what is and is not a dnp project...• projects are no longer called a “capstone project” or...

What is and is not a DNP project

Change in Name• Projects are no longer called a “capstone project” or “scholarly project” • Now referred to as DNP Projects

UMSON DNP Project Courses

• DNP Project Identification

NDNP 810

• DNP Project Development

NDNP 811

• DNP Project Implementation

NDNP 812

• DNP Project Evaluation / Dissemination

NDNP 813

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Note: The project should be identified in the Diagnosis and Management courses prior to entering NDNP 810.

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Presentation Notes

There are 4 courses related to the DNP project in this program. NDNP 810 is the first of the four project courses. In this course, you will examine the evidence to support your project and begin to write the proposal. This course is only offered in the Spring semester. In the second course – NDNP 811, you will finish writing your proposal, plan a presentation of your proposal, and submit your proposal to the Institutional Review Board. This course is offered in the Summer semester In the next course – NDNP 812, you will implement your project . This course is always offered in the Fall semester. Keep in mind that all of the implementation of the project must be done in this 15 week semester, including the collection of all evaluation data for your project. You will receive 45 practicum hours for implementing your project. The last course is NDNP 813, in which you will evaluate the data you collected the previous semester and write up a final report. This course is offered in the Spring semester. You will receive 45 practicum hours for evaluating your data and writing the final report and presenting it. Note: Prior to entering NDNP 810, the project should be identified by faculty and students in the Diagnosis & Management courses. Students who wait until taking NDNP 810 to begin identifying a project will be challenged to meet the assignment deadlines and be successful in the course.

What is a DNP project?

AACN Guidelines for DNP Projects• The DNP Project should be the same for all students and

include planning, implementation, and evaluation components.

• As an outcome of the program, students must have the opportunity to integrate all DNP Essentials into practice. However, all eight Essentials do not have to be demonstrated in the DNP Project.

(AACN Report from the Task Force on the Implementation of the DNP, 2015)

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Some of the guidelines from the white paper are listed here.

All DNP projects should:a) Focus on a change that impacts healthcare outcomes either

through direct or indirect care. b) Have a systems (micro-, meso-, or macro- level) or

population/aggregate focus. c) Demonstrate implementation in the appropriate arena or area of

practice. d) Include a plan for sustainability (e.g. financial, systems or political

realities, not only theoretical abstractions). e) Include an evaluation of processes and/or outcomes (formative or

summative). f) Provide a foundation for future practice scholarship.

(AACN Report from the Task Force on the Implementation of the DNP, 2015)

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These guidelines are also taken from the DNP White paper.

Quality Improvement“the combined and unceasing efforts of everyone – health care professionals, patients and their families, researchers, administrators, payers, planners, educators – to make changes that will lead to better patient outcomes, better system performance, and better professional development”

Ogrinc et al., 2013Ogrinc, G., Nelson, W.A., Adams, S.M., & O’Hara, A.E. (2013). An instrument to differentiate between clinical research and quality improvement. IRB Ethics & Human

Research 35(5), pp. 4-5.

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Most of the DNP projects at UMSON consist of some form of quality improvement (QI). Here is a definition of QI. Ogrinc, G., Nelson, W.A., Adams, S.M., & O’Hara, A.E. (2013). An instrument to differentiate between clinical research and quality improvement. IRB Ethics & Human Research 35(5), 4-5.

Quality Improvement is the Responsibility of Health Care

Providers“QI is an ongoing process undertaken as a consequence of health care providers’ responsibility to serve their patients’ interests. This makes it very different from research.”

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Baily, M.A., Bottrell, M., Lynn, J., & Jennings (2006). Special report: the ethics of using QI methods to improve healthcare quality and safety. The Hastings Center:

Garrison New York.

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Presentation Notes

In 2006, The Hasting Center, a healthcare ethics think tank, formed an expert panel that released a special report titled The Ethics of Using QI Methods to Improve Healthcare quality and safety. In this report they state that Quality Improvement is the responsibility of health care providers “as a consequence of health care providers’ responsibility to serve their patients’ interests”. This is different than research because human subjects research is being conducted to find out the effects of a given treatment on patients. We won’t know until the research is completed whether the treatment improved patient outcomes. However, QI is working to ensure that all patients are provided high quality and safe evidence-based healthcare. Thus, it is the responsibility of all health care workers to perform QI, but it is not their responsibility to perform research. There is more to explore on the topic of QI Ethics so an entire segment on QI ethical considerations is being developed.

