The Doctor of Nursing Practice Project: A Framework for Success [4 ed.] 1284255441, 9781284255447

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FOURTH EDITION

The Doctor

of Nursing Practice

Project A Framework for Success Katherine J. Moran, DNP, RN, CDCES, FADCES, FNAP Rosanne Burson, DNP, ACNS-BC, CNE, CDCES, FADCES, FNAP

Dianne Conrad, DNP, RN, FNP-BC, BC-ADM, FNAP

aJONES & BARTLETT

LEARNING

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The authors, editor, and publisher have made every effort to provide accurate information. However, they are not responsible for errors, omissions, or for any outcomes related to the use of the contents of this book and take no responsibility for the use of the products and procedures described. Treatments and side effects described in this book may not be applicable to all people; likewise, some people may require a dose or experience a side effect that is not described herein. Drugs and medical devices are discussed that may have limited availability controlled by the Food and Drug Administration (FDA) for use only in a research study or clinical trial. Research, clinical practice, and government regulations often change the accepted standard in this field. When consideration is being given to use of any drug in the clinical setting, the healthcare provider or reader is responsible for determining FDA status of the drug, reading the package insert, and reviewing prescribing information for the most up-to-date recommendations on dose, precautions, and contraindications, and determining the appropriate usage for the product. This is especially important in the case of drugs that arc new or seldom used. 25553-9

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DEDICATION

In dedication to nny family ... my husband Dave for always believing in me; my parents, James and Margaret Porrett, for their valuable life lessons; my son David, daughter-in-law Amy. daughter Nicole, and son-in-law Steven for continuing to inspire me; my sisters Lori and Lisa for their unwavering support; and my grandchildren Caleb. Ana. Ayla. Ella, and Connor for the absolute joy that they have brought to my life ... I am blessed. -Katherine Moran

This book is dedicated to my husband Steve, who has supported every endeavor along the way. Thank you for being an exemplary partner for every facet of our life and a wonderful role model for our

children, Lisa and Schuyler. Special thanks to my parents, Bev and Don. for always encouraging and believing in me. -Rosanne Burson

I dedicate this book to my husband and lifelong

partner, Alan J. Conrad, MD. He has always valued higher education and has encouraged me, as well as our sons, Paul and Mark, to prepare for our respective professions. He has made it possible and walked alongside me as I pursued each nursing degree from diploma to DNP. He is my mentor and collaborator in exemplifying the art and science of excellence in providing primary health care.

I also dedicate this book to my parents. Daniel and Carol Koval, who provided the foundation of instilling the values of hard work, dedication, and perseverance, as well as encouragement throughout my lifetime. —Dianne Conrad

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Brief Contents Acknowledgments

xiv

Contributors

XV

Foreword

xvii

Prefece

SECTION I

The Doctor of Nursing Practice Degree CHAPTER 1

CHAPTER 2

CHAPTER 3

SECTION II

xxiv

1

Setting the Stage for the Doctor of Nursing Practice Project

Defining the Doctor of Nursing Practice: Historical and Current Trends

19

Scholarship in Practice

51

Problem Identification

CHAPTER 4

CHAPTER 5

3

75

Population Health and Healthcare Policy

77

The Phenomenon of Interest:

Leading to Problem Identification

SECTION III

Assessment

CHAPTERS

iv

109

137

Validating the Problem and Conceptualizing the Project Plan

139

© Sandipkuinsi Patel/OigitalVision Vectoia/Getty Images

Brief Contents

SECTION IV Project Plan CHAPTER 7

V

197

Aligning Design, Method, and Evaluation with

CHAPTER 8

CHAPTER 9

the Clinical Question

199

The DNP Project Team: Preparing for Project Implementation

231

The Proposal

SECTION V Implementation CHAPTER 10

CHAPTER 11

CHAPTER 12

303

Leading Implementation Through Collaboration...

.305

Driving the Practicum to Attain Competency and Leverage Impact Through the DNP Project

343

Evaluating the Doctor of Nursing Practice (DNP) Project

367

417

SECTION VI Impact CHAPTER 13

259

From Data to Knowledge: Disseminating the Results.

419

CHAPTER 14 The Value and Impact of Practice Doctorate

Scholarship Index

439

469

Contents Acknowledgments

.xiv

Contributors

XV

Foreword

.xvii

Prefece

xxiv

SECTION I The Doctor of Nursing Practice Degree

1

CHAPTER 1 Setting the Stage for the Doctor of Nursing Practice Project

3

Katherine Moran and Lydia Rotondo

Taking the Journey

Health Systems Science: The Path to Systems Citizenship for DNP-Prepared Practice Scholars The DNP Project The Purpose of the DNP Project

3

5 6

7

Chapters at a Glance

9

Summary

16

Key Messages Action Plan—Next Steps

16

References

17

16

CHAPTER 2 Defining the Doctor of Nursing Practice: Historical and Current Trends

19

Dianne Conrad. Karen Kesten. and Lydia Rotondo

Defining the Practice Doctorate in Nursing Comparison of the DNP and PhD in Nursing

30

Current Trends in Doctoral Education

32

Reports Affecting DNP Education Trends in Support for DNP Requirement for APRN Educational Preparation

34

vi

19

43

© Sandipkumaf Patel/OigitalVision Vectors/Getty Images

vli

Contents

Summary of Trends

45

Summary

45

Key Messages . , . .

48

References

48

CHAPTER 3 Scholarship in Practice...

51

Karen Kesten and Rosanne Burson

What Is Scholarship?

