NUR699 GCU Organizational Culture and Readiness Assessment Final Paper

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Health Medical

NUR699

Grand Canyon University

Description

Throughout this course you will be developing a formal, evidence‐based practice proposal.

The proposal is the plan for an evidence‐based practice project designed to address a problem, issue, or concern in the professional work setting. Although several types of evidence can be used to support a proposed solution, a sufficient and compelling base of support from valid research studies is required as the major component of that evidence. Proposals are submitted in a format suitable for obtaining formal approval in the work setting. Proposals will vary in length depending upon the problem or issue addressed; they can be between 3,500 and 5,000 words. The cover sheet, abstract, references page, and appendices are not included in the word limit.

Section headings and letters for each section component are required. Responses are addressed in narrative form in relation to that number. Evaluation of the proposal in all sections is based upon the extent to which the depth of content reflects graduate‐level critical‐thinking skills.


This project contains seven formal sections: These are the ones we worked over past weeks and links provided at the end .



  1. Section A: Organizational Culture and Readiness Assessment

Required revision - Need to add discussion of barriers. Make sure to include for final paper


  1. Section B: Problem Description

Required revision - None


  1. Section C: Literature Support

Required revision - Add description of the validity


  1. Section D: Solution Description

Required revision -You have developed a nice program. You nicely developed a solution. Can you describe what barriers you might experience?


  1. Section E: Change Model

Required revision - None


  1. Section F: Implementation Plan

Required revision - There are a couple of sections that are missing (budget and references). In addition, a couple of sections need a little more detail - setting, instruments - what are you going to collect? When? how? Where will the data be stored? Dr. Gallegos


  1. Section G: Evaluation of Process

Required revision - None


Each section (A‐G) will be submitted as separate assignments so your instructor can provide feedback (refer to applicable modules for further descriptions of each section).

The final paper will consist of the completed project (with revisions to all sections-), title page, abstract, reference list, and appendices. Appendices will include a conceptual model for the project, handouts, data and evaluation collection tools, a budget, a timeline, resource lists, and approval forms.

Use the "NUR‐699 EBP Implementation Plan Guide" and "NUR‐699 Evidence‐Based Practice Project Student Example" to assist you. Also refer to "NUR‐699 Evidence‐Based Practice Project Proposal Format." (ATTACHED)

RUBRIC (ATTACHED)



https://www.studypool.com/discuss/12676846/evidence-based-practice-proposal-section-c-literature-support-1

https://www.studypool.com/discuss/12537200/evidence-based-practice-proposal-1

https://www.studypool.com/discuss/12264457/benchmark-change-initiative-implementation-evaluation-and-sustainability-3

https://www.studypool.com/discuss/12816916/evidence-based-practice-proposal-section-d-solution-description-3

https://www.studypool.com/discuss/12932371/evidence-based-practice-proposal-section-e-change-model-1

https://www.studypool.com/discuss/13084558/evidence-based-practice-proposal-section-g-evaluation-of-process-2