“It has become generally understood that discovery is the domain of the former [PhD] and translation the work of the latter [DNP].”

“…translation seeks to bring evidence to bear on challenges in the real world of practice using reliable and valid evidence to improve care.”

[email protected] 9

White, K.M., Dudley-Brown, S., & Terhaar, M.F. (2016). Translation of evidence into nursing and health care. Springer Publishing Company, New York, NY, pg. XV.

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It is now generally understood and there is general agreement that … Someone with a PhD is prepared to do research or discover new treatments. Someone with a DNP is prepared to translate new research findings into practice

Bingham’s Flow Chart Illustrating the Distinctions Among Evidence-Based Practice, Research, Implementation and Improvement

Science, and Quality Improvement

1. Evaluate & Grade the

Research or Evidence for the Practice (EBP),

Review Population

Health Data & Clinical

Outcomes*Review surveillance & utilization data to track and review population health and outcomes.*Review the research literature to determine which current practices need to change & how. *Determine the level of evidence and Evidence-Based Practice (EBP) Gaps

Human Subjects Research

to Generate

New Clinical

Knowledge

Implementation Science Research

Develop and test theories, frameworks,

models

2. Design and Implement a

Quality Improvement

Initiatives*Implement evidence-based care using QI implementation and improvement science.*Utilize process models, determinant frameworks, classic theories, & implementation theories*Small tests of change

3. Evaluate & Determine Next Steps

*Program evaluation:-Structures, -Processes, -Outcomes (Healthcare & Population Health)*Identify practice & policy implications*Track un-intended consequences*Recommend modifications*Sustain*Spread

©Institute for Perinatal Quality Improvement

Improvement Science

(Translation)Study Implementation Methods (Strategies &

Tactics, Validated Measures,

Organizational Readiness, Barriers & Facilitators, Fidelity,

etc.)

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Presentation Notes

Bingham’s flow chart may be helpful for further illustrating how the DNP Quality Improvement projects relate to Evidence-based practice, human subjects research, implementation science, and improvement science. This flow chart divides QI into 3 steps. First, Evaluate and grade the research, evaluate current practice gaps, and review population health data and clinical outcomes to determine what needs to change or what research is needed. This review of evidence is the foundation for both Research and QI. There are several models for helping guide this level of exploration, e.g., the IOWA Model, PICO. This section corresponds with 810. The 2nd step in developing a QI project is to then design and implement the project. This step needs to include acknowledgement and awareness of implementation science research as well as improvement science methods. There are process models and theories that are more commonly utilized than others. At a minimum the QI leader needs to know what are the most common constructs within these models and theories. The 2nd step corresponds with 811 and 812. The 3rd QI step is then to evaluate the QI initiative and determine the next steps. This step corresponds with 813. Within the research domain there are 3 different types of Inquiry There is human subjects research – this type of research generates new clinical knowledge There is Implementation Science Research – this type of research is published in the Journal of Implementation Science. According to the National Institutes for Health Implementation science is the study of methods to promote the integration of research findings and evidence into healthcare policy and practice (NIH, 2015). Improvement Science or the translation of knowledge into practice or the Diffusion of Innovations refers to the methods that were used to translate research into practice. For example, what were the strategies and tactics the implementer utilized, what were their measures of progress – were these measures validated, what were the barriers and facilitators that were identified during implementation. This flow chart was designed to highlight the distinctions between QI and research. However, as indicated by the arrows, there is a great deal of interaction between QI and Research. In addition, there are multiple frameworks, theories, and models, and tools that are utilized within each of the boxes. For example, If your students are working in QI Box #2 – titled Design and implement a QI Improvement initiative, you will want to help them select an implementation framework and a process model that will guide their implementation design and processes. DNP student projects should be developed based on the findings from human subjects research, implementation science research, and utilize improvement science methods.

DNP QI projects should be based on the findings from human subjects research, implementation science research, and utilize improvement science methods.

Steps in QI projects1) Understand and summarize the current evidence related to the practice problem – make the case for why the change is needed.2) Assess the current practice to identify gaps (communication, knowledge, workflow, etc.).3) Utilize an Implementation Science Theoretical Framework, QI Improvement Science methods, and QI Process Models to create a plan for implementation of a practice change to address these gaps.4) Implement, monitor, and revise plan as needed.5) Evaluate and disseminate findings including recommendations for sustainability and possibly spread.

