision making model within the hospital. In addition, the underlying root cause of the problem, the third “why,” was the lack of a shared leadership structure and model in the organization. The student developed a plan for a shared governance intervention to address this underlying “why,” which in turn would be expected to alleviate the other two more proximal causes.
Module 3: Describing the Intervention Plan In this module, students describe their evidence-based intervention and develop a clinical data management and evaluation plan for the study. In the first assignment, students succinctly describe their findings from the synthesis work they did in the Inquiry I course in which they identified a best practice for their care environment. In the second assignment, students use methods and statistical knowledge gained in previous courses to plan the study design. They determine the study aim and primary research question(s). For each question, they specify instruments to be used; what, when, and how data will be collected; sample size; and the analysis strategy that will be used. A timeline is developed that includes the expected period for obtaining the sample, collecting data, inputting the data into the statistical program, conducting the tests/ analyses, analyzing the results, and writing up the results of the analyses. Example. One student planned and conducted a study to evaluate the implementation and effectiveness of a customized clinical decision support system (CDSS) to identify improvements in clinician compliance with hepatitis C virus (HCV) quality indicators. A comprehensive CDSS that aligned with HCV quality indicators
was developed to successfully integrate the CDSS into the clinic workflow. Using a pre/posttest comparative design, the documentation of quality indicators was measured in the pre-CDSS group and compared with the post-CDSS group. The data were entered into Excel and exported into SPSS 19.0 software for analysis. Fisher's exact test was used to determine the difference between groups.
Module 4: Plans for Implementing the Intervention Each student develops a practical framework of how his or her intervention is expected to work, that is, what has been referred to as the theory of implementation (Grembrowski, 2001; Lipsey, 1993). Students describe their assumptions about the components needed to support success of the intervention. This is a series of if–then statements that are represented visually as well as by narrative. The student also develops a plan to evaluate the implementation process. This involves identifying factors and measures that will be used to evaluate outcomes and processes of implementing the intervention or program. The student writes a five- to six-page narrative describing why his or her implementation plan can be expected to support critical aspects of the intervention. In this assignment, students (a) state aims and research questions about the implementation process based on the implementation science model selected; (b) specify elements of their local care environment considered likely to influence change/improvement; (c) describe how they will implement the intervention in sufficient detail so that others could reproduce it; (d) describe mechanisms by which intervention components are expected to cause changes, as well as plans for testing effectiveness; and (e) describe plans for assessing how well the intervention is implemented (what data will be collected, when, by whom, and how), all allowing later reporting of how the process impacted the delivery of the intervention components and context factors; (f) identify methods that will be used to ensure data quality and adequacy (efforts to validate and test reliability of assessment instruments); and (g) describe
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analytic methods that will be used to demonstrate effects of the implementation process.
With the first cohort we found the additional semester was not as beneficial as anticipated. Students needed a more concentrated learning experience earlier in the program to allow more time for data collection. After the first cohort, we scheduled Inquiry I for the fall and Inquiry II for the spring semester. The first cohort of students included nurse practitioners and clinical specialists. This meant there was significant homogeneity in perspectives and types of projects undertaken. With subsequent and more diverse cohorts, we found that a diversity of student backgrounds brought diversity of perspectives. Initially, Inquiry Projects focused on primary care. As the mix of student backgrounds began to include administrators and educators, the focus of projects included implementing system-wide change and nursing education practice improvement projects. Because in all roles nurses rely on available evidence for improving their work, the use of an implementation model was applicable. By the end of the third iteration of Inquiry II, we decided to make a more defined separation between student assignments for the course and the work students were doing for their Inquiry Project under the supervision of their faculty advisor. We decided to take a more methods-based approach and put the focus on critiquing implementation science models and on how studies using this method are conducted. This allowed students to develop deeper knowledge about the design and analysis strategies frequently used in implementation science.
Example. Another student used the Cycle of Change model to design a study on use of an evidence-based decision support algorithm for seizure management in the intellectual and developmental disability (IDD) population living in community settings. The goal was to increase the confidence of IDD nurses when guiding care during telephone triage. The Cycle of Change includes a threephased cyclical process that helps to describe a systematic approach to improvement of health outcomes through acceptance of evidence-based guidelines and recommendations into actual clinical practice. The evaluation plan developed by the student incorporated short-, medium-, and long-term impact outcomes as part of the evaluation process. See Figure 2 for part of the plan.