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Course Code NUR-699 Class Code NUR-699-O501 Criteria Content Percentage 55.0% Abstract Presents a complete, concise overview of all phases of the proposed project. 10.0% Project / Content Comprehension 25.0% Sections A-G Synthesis 20.0% Organization and Effectiveness 30.0% Appendices 15.0% Mechanics of Writing (includes spelling, punctuation, grammar, language use) 15.0% Format 15.0% Research Citations (In-text citations for paraphrasing and direct quotes, and reference page listing and formatting, as appropriate to assignment and style) 15.0% Total Weightage 100% Assignment Title Benchmark - Evidence-Based Practice Proposal Final Paper No Submissions (71.00%) None None None None None None Total Points 250.0 Unsatisfactory (75.00%) No abstract Content is incomplete or omits most of the requirements stated in the assignment criteria. Does not demonstrate an understanding of the basic principles. Does not demonstrate critical thinking and analysis of the overall program subject. The main sections are not easily identified; some of the subconcepts do not successfully integrate to form a cohesive whole. Within section revisions methods and strategies are described poorly. Basic descriptions, connections, and alignment are not clearly presented. Logic flow is random, not easily understood. Several of the appendices are missing. Designs are not neat or organized, and do not include all required elements. Unprofessionally developed. Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice and/or sentence construction are used. No reference page is included. No citations are used. Less Than Satisfactory (83.00%) Abstract minimally written, clearly not sufficient to provide the reader with an understanding of the project. Content is incomplete or omits some requirements stated in the assignment criteria. Demonstrates shallow understanding of the basic principles. Within section revisions components may be missing details, only a surface level of evaluation is offered, methods are described but flawed or unrealistic and strategies are discussed, but incomplete. The main sections are somewhat identified; some of the subconcepts branch appropriately from the main sections. Basic descriptions, connections, and alignment as well as a clear logic flow are somewhat fragmented, not easily understood. Several of the appendices are missing. Design detracts from purpose. The work is not neat and includes minor flaws or omissions of required elements. Limited understanding of the topic is present as evidenced by the design. Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register), sentence structure, and/or word choice are present. Reference page is present. Citations are inconsistently used. Satisfactory (88.00%) Abstract provides overview of part of the project, but does not cover each section. Content is complete, but somewhat inaccurate and/or irrelevant. Demonstrates adequate understanding of the basic principles. The major sections have had revisions but some components may be missing details. Reasonable but limited inferences and conclusions are drawn but lack development. Supporting research is inadequate in relevance, All of the main sections are easily identified, and subconcepts branch appropriately from the main sections. Recognizes links among sections; however, some connections may be ambiguous. Basic descriptions, connections and alignment as well as basic logic flow are understandable, but are somewhat lacking in a clear progression. All of the appendices have been provided. Design is fairly clean, with a few exceptions. Appearance is general, and major elements are missing. Provides minimal details. Appropriate for the audience and the content but some of the development of the material is inadequate. Basic understanding of the topic is present as evidenced by the Some mechanical errors or typos are present, but are not overly distracting to the reader. Correct sentence structure and audience-appropriate language are used. Reference page is included and lists sources used in the paper. Sources are appropriately documented, although some errors may be present. Good (92.00%) Abstract provides a quick or too brief overview of all phases of the proposed project. Contains project title, project director's name, and affiliation. Content is comprehensive and accurate, and definitions are clearly stated. Sections form a cohesive logical and justified whole. All of the major sections have been revised based upon logical feedback, conclusions, and sound research. Shows careful planning and attention to details and illuminates relationships. Research is adequate, current, and All of the main sections are easily identified, and subconcepts branch appropriately from the main sections. Descriptions, connections, and alignments are provided. Logic flow is smooth and easily understood, facilitating a thorough understanding of the various sections as they interrelate. All of the appendices have been provided. Designs are appropriate and present quality products. Appearance is neat, with a few minor flaws or missing elements. Provides details with accuracy. Reveals a solid understanding of the topic as evidenced by design. Prose is largely free of mechanical errors, although a few may be present. A variety of sentence structures and effective figures of speech are used. Reference page is present and fully inclusive of all cited sources. Documentation is appropriate and citation style is usually correct. Excellent (100.00%) Abstract provides a complete concise overview of all phases of the proposed project and flows well with the rest of the paper. Contains project title, project director's name, and affiliation. Content is comprehensive. Presents ideas and information beyond that presented throughout the course, and substantiates their validity through solid, academic research where appropriate. Research is thorough, current, and relevant, and addresses all of the issues stated in assignment criteria. Final paper exhibits process of creative thinking and All main sections are easily identified, and sub concepts branch appropriately from main sections. Descriptions, connections, and alignments are obvious and well supported. Logic flow is smooth and easily understood, facilitating a thorough understanding of various sections as they interrelate. Connection to extraneous materials are well All of the appendices have been provided. They are effective and functional. The work is well presented and includes all required elements. The overall appearance is neat and professional. Gives sufficient detail with precision and specificity. Reveals a solid understanding of the topic as evidenced by the design. Writer is clearly in command of standard, written, academic English. In-text citations and a reference page are complete and correct. The documentation of cited sources is free of error. Comments Points Earned EBP Implementation Plan Guide PICOT Question Topic 1 • Preliminary Checkpoint • • • Topic 2 • • Checkpoint 1 • • • • • Topic 3 • Checkpoint 2 • • • Topic 4 • Checkpoint 3 • • Identify a health care issue you want to see change. Understand the culture of the organization in its readiness for EBP implementation. Develop PICOT question. Build EBP knowledge and skills. Define project purpose. Who are the stakeholders for your project? Identify active (on the implementation team) and supportive (not on the team, but essential to success) roles. Identify project team roles and leadership. Begin acquisition of any necessary approvals for project implementation and dissemination (e.g., system leadership, unit leadership, ethics board [IRB]). Feasibility: Briefly integrate the evidence with stakeholder influence to inform evidencebased recommendations. Hone PICOT question. Conduct literature search and retain studies that meet criteria for inclusion. Connect with librarian. Critically appraise literature. Summarize evidence with focus on implications for practice. Begin formulating a detailed plan for implementation of evidence. Include who must know about the project, when they will know, how they will know. Connect the evidence and the Notes: Notes: Notes: Notes: © 2014. Grand Canyon University. All Rights Reserved. • • Topic 5 • Checkpoint 4 • • • • • Topic 6 • Checkpoint 5 • • Topic 7 • • Checkpoint 6 Topic 8 • • Checkpoint 7 project. Identify and address known barriers and facilitators of project. Define post-project outcome indicators of a successful project. Define baseline data collection Notes: source(s) (e.g., existing data set, electronic health record), methods, and measures. Identify resources (human, fiscal, and other) necessary to complete project. Gather outcome measures. Write data collection protocol. Write the project protocol (data collection fits in this document). Finalize any necessary approvals for project implementation and dissemination (e.g., system leadership, unit leadership, IRB). Finalize protocol for Notes: implementation of evidence. Complete final data collection for project evaluation. Include specific plan for how the evaluation will take place: who, what, when, where and how, and communication mechanisms to stakeholders. Complete proposal. Notes: Develop proposal presentation. Present proposal. Review proposals, addressing new questions generated from process of the peer review. Notes: Adapted from Melnyk, B. M., & Fineout-Overholt, E. (Eds.). (2010). Evidence-based practice in nursing & healthcare: A guide to best practice (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. 1 Evidence-Based Practice Project Student Example 2 Table of Contents Generating Evidence for Evidence-based Practice Part 1: Introduction I. The problem statement ………………………………….……………………....……….3 II. The evidence-based question ………………………………………..……….……….…4 Part 2: Assemble relevant evidence & related literature III. Locating credible evidence………………………………………………….…...………3 IV. Appraise the evidence……………………………………………………….……...……4 Part 3: Implementation of the intervention I. Planning of change………………………………………………………………..…....8-9 II. Clinical protocol and pilot project………………………………………………9-14 & 23 III. Integration and Maintenance …………………………………………………….…..14-15 IV. Barriers and strategies………………………………………………….……………15-18 Part 4: Conclusion ………………………………………………..…………………………….18 Part 5: References……………………………………………………………………………20-22 Part 6: Appendices …………………………………………………………..…………….……23 I. Management of Mechanically Ventilated Patients: Pilot Project ……………………23-24 II. Questions for Patient Ventilator Rounds ………………………………………………..25 III. Methodological matrix ………………………………………………………………26-28 IV. Prevention In- Service Flyer ……………………………………………………………27 3 Problem Statement The development of pneumonia caused by mechanical ventilation is a significant problem in the intensive care units of hospital facilities. Ventilator-associated pneumonia (VAP) is the “most commonly reported healthcare-acquired infection” in patients requiring mechanical ventilation support (Garcia et al., 2009, p. 524). One of the most common reasons for an ICU admission is related to respiratory distress or failure. VAP is described as a form of nosocomial infection which occurs after the first 48 hours of receiving mechanical ventilation (Augustyn, 2007). The length of stay (LOS) for patients developing VAP is higher than those never requiring mechanical ventilation by an increase of approximately six days (Garcia et al. 2009). In intensive care units (ICUs) across the United States (US), ventilator-acquired pneumonia also results in prolonged periods of actual mechanical ventilation, the excess use of antimicrobial products, increased utilization of healthcare resources and costs, and significant increase in morbidity and mortality (Coffin et al., 2008). Garcia et al. (2009) found on average, estimated costs of an additional $11, 897 to $150,841 per individual case were spent. VAP has a significant economic impact on our society, costing hospitals money which potentially could have been saved. Numerous risks factors contribute to the development of ventilator-acquired pneumonia as mechanical ventilation presents a unique set of challenges for the patient requiring intubation and ventilator support. Rigorous clinical studies show oral secretions pose an increased risk for developing VAP (Augustyn, 2007). Treatments, strategies and evidence-based interventions have been developed to decrease the risks and reduce the prevalence of VAP. There is evidence indicating the use of oral chlorhexidine and the removal of oral secretions before position changes may diminish the risks of developing ventilator-acquired pneumonia. By reducing the levels of bacteria in the oropharynx there would theoretically be a decrease in the prevalence of 4 nosocomial pneumonia (Houston