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Presentation Notes

As part of the implementing a QI project, the DNP student must: understand the current evidence related to the practice problem assess your current practice to identify gaps (communication, knowledge, workflow, etc. ) use a QI methodology to create your plan for implementation of a practice change to address these gaps implement, monitor, and revise plan as needed

Quality Improvement

Program Development,

implementation, & Evaluation

Development of a Clinical Practice

GuidelineHealth Policy Projects

Implementation of an Evidence Based Practice

Change

Types of QI Projects

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Presentation Notes

There are 4 common types of QI projects that UMSON students typically implement - implementation of an evidence-based practice change health policy projects development of a clinical practice guideline program development, implementation, and evaluation The next few slides will provide some examples of each type of QI project that have been implemented by UMSON students

Examples: Implementing an Evidence Based Practice Change

• Implementing a standardized tool for reporting violence in an emergency

• Implementing an obesity clinical practice guideline in a primary care group

• Implementing an evidence-based EKG prioritization rule to decrease door-to-EKG times

• Implementing a surgical bundle to reduce surgical site infection

Examples: Health Policy Projects

• Development of a policy toolkit to support reintroduction of a nurse practitioner (NP) full practice authority bill

• Identification and removal of signatory barriers for Advanced Practice Registered Nurses

Examples: Program Development, Implementation and Evaluation

• Implementing a school based asthma action program to increase knowledge of asthma and self-care management skills among elementary school children

• Implementing a nurse-led program for the early identification of substance use disorders in primary care

• Implementing a nurse residency program for Army Public Health Nurses

Examples: Clinical Practice Guideline (CPG) Development

• Development of a CPG for preoperative glucose management for diabetic patients undergoing orthopedic surgery

• Development of a CPG for intraopearative glucose management for diabetic patients undergoing orthopedic surgery

• Development of a CPG for postoperative glucose management for diabetic patients undergoing orthopedic surgery

Clinical Practice Guidelines• Implementation of a CPGs by DNP student(s) is often focused on

the initial stage of developing the guideline with a team of experts, and then having that guideline evaluated by key stakeholders– Development begins with the student providing a first draft of the CPG to the

team of experts and getting their input, revisions, and evaluation using the AGREE II tool

– Evaluation of a final draft is often done through surveys and requests for feedback of key stakeholders, and seeking administrative approval of the CPG

Since the above process usually takes the entire Fall Semester, implementation of the CPG itself (e.g., with patients at a clinical site)

should be reserved for a future DNP student(s) as a DNP project, or by staff and administrators in the area of practice

Group Projects• Maximum group size 3• Each member may work on a similar project at a

different clinical site or work on a separate part of a very large project at the same site.

• While some DNP projects may be done in small groups, each student is responsible for:– submitting separate and distinctly different course

deliverables (i.e., overview, literature review, evidence-review table, and implementation plan)

Presenter

Presentation Notes

Some students are working in groups on projects. Groups can be no larger than 3 students. Students must either be working on a similar project in a different clinical site or work on a part of a very large project in the same site. With the group projects, each student is responsible for a substantial contribution in implementing that project. We expect that the individual effort for these group projects will be no less than that for an individual project While some DNP projects may be done in small groups, each student is responsible for submitting separate and distinctly different course deliverables (i.e., overview, theoretical framework, literature review, evidence-review table, and implementation plan outline). Students within the same group are encouraged to discuss generalities of their projects and share evidence, but it is highly recommended that students within the same group do not proofread each other’s papers to minimize the possibility of plagiarism (intended or accidental). Student assignments will be checked for any duplication of written work with other group members through matches in SafeAssign. If matches are detected, the assignment will not be accepted for grading and a late penalty will be enforced until the student submits the assignment without matches. Students are encouraged to submit a draft of their assignment and check for matches to their group member’s work prior to submitting a final assignment for grading.

Example of Group Project at the Same Site (Preop Center)

• Implementing a clinical practice guideline for using chlorhexidine cloths preoperatively

• Implementing electronic prescribing of preoperatove medications

• Screening preoperatively for methicillin-resistant staphylococcus aureus colonization

Example of Group Projects in Different Sites

• Using TeamSTEPPS to enhance interdisciplinary communication and team skills among a cardiac surgery team across two units in the same hospital

• Creating a culture of teamwork in an emergency department through the use of TeamsSTEPPS framework across three units in the same hospital

What is not a DNP Project?