Discussion Over the initial 3 years of teaching these courses and working with faculty to facilitate the uptake of students' Inquiry Projects, we gained valuable insights resulting in design and delivery refinements. We initially taught both the Inquiry I and II courses across two semesters. The intent was to allow students time to apply their new knowledge to developing their Inquiry Project proposal. This design was particularly challenging when Inquiry II was scheduled for a 12-week summer session rather than the longer 15-week fall and spring semesters.
Need: Short-and Medium-Term Impact
a. Participating IDD Nurses within the Indiana Developmental and Disability Nurses Association (INDDNA) use the evidence-based seizure algorithm to guide seizure care during telephone triage for three months as evidenced by participation verification in the study. Evaluation method: IDD Nurses will provide the number of times via email that they implemented the seizure algorithm during the three-month study
b. Was the confidence of participating nurses in the INDDNA increased? Evaluation method: Likert Scale Surrogate Decision-Making Self Efficacy Scale Pre/Post Testing results
c. Was the nursing practice behavior of participating nurses in INDDNA changed? Evaluation method: Post-study survey of INDDNA Nurses via email two months following the end of the study. Figure 2. Example of plan for implementing the intervention.
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It became clear that the students would benefit from a structured project management component within the practicum credits to progressively build the Inquiry Project. We responded to this need by developing modules and conducting monthly “Cohort Cafés,” which involved monthly teleconference calls with a faculty member, a senior student leader, and small groups of students. The modules included readings from two books respectively written for scholarly projects (Maron, Burson, & Conrad, 2014) and project management (Harris, Roussel, Walters, & Dearman, 2011). After the first year of implementing the Cohort Cafés, feedback from new students indicated they had a clear idea of the focus of their project, were able to articulate a problem statement, and had met with their faculty and clinical agency mentors several times. It was clear to the faculty and student leader conducting the calls that students benefitted greatly in terms of defining “doable” projects early in their programs. As would be expected of any new academic program, there was a faculty development component to address. We developed a structure that included a DNP Advisory Committee. The Inquiry Project was refined and faculty consensus reached about types of projects and scope during these committee meetings. During the first year, we had guest speakers and read about implementation science, discussed student projects, shared experiences, and developed common agreement on issues and standards of expectations. In the second year, we organized a consultation from a program director with a similar Inquiry Project to assist in further tailoring the course and Inquiry Project. With the increasing diversity of students, we faced the need to explore additional ways of handling their specific interests. Furthermore, faculty supervision was becoming a workload management issue, and we developed agreements on what was expected of the faculty advisors and of students. This resulted in developing a document on best practices for facultystudent advising relationships. In addition to locally based Inquiry Projects, students have become involved in global projects. This has required gaining university permission for travel, working within ethical research practices for research abroad, and partnering with existing organizations the school is currently involved with on needed clinical practice improvement. The recent work by the World Health Organization (2014) on implementation research will be used as the framework. It fits our model extremely well and will allow us to use a global standard for these student projects. From the first cohort, three students have published five papers from their projects. One student was selected by the school for a poster presentation at the Midwest Nursing Research Society, and at least two others have given peer-reviewed national presentations. Another source of program evaluation is the alumni survey conducted annually with each new cohort. The results so far indicate that alumni believe they developed valuable nursing science knowledge in the DNP program and advanced as clinical practice leaders.
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Conclusion It is important that DNP graduates are prepared to lead practice improvement initiatives that contribute to improved organizational effectiveness and high-quality patient outcomes. DNP programs providing these types of learning opportunities are preparing leaders who are experienced in applying the range of knowledge and skills required in implementing and evaluating projects. The program components described here provide a model that represents an appropriate standard for implementing science into practice, within the U.S. health care system and globally. The call to implement EBP in health care agencies is clear. It is up to educators to provide the knowledge and skills necessary to make it happen.
Acknowledgments The author would like to posthumously acknowledge Dr. Joe Burrage, PhD, RN, FAAN, as co-developer of the course. In addition, she acknowledges the scholarly work of program students and alumni Anne Connor, Laura Fauthauer, and Melissa Lowery. The development of the course presented in this paper was supported by funding from the Health and Human Resources Administration.