et al., 2002). Research demonstrates the use of 0.12% chlorhexidine gluconate oral rinse (CHX) pre and postoperatively reduces the incidence of VAP in patients who are intubated greater than 24 hours. Foreground Question In adults supported with mechanical ventilation, what is the effect of oral chlorhexidine use and removal of oral secretions prior to position changing on the development of ventilatoracquired pneumonia? Review of Evidence and Synthesis of Literature This is a literature analysis of research reports and literature reviews which studied the effects of removal of oral secretions prior to position change on the occurrence of VAP. A summary of the articles can be found in Appendix C. The studies varied in design; from randomized to non-randomized, placebo, to longitudinal and a pilot study. Strength for each study is noted at Level II on the hierarchy as each one is a randomized or nonrandomized clinical study. The research supports our clinical question and was utilized with the development of additions to be incorporated into the already existing ICU VAP protocol. The studies focused on in this review consisted of evidence evaluating oral secretion removal and the use of chlorhexidine gluconate oral rinse to prevent VAP. The cost effectiveness of these interventions was found to be significant. Studies showed oral secretions as being the medium to carry pathogens within the oropharyngeal site down into the respiratory track. The literature hypothesized removing oral secretions prior to the position change of a patient can prevent or minimize the movement of organisms into the respiratory tract which lead to VAP development. Some researchers also concluded the significance of chlorhexidine use for reducing nosocomial infections. The combination of both interventions creates a profound effect 5 on reducing VAP occurrences its research importance, which this practice change aims to strongly support. The review of literature consists of evidence dating from 1996 to 2008, indicating the need for continued research and close monitoring of clinical practice changes based on the best evidence at the moment. This problem was identified long ago and yet still needs further evidence for best practice. Three articles discuss removing oral secretions prior to position changes of patients which are one of the two independent variables of interest for this review. In one of those studies, VAP was diagnosed in 24 of 159 patients in the control group, but only in five of 102 patients in the study group within the study group receiving oral suctioning prior to all position changes (Chao, Chen, Wang, Lee, & Tsai, 2008). A similar study showed VAP occurrence at 2.6% in the study group and 11% in the control group with probability of < 0.001 (Tsai, Lin, Chang, 2008). Studies by DeRiso et al. (1996) and Houston et al. (2002) each sought to evaluate the efficacy of oropharyngeal decontamination on nosocomial infections in patients undergoing heart surgery using CHX before and after surgery. Both DeRiso et al. and Houston et al. discovered an overall reduced rate of VAP (52% and 69% respectively for each study). The significance level for both studies was less than .01 (use the higher of the two) with the use of CHX with oral suctioning of subjects for these studies. Another related intervention assessed in a similar randomized clinical study was the use of subglottal suctioning by Smulders et al. (2002) and its effect on VAP incidence. This intervention was appropriate for this review of literature; four percent of patients who underwent continuous suctioning developed VAP as compared to 16% in the control group. A common finding in the studies reviewed was the savings in spite of the costs of using CHX and equipment 6 for oral and subglottal secretion removal. The majority of these studies revealed a significantly reduced duration of mechanical ventilation and LOS in the ICU. All research studies in this literature review, with the exception of Tsai et al.’s study, consisted of study groups homogenous in patient samples, which suggest effective randomization. Tsai et al.’s study has patient heterogeneity (of both medical and surgical ICU patients) which may have confounded the results. Also, the results of Chao et al.’s study did yield a significant difference with the distribution of patients having a history of COPD, DM, use of antacids, and surgery. These variables were then evaluated with logistic regression for their relationship in VAP development, and the results of the logistic regression showed no significant impact on the direct development. Overall the reviews are well organized, use appropriate language, and use mostly all paraphrasing. This review summarizes key finding of evidence for clinical practice, and provides similar conclusions like our study regarding interventions to implement in practice. This literature review consisted of all but one study which were experimental in nature and hold “a high degree of internal validity because of the use of manipulation and randomization” (Polit & Beck, 2008, p. 295). Tsai et al.’s study was a time-sequenced, nonrandomized quasi-experimental study most vulnerable to threats to internal validity out of all the literature reviewed. But the remaining study participants in the rest of these experimental designs were all randomized after meeting inclusion criteria. Only two studies (by Houston et al. and Tsai et al.) may have had questionable internal validity. Houston et al.’s study group was large but possibly too broad with subjects intubated for too short of a period to have the intervention be significant. This provides evidence for the need to implement such an intervention and continue research. This may have led to potential Type I and II errors. Tsai et al.’s weakness was the limitation of a non-randomized control study and patient heterogeneity as 7 previously mentioned. In addition, Chao et al. used a staff nurse of the ICU to conduct data collection; because it is her ICU she may want “her unit” to do well with compliance with the study, creating bias. Also, in both this and Smulders et al.’s studies suctioning pressure was discussed. Internal consistency was not documented and this lack of information affects the reliability of the measurement tools. Selection bias does not appear to be a concern in these studies, and there appears to be no threat of history and the groups were mainly homogenous. Overall the internal validity of the research in this literature review is rather strong taking into consideration these few discussed weaknesses. Regarding external validity, the research findings in these studies can easily be generalized to similar mechanically-ventilated ICU adult populations. The patient populations were representative of the typical ICU population and because of this, external validity is strong. Steps were taken to control characteristics which could impact the groups being compared, and any requirements for participants were taken into consideration when developing the sample. The study by DeRiso et al. was double-blinded and placebo-controlled in design techniques, and Smulders et al.’s study reported blinding with the radiologists in regards to reading all X-ray reports. These techniques enhanced the internal validity. The studies were each performed in only one setting, but could very easily be replicated in another ICU environment. Tsai et al. and Chao et al.’s studies had a period during their research which was dedicated to educating staff on the protocol to be implemented to the experimental group. This enhanced intervention fidelity in both studies. Also, the individual collecting the data from Chao et al.’s study group was a trained staff member of the ICU floor, and such actions facilitated a strong reaction with the intervention and validated construct. No incentives were provided to staff members for compliance with Chao et al.’s study, but staff was aware of the fact that the clinical setting was being monitored and data collected based upon their performance. However, 8 normally nurses are not monitored closely and corrected for actions. Education for new changes to protocols is usually brief, and like any change, will take some time for the staff to acclimate to. There appears to be no apparent threat to construct validity with the discussed literature. However one could argue the researcher’s expectancies for desired outcomes playing an effect. For example, Tsai et al. and Chao et al.’s studies involved the staff received a thorough education and period of time to learn the protocol for the study’s intervention. Knowing the researcher’s expectations, this could “become part of the treatment construct that is being tested” (Polit and Beck, 2008, p. 301). Researchers appropriately balanced all concerns for validity in their study. Planning a Change After critically analyzing the evidence, the nurse develops a plan to apply the findings to a clinical practice. Developing a plan for change includes identifying strategies to gain cooperation and evaluating outcomes. Once it is decided that evidence supports a practice change, the change agent or facilitators must develop and test the improvement. This step requires some preliminary planning and research. Is the innovation practical, the evidence transferable, is the organization ready for change, are outcomes measurable and will is it possible to implement the EBP within the organization (Newhouse, Dearholt, Poe, Pugh & White, 2007)? If the answers are agreeable, the innovation must be authorized through the appropriate organizational channels. The implementation of an evidence-based practice is considered a quality improvement initiative and does not require the hospital Institutional Review Board approval. The Quality Care Committee, which oversees process improvement, protocol, and policy changes, will review and approve this proposed implementation of evidence-based practice, as part of the initial planning. The planning phase includes assessing the feasibility of 9 change, defining the change, identifying resources, and defining the desired outcomes (Reavy & Tavernier, 2008). The proposed EBP innovation is to complement the policy for oral care and suctioning of mechanically ventilated patients with a 10% chlorhexidine gluconate oral rinse and increase suctioning to every two hours prior to repositioning. These interventions can also be increased according to the patients’ needs. The expected outcomes of the change are improved patient care, reduced costs related to VAP infection and increased lengths of stay, and the reduction of the incidence of VAP in patients mechanically ventilated for more than 24 hours. The project feasibility is very good, due to the small scale of the intervention, the ease of implementation into protocol already in place, it’s compatibility with the practice environment, and it is simple to test in a small sample (Newhouse, Dearholt, Poe, Pugh & White, 2007). Other aspects contributing to the project’s potential for success is the availability of ample resources including the Quality Care Committee, Clinical Nurse Specialist, ICU Nurse Educator, Unit Preceptors, Clinical Managers, and Infection Control Nurse. Implementation and Evaluation of Change Proposed Project The authors plan to implement changes in current policy of management of ventilated patients as a pilot project at Scottsdale Healthcare Shea ICU. The change will be to add chlorhexidine rinse for oral care every two hours and suctioning of oral secretions prior to repositioning the patient. The data will be collected on all ventilated patients during daily multidisciplinary team vent rounds by the infection control nurse. See Appendix A for pilot project with current changes in policy. We plan to implement the change at Scottsdale Healthcare Shea medical surgical ICU from June 1, 2010 to April 1, 2011. 