51

History of Scholarship and Nursing Practice Scholarship Evolution Types of Scholarship Practice Scholarship and Nursing Theory. .

53

The Actualized DNP Model

62

What Is the Purpose of the DNP Project? . .

63

What Qualifies as a DNP Project?

65

Current Views of the DNP Project

66

Scholarship Beyond the DNP Project

66

Recommendations

70

Impact

71

Key Messages

71

Action Plan—Next Steps

71

References

72

SECTION II Problem Identification CHAPTER 4 Population Health and Healthcare Policy

54 57 59

75

77

Katherine Moran

Health Policy Historical Perspective

78

The Potential Impact of the DNP-Prepared Nurse

83

Evidence-Based Health Policy

84

DNP Essential Core Competencies Used to Advocate for Healthcare Policy Change

86

The DNP Project and Health Policy Your Health Policy Journey

86

Advocacy Opportunities The DNP Project and Advocacy Summary Impact

93

92

94 103

103

viii

Contents

Key Messages Action Plan—Next Steps

104

References

105

Helpful Resources

108

104

CHAPTER 5 The Phenomenon of Interest: Leading to Problem Identification

109

Katherine Moran, Rosanne Burson, Karen Mihelich, and Lydia Rotondo

The Expertise of Nursing Practice Identifying the Phenomenon of interest Utilizing Systems Thinking to Explore the Phenomenon

110

of Interest

114

Identification of a Problem or Concern

118

Using Nursing Theory to Explore a Phenomenon Looking at a Phenomenon Through a Different Lens Keeping Your Options Open Impact Key Messages Action Plan—Next Steps

119

References

135

Helpful Resources

136

SECTION III Assessment

CHAPTERS Validating the Problem and Conceptualizing the Project Plan

112

122 131 133 134 134

137

139

Katherine Moran and Karen Mihelich

Developing the DNP Project

140

Defining the Project Type

165

Impact

174

Key Messages Action Plan —Next Steps

174

Tools

174

Appendix A6: Organizational Structure .... Appendix B6: Definition of Key Terms

188

Appendix C6: References

190

References

193

Helpful Resources

195

174

189

ix

Contents

SECTION IV Project Plan

197

CHAPTER 7 Aligning Design, Method, and Evaluation with the Clinical Question

199

Patricia Rouen and Karen Mihelich

It Starts With Design

200

Diversity in DNP Projects

210

Driven by Design: Data Collection Methods Resources for Data Collection: Registries and Surveys

213

It Takes a Team: Data Collection

219

Data Management Data Entry Data Analysis

220

Telling the Story

224

Impact

225

Key Messages

225

Action Plan—Next Steps

225

References

225

Helpful Resources

229

CHAPTER 8 The DNP Project Team: Preparing for Project Implementation

231

219

221

222

Shannon Idzik and Dianne Conrad

Thesis, Dissertation, and the DNP Project

232

Choosing the DNP Project Faculty Mentor and Project Team Members

234

Forming the Project Team Roles and Expectations of Project Team Members.... Defining the Timeline for the DNP Project

235

Enhancing Team Productivity Alternative Approaches to a Traditional Committee for Project Supervision Crediting the Project Team Preparing for Implementation of the DNP Project ....

239

Summary

248

Key Messages

250

Impact

251

Action Plan—Next Steps

251

References

252

237 238

241 244 244

X

Contents

Tools and Resources

253

Appendix A8: DNP Communication Plan

255

Appendix B8; DNP Project Meeting . .. .

257

CHAPTER 9 The Proposal

259

Katherine Moran and Karen Mihelich

Professional Writing Writing the Proposal Components of the Proposal Project Design Citing References

259 263 264 271 277

Appendices

278

Writing Tips

278

institutional Review Board Approval.. .. Submitting for Grant Support

281

Summary

284

Key Messages

284

Action Plan—Next Steps

285

References

285

Helpful Resources

286

Appendix

288

SECTION V Implementation

284

303

CHAPTER 10 Leading Implementation Through Collaboration

305

Dianne Conrad. Evelyn Clingerman, Katherine Moran, and Rosanne Burson

The Implementation Process

306

Factors to Consider During Project Implementation

308

Collaboration

311

Models/Frameworks Supporting Collaboration Components of Collaboration in the DNP Project; Who, What

314

Where, When, and How

316

Operationalizing the Project Plan Summary

323

Impact

330

Key Messages

331

Action Plan—Next Steps

331

330

xi

Contents

References

332

Resources

334

Project Status Report

338

CHAPTER 11 Driving the Practicum to Attain Competency and Leverage Impact Through the DNP Project Amy Manderscheid and Rosanne Burson

343

Practicum Purpose

344

Identifying the Setting Matching Student Competency with Project Needs . Site Agreements

344

Practicum Hours

351

Choosing a Mentor

351

Developing Objectives for the Practicum

346 350



358

Practicum Deliverables

359

Presenting the Practicum Plan

362

Implementing the Practicum Practicum Evaluation—Were the Objectives Met?... Setting the Stage for the DNP Project Closing Out the Practicum

362

Impact

364

Key Messages Action Plan—Next Steps

364

Tools

365

References

365

363 363 363

364

CHAPTER 12 Evaluating the Doctor of Nursing Practice (DNP) Project Sandra L Spoelstra and Marie VanderKooi

367

What Is Evaluation?

368

The Importance of Evaluation

368

Why Do an Evaluation?