References Broome, M. E., Riner, M. E. & Allam, E. (2013). Scholarly Publication Practices of Doctor of Nursing Practice-Prepared Nurses. Journal of Nursing Education, 52, (8), 429–434. Brown, M. A. & Crabtree, K. (2013). The Development of Practice Scholarship in DNP Programs: A Paradigm Shift. Journal of Professional Nursing, 29, (6), 330–337. Carey, M., Buchan, H. & Sanson-Fisher, R. (2009). The cycle of change: Implementing best-evidence clinical practice. International Journal for Quality in Health Care, 21, 37–43. Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A. & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4, http://dx.doi.org/10.1186/1748-59084-50. Fieldstein, A. C. & Glasgow, R. E. (2008). A Practical, Robust Implementation and Sustainability Model (PRISM) for integrating research findings into practice. The Joint Commission Journal of Quality and Patient Safety, 34, 228–243. Grembrowski, D. (2001). The practice of health program evaluation. Thousand Oaks: Sage. Harris, J. L., Roussel, L., Walters, S. E. & Dearman, C. (2011). Project planning and management: A guide for CNLs, DNPs, and nurse executives. Sudberry, MA: Jones & Bartlett Publishing. Institute of Medicine (2001). Crossing the quality chasm: A new health system for the 21st century. IOM. Washington, DC: National Academy Press. Kellogg, W. K. (2000). Foundation. Using logic models to bring together planning, evaluation and action: Logic model development guide. Battle Creek, MI: Author (Retrieved from http://apps. publichealth.arizona.edu/chwtoolkit/pdfs/logicmod/logicmod. pdf). Kitson, A. L., Rycroft-Malone, J., Harvey, G., McCormack, B., Seers, K. & Titchen, A. (2008). Evaluating the successful
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implementation of evidence into practice using the PARiHS framework: Theoretical and practical challenges. Implementation Science, 3, http://dx.doi.org/10.1186/1748-5908-3-1. Lipsey, M. W. (1993). Theory as method: Small theories of treatments. New Directions for Program Evaluation, 57, 5–38. Lowder, M. A. (2013). Description of the Intervention and Implementation Plan of a Shared Governance Model in the Hospital Setting. Unpublished manuscript. Maron, K., Burson, R. & Conrad, D. (2014). The doctor of nursing practice scholarly project: A framework for success. Sudberry, MA: Jones & Bartlett Publishing. May, C. (2013). Towards a general theory of implementation. Implementation Science, 8, 18. McGlynn, E. A., Asch, S. M., Adams, J., et al(2003). The quality of health care delivered to adults in the United States. New England Journal of Medicine, 348, 2635–2645. National Center for Advancing Translational Science (n.d.). About NCATS. Accessed May 13, 2014 at http://www.ncats.nih. gov/about/about.html Newhouse, R., Bobay, K., Dykes, P. C., Stevens, K. R. & Titler, M. (2013). Methodology issues in implementation science. Medical Care, 51, S32–S40.
Renger, R. & Titcomb, A. (2002). A three-step approach to teaching logic models. American Journal of Evaluation, 23, 493–503. Riesenberg, L. A., Leitzsch, J. & Little, B. W. (2009). Systematic review of handoff mnemonics literature. American Journal of Medical Quality, 24, http://dx.doi.org/10.1177/ 1062860609332512. Stein, K. F. (2010). The doctorate of nursing practice and the clinical project: Use of the SQUIRE Guidelines for Project Dissemination and Evaluation. Journal of the American Psychiatric Nurses Association, 16, 278–279. Stetler, C. B., Mittman, B. S. & Francis, J. (2008). Overview of the VA Quality Enhancement Research Initiative (QUERI) and QUERI theme articles: QUERI Series. Implementation Science, 3, 8. The SQUIRE Group (2008). SQUIRE Guidelines. Accessed April 26, 2014 at http://squire-statement.org/. Ward, M. M., Evans, T. C., Spies, A. J., et al(2006). National Quality Forum 30 safe practices: Priority and progress in Iowa hospitals. American Journal of Medical Quality, 21, 101–108. World Health Organization (2014). Implementation research toolkit: Faciliators' guide. Accessed May 28, 2014 at http://www. who.int/tdr/publications/year/2014/Facilitators_guide_final. pdf?ua=1.