10 Implementation Plan To enhance the patient outcome during hospitalization, an evidence-based pilot project will be implemented. As mentioned earlier, the problem of VAP pertains to all ventilated patients in different ICUs, but it is easier to start the pilot project in one unit and expand it to the other ICUs of the Scottsdale Healthcare hospitals after assessing the effectiveness of the plan and making any necessary changes after the evaluation process. The authors propose to implement the pilot project initially in the ICU of Scottsdale Healthcare at Shea campus. The plan will be presented to the ICU nurse manager, supervisors, infection control nurse, and the clinical educator of the ICU to obtain permission and approval in order to implement the plan. The plan will also be presented to Quality Care Committee May 2010 meeting for their permission for the change. After obtaining permission for the plot project, evidence base education material containing prevalence of VAP rate, its complications, cost, recommended change with use of chlorhexidine gluconate in oral care, and oral secretion suctioning prior to position change will be presented to the staff during ICU Unit Base Committee (UBC). Four more teaching sessions will be provided, two in each day and night shift, so that staff can attend a session which is more convenient to them. All the registered nurses working in ICU will be required to attend one of the teaching sessions. The teaching session or in-service will be on May 20, 2010 from 8 a.m. to 9 a.m. and from 8 p.m. to 9 p.m. These times are chosen to make it convenient for nurses to attend the in-service before going home at the end of their shift. Two more teaching sessions will be provided on May 23, 2010 from 11 a.m. to 12 noon and from 10 p.m. to 11 p.m. Six brochures to notify staff of the in-service dates and times will be prepared and placed in the restrooms, break rooms and in hallways within the unit (Appendix D). A power point presentation along with two poster boards containing evidence based information about VAP prevalence and its outcomes and changes in practice will be prepared 11 and presented to staff during the in-service. One poster board will be placed in break room and the other poster will be placed in meeting room of ICU to enhance teaching. Time for answering any questions will be provided at the end of the teaching session. The teaching will be conducted in an informal way, and the research assistant will be available to re-educate and answer questions for staff as needed. One day shift nurse and one night shift nurse will be prepared by the nurse educator to do the teaching for the rest of the ICU staff. The physicians and respiratory therapists of ICU will also be notified of this evidence based plan so they will be knowledgeable about this VAP pilot project. The resources needed for the implementation of this plan are two poster boards, a power point, and a jump drive to store the teaching material. Also required would be the chlorhexidine gluconate oral rinse, which would be ordered from pharmacy for each ventilated patient in the intervention group. The other resources needed are the staff education time for the RNs who are teaching the in-service and the staff who is attending the in-service. There are twenty-three day shift RNs and twenty night shift RNs in ICU who will need to attend these in-services, so one hour in-service for each RN will need forty-three hours of education time for registered nurses in addition to five hours of teaching time for the RNs who are teaching these in-services. Most of the cost of this project is the cost of education time for the staff nurses. The two poster boards will cost seven dollars each, a small jump drive for twenty dollars and the power point is free. The cost of chlorhexidine is also negligible when compared with the cost of VAP. This will be the money well spent and pay for itself with shorter length of stay of ventilated patients due to VAP prevention or reduction. This project will save money for the hospital by improving patient outcome and decreasing VAP rates and the hospital length of stay. Having a theoretical framework enhances the worth of the study according to Polit and Beck (2008). This plan will be guided by the Kurt Lewin’s change theory to improve delivery 12 of information to staff. Lewin’s change theory involves a three stage model of change, which are unfreezing, change, and re-freezing (Neil, 2004). The first stage of unfreezing involves the concept of becoming motivated to change or unfreeze from previous practices. In ICU, the staff will be prepared for the change by explaining them the magnitude of the problem, so that they feel the need for the change. They will be notified about the statistics of VAP prevalence and the magnitude of the complications of VAP. These measures will motivate the staff for a change in practice. The second stage of Lewin’s change theory is implementation of the change. This stage is the actual stage of alteration and will be most essential in maintaining consistency with the use of chlorhexidine in oral care and suctioning the patients prior to position change. Support will be provided to staff during this stage by answering their questions and addressing any concerns they have. The registered nurses will implement the learned techniques of using chlorhexidine in oral care and suction patients prior to position change every two hours and as needed for the duration of plot project from June 1, 2010 to April 1, 2011. The multidisciplinary vent round will continue to enforce the change and collect data on ventilated patients. The physicians will also be supported and welcomed for their input in this process. Lewin’s final stage of the change theory is the concept of re-freezing or making the change permanent. In this last stage of change theory, the newly learned changes become habitual for the staff (Neil, 2004). The staff will be reinforced and encouraged to continue to follow the recommended changes at each month’s staff meeting and daily multidisciplinary vent rounds for the duration of pilot project. The staff will also be encouraged for their feedback on this project. They will also be reinforced about this newly learned skill at the annual skills fair and have opportunity to get their questions answered. The future of the healthcare is moving 13 towards pay for performance measures and this teaching plan will lead Scottsdale Healthcare towards delivering a better patient outcome. Evaluation Plan The evaluation of this teaching plan is relatively simple. The infection control nurse keeps the data of VAP rate of all ventilated patients. The data including VAP rate obtained by infection control nurse from vent rounds during the pilot project will be compared with the VAP rate of ventilated ICU patients of this unit from the previous year. The VAP rate during pilot project for the months of June 1, 2010 to April 1, 2011 will be compared with the VAP rate of previous year for the months of June 1, 1009 to April 1, 2010 to promote validity. The types of patients vary by season, and by doing this we increase the likelihood of having a similar patient population which is representative of the months of June to April. These findings will be discussed among the ICU manager, supervisors, clinical educator and infection control nurse in May 2011 upon completion of pilot project. A decision will be taken to adopt the change or reject the change depending on the findings if VAP rate was reduced or not. Dissemination Plan The staff will be will be notified of the project completion in monthly staff meeting in May 2011. The goal of this dissemination plan is to utilize this new research or evidence based information to improve patient outcome. If the finding suggests a decrease in VAP rate during pilot project, the change will need to be implemented to other ICUs of Scottsdale Healthcare. All the nurses at Scottsdale Healthcare ICUs will need to be reached to ensure that everyone can benefit from this information. Since the problem of VAP pertains to all the ICUs of Scottsdale Healthcare hospitals this information needs to be disseminated to the Scottsdale Healthcare Shea CVICU, and eventually to ICUs at Osborn and Thompson Peak campuses. With the permission from the PCC’s chair, the committee will be presented with recommended changes. The project 14 will be presented in detail and the importance of the need for a change in practice for VAP reduction will be stressed with the supporting evidence. Again the goal will be to obtain permission to expand the changes to CVICU of Scottsdale Healthcare Shea. Two to four nurses from each floor can be prepared to teach the rest of the staff on CVICU. In-service time to prepare them will be arranged at a convenient time. The power point presentation containing the teaching material will be made available to all the hospital employees on the Scottsdale Healthcare Shea campus’s Special Care Unit’s web site. This will promote access to the teaching contents for the staff. The other sources of information will be the RNs of ICU who performed the in-service for their staff. A copy of this plan will be made available to the staff through Scottsdale Healthcare Library also. To include Osborn and Thompson Peak in the teaching plan, the Nursing Leadership Committee will be approached, where the nursing managers from all three campuses are available. They will also be approached the same way as mentioned above to disseminate the pilot project recommended changes plan to the two other campuses. The resources, the contents of the VAP teaching plan, and the medium will be made accessible to them as well. A dissemination plan as mentioned above will be carried out in a similar fashion for the other two campuses also. Integration and Maintenance of Change Initiating the changes to the pre-existing protocol would first involve several steps as previously mentioned. There would be a decision on who would be collecting the research data. After the Quality Care Committee approves the change, we would select a research assistant experienced in infection control to collect data and monitor the process during the study. This study would also require a qualified personal to educate the staff on the protocol changes and be available to answer any questions which may arise. The pilot study (see Appendix A) would 15 then take place. Prior to the study, daily rounds are completed on each ventilated patient to collect information for VAP. After implementing this study, this research assistant would accompany the ventilator rounds team and collect information applicable to the study. This would help facilitate monitoring the process and outcomes of the intervention. See Appendix B for examples of major questions included during ventilator rounds. Questions italicized would be additions made to the rounds during the study for data collection purposes. This information on VAP rates and patient length of stay after implementing the new interventions would be put together and submitted to the appropriate committees. Integrating the new policy on the unit, staff will be much more likely to accept and support the new process if they know what to expect at each phase of the change. Additionally, staff members are able to contribute ideas drawn from their varied experience. Staff ideas often improve the process, save money, and avoid potential obstacles (Gotsill & Natchez, 2007). Implementing this change of protocol would involve the cooperation of both the research and hospital staff. Communication between both groups is crucial, and a key concept of implementing a practice change. Providing updates to the Quality Care Committee, Infection Control Team, unit manager, and the staff throughout the study would be crucial. Quarterly feedback to the staff alone will help visually show their cooperation in this study and the beneficial outcomes yielded from the implementation change. Barriers and Strategies of Change The work environment healthcare professionals face daily is demanding. Nurses manage heavy workloads and high acuity patients along with staffing shortages and cost cuts, which reduce all available resources. This creates challenges to implementing new policies, protocols, or evidence-based practice (EBP). Some of the potential barriers to implementing EBP clinical changes can be categorized as individual, organizational, environmental, and communication 16 based barriers (Udod & Care, 2006). Although it appears to be an impossible task, there are many strategies to help gain cooperation from the individuals responsible for implementing change. A few strategies are managerial support, clearly written research, exposure to real-life case studies, role modeling, staff engagement opportunities, and psychosocial support (Udod & Care; Thompson, Bell & Prevost, 1999). Potential Barriers to Implementing EBP Healthcare professionals have reported a variety of barriers to implementing EBP. Nurses can be skeptical, especially if they have misperceptions, fears, or anxiety that prevents them from having a clear vision when implementing change (Melnyk & Fineout-Overholt, 2005). Individual barriers include a lack of competence of nurses and managers regarding the implementation of EBP strategies, a lack of academic skills, and an inability to apply research to practice as evidenced by the large research-practice gap that exists in the profession (Udod & Care, 2006). Overwhelming workloads may also leave nurses drained, lacking motivation, confidence, awareness, and time (Thompson, Bell & Prevost, 1999). Melnyk and FineoutOverholt state that barriers to EBP implementation and adherence are oftentimes related to individual attitudes. A lack of confidence in the plan or its creator, an inability to visualize a positive outcome, or doubt in one’s own skills are a few examples (2005). Some individual barriers can be associated with the organization. However, nurses must overcome other organizational barriers. Examples are administrative constraints such as a lack of funding for skill development, opposing managerial priorities, or a lack of support from management and administration (Udod & Care, 2006). Other workplace barriers are difficulty accessing journals and evidence to support EBP, peer pressure to continue traditional practices, patient demands for widely prescribed treatment, and heavy patient loads which prevent learning and EBP implementation (Melnyk & Fineout-Overholt, 2005). 