370

A Framework to Guide an Evaluation Plan

370

Types of Evaluation Evaluation for Research or Improvement

373

Designing an Evaluation Plan Enacting the Evaluation Plan Data Collection, Storage, and Security

379

376

400 403

xii

Contents

Analyzing and Displaying Results of the Evaluation Plan Telling the Evaluation Story

403

Sumnnary

413

Impact

413

Key Messages Action Plan—Next Steps

414

References

414

SECTION VI Impact CHAPTER 13 From Data to Knowledge: Disseminating the Results

411

414

417

419

Rosanne Burson and Catherine Corrigan What Are the Deliverables?

420

Public Presentations

421

Portfolios

425

Executive Summary

425

Written Manuscript

426

Journal Submissions

426

Process for Journal Submissions

427

Tips for Successful Journal Submission

428

Summary

432

Impact

435

Key Messages

435

Action Plan—Next Steps

435

References

436

CHAPTER 14 The Value and Impact of Practice Doctorate Scholarship

.439

Karen Kesten and Dianne Conrad

The Actualized DNP Framework: Continuous Quality Improvement of the Degree, DNP Graduate Practice, Outcomes, and Impact Advanced Nursing Knowledge—DNP Education Healthcare Delivery by the DNP-Prepared Nurse The Outcomes of the DNP-Prepared Nurse on Patients, Systems, Populations, and Policy

441

442

453 458

Contents

xiii

The Impact of the DNP Graduate in Practice

460

Summary

466

Key Messages

466

Action Plan—Next Steps

466

References

467

Index

469

Project Exemplars with Theoretical Frameworks

The following project exemplars are available in the eBook:

Exemplar 1: Creating a PICU Culture Wherein Error Disclosure Communication is Appropriate and Effective Exemplar 2: Assessing Feasibility of ECHO^ FASD for Increasing Access to Fetal Alcohol Spectrum Disorder (FASD) Diagnosis Exemplar 3: Implementation of Multi-Modal Opt-Out Program to Improve Screening, Referrals, and Engagement to a Dedicated Oncology Tobacco

Exemplar 4: Passing Life On: An Organ Procurement Organization Medical Center Collaboration to Improve the Organ Donation Process

’ Extension for Community Healthcare Outcomes

Acknowledgments Our heartfelt thanks go out to the DNP faculty at Madonna University who were there when we started our DNP journey. Your vision, encouragement, and con tinued support provided us with a wonderful foundation for which we are most

grateful. We extend our gratitude to Tina Chen, Jones & Bartlett Learning Product Manager, for recognizing the value of this project and Paula-Yuan Gregory, Content Strategist, for guidance in completing this project.

xiv

(D Sandipkumar Patel/DigiUlVtsion Vclws/Cetty Images

Contributors Rosanne Burson, DNP, ACNS-BC, CNE, CDCES, FADCES, FNAP

Shannon Reedy Idzik, DNP, ANP-BC, FAAN, FAANP

Professor

Associate Professor

Graduate Coordinator

Associate Dean, Doctor of Nursing

McAuley School of Nursing University of Detroit Mercy Doctor of Nursing Practice

University of Maryland School of

Consultants

Detroit, Michigan Evelyn Clingerman, PhD, CNE, RN. FNAP

Practice Program Nursing

Baltimore, Mar)'land Karen Kesten, DNP, APRN, CCNS, CNE, FAAN Associate Professor

Adjunct Faculty Kirkhof College of Nursing Grand Valley State University Grand Rapids, Michigan

Director of DNP Scholarly Projects The George Washington University School of Nursing

Dianne Conrad, DNP, RN, FNP-BC, BC-ADM,FNAP

Amy Manderscheid, DNP, RN, AGPCNP-BC, AGNP-C, CMSRN

Adjunct Faculty Kirkhof College of Nursing Grand Valley State University Doctor of Nursing Practice

Associate Professor

Washington, District of Columbia

DNP Immersion Course Coordinator

Cadillac, Michigan

Kirkhof College of Nursing Grand Valley State University Grand Rapids, Michigan Vice President, Sigma Theta Tau Kappa Epsilon chapter Grand Rapids, Michigan

Catherine Corrigan, DNP, RN,

Karen Mihelich DNP, ANCS-BC,

Consultants

Grand Rapids, Michigan Conrad Health Consultants, PC

FNP.CNM

CDCES

Researcher

Assistant Professor

Centre for elntegrated Care Dublin City University

DNP Program Coordinator University of Detroit Mercy Detroit, Michigan

Healthcare Consultant

Dublin, Ireland

® Sandipkunat Pal^l/DigilalVision Vectns/Cetty Images

XV

xvi

Contributors

Katherine Moran, DNP, RN, CDCES, FADCES, FNAP

Professor

Associate Dean, Graduate Nursing

McAuley School of Nursing

Programs and Research Associate Professor

Kirkhof College of Nursing Grand Valley State University Doctor of Nursing Practice Consultants

Grand Rapids, Michigan Lydia D. Rotondo, DNP, RN, CNS, FNAP Associate Dean for Education & Student Affairs

Director, Doctor of Nursing Practice Program

Professor of Clinical Nursing University of Rochester School of Nursing Rochester, New York

Patricia Rouen, PhD, FNP-BC

College of Health Professions University of Detroit Mercy Detroit, Michigan Sandra L. Spoelstra, PhD, RN, FGSA, FAAN Associate Professor

Kirkhof College of Nursing Grand Valley State University Grand Rapids, Michigan Marie VanderKooi, DNP, MSN, RN-BC Associate Professor