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VIDENCE-BASED PRACTICES (EBPs) that improve patient outcomes are available but are underused (Newhouse, Bobay, Dykes, Stevens, & Titler;, 2013), which adds to the proliferation of substantial unjustified variations in practices (Institute of Medicine, 2001; McGlynn, Asch, Adams, et al., 2003; Ward, Evans, Spies, et al., 2006). Preparing practice leaders for integrating EBPs into standard practice is an important challenge that doctor of nursing practice (DNP) programs are in the position to address. Health care agencies and the people they serve stand to benefit when DNP programs provide opportunities for students to find and apply current science through conducting practice improvement studies. A wide range of scholarly projects are completed by DNP students in meeting the eight Essentials established by the American Association of Colleges of Nursing. A Web search of DNP programs found, for example, that projects have included developing a portfolio based on course and practicum experiences, conducting project development work such as a business plan for a home Advanced Practice Associate Professor of Community and Health Systems, Associate Dean for Global Affairs, Indiana University Purdue University Indianapolis (IUPUI), Indianapolis, IN. Address correspondence to Dr. Riner: Associate Professor of Community and Health Systems, Associate Dean for Global Affairs, Indiana University School of Nursing (IUSON), 1111 Middle Drive, Indianapolis, IN 46202. E-mail: [email protected] 8755-7223
http://dx.doi.org/10.1016/j.profnurs.2014.11.002
Register Nurse business (Brown & Crabtree, 2013), and dissertation-type studies. DNP scholarly projects are increasingly being published in the professional literature. In a recent review of this literature, the manuscript categories included the following: designing informatics solutions in primary care and acute care settings, using evidence-based education solutions for academic and clinical learning, studies on how evidence-based research was implemented to address a specific concern, and conducting traditional research studies designed to generate clinical knowledge (Broome, Riner, & Allam, 2013). This wide range of DNP projects occurring in programs across the country suggests that further dialogue would be beneficial to identify best educational practices for practice doctorate scholarship. When developing our DNP Program in 2008-2009, there was little published information by or about DNP graduates or programs. As program faculty, we wanted to stay close to our clinical agency partners' needs for clinical practice improvement. The question that challenged our faculty as we developed the curriculum and inquiry project was, “What knowledge and skills do the clinical agencies need from nurses with a practice doctorate to address the complex clinical and regulatory environments they are facing?” Chief nursing officers and primary care nurse administrators stated that they needed nurses with practice doctorates to develop and manage solutions to patient population problems, department-level problems such as purchasing decisions, and reimbursement issues such as
Journal of Professional Nursing, Vol 31, No. 3 (May/June), 2015: pp 200–207 © 2015 Elsevier Inc. All rights reserved.
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those related to 30-day readmission rates. To address these identified needs, we determined that the graduate would need experience in the following: advanced literature searching and synthesizing to identify the evidence for an intervention; developing a plan to implement the solution; and carrying it out, evaluating it, and disseminating the findings. The faculty believed it was important for graduates to demonstrate leadership and accountability for the full practice improvement process. We selected implementation science as the framework for structuring the experience.
Implementation Science as a Branch of Translational Science Translational science is a widely used term referring to moving knowledge discovery along the continuum from “bench to bedside to curbside.” According to the National Center for Advancing Translational Science, it “comprises the process of turning observations in the laboratory and clinic into effective interventions that improve the health of individuals and the public—from diagnostics and therapeutics to medical procedures and behavioral changes.” Translational science involves a wide range of experimental and quasi-experimental studies along the research continuum from bench science to wide-scale dissemination and adoption. A number of terms are associated with translational science, including knowledge translation, adoption of innovation, quality improvement, improvement science, implementation science, and dissemination (Newhouse et al., 2013). Implementing new knowledge, at each stage of the discovery process, requires investigations conducted under controlled conditions. Once this efficacy is established, the intervention is ready to be tested in less controlled environments and requires a process of tailoring the intervention to the local context. Implementation science is a form of applied research that has been linked to practice-based quality and safety improvement studies (May, 2013). Applied research is often thought of as a systematic inquiry into solving practical problems. For DNP education, this emerging field provides the conceptual link between scientific knowledge and implementing this knowledge in practice. Implementation science provides a structure and tools for increasing the rigor of studies on how evidence can be adopted into new practice settings. Implementation science can assist in identifying, describing, and explaining elements of implementation processes and their outcomes (May, 2013). Another way to think about implementation science is that it is the study of the processes used to make a practice change. Consensus is growing around a workable definition of implementation science as “the study of methods, interventions, and variables that promote the uptake and use of research findings and other EBPs by individuals and organizations to improve clinical and operational decision-making in health care with the goal of improving health care quality” (Newhouse et al., 2013, p. S32). This emerging field of science provided the basis for developing the “Inquiry Project” in our DNP program focused on health systems leadership.