Research• Development and evaluation of a Vitamin D

deficiency risk tool

Why not? • This is a research study.•The study does not focus on the expected outcomes of the DNP program, such as analysis of evidence, translation of evidence into practice, leadership etc.

Integrative and Systematic Reviews• An integrated review of techniques for PTSD

and associated symptoms

Why not? • All DNP projects should be based on a thorough review of the literature. •Integrative and systematic reviews alone do not provide opportunities for students to develop and integrate scholarship into their practice.•All DNP projects must demonstrate implementation in the appropriate arena or area of practice.

In-service or Education Only• Improving diabetes treatment: An in-service

on clinical practice guidelines

Why not? • Providing an in-service is not considered doctoral level work, and the evidence shows that in-services alone are not effective in bringing about a change in practice. •All DNP projects must demonstrate implementation in the appropriate arena or area of practice.

Nursing Education• Use of simulation to increase knowledge

retention in undergraduate nursing studentsWhy not? • DNP projects must provide a more direct link to patient outcomes than education provided to nursing students. •The target population for a DNP project cannot be nursing students. •The DNP is a practice degree, and education is not considered an advanced practice specialty in nursing.

Needs Assessment• Needs assessment of high central line

infection rates in a surgical ICU

Why not? • A DNP project should not be considered unless there is enough evidence to determine that there is a need for practice change that is to be implemented. • The IRB will not approve implementation of a practice change without the details of what the needs are and what change will be implemented.

Development of a Policy or Procedure• Development of a policy and procedure for

the use of intranasal fentanyl in the emergency room

Why not? • All DNP projects must demonstrate implementation in the appropriate arena or area of practice. • There is no well established reliable and valid evaluation tool that can be used systematically for policies and procedures.

Resources for Faculty

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Presentation Notes

The slides that follow are resources for faculty members and may not be included in the use of slides for students.

Klein & Sorra’sImplementation Framework

[email protected] 30Klein, K.J., & Sorra, J.S. (1996). The challenge of innovation implementation. The Academy of

Management Review, 21(4), 1055-1080.

An example of a implementation framework that DNP Students

can use to guide their

implementation efforts.

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Presentation Notes

The Klein and Sorra implementation framework is an example of an implementation framework that DNP Students can use to guide their implementation efforts.

Mobilize

Assess

PlanImplement

Track

Mobilize

Assess

PlanImplement

Track

Mobilize

Assess

PlanImplement

Track

MAP-IT - A QI Process Model

Cycle 1 Cycle 2 Cycle 3

Mobilize – Assess – Plan – Implement - Track

Guidry, M., Vischi, T., Han, R., & Passons, O. Healthy people in healthy communities: a community planning guide using healthy people 2020. Washington, D.C., U.S. Department of

Health and Human Services. The Office of Disease Prevention and Health Promotion. Accessed 8/24/17: https://www.healthypeople.gov/2020/tools-and-resources/Program-

Planning

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Presentation Notes

MAP-IT is one QI Process Model that students can use to guide the planning and implementation phases of their DNP Projects. Other QI Process Models are: PDSA (Plan – Do – Study – Act) QI Process Models Emphasize the Importance of performing small tests of change, learning, then adjusting, as often as needed.

https://www.healthypeople.gov/2020/tools-and-resources/Program-Planning

Examples of QI Tools

• Process Flow Charts• Fish Bone Diagrams• Logic Models• Driver Diagrams

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Presentation Notes

There are many different types of QI Tools that Students can utilize when planning and implementing their DNP QI Projects. These tools are useful for helping clarify and synthesize their QI projects for themselves and for others.

QI Briefs - for FacultyA series of QI Briefs are being developed for the DNP Faculty. These Briefs are divided into 5 Parts:

1) QI Concepts2) QI Project Mobilizing, Assessing, & Planning3) QI Project Implementation & Tracking4) Sustainability and Spread5) Dissemination

QI Brief

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Presentation Notes

QI Briefs for faculty are recorded lectures for UMSON faculty and are available through Blackboard. You can find them by logging into Blackboard and click on the “My Institution” tab. Find the heading "My Organizations". Under the heading, click on "UMSON Quality & Safety Briefs Series". Click on this link and you should be able to see the QI Briefs Series menu sidebar on the left. Click on “Content” to ask the briefs.

what is and is not a dnp project...• projects are no longer called a “capstone project” or...

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