Assistant Unit Head, Graduate

Programs

Kirkhof College of Nursing Grand Valley State University Grand Rapids, Michigan

Foreword Cynthia McCurren, PhD, RN A decade of collegial collaboration with the authors (Drs. Moran, Burson, and Con rad) has led to a high degree of professional respect for them, and thus it is an honor to write the Foreword for the fourth edition of their text, T]\c Doctor ojNursing Prac tice Project: A Pramework jor Success. The first edition of this text was published in 2014. At that time, the implementation and adoption of the Doctor of Nursing Prac tice (DNP) degree was in a period of rapid evolution. There was limited guidance for students and faculty to chart a path for a successful DNP practice project. How the project was operationalized across degree programs was inconsistent and variable. Thus, a “framework for success” for the practice project was a major contribution to fill a void. From the inception of the idea to develop this text, the authors have consistently applied to each edition (first through third) their own collective expe riences as DNP-prepared professionals and the evolving understanding of the issues impacting the desired goal of DNP graduates. In writing this foreword, a reflection of the past to the present is helpful, especially in highlighting significant revisions the authors have made in this fourth edition.

The launching of the Doctor of Nursing Practice degree began in 2004 when the member schools of The American Association of Colleges of Nursing (AACN) endorsed the Position Statement on the Practice Doctorate in Nursing (AACN, 2004). This decision called for moving the level of preparation necessary for advanced

nursing practice from the master’s degree to the doctorate level. The position state ment was the culmination of research and consensus-building by an AACN Task force, responding to three key Institute of Medicine (lOM) reports: To Err Is Human: Building a Safer Health System (1999); Crossing the Quality Chasm: A New Health Sys tem/or the 2lst Century (2001); and Health Professions Education: A Bndge to Quality (2003). Collectively these publications brought to light serious concerns in the U.S. healthcare system related to safety, effectiveness, patient-cenieredness, timeliness, efficiency, and equity; and called for realignment of expected competencies of all healthcare students to ensure intentional preparation of graduates for transforming health care in the United Stales.

With consideration of these significant factors in health care, and that nursing education must be reenvisioned to ensure graduates possess the knowledge and skills for 21st century health care, the AACN membership endorsed in 2006 the Essentials of Doctoral Education for Advanced Nursing Practice (AACN, 2006). Therein, the required curricular elements and competencies were defined for the DNP de gree. A DNP Tool Kit (AACN, 2022a) was developed to inform development and implementation of DNP degree programs within AACN member schools. In order for the transformation of health care to occur in the United Slates, nursing would need to be a formidable contributor. This was made clear in the 2010 Institute

SandiplutMr Patel/DiglUlVishon Vectors/Getty Images

xvii

xviii

Foreword

of Medicine/Robert Wood Johnson Foundation report, The Future of Nursing (FON): Leading Change, Advancing Health (lOM, 2010). This report reinforced the movement in nursing education to prepare nurses for the highest level of practice, recommend ing that the number of doctorally prepared nurses (practice and research-focused) be doubled by the year 2020. The FON Committee was charged to identify the roles nursing should assume to address the increasing demand for safe, high-quality, and effective health care, and bring about transformation. Four key messages were formu lated, to include, “Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression." Doctor of Nursing Practice degree programs began to proliferate and numbered 274 by 2014. The AACN was astutely following the successes and challenges that arose with the rapid growth, ever mindful of monitoring metrics to assess if DNP programs were achieving expected outcomes. It was in 2014 that the AACN Board of Directors commissioned the RAND Corporation to conduct a national study to examine progress made by nursing schools in transitioning to the practice doctor ate. In 2015, the report, titled The DNP by 2015: A Study of the Institutional, Political,

and Professional Issues that Facilitate or Impede Establishing a Post-Baccalaureate Doctor of Nursing Practice Program (Auerbach et al., 2015) was released, supporting agree ment among the majority of nurse educators about the value of the DNP for pre paring for advanced nursing practice. This report informed ongoing dialogue about the DNP and accentuated the need to clarify curricular and practice expectations, scholarship, and academic/practice partnerships. The AACN Board of Directors charged a task force with the development of a white paper that would clarify the purpose of the DNP final scholarly product and the clinical learning practice hour requirements; and identify innovations to promote successful collaborative practice strategies. The outcome of this task force was the 2015 White Paper: The Doctor of Nursing Practice: Current Issues and Clarifying Recommendations (AACN, 2015). Also in 2015, AACN commissioned Manatt Health to complete a national study on

optimizing nursings role to enhance clinical practice and strengthen practice and research partnerships. A report of this study. Advancing Healthcare Transformation: A New Era for Academic Nursing (AACN, 2016) was released in March 2016, providing a strategic framework for engaging health systems leadership with university presi dents and chancellors in the collaborative work needed to advance innovation, align resources, and enhance public health. An additional key AACN document that has served to influence the evolving

understanding of the DNP degree requirements and practice project is the 2018 position statement. Defining Scholarship for Academic Nursing (AACN, 2018). The traditional definition of research was broadened and stated as follows:

Nursing scholarship is the generation, synthesis, translation, applica

tion, and dissemination of knowledge that aims to improve health and transform health care. Scholarship is the communication of knowledge generated through multiple forms of inquiry that inform clinical practice, nursing education, policy, and healthcare delivery. Scholarship is inclu

sive of discovery, integration, application, and teaching (Boyer, 1999). The hallmark attribute of scholarship is the cumulative impact of the scholar’s work on the field of nursing and health care. The authors incorporated in their first three editions of the text the evolving

context and lessons learned to frame their thinking related to the DNP practice

Foreword

xix

project, and used the collective insight that had been brought forth. Most recently in 2021 and 2022, there were four other major releases that now inform their fourth edition.