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Curriculum Development and Course Mapping Our school of nursing is located on an urban, researchintensive academic health campus in the Midwest. The program has a health systems leadership focus, is 37 credits, and is open to students with a nursing master's degree, including nurse practitioners, clinical nurse specialists, nurse administrators, and nursing educators. Students work in both primary and acute care roles in a wide range of facilities. The curriculum includes nine courses: Relationship-Centered Leadership in Complex Systems, Knowledge Complexity, Influencing Public Health Policy, Introduction to Nursing Informatics, Health Care Outcomes and Decision-Making, Clinical Epidemiology/Statistics in Nursing, Strategic Resource Management in Nursing and Health Systems, Inquiry I: Evidence-Based Research and Translation Science, and Inquiry II: Evidence-Based Research and Translational Science; an elective; and seven practicum credits. During the Inquiry courses, a detailed plan for an intervention targeting a problem in the students' own organization is developed, with the plan being implemented during the practicum experiences. The Inquiry Project core was developed using strengths of our academic health science campus and faculty. It involves three components: two didactic courses and seven practicum credits. In the Inquiry I: Evidence-Based Research and Translational Science course, students do a comprehensive literature searching and synthesis assignment. They identify an important problem from their own clinical agency, conduct a literature review using the Joanna Briggs Institute resources for evaluating and synthesizing the evidence, and develop a recommended course of action to address the clinical problem. This is followed by the Inquiry II: Evidence-Based Research and Translational Science course, which is discussed in detail in this paper. Here, students progressively develop a plan to implement the best practice he or she identified in the Inquiry I course. Specific coursework that prepares students for their practice improvement project includes a combined epidemiology and statistics course, a graduate-level statistics course (a pre-requisite for program admission), and a course focusing on data for decision making in which students use data, conduct analyses, and make decisions for clinical care. In the Inquiry I course, students critique a large number of studies related to their issue and identify a design that fits their project. In addition to the course faculty, students are each assigned a faculty mentor and a clinical agency mentor to support them in developing their proposal and in collecting, analyzing, and interpreting the data. The seven practicum credits provide the framework for the Inquiry Project and are taken progressively throughout the program under the supervision of a faculty advisor and agency mentor. The faculty advisor has major responsibility for supporting the student in developing, implementing, and evaluating the project and in writing the final paper. In addition, the faculty advisor works with the
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student in completing the institutional review board (IRB) process. Most projects are approved by IRB staff as quality improvement studies, but for projects with a more complex design, the faculty member works with the student to receive IRB approval. The student works with an agency mentor who serves as a “champion” and provides on-site support, helps solve problems, and participates in evaluating the final product. A second faculty member joins the committee when the student is ready to develop his or her proposal. As we planned the courses, we focused on identifying the most valuable and needed aspects of implementing evidence into practice. On the basis of our reflections, the two co-faculty course developers identified learning assignments we believed were essential for students to demonstrate competence in when planning, implementing, and evaluating their Inquiry Project. Although it may seem like a high bar, if the student pursuing a practice doctorate does not implement and evaluate an EBP during the education program, where will she or he get supervised experience to develop such knowledge and skills? The faculty conceptualized the Inquiry Project as a practice improvement project for the student within his or her work setting. This served to frame the Inquiry Project as a quality or safety project. For this reason, we decided to use the Standards for Quality Improvement Reporting Excellence (The SQUIRE Group, 2008) as the standard for writing the final paper. These guidelines were developed by an international group of journal editors to guide manuscript development of quality improvement studies. They are used in multiple ways within the Inquiry Project core as well as in other courses to guide learning experiences. Recent literature shows that the SQUIRE guidelines are becoming accepted practice within DNP programs and quality improvement studies (Riesenberg, Leitzsch, & Little, 2009; Stein, 2010).
Inquiry II: Evidence-Based Research and Translational Science Course We designed Inquiry II so student assignments would result in a completed proposal for their implementation intervention that included a data management and analysis component. A course map (Table 1) links assignments with course objectives, program outcomes, and DNP Essentials. Following is a description of the modules and assignments students complete that lead to development of their study proposal.
Module 1: Identifying an Implementation Science Framework Here, students are exposed to a variety of translational science models, primarily those focused on the elements and processes of translating evidence into practice. These include the Practical, Robust Implementation and Sustainability Model (PRISM; Fieldstein & Glasgow, 2008), the Promoting Action on Research Implementation in Health Services framework (Kitson et al., 2008),
the VA Quality Enhancement Research Initiative (Stetler, Mittman, & Francis, 2008), the Consolidated Framework For Implementation Research (Damschroder et al., 2009), and the Cycle of Change model (Carey, Buchan, & Sanson-Fisher, 2009). Early models tended to be conceptual, with minimal specificity relative to implementation strategies and measures for use. Recently, other models and beginning theories that are more detailed have emerged and been added to the readings list. In particular, May (2013) has made a significant contribution to this field with his general theory of implementation. An initial assignment requires the student to critique multiple implementation models and discuss them with peers in the discussion forum. The student does an in-depth critique of the model he or she selects to guide his or her Inquiry Project as a key learning assignment. In a second component of the module, the student critiques an article relevant to his or her Inquiry Project focus area using the SQUIRE Guidelines. This activity familiarizes the student with the standards faculty will use in judging the capstone paper. Example. One student used an experimental design to identify whether time to appointment for patients with dysuria could be reduced and patient satisfaction with care improved through use of an evidence-based protocol, as compared with a traditional appointment, at a Federally Qualifying Health Center. This student applied the PRISM model to plan for how the intervention would need to consider external factors, the implementation process, the sustainability of the infrastructure, and how particular characteristics of patients would likely influence program adoption, implementation, and maintenance.