17 Nursing professionals face environmental barriers, as well, in the implementation of EBP. EBP can be affected by government policy or may be controlled by laws and legislation. An example is the use of medical marijuana for nausea and anorexia in cancer patients, which is illegal in many states. Coworkers and managers with different agendas in the workplace can be considered an environmental barrier to change. Occasionally an organization has such a fast moving culture of change, it leaves nurses too overwhelmed to cope (Udod & Care, 2006). Finally, there are communication barriers in every aspect of life. The implementation of EBP can be affected by a lack of appropriate collaboration and communication between every level of provider involved including researchers, nurses, educators, managers, and administrators (Thompson, Bell & Prevost, 1999). Communication errors and barriers can occur in the educational programs and training for EBP, the interpretation of research, and in publications and presentations (Melnyk & Fineout-Overholt, 2005). This issue can be further complicated with the addition of multidisciplinary involvement, which requires another level of communication to be successful. Strategies for Successful Implementation of EBP The implementation of EBP provides for safer, more cost-effective care with patientspecific interventions. In order to accomplish this, organizations must employ a plan to gain cooperation from the individuals who are responsible for implementing the EBP. Successful implementation requires organizational change and buy-in. The most important strategy for EBP implementation is ensuring the support of the organization and management. This will assist in eliminating constraints, allow for budgeting and possibly funding for education and incentives, and provide encouragement and persuasion as the organization forms its opinion about the EBP implementation (Newhouse, Dearholt, Poe, Pugh & White, 2007). 18 Nurses and physicians cite the desire for clearly written research reports and exposure to case studies where EBP resulted in improved outcomes. Providing appropriate education and tools for EBP implementation and ensuring access to evidence will reinforce and help providers understand the benefits (Melnyk & Fineout-Overholt, 2005). Psychosocial support is an important strategy, which simply means nurses are enabled and encouraged to perform the desired change. This is accomplished with good education, clear-cut expectations, reinforcement, acknowledgement, and rewards. Another similar strategy is role modeling nursing practice. This is done by demonstrating commitment and supporting the cause for advancing the EBP, while performing or educating staff about the desired change. Staff involvement is important when implementing change. Strategies can include encouraging nurse participation in a journal club or other collaborative opportunity to share evidence. Super users, trainers, champions or stakeholders, whatever title one chooses, can be trained to coach staff and provide collegial support and role modeling. Staff can also share in leadership and decision-making, give their feedback and opinions, and contribute new ideas regarding EBP implementation through Shared Leadership, focus groups, and surveys. This allows the organization to measure nursing staff knowledge, attitudes, and beliefs and identify implementation challenges (Melnyk & Fineout-Overholt, 2005). Conclusion The evidence in totality supports this practice change. This implemented change would include the variables of interest discussed previously in the literature review and pilot plan. The benefits of such an intervention change have the potential to support EBP and nursing practice. Contrary to the misperceptions many nurses have about EBP, it does not take away from the nurses’ clinical expertise. EBP integrates the best care with research evidence, patient’s individualized needs, preferences and circumstances (Polit & Beck, 2006). It also allows for 19 exceptions in clinical setting and resource constraints. EBP can also be used as a problemsolving strategy in clinical care by taking away decisions based on custom, authority, opinion, or ritual (Polit & Beck). 20 References American Association of Critical-Care Nurses. (2005). AACN procedure manual for critical th care, (5 ed.). St. Louis, MO: Elsevier Saunders. American Association of Critical-Care Nurses (rev. 1 0/07). AACN Practice alert: Oral care in the critically ill. Retrieved June 3,2008 from http://www.aacn.orgIWD/PracticeIDOCS/Oral_ Care_in_the_ Critically_1I1.pdf Augustyn, B. (2007). Ventilator-associated pneumonia: Risk factors and prevention. Critical Care Nurse, 27, 32-39. Retrieved from http://web.ebscohost.com.library.gcu.edu:2048/ehost/search? Chao, Y. C., Chen, Y., Wang, K. K., Lee, R., & Tsai, H. (2008). Removal of secretions prior to position change can reduce the incidence of ventilator-associated pneumonia for adult ICU patients: A clinical controlled study. Journal of Clinical Nursing, 18, 22-28. doi:10.1111/j.1365-2702.2007.02193.x Coffin, S. E., Klompas, M., Classen, D., Arias, K. M., Podgorny, K., Anderson, D. J.,...Yokoe, D. S. (2008). Strategies to prevent ventilator-associated pneumonia. Infection Control and Hospital Epidemiology, 29, 31-40. doi:10.1086/591062 DeRiso, A., Ladowski, J., Dillon, T., Justice, J., & Peterson, A. (1996). Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery. CHEST, 109(6), 1556-1561. Garcia, R., Jendresky, L., Colbert, L., Bailey, A., Zaman, M., & Majumder, M. (2009). Reducing ventilator-associated pneumonia through advanced oral-dental care: A 48-month study. American Journal of Critical Care, 18, 523-532. doi:10.4037/ajcc2009311 21 Gotsill, G., & Natchez, M. (2007). From resistance to acceptance: How to implement change management. Training & Development, 61(11), 24-27. Retrieved from http://web.ebscohost.com.library.gcu.edu:2048/ehost/search Houston, S., Houghland, P., Anderson, J., LaRocco, M., Kennedy, V., & Gentry, L. (2002). Effectiveness of 0.12% chlorhexidine gluconate oral rinse in reducing prevalence of nosocomial pneumonia in patients undergoing heart surgery. American Journal of Critical Care, 11, 567-570. McEwen, M., & Wills, E. M. (2007). Theoretical basis for nursing (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Melnyk, B., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & healthcare: A guide to best practice. Philadelphia, PA: Lippincott, Williams & Wilkins. Neil, J. (2004, June 04). Unfreeze-change-refreeze or square-blob-star model of change. Retrieved April 10, 2010, from http://wilderdom.com/theory/UnfreezeCgangeRefreeze.html Newhouse, R., Dearholt, S., Poe, S., Pugh, L., & White, K. (2007, December 1). Organizational change strategies for evidence-based practice. The Journal of Nursing Administration, 37(12), 552-557. Polit, D. F., & Beck, C. T. (2008). Nursing research: Generating and assessing evidence for nursing practice (8th ed.). Philadelphia, PA: Lippincott Williams & Willkins. Reavy, K., & Tavernier, S. (2008, April). Nurses reclaiming ownership of their practice: Implementation of an evidence-based practice model and process. The Journal of Continuing Education in Nursing, 39(4), 166-172. 22 Smulders, K., Hoeven, H., Pothoff, I. W., & Grauls, C. V. (2002). A randomized clinical trial of intermittent subglottic secretion drainage in patients receiving mechanical ventilation. CHEST, 121, 858-862. Thompson, P., Bell, P., & Prevost, S. (1999, February). Overcoming barriers to research-based practice. MedSurg Nursing, 8(1), 59-63. Tsai, H. H., Lin, F. C., & Chang, S. C. (2008). Intermittent suction of oral secretions before each positional change may reduce ventilator-associated pneumonia: A pilot study. The American Journal of the Medical Sciences, 336, 397-401. doi:10.1097/MAJ.0b013e31816b8761 Udod, S., & Care, W. (2006, October). Setting the climate for evidence-based nursing practice: What is the leader's role? Canadian Journal of Nursing Leadership, 17(4), 64-75. 23 Appendix A Management of Mechanically Ventilated Patients: Pilot Project Goals/outcomes The patient will maintain adequate breathing pattern to provide appropriate oxygenation and acid/base balance while providing respiratory muscle rest. The incidence for VAP will be reduced due to EBP pilot project interventions. Definitions Acid/base balance = determined by pH values from arterial blood gas VAP = Ventilator Associated Pneumonia RCP = respiratory care practitioner EBP = evidence based practice Assessment • Assess and document breath sounds every four (4) hours and as needed. • Monitor and verify ventilator settings every two (2) hours and as needed. Assure that ventilator alarm volumes are audible at all times. • Monitor arterial blood gases per physician order. Notify physician as needed. Interventions A. Wash hands with antiseptic soap and water or apply alcohol-based hand gel before and after performing interventions. B. The patient will be assigned to a hospital bed allowing maximum visibility at all times. C. Utilize oral airway if patient is obstructing oral endotracheal tube. D. Suction as needed; document amount, color and character of tracheal secretions. (Utilize humidified oxygen set-up to maximize mobilization of secretions.) E. Reposition every two hours and as needed (unless contraindicated), suction oral 24 Appendix A Continued secretions prior to position change. Elevate head of bed to at least 30 degrees (unless contraindicated). F. Use oral cleaning and suction system. 1. Brush teeth and tongue a minimum of once every 12 hour shift. 2. Provide oral care every 2 hours with chlorhexidine rinse. 3. Perform oral suctioning every two hours and prior to position change. G. Document and report to physician significant changes in pulmonary status and secretions through collaboration of RCP and RN. H. Culture tracheal secretions per physician's order. I. Keep Ambu-bag mask and adapter with patient at all times for transport and/or emergency. J. If the patient exhibits signs/symptoms of respiratory distress or ventilator alarm sounds and problem cannot be quickly identified, disconnect patient from the ventilator, manually ventilate, and call for appropriate assistance. K. Reduce anxiety by: 1. Explaining all procedures to the patient. 2. Providing alternative methods of communication while intubated. 3. Re-assuring the patient that extraneous alarms are normal and do not usually indicate an emergency situation. Indicate appropriate medical personnel are always close by. 4. Placing the "nurse call" button within patient's reach. 