The Essentials: Core Competencies for Professional Nursing Education (AACN, 2021) were approved by the AACN membership in April 2021. The journey had begun in 2017 when AACN charged a task force to clarify preferred educational pathways and preparation necessary to be successful in evolving expectations of nursing professionals. In 2019, AACN’s Vision for Academic Nursing (AACN, 2019) was released and served to inform the charge of the next task force appointed to reenvision the Essentials (the Essentials are published by AACN to provide the edu cational expectations for college/university degrees in nursing). This task force was comprised of 36 nurse leaders representing education and practice, committed to “listening to understand” and deep reflection that eventually revealed the realities within the profession that must be addressed so that we may be united as transfor mational leaders in health care. The new Essentials are grounded in an emphasis on nursing as a discipline, clarity of our professional identity, the benefits of a liberal education, and the principles of competency-based education. The Essentials frame work is composed of 10 domains, with expected competencies for each domain that represent professional nursing practice, applicable across practice settings. Subcompetencies are made explicit for each domain and competency statement, with Level 1 subcompetencies for entry into practice and Level 2 subcompetencies for advanced nursing practice. The new Essentials represent a landmark time for nursing, a shared vision for the profession, clarity for the expectations of graduates, and a disciplined approach to nursing education informed by the demands and needs of practice/society. They look to the future, informed by the rapid changes needed in clinical care, nursing education, nursing leadership, population health, and nursing-community partnerships. As the new Essentials were being developed, there was also a significant under taking taking place, building on the 2010 Future of Nursing report. Distinguished members of an interdisciplinary expert committee conducted a consensus study, identifying nursing’s role in the next decade amidst rapid change occurring across all sectors of society affected by health and well-being. The National Academy of Medicine released The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity in 2021 (National Academies of Sciences, Engineering, and Medicine, 2021). Under development prior to the onset of the COVID-19 pandemic, and completed in 2021, the charge to nurses is heavily influenced by the impact of this global event. The emphasis is on the critical importance of health to all aspects of life, with attention to the social determinants of health, health equity, and health outcomes. Key messages focus on addressing systemic inequities and persistent health dis parities, built on a strengthened nursing capacity and expertise. Nurses are called to have a major influence on aligning public health, social services, and public policies. Among many salient recommendations, are themes also consistent with the Essentials: (a) shared agenda for education, practice and policy; (b) lifting barri ers to expand the contributions of nursing; (c) strengthening nursing education so graduates can identify and act on the complex social, economic, and environmental factors, using experiential learning that ensures competency achievement that can affect change.

Nursing science remains at the core of the profession to inform practice, and in 2020, AACN convened a task force to revise the AACN’s 2010 position statement

XX

Foreword

related to the research-focused doctorate, to articulate a preferred vision of PhD education in nursing. The Research-Focused Doctoral Program in Nursing: Pathways to Excellence position statement was released in 2022 (AACN, 2022b). While this document is focused on the PhD in nursing, there is relevant content that informs thinking about the learner in the DNP degree program and the practice project. It is noted that the academic preparation leading to the PhD and the DNP are distinct yet share similarities. Concepts identified in the updated 2021 Essentials are rele vant to PhD and DNP educational preparation, for example ethics, health policy, and social determinants of health. Both groups of doctorally prepared nurses have unique competencies, that when brought together in collaboration can foster the integration of research into practice, yielding higher impact and better outcomes.

This perception adds further insight for the DNP project. Dialogue has continued in the profession about the DNP, and despite ef forts to standardize educational endeavors, concerns continued to emerge. These were made explicit from intentional conversations conducted by the task force

for reenvisioning the Essentials. Many current realities related to the DNP were made evident: There is great variability in DNP educational programs, including variability in program length, scope, expectations, and quality; and that students, graduates, faculty, and employers often struggle to articulate that which differ entiates MSN and DNP graduates. Ever mindful of the need to ensure systematic inquiry, the Board of Directors for AACN agreed in July 2020 to launch a national study to assess the current state of graduates from Doctor of Nursing Practice (DNP) programs. Focusing on nurses in practice and academia, the study exam ined the current utilization of DNP-prepared nurses, including employer, faculty, and student perceptions of DNP preparation, and the impact of DNPs on patient and system outcomes, quality of care, leadership, education, and policy develop ment. The study was conducted by IMPAQ, with the final report released in June 2022, The State of Doctor of Nursing Practice Education in 2022 (AACN, 2022c). As a context, the challenges noted in the 2015 report by the RAND Corporation were reviewed, to include market demand, institutional barriers, state policy and regulatory constraints, and resource and financial factors. Even though seven years have passed, these challenges persist; the perceptions identified by the task force for reenvisioning the Essentials were confirmed, with expanded validation

and insight. DNP curricula and skill sets of graduates continue to vary. Some relevant findings: (a) there is significant variability in how the DNP project is implemented among programs; (b) challenges among graduates included limited time to devote to the DNP project; (c) improvements suggested by graduates

included the need to focus on large-scale systems changes in the curricula, add business-related classes in areas of finance, project management, and process improvement; (d) employers want to hire graduates who understand how to

translate science to practice, implement quality improvement policies, and un derstand systems change on a larger scale; (e) employers reflected on the value of the DNP degree, suggesting rigor of the DNP project and clearly differentiate between the MSN and DNP skill sets; (0 employers suggested increasing the practicum hour requirements, limit the online programs, increase the focus on business education (finance and statistics), and increase emphasis on policy and legislation. Overall, the variation in programs was reported to lead to confusion

regarding what skills and value DNP graduates bring, the inability to distinguish DNP graduates from other nurses with advanced degrees, and finally that DNP