Module 2: Developing a Logic Model The intent of this module is to facilitate students' critical thinking about how they will implement their practice improvement project. The ability to visualize and articulate the rationale and logic underlying the intervention and the strategies selected for implementing it are essential in designing a tight study that links resources, actions, and outcomes in a linear fashion through the entire cycle-of-change process. Through a variety of logic model readings including Kellogg (2000), forum discussions, and assignments, the student develops a visual program logic model that shows the linkages among the situation, assumptions, activities, outcomes, and intended impact of the intervention and implementation strategies. This is accompanied by a narrative, integrative review of the literature that supports the visual model. Example. Nurse-sensitive indicators (NSIs) are extremely important in today's hospital environment. Decreasing nurse turnover is important to hospitals because such turnover affects the quality of nursing care provided and, in turn, patient outcomes such as complications. Financially, there is a significant cost associated with nursing turnover, and hospitals are financially penalized for the hospital-acquired conditions related to many of these NSI
Topic Implementation Science Theory
Artifact • Critique implementation science articles
Program logic model
• Critique an article using SQUIRE Guidelines Develop a visual program logic model and write an integrated review of the literature that addresses key components of the i ntervention and implementation.
Intervention Plan with Measurement and Evaluation Component
Describe your intervention including a measurement and evaluation component with timeline. See SQUIRE Guidelines (Steps 11 and 12)
Implementation Plan with Measurement and Evaluation Component
Describe how you will implement the intervention including a measurement and evaluation component with timeline.
Reflection on practice
Reflective journals 1,2,3,4 for D737 and D749.
IRB
Develops IRB proposal with Program Committee.
• CC 1. Students critique and apply theoretical, conceptual, and operational perspectives relative to implementation science as a basis for developing a project proposal. • PO 5. Translate knowledge for application to the delivery of advanced nursing practice. • E2. Organizational and systems leadership for quality improvement and systems thinking (#1 Develop and evaluate care delivery approaches…). • CC2. Write an integrated review of the literature that addresses key components of the project proposal. • PO3. Integrate the needs of diverse societies in the design, delivery, and evaluation of health services in complex systems. • E1. Scientific underpinnings for practice (#2 Use science… to describe the actions and advanced strategies to enhance, alleviate, and ameliorate health and health care delivery phenomena…). • CC4. Project how the evaluation results will be utilized and disseminated. • PO #7 Evaluate the impact of change on complex health systems including individuals and populations. • Essential 7: Clinical prevention and population health for improving the nation’s health (#1 analyze…scientific data…). • E 3: Clinical scholarship and analytical methods for EBP (#3 Design, direct, and evaluate quality improvement methodologies to promote safe, timely, effective, efficient, equitable, and patient-centered care). • CC3 Write an integrated review of the literature that addresses key components of the project proposal. • PO #6 Implement changes based on evaluation of health systems, health policy, and nursing science in response to social, political, economic, and ethical issues. • Essential 7: Clinical prevention and population health for improving the nation’s health (#2 synthesize concepts…to, improve health status/access patterns, and/or address gaps in care…). Essential 3: Clinical scholarship and analytical methods for EBP (#2 Design and implement processes to evaluate outcomes of practice, practice patterns, and systems of care…) AND (#5 Use information technology and research methods appropriately to design evidence-based interventions). • CC5. Utilize reflective practice concepts in understanding and implementing the role of change agent. • PO4. Transform clinical practice through reflection, action, inquiry, strategic resource management, information technology, and/or knowledge-based resources. • Essential VI: Interprofessional Collaboration for Improving Patient and Population Health Outcomes (#3 employ consultative and leadership skills with intraprofessional and interprofessional teams to create change in health care and complex health care delivery systems). • CC6. Project IRB application submitted to IUPUI IRB. • PO7. Evaluate the impact of change on complex health systems including individuals and populations. • E3. Clinical scholarship and analytical methods for EBP.