5. Administering sedatives/analgesics as ordered. L. Weaning - Follow specific weaning/extubation orders per respiratory protocol or as written by the physician. Supportive Data See Reference list 25 Appendix B Questions for Patient Ventilator Rounds Patient Care Question Answer from Staff Hospital day number Number of days ventilated Oral care Q2 Use or Chlorhexidine with oral care* Removal of secretions prior to position changes* Head of bed 30 degrees Repositioning Every 2 hours SUP prophylaxis DVT prophylaxis Sedation vacation White Blood Cell Count Temperature (max/low in 24 hours) “*” indicates interventions added to the current existing protocol 26 Appendix C Methodological Matrix and Evaluation Matrix Country Theory Dependent Variables Independent Variables Study design Sample size DeRiso, 2002 A. Ladowski , J.Dillon, T. Justice, J.Peterson , A. USA Quantitative nosocomial infections chlorhexidine gluconate oral rinse Prospective randomized placebocontrolled double-blind experiment 353 Randomized surgical patients undergoing heart surgery data analyzed of patient outcomes after interventions complete Houston, 1996 S. Hougland , P. Anderson, J. LaRocco, M. Kennedy, V Gentry, L. USA Quantitative nosocomial pneumonia chlorhexidine gluconate oral rinse Prospective Randomized case-controlled 561 Randomized surgical patients undergoing heart surgery Observation &Self report Author Pub Yr Sampling Method How data collected 27 Appendix C Methodological Matrix and Evaluation Matrix Continued Author Pub Year Country Theory Dependent Variables Independent Variables Study Design Sample Sampling Method Size How data collected Smulders, K., Hoeven, H., Pothoff, I. W., & Grauls, C. V. 2002 Netherlands None Incidence of VAP; duration of mechanical ventilation; length of ICU stay; length of hospital stay; and mortality Intermittent suctioning of subglottic secretion with 100mg Hg for 8 sec. duration and 20 sec. interval. A randomized clinical Trial N= 150 Random assignment of patients into experimental or control group, who were admitted to ICU over 13 month period and were expected to receive mechanical ventilation >3 days Observation & Self report Chao, Y. C., Chen, Y., Wang, K. K., Lee, R., & Tsai, H 2008 Pulmonary infection causing VAP Removal of secretions prior to position change 2-group comparison randomized study Random ICU patient admission. Patients 18 yrs of age or older. On a ventilator for more than 24 hours. Observation & Self report from staff Taipei, Taiwan Not listed in Article but assumed by reader= Germ Theory of Louis Pasteur Study group= 75 Control gp= 75 Control group= 159 Study group= 102 (Those with pneumonia before intubation or within 48 hours after intubation were excluded) 28 Appendix C Methodological Matrix and Evaluation Matrix Continued Author H-H Tsai, F-C Lin, S-C Chang Pub Year 2008 Country Theory Taiwan None Dependent Variables VAP occurrence and incidence Independent Variables Intermittent suction of Oral Secretions before each position change Study Design Quasi-exp. Nonrandomized Pilot Study Sample Size Study group= 227 Control group= 237 Sampling Method How data collected All patients admitted Self-report to ICU who did not and have: observation endotracheal by senior intubation (EI) and staff mechanical ventilation (MV) more than 3 days prior to ICU admission, presence of tracheostomy, pneumonia before ICU admission, nonventilated, EI & MV < 48 Hours, ICU admission less than 48 Hours. 29 Appendix D VAP Prevention In- Service Flyer VAP Prevention In-service for New Interventions! Mandatory for All Nursing Staff in ICU. Please attend one of the following: November 20, 2010 8 a.m. – 9 a.m. and 8 p.m. – 9 p.m. Or November 23, 2010 11 a.m. - 12 noon and 10p.m. - 11p.m. Evidence-Based Practice Proposal Final Paper Overview 1. Throughout this course you will be developing a formal, evidence-based practice proposal. 2. The proposal is the plan for an evidence-based practice project designed to address a problem, issue, or concern in the professional work setting. Although several types of evidence can be used to support a proposed solution, a sufficient and compelling base of support from valid research studies is required as the major component of that evidence. Proposals are submitted in a format suitable for obtaining formal approval in the work setting. Proposals will vary in length depending upon the problem or issue addressed; they can be between 3,500 and 5,000 words. The cover sheet, abstract, references page, and appendices are not included in the word limit. 3. Section headings and letters for each section component are required. Responses are addressed in narrative form in relation to that number. Evaluation of the proposal in all sections is based upon the extent to which the depth of content reflects graduatelevel critical-thinking skills. 4. This project contains six formal sections: a) Section A: Organizational Culture and Readiness Assessment b) Section B: Problem Description c) Section C: Literature Support d) Section D: Solution Description e) Section E: Change Model f) Section F: Implementation Plan g) Section G: Evaluation of Process 5. Each section (A – G) will be submitted as separate assignments so your instructor can provide feedback (refer to each Module and the Course Assignment Matrix). 6. The final paper will consist of the completed project (with revisions to all sections), title page, abstract, reference list, and appendices. Appendices will include a conceptual model for the project, handouts, data and evaluation collection tools, a budget, a timeline, resource lists, and approval forms. 7. Use the EBP Implementation Plan Guide and the Evidence-Based Practice Project Student Example to assist you. © 2014. Grand Canyon University. All Rights Reserved. Evidence-Based Practice Project Proposal Format Use the following format and headings when constructing your final evidence-based practice project proposal paper. 1) Abstract (Needs to be between 120 and 350 words) a) Contains project title, project director’s name, and affiliation. b) Presents a complete concise overview of all phases of the proposed project. 2) Section A: Organizational Culture and Readiness Assessment 3) Section B: Problem Description 4) Section C: Literature Support 5) Section D: Solution Description 6) Section E: Change Model 7) Section F: Implementation Plan 8) Section G: Evaluation 9) Appendices a) Critical Appraisal Checklists b) Evaluation Table c) Conceptual Models d) Timeline e) Resource List f) Proposal Instruments g) Data Collection Tool h) Budget i) Optional i) Approval Forms ii) Handouts iii) Evaluation Tools © 2014. Grand Canyon University. All Rights Reserved. Course Code NUR-699 Class Code NUR-699-O501 Criteria Content Percentage 55.0% Abstract Presents a complete, concise overview of all phases of the proposed project. 10.0% Project / Content Comprehension 25.0% Sections A-G Synthesis 20.0% Organization and Effectiveness 30.0% Appendices 15.0% Mechanics of Writing (includes spelling, punctuation, grammar, language use) 15.0% Format 15.0% Research Citations (In-text citations for paraphrasing and direct quotes, and reference page listing and formatting, as appropriate to assignment and style) 15.0% Total Weightage 100% Assignment Title Benchmark - Evidence-Based Practice Proposal Final Paper No Submissions (71.00%) None None None None None None Total Points 250.0 Unsatisfactory (75.00%) No abstract Content is incomplete or omits most of the requirements stated in the assignment criteria. Does not demonstrate an understanding of the basic principles. Does not demonstrate critical thinking and analysis of the overall program subject. The main sections are not easily identified; some of the subconcepts do not successfully integrate to form a cohesive whole. Within section revisions methods and strategies are described poorly. Basic descriptions, connections, and alignment are not clearly presented. Logic flow is random, not easily understood. Several of the appendices are missing. Designs are not neat or organized, and do not include all required elements. Unprofessionally developed. Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice and/or sentence construction are used. No reference page is included. No citations are used. Less Than Satisfactory (83.00%) Abstract minimally written, clearly not sufficient to provide the reader with an understanding of the project. Content is incomplete or omits some requirements stated in the assignment criteria. Demonstrates shallow understanding of the basic principles. Within section revisions components may be missing details, only a surface level of evaluation is offered, methods are described but flawed or unrealistic and strategies are discussed, but incomplete. The main sections are somewhat identified; some of the subconcepts branch appropriately from the main sections. Basic descriptions, connections, and alignment as well as a clear logic flow are somewhat fragmented, not easily understood. Several of the appendices are missing. Design detracts from purpose. The work is not neat and includes minor flaws or omissions of required elements. Limited understanding of the topic is present as evidenced by the design. Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register), sentence structure, and/or word choice are present. Reference page is present. Citations are inconsistently used. Satisfactory (88.00%) Abstract provides overview of part of the project, but does not cover each section. Content is complete, but somewhat inaccurate and/or irrelevant. Demonstrates adequate understanding of the basic principles. The major sections have had revisions but some components may be missing details. Reasonable but limited inferences and conclusions are drawn but lack development. Supporting research is inadequate in relevance, All of the main sections are easily identified, and subconcepts branch appropriately from the main sections. Recognizes links among sections; however, some connections may be ambiguous. Basic descriptions, connections and alignment as well as basic logic flow are understandable, but are somewhat lacking in a clear progression. All of the appendices have been provided. Design is fairly clean, with a few exceptions. Appearance is general, and major elements are missing. Provides minimal details. Appropriate for the audience and the content but some of the development of the material is inadequate. Basic understanding of the topic is present as evidenced by the Some mechanical errors or typos are present, but are not overly distracting to the reader. Correct sentence structure and audience-appropriate language are used. Reference page is included and lists sources used in the paper. Sources are appropriately documented, although some errors may be present. Good (92.00%) Abstract provides a quick or too brief overview of all phases of the proposed project. Contains project title, project director's name, and affiliation. Content is comprehensive and accurate, and definitions are clearly stated. Sections form a cohesive logical and justified whole. All of the major sections have been revised based upon logical feedback, conclusions, and sound research. Shows careful planning and attention to details and illuminates relationships. Research is adequate, current, and All of the main sections are easily identified, and subconcepts branch appropriately from the main sections. Descriptions, connections, and alignments are provided. Logic flow is smooth and easily understood, facilitating a thorough understanding of the various sections as they interrelate. All of the appendices have been provided. Designs are appropriate and present quality products. Appearance is neat, with a few minor flaws or missing elements. Provides details with accuracy. Reveals a solid understanding of the topic as evidenced by design. Prose is largely free of mechanical errors, although a few may be present. A variety of sentence structures and effective figures of speech are used. Reference page is present and fully inclusive of all cited sources. Documentation is appropriate and citation style is usually correct. Excellent (100.00%) Abstract provides a complete concise overview of all phases of the proposed project and flows well with the rest of the paper. Contains project title, project director's name, and affiliation. Content is comprehensive. Presents ideas and information beyond that presented throughout the course, and substantiates their validity through solid, academic research where appropriate. Research is thorough, current, and relevant, and addresses all of the issues stated in assignment criteria. Final paper exhibits process of creative thinking and All main sections are easily identified, and sub concepts branch appropriately from main sections. Descriptions, connections, and alignments are obvious and well supported. Logic flow is smooth and easily understood, facilitating a thorough understanding of various sections as they interrelate. Connection to extraneous materials are well All of the appendices have been provided. They are effective and functional. The work is well presented and includes all required elements. The overall appearance is neat and professional. Gives sufficient detail with precision and specificity. Reveals a solid understanding of the topic as evidenced by the design. Writer is clearly in command of standard, written, academic English. In-text citations and a reference page are complete and correct. The documentation of cited sources is free of error. Comments Points Earned
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Evidence-Based Proposal for Adult Influenza Vaccination- Outline
Thesis Statement: While the influenza vaccine is crucial for preventing the flu, there is little
knowledge and efforts to obtain it among many adults. There is therefore the need to look into
the effectiveness of the flu vaccine among adults as a move towards convincing more people to
get vaccinated regularly.
I. Section A: Organizational Culture and Readiness Assessment
II. Section B: Problem Description
III. Section C: Literature Support
IV. Section D: Solution Description
V. Section E: Change Model
VI. Section F: Implementation Plan
VII.