Foreword

xxi

graduates themselves struggle with explaining their unique skill set and how to capitalize in practice. Seven recommendations were made: ● ● ● ● ● ●

●

Clarify the goals and identity of the DNP degree. Examine curriculum and rigor of DNP programs and DNP projects. Engage with APRN certification organizations. Educate employers about the unique skill sets and value of DNP graduates. Develop processes for measuring DNP process and system-level outcome data. Conduct research to isolate the impact of DNP graduates on patient and system-level outcomes. Encourage academic-practice partnerships.

Coming full circle, it was the serious concerns in the U.S. healthcare system related to safety, effectiveness, patient-centeredness, timeliness, efficiency, and eq uity noted in the 2001 Institute of Medicine report that ignited the profession of nursing to take action. Based on the transformation needed in health care, nursing was called to prepare graduates at a higher level, hard wiring into their approach to practice a systems perspective, quality improvement, and patient-centered care. The need to keep persisting in the refinement of the DNP degree with intentionality, to ensure the intended outcomes, is made evident in a recent publication: Mirro,r Mirror 2021—Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries (Commonwealth Fund, 2021). This is but one report among many that summarizes harsh realities that have persisted over 20 years after the call to action to transform U.S. health care. An analysis of 71 performance measures across five domains (access to care, care processes, administrative efficiency, equity, and health care outcomes) was conducted, comparing 11 high-income countries. The United States ranked last overall, despite spending far more of its gross domestic product

on health care. To note, the United States was last on access to care, administrative

efficiency, equity, and healthcare outcomes. The COVlD-19 pandemic made these realities ever more painful.

It can be seen with clarity now the influence of the fourth edition of The Doctor of Nursing Practice Project: A Framework for Success. It reflects the deep understand ing possessed by the authors related to the Doctor of Nursing Practice (DNP) de gree, and the significance of the DNP project as a degree requirement. The authors’ understanding and revisions in this latest edition are influenced by the evolving context of health and health care in the United States and globally, the expectation

of contributions from the discipline of nursing to bring about transformation, and

the responses from nursing education. The fourth edition of The Doctor of Nursing Practice Project is now front and center as a “north star” to guide the relevancy of the project that is the culminating experience in the DNP degree education. Recom mendations from The State of Doctor of Nursing Practice Education in 2022 (AACN, 2022c) are addressed to include ensuring rigor of the DNP project; leveraging academic/practice partnerships to ensure the unique skill set and value of DNP graduates is understood; and using systematic strategies to measure and dissemi nate the impact of DNP projects on patient and system-level outcomes. The Doctor of Nursing Practice project emerges as a critical link to ensuring the achievement of competencies that distinguish the DNP graduate, but more impor tantly that can serve as a powerful learning experience to impact the “harsh realities” in health care that MUST be addressed. In 2021, there were 394 DNP degree pro

grams in the United States and 40,834 students (AACN, 2022c). One project can

xxii

Foreword

make a difference—imagine the impact of 40,834 projects to bring about change, and continue to multiply by the number of DNP graduates that have entered the workforce and will continue to do so. In Chapter 5 of the updated text, the authors drive home the importance of pursuing relevancy of the project by “strengthening the systems thinker perspective to understand the phenomenon of interest; and connecting ‘problem identification’ as it relates to the balance/interconnectionof organizational, policy, professional, and population need.” Throughout this updated fourth edition of the text, revised chapters reveal ad ditional examples of how the evolving context of health care and nursing education is incorporated. Highlights are as follows that substantiate strengths:

●

●

●

●

The importance of the DNP project and practice scholarship is explained as a driving force to foster achievement of the goals of the Future of Nursing 20202030, the lOM Aims, the new AACN 2021 Essentials, and the connection to Healthy People 2030 (Office of Disease Prevention and Health Promotion, n.d.). A connection is made to health systems science (Skochelak et al., 2021). The Level 2 sub-competencies for advanced level nursing from the new AACN Essentials are introduced and practice scholarship is stressed in the context of the research/theory/practice continuum. Scholarship in practice is emphasized

as important to impact health outcomes and health delivery. With policy and advocacy as concepts in the new AACN Essentials, the authors emphasize how policy influences all levels of health care, expanding on popu lation health and the social determinants of health.

● ●

● ●

The need for business acumen, financial analysis, and engagement with stake holders is stressed to validate the identified problem of interest. Skills for project development, implementation, and evaluation are provided, to include insight for effective strategies for group projects. The importance of collaboration and practice partnerships is stressed, along with attention to sustainability and sequential projects. A new chapter focuses on evaluation methods and plans for analysis, all to reinforce the importance of rigor and validity of the project.