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Notes. PO = program outcome, CC = course competency, E = DNP Essential. Riner, M.E. Developed by.
Course competencies/PO/essential
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Table 1. Course Map
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Figure 1. Logic problem tracing (M. Lowder, 2013).
phenomena. Using Renger and Titcomb’s (2002) method of peeling back to the root of a problem, one of our DNP students analyzed this situation as follows (see Figure 1). She determined that the first “why” associated with the poor NSIs was the lack of autonomy, control, and accountability possessed by direct nursing caregivers. The second “why” was a bureaucratic, linear decision making model within the hospital. In addition, the underlying root cause of the problem, the third “why,” was the lack of a shared leadership structure and model in the organization. The student developed a plan for a shared governance intervention to address this underlying “why,” which in turn would be expected to alleviate the other two more proximal causes.
Module 3: Describing the Intervention Plan In this module, students describe their evidence-based intervention and develop a clinical data management and evaluation plan for the study. In the first assignment, students succinctly describe their findings from the synthesis work they did in the Inquiry I course in which they identified a best practice for their care environment. In the second assignment, students use methods and statistical knowledge gained in previous courses to plan the study design. They determine the study aim and primary research question(s). For each question, they specify instruments to be used; what, when, and how data will be collected; sample size; and the analysis strategy that will be used. A timeline is developed that includes the expected period for obtaining the sample, collecting data, inputting the data into the statistical program, conducting the tests/ analyses, analyzing the results, and writing up the results of the analyses. Example. One student planned and conducted a study to evaluate the implementation and effectiveness of a customized clinical decision support system (CDSS) to identify improvements in clinician compliance with hepatitis C virus (HCV) quality indicators. A comprehensive CDSS that aligned with HCV quality indicators
was developed to successfully integrate the CDSS into the clinic workflow. Using a pre/posttest comparative design, the documentation of quality indicators was measured in the pre-CDSS group and compared with the post-CDSS group. The data were entered into Excel and exported into SPSS 19.0 software for analysis. Fisher's exact test was used to determine the difference between groups.
Module 4: Plans for Implementing the Intervention Each student develops a practical framework of how his or her intervention is expected to work, that is, what has been referred to as the theory of implementation (Grembrowski, 2001; Lipsey, 1993). Students describe their assumptions about the components needed to support success of the intervention. This is a series of if–then statements that are represented visually as well as by narrative. The student also develops a plan to evaluate the implementation process. This involves identifying factors and measures that will be used to evaluate outcomes and processes of implementing the intervention or program. The student writes a five- to six-page narrative describing why his or her implementation plan can be expected to support critical aspects of the intervention. In this assignment, students (a) state aims and research questions about the implementation process based on the implementation science model selected; (b) specify elements of their local care environment considered likely to influence change/improvement; (c) describe how they will implement the intervention in sufficient detail so that others could reproduce it; (d) describe mechanisms by which intervention components are expected to cause changes, as well as plans for testing effectiveness; and (e) describe plans for assessing how well the intervention is implemented (what data will be collected, when, by whom, and how), all allowing later reporting of how the process impacted the delivery of the intervention components and context factors; (f) identify methods that will be used to ensure data quality and adequacy (efforts to validate and test reliability of assessment instruments); and (g) describe
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analytic methods that will be used to demonstrate effects of the implementation process.
With the first cohort we found the additional semester was not as beneficial as anticipated. Students needed a more concentrated learning experience earlier in the program to allow more time for data collection. After the first cohort, we scheduled Inquiry I for the fall and Inquiry II for the spring semester. The first cohort of students included nurse practitioners and clinical specialists. This meant there was significant homogeneity in perspectives and types of projects undertaken. With subsequent and more diverse cohorts, we found that a diversity of student backgrounds brought diversity of perspectives. Initially, Inquiry Projects focused on primary care. As the mix of student backgrounds began to include administrators and educators, the focus of projects included implementing system-wide change and nursing education practice improvement projects. Because in all roles nurses rely on available evidence for improving their work, the use of an implementation model was applicable. By the end of the third iteration of Inquiry II, we decided to make a more defined separation between student assignments for the course and the work students were doing for their Inquiry Project under the supervision of their faculty advisor. We decided to take a more methods-based approach and put the focus on critiquing implementation science models and on how studies using this method are conducted. This allowed students to develop deeper knowledge about the design and analysis strategies frequently used in implementation science.