Section G: Evaluation of Process


Running head: EVIDENCE-BASED PROPOSAL

Evidence-Based Proposal for Adult Influenza Vaccination
Name
Institution

1

EVIDENCE-BASED PROPOSAL

2
Abstract

Influenza vaccinations are essential in preventing death caused by the flu. As one of the adult
vaccinations, influenza vaccines have not been welcome for most of adult population and this
project works to increase acceptance and also vaccination rates. Focused in a healthcare
organization, the researcher sets out to sensitize medical personnel on the importance of the
vaccine and also train them on attracting patients for the vaccination. The training takes place
over a two-week period and follow-up on medical personnel’s education of patients takes two
months. The main focus of this evidence-based proposal is to implement a project of vaccination
based on education to both medical employees and patients as well. The anticipated change is
that a positive attitude and an increase in influenza vaccination rates will be realized in the
participants.

EVIDENCE-BASED PROPOSAL

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Contents
Abstract ........................................................................................................................................... 2
Section A: Organizational Culture and Readiness Assessment ...................................................... 4
Section B: Problem Description...................................................................................................... 5
Section C: Literature Support ......................................................................................................... 7
Section D: Solution Description ..................................................................................................... 9
Section E: Change Model ............................................................................................................. 12
Section F: Implementation Plan .................................................................................................... 14
Section G: Evaluation of Process .................................................................................................. 16
References ..................................................................................................................................... 19

EVIDENCE-BASED PROPOSAL

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Section A: Organizational Culture and Readiness Assessment
To assess the readiness of the organization for the evidence-based practice (EBP) project,
an organizational culture assessment survey was conducted. The organization is averagely ready
for the intervention. Primarily, the survey tool looked into communication, employee
satisfaction, change management, inter- and intra-departmental relations, and comparison of the
organization with other organizations. The highest scores among employees were in
communication and departmental relations. One of the causes for high scores in communication
was the fact that many employees found communication very open. According to Kowalski
(2017), strong and open communication channels are effective in promoting a culture of
collaboration in projects and that is expected of the organization in focus. Secondly,
departmental relations can be seen as an extension of communication capabilities. For instance, a
majority of respondents answered that their departments dealt fairly with everyone and did not
play favorites. Fairness at the departmental level affects project implementation by determining
the support which the employees will provide to it (Seifert et al., 2016). Therefore, it is expected
that departmental relationships within and outside the department will support the EBP and make
it a success.
On the other hand, significantly low scores were realized in change and change
management hence providing a weakness in implementing new projects. Majority of employees
scored company support to change very low (2/5 and below). Farzandipur (2016) claims that
management support is a huge barrier to project implementation if the management does not
support change. Therefore, the major barrier in this organization will be the organization’s
management. However, a strong cooperation culture as observed in the departments will be the
main facilitator for the project.