Overall, there is clear emphasis on the value and impact of practice doctorate scholarship—the resounding strength of this text that will be invaluable for stu dents, faculty, and DNP graduates as they continue to make a difference in health care throughout their careers. This text ensures that nurses are not just told to contribute to healthcare transformation, but they are guided to know how. My respect

for the authors is reinforced by the significance of their work.

k References American Association of Colleges of Nursing (AACN). (2004). AACN position statement on the prac

tice doctorate in nursing. https://www.aacnnursing.org/Ponals/42 /News/Position-Statements

/DNRpdf

American Association of Colleges of Nursing (AACN). (2006). The essentials of doctoral education for advanced nursing practice. httpsv7www.aacnnursing.org/Ponals/42/ Publications/DNPEssentials.pdf. American Association of Colleges of Nursing (AACN). (2015). The doctor of nursing practice: Current issues and clarifying recommendations. https://www.pncb.org/site s/default/files/2017-02/AACN _DNP_Recommendations.pdf

Foreword

xxiii

American Association of Colleges of Nursing (AACN). (2016). Advancing healthcare transformation: A new era for academic nursing. https:/Avww.aacnnursing.org/News -Information/Press-Releases A/iew/Articleld/21495/mannatt-report

American Association of Colleges of Nursing (AACN). (2018). Position Statement: Defining schol arship for academic nursing. https://w\vw.aacnnursing.org/Portal s/42/News/Position-Statements /Defining-Scholarship.pdf American Association of Colleges of Nursing (AACN). (2019). AACN’s vision for academic nursing. https://www.aacnnursing.org/Portals/42/NewsAVhite-PapersA^ision- Academic-Nursing.pdf American Association of Colleges of Nursing (AACN). (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.orgA ’onals/42/AcademicNursing /pdf/Essentials-2021 .pdf American Association of Colleges of Nursing (AACN). (2022a). Doctor of nursing practice (DNP) tool kit. https://www.aacnnursing.org/DNP/Tool-Kit American Association of Colleges of Nursing (AACN). (2022b). The research-focused doctoral

program in nursing: Pathways to excellence. https://www.aacnnurs ing.org/News-lnformation /Position-Statements-Whiie-Papers/Research-Focused-Pathways-to-E xcellence American Association of Colleges of Nursing (AACN). (2022c). The state of doctor of nursing practice education in 2022. https://www.aacnnursing.org/News-Information/News/View/ArlicleId/25226 /New-Report-on-DNP-Education-2022 Auerbach, D. I., Martsolf, G. R., Pearson, M. L., Taylor, E. A., Zaydman, M., Muchow, A. N., Spetz, J., & Lee, Y. (2015). The DNPby2015: A study of the institutional, political, and professional issues that facilitate or impede establishing a post-baccalaurea te doctor of nursing practice program. Santa Monica, CA: RAND Corporation. https://www.rand.org/pubs/re search_reports/RR730 .html.

Commonwealth Fund. (2021). Mirror, mirror 2021—Reflecting poorly: Health care in the U.S. com

pared to other high-income countries, https://www.commonwealthfu nd.org/publications/fund -reports/202 l/aug/mirror-mirror-2021 -reflecting-poorly Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: The National Academies Press. Institute of Medicine. (2003). Health professions education: A bridge to quality. Washington, DC: The National Academies Press.

Institute of Medicine. (2010). The future of nursing; Leading change, advancing health. http://books .nap.edu/openbook.php?record_id=12956&page=Rl

Kohn K. T., Corrigan J. M., Donaldson M. S. (Eds.). (1999). To err is human: Building a safer health system. Washington, DC: Committee on Quality Health Care in America, Institute of Medicine: National Academy Press.

National Academies of Sciences, Engineering, and Medicine (2021). The future of nursing 2020-2030:

Charting a path to achieve health equity. Washington, DC: The National Academies Press, https:// doi.org/10.17226/25982 Office of Disease Prevention and Health Promotion, (n.d.). Diabetes. Healthy people 2030. U.S. De

partment of Health and Human Services..https://health.gov/health ypeople/objeciives-and-data ^rowse-objectives/diabetes Schneider, E., Shah, A., Doty, M., Tikkanen, R., Fields, K., & Williams, R. (2021). Mirror; mirror 2021—Reflectingpoorly: Health care in the U.S. compared to other high-income countries. (Common

wealth Fund, 2021). https://www.commonweallhfund.org/publication s/fund-reports/2021/aug /mirror-mirror-2021-reflecting-poorly Skochelak, S. E., Hammond, M. M., Lomis, K. D., Borkam, J. M., Gonzalo, J. D., Lawson, L. E., &

Starr, S. R. (2021). Health systems science (2nd ed.). Philadelphia, PA: AMA Education Consor tium Elsevier.

Preface Healthcare reform has been on the minds of many individuals across the United States since the introduction of the Patient Protection and Affordable Care Act in

2010, As decisions are made about implementing reform, it is important to thoughttully consider how we as a nation will meet the healthcare needs of the people. Re gardless of the outcome, it is clear that the availability of highly educated nurses to care for individuals is imperative to the health of our nation. The Institute of Medicine (lOM) and the Robert Wood Johnson Foundation (RWJF) have recognized the need to strengthen the largest component of the health care workforce—nurses—to become partners and leaders in improving the delivery of care and the healthcare system as a whole (lOM, 2010, p. ix). Both the lOM and RWJF agree that accessible, high-quality care cannot be achieved without ex ceptional nursing care and leadership and, as such, have partnered in creating the RWJF Initiative on the Future of Nursing to explore challenges central to the future of the nursing profession (lOM, 2010, p. ix). Two specific recommendations coming from this report that are relevant involve (1) ensuring nurses achieve higher levels of education and training and (2) ensuring nurses become full partners with physicians and other healthcare professionals in redesigning health care. In 2021, the renamed lOM, the National Academies of Sciences, Engineering, and Medi cine (2021) released The Future of Nursing 2020-2030 report that reinforced and expanded on prior recommendations with an emphasis on achieving health equity for all, as well as the central role that nurses play in addressing the healthcare needs of the population. In 2004, the American Association of Colleges of Nursing (AACN) recognized the need to develop nurses as healthcare leadere and subsequently released a position state ment advocating that by 2015, a doctor of nursing practice (DNP) degree be required for advanced practice nurses. Since that time, schools of nursing across the nation have introduced this terminal degree into their respective programs (AACN, 2011). One universal requirement for any DNP candidate, regardless of the institution attended, is the successful completion of a DNP project that uses evidence-based practice (EBP) for improved delivery of care, patient outcomes, and clinical systems