Example. Another student used the Cycle of Change model to design a study on use of an evidence-based decision support algorithm for seizure management in the intellectual and developmental disability (IDD) population living in community settings. The goal was to increase the confidence of IDD nurses when guiding care during telephone triage. The Cycle of Change includes a threephased cyclical process that helps to describe a systematic approach to improvement of health outcomes through acceptance of evidence-based guidelines and recommendations into actual clinical practice. The evaluation plan developed by the student incorporated short-, medium-, and long-term impact outcomes as part of the evaluation process. See Figure 2 for part of the plan.
Discussion Over the initial 3 years of teaching these courses and working with faculty to facilitate the uptake of students' Inquiry Projects, we gained valuable insights resulting in design and delivery refinements. We initially taught both the Inquiry I and II courses across two semesters. The intent was to allow students time to apply their new knowledge to developing their Inquiry Project proposal. This design was particularly challenging when Inquiry II was scheduled for a 12-week summer session rather than the longer 15-week fall and spring semesters.
Need: Short-and Medium-Term Impact
a. Participating IDD Nurses within the Indiana Developmental and Disability Nurses Association (INDDNA) use the evidence-based seizure algorithm to guide seizure care during telephone triage for three months as evidenced by participation verification in the study. Evaluation method: IDD Nurses will provide the number of times via email that they implemented the seizure algorithm during the three-month study
b. Was the confidence of participating nurses in the INDDNA increased? Evaluation method: Likert Scale Surrogate Decision-Making Self Efficacy Scale Pre/Post Testing results
c. Was the nursing practice behavior of participating nurses in INDDNA changed? Evaluation method: Post-study survey of INDDNA Nurses via email two months following the end of the study. Figure 2. Example of plan for implementing the intervention.
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It became clear that the students would benefit from a structured project management component within the practicum credits to progressively build the Inquiry Project. We responded to this need by developing modules and conducting monthly “Cohort Cafés,” which involved monthly teleconference calls with a faculty member, a senior student leader, and small groups of students. The modules included readings from two books respectively written for scholarly projects (Maron, Burson, & Conrad, 2014) and project management (Harris, Roussel, Walters, & Dearman, 2011). After the first year of implementing the Cohort Cafés, feedback from new students indicated they had a clear idea of the focus of their project, were able to articulate a problem statement, and had met with their faculty and clinical agency mentors several times. It was clear to the faculty and student leader conducting the calls that students benefitted greatly in terms of defining “doable” projects early in their programs. As would be expected of any new academic program, there was a faculty development component to address. We developed a structure that included a DNP Advisory Committee. The Inquiry Project was refined and faculty consensus reached about types of projects and scope during these committee meetings. During the first year, we had guest speakers and read about implementation science, discussed student projects, shared experiences, and developed common agreement on issues and standards of expectations. In the second year, we organized a consultation from a program director with a similar Inquiry Project to assist in further tailoring the course and Inquiry Project. With the increasing diversity of students, we faced the need to explore additional ways of handling their specific interests. Furthermore, faculty supervision was becoming a workload management issue, and we developed agreements on what was expected of the faculty advisors and of students. This resulted in developing a document on best practices for facultystudent advising relationships. In addition to locally based Inquiry Projects, students have become involved in global projects. This has required gaining university permission for travel, working within ethical research practices for research abroad, and partnering with existing organizations the school is currently involved with on needed clinical practice improvement. The recent work by the World Health Organization (2014) on implementation research will be used as the framework. It fits our model extremely well and will allow us to use a global standard for these student projects. From the first cohort, three students have published five papers from their projects. One student was selected by the school for a poster presentation at the Midwest Nursing Research Society, and at least two others have given peer-reviewed national presentations. Another source of program evaluation is the alumni survey conducted annually with each new cohort. The results so far indicate that alumni believe they developed valuable nursing science knowledge in the DNP program and advanced as clinical practice leaders.
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Conclusion It is important that DNP graduates are prepared to lead practice improvement initiatives that contribute to improved organizational effectiveness and high-quality patient outcomes. DNP programs providing these types of learning opportunities are preparing leaders who are experienced in applying the range of knowledge and skills required in implementing and evaluating projects. The program components described here provide a model that represents an appropriate standard for implementing science into practice, within the U.S. health care system and globally. The call to implement EBP in health care agencies is clear. It is up to educators to provide the knowledge and skills necessary to make it happen.
Acknowledgments The author would like to posthumously acknowledge Dr. Joe Burrage, PhD, RN, FAAN, as co-developer of the course. In addition, she acknowledges the scholarly work of program students and alumni Anne Connor, Laura Fauthauer, and Melissa Lowery. The development of the course presented in this paper was supported by funding from the Health and Human Resources Administration.
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