EVIDENCE-BASED PROPOSAL

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Moreover, clinical inquiry using the PICOT question will be necessary to implement EBP
in the organization. The integration of clinical inquiry will require the support of the organization
management for project success (Breckenridge-Sproat et al., 2015). The project will thus focus
on selling the idea to the management and persuading it to gain access to the organization’s
employees for EBP. Additionally, for clinical inquiry to work, targeted material resources will be
used for assessing employee outcomes on the PICOT question (Bober et al., 2016). The reason
for using targeted material is that since the PICOT is specific and timed, the characteristics of the
participants need to be incorporated as well. Overall, the employees of the organization are ready
for EBP but the management is not entirely ready to support the same. The main barrier to
implementation is the acquisition of cooperation from the organization management. Other than
the management, implementation of changes in the workplace may be problematic due to the
researcher’s lack of authority in the organization; it is possible that employees may resist the
EBP because the researcher is an outsider.
Section B: Problem Description
Vaccination is often seen as a health practice for children to be protected from diseases
when they are growing up. However, adults also require vaccination for various diseases and one
of the least utilized vaccinations recommended by the Centers for Disease Control Prevention is
the seasonal influenza vaccination (CDC, 2018). Influenza vaccines have been promoted by the
Department of Health Human Services and especially for people with chronic diseases, pregnant
women, and older adults. While the influenza vaccine is crucial for preventing the flu, there is
little knowledge and efforts to obtain it among many adults. There is therefore the need to look
into the effectiveness of the flu vaccine among adults as a move towards convincing more people
to get vaccinated regularly.

EVIDENCE-BASED PROPOSAL

6

The vaccination of adults has numerous stakeholders and change agents who should be
included or consulted for this clinical inquiry. The Adult Vaccine Access Coalition (AVAC) is a
body that has come together to raise awareness and improve access to vaccines by adults
(AVAC, n.d.). Similarly, the CDC is a major stakeholder as it is the official governmental
agency which oversees the administration of vaccines and it also promotes awareness on the flu
vaccine (CDC, 2018). The organizational employees will benefit from this proposal because they
are the primary participants in the inquiry question and also the target population. Additionally,
students performing this research will benefit from finding applicable results in practice and
these will be transferred to the nursing profession.
Moreover, to complete this EBP project, the following PICOT question will be used: In
patients 35 years and older (P), that receive vaccinations (I) compared to not receiving
vaccinations (C) what is the rate of flu infections (O) over five months (T)?
This question focuses specifically on adult vaccination for influenza.
Furthermore, the specific, realistic, and measurable project objectives are as shown below:
1. To determine the number of people who are infected by flu virus after adult vaccinations
have been administered.
2. To measure any changes in flu infection rates among adults 35 years and older after
vaccinations have been administered.
To achieve the above objectives, measurements will be taken before and after the
intervention. The pre-test measurements will be in order to track the changes that occur with the
intervention and hence make it measurable (Valente and Mackinnon, 2017). Additionally, these
objectives generally seek to identify whether the vaccination is effective in reducing rates of flu
infection among the participants.

EVIDENCE-BASED PROPOSAL

7

Influenza vaccination rates are low in the U.S despite the requirement that people should get
vaccinated every year. In the 2017-2018 season, the vaccination rates were 37.1% for all adults
and this was a decrease of 6.2% from the previous season vaccination (CDC, 2017). These
numbers are worrying and there is the need to show the importance of the vaccination.
Moreover, every season has unique characteristics of flu and hence there is a rising need to
understand these characteristics and work with the vaccines to prevent increase in deaths
(Bekkat-Berkani and Romano-Mazzotti, 2018). Influenza is a menace to the U.S and it even kills
hence the need to focus on the symptoms and vaccination against the disease.
Section C: Literature Support
A comprehensive electronic search was contributed using the following databases:
Google Scholar, Medline, Cochrane, and CINAHL. The study was limited to scholarly, peerreviewed articles between 2010 and 2019 hence ensuring the currency of these studies. The study
was conducted using the following key words: adult vaccination, influenza vaccination, health
education, and vaccination. From the search, 29 articles were found. Out of the 29, a close
assessment and screening narrowed them to 7 articles that handled matters of influence
vaccination and its effectiveness in preventing the infection in adults. The full reference of these
studies is in Appendix A. From the 7 articles found in this literature review, various findings
regarding the influenza vaccination were discovered. This review also looks into the validity of
articles. Validity is an indication of how sound each research it in terms of the measurement of
the variables and methods used.
The first step into understanding influenza vaccination is looking into the nature of the
illness. In the article by Bekkat-Berkani & Romano-Mazzotti (2018), the authors look into the
characteristics of the seasonal influenza affecting many Americans. The authors conducted a

EVIDENCE-BASED PROPOSAL

8

review of the current state of influenza vaccinations in the country. They looked into the
coverage if the vaccine and compared it to the Healthy People 2020 plan and found that coverage
is currently below the predicted levels of 70%. Additionally, they identified that the seasonality
of the vaccine produces an extra burden to people who perceive the requirement to be vaccinated
every season as a burden to them. This article’s validity is limited by the fact that it depends on
secondary data to conclude on the current state of the vaccination in the U.S. Generally,
however, it captures the interesting phenomenon of burdening Americans with the vaccine.
Additionally, Hopping et al. (2016) looked into the effects of age on the effectiveness of
vaccine. Their study included two age groups; one between ages 16 and 39 while the other was
between 62 and 92 years of age. The results showed that the difference in effectiveness of
vaccines really depended on the pre-vaccination treatment and not age. The internal validity of
this research is boosted by the use of quasi-experimental approaches in conducting the study.
However, the external validity is interrupted by the lack of generalization of the findings to
population outside of the U.S. Overall; the study shows that vaccinating older adults is just as
necessary as vaccinating middle-aged adults with the influenza shot.
More research on the topic has been conducted on the socio-psychological factors
surrounding adult vaccinations and the issues that might work to limit the move. Primarily,
Wheelock et al. (2014) looked into the social influences and risk perceptions of diseases among
adults and how they affect vaccination. In this qualitative study, the researchers conducted 20
face-to-face interviews with members of the public in the United Kingdom to understand their
understanding of adult vaccines. They found that adults’ uptake of the influenza vaccine was
largely determined by their perception of risk and illness while vaccines for tetanus depended on
whether they found them safe and tested (Wheelock et al., 2014). This research shows that the

EVIDENCE-BASED PROPOSAL

9

individual perceptions of risk affect the people’s acceptance of influenza vaccines among others.
While this research was an effective qualitative effort to understand factors affecting vaccines, it
cannot be generalized in the U.S since it was conducted in the U.K and the two communities
may have distinct characteristics.
In another study, an analysis of studies of the effectiveness of adult vaccines for influenza
was conducted. This systematic review of studies was conducted by Jefferson et al. (2010) and it
showed that influenza vaccines have a moderate effect on the infection of influenza on adults.
The study thus showed that the vaccines cannot be depended on to adequately prevent the virus.
It also showed that it cannot be depended upon for complications such as pneumonia and
transmission and hence should not be effected for such. The internal validity of this study is seen
in the way it was created as a review of articles on the same and hence produces a large list of
articles for review. This increases the validity of the results due to a large sample for the study.
In another meta-analysis of the efficacy and effectiveness of licensed influenza vaccines
in the U.S.A, the researchers confirmed that influenza vaccinations can provide moderate
protection against the influenza virus (Osterholm et al., 2012). In this meta-analysis, the authors
realized that there was an urgent need for new vaccines which effectively reduce mortality and
morbidity in both adults and children. The major weakness of this study is that it did not capture
data for adults aged 65 years and above. As such, the study cannot be generalized to the entire
population. Notably, the study confirmed the findings of Jefferson et al. (2010) regarding the
efficacy and effectiveness of the influenza vaccine.
Section D: Solution Description
The identified problem for this evidence-based practice (EBP) project is the lack of
knowledge and adoption of the adult influenza vaccination. The proposed solution, therefore, is

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10

to implement staff and patient education on influenza vaccines for adults. The proposed
intervention is aimed to increase awareness and also increase the recipients’ willingness to
receive vaccinations. According to research performed by Malosh et al. (2014), adults who were
more educated on vaccination were more likely to avail themselves for vaccination. Additionally,
the intervention educates not only the population but also the staff in the healthcar...


Anonymous
Really helpful material, saved me a great deal of time.

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