management (AACN, 2004). The requirements for the DNP project are similar to the dissertation requirement for the PhD candidate insofar as both require rigorous scholarly work. The difference is in the focus; for the PhD candidate, the focus is

generally on knowledge generation and discover)', whereas the focus for the DNP stu dent is to apply this knowledge in some meaningful way to ultimately serve the needs of society. As mentioned in Chapter 3, Scholarship in Practice, both types of scholars contribute to knowledge generation and are interdependent to fully impact health. Unfortunately, there are limited comprehensive resources available to guide students in completing the DNP project. Therefore, there is a need for a book that xxiv

® Sami pkumar Patel/DisiUlVisior Veclors/Getty linages

Preface

XXV

not only explores the journey the student embarks on when completing scholarly work, but also a book that provides a framework for success. For these reasons, this book was designed and written by advanced practice nurses who have earned a DNP degree especially for nurses working toward that end. Some of the unique features of this book include clearly identified learning ob jectives at the beginning of each chapter, multiple examples to help illustrate key points, and significant features that are highlighted for easy reference. Where appli cable, chapters conclude with impact statements, key messages, and an action plan to help the student through the DNP project development and implementation process. The authors are proud to include work from DNP scholars across the country that are highlighted in various chapters throughout the book, such as in Chapter 5 where the student will find wonderful examples of theoretical frameworks that were used to guide their projects. There are also project tools incorporated in each chapter where applicable, and a dedicated DNP Project Toolkit is available online that in cludes tools and templates that the DNP student may find useful when embarking on the project process. These downloadable tools and templates are available within the Navigate course. The authors encourage students to disseminate their work for the good of nursing and the health of our nation. Ultimately, this book is a demonstra tion of intraprofessional collaboration of DNP-prepared nurses vdth PhD colleagues as contributing authors, to produce a resource for enhancing the nursing profession.

^ References American Association of Colleges of Nursing (AACN). (2004). Position statement on the practice doc torate in nursing. http;//www.aacn.nche.edu/publicaiions/posilio n/DNP posilionstatemeni.pdf American Association of Colleges of Nursing (AACN). (2011). Fact sheet: The doctor of nursing prac tice. http://www.aacn.nche.edu/media-relations/fact-sheets/dnp Institute of Medicine (lOM). (2010). The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press. National Academies of Sciences, Engineering, and Medicine. (2021). The future of nursing 2020-2030: Charting a path to achieve health equity. Washington, DC: The National Academies Press, https:// doi.org/10.17226/25982

k Purpose The purpose of this book is to provide a road map for DNP students to use on their journey from project conception through completion and dissemination. The goal is to introduce a process that will enable DNP students to work through their projects in a more effective, efficient manner and will assist in resolving the current variability of DNP projects virithin DNP programs around the country. This book is not intended to be prescriptive. Rather, it was developed from a broad, inclusive perspective to address the varying needs of DNP students across the country. The authors hope that it will be useful for practical application and that it gives a frame work for the scholarly work process. This book will also serve as an aid to assist faculty who are mentoring, coun seling, or coaching students on the process of completing DNP scholarly work. Finally, this resource wall assist preceptors and mentors of DNP students in health organizations as many DNP projects are completed within these systems.

Impact

r i

r

/

Implementation

\

Project Plan

r

'f

Problem

SECTION I

Identification

%

The Doctor of

Nursing Practice Degree CHAPTER 1

CHAPTER 2

CHAPTER 3

Setting the Stage for the Doctor of Nursing Practice Project

3

Defining the Doctor of Nursing Practice; Historical and Current Trends

19

Scholarship in Practice.

51

1

CHAPTER 1

Setting the Stage for the Doctor of Nursing Practice Project Katherine Moran and Lydia Rotondo CHAPTER OVERVIEW

The purpose of this chapter is to help the student recognize the value of doctoral education and the practice doctorate and understand the significance of the

doctor of nursing practice [DNP] project as a demonstration of practice (clinical) scholarship within complex health systems. This will be accomplished by introducing the student to concepts that will be discussed throughout this text and by highlighting a framework that students can use to complete the DNP project, which reflects attainment of The Essentials: Core Competencies for Professional Nursing Education (AACN, 2021).

CHAPTER OBJECTIVES After completing the chapter, the learner will be able to; 1. 2. 3. 4.

Describe the DNP-prepared practice scholar. Understand implications of health system leadership as system citizens. Conceptualize the evolutionary nature of the DNP project. Discern the purpose of the DNP project.

y Taking the Journey It is well known that the nation’s healthcare needs

are becoming more complex, the cost of health care is increasing, and the quality of health care is being questioned, especially in light of growing health inequities in our population. Many Ameri cans are concerned about how these issues will be resolved. Recognizing these challenges, the Institute of Medicine (lOMj published Crossing tJic Quality Chasm (2001), followed by Health Professions Education: A Bridge to Qualify (2003) and the Future of Nursing (2011), calling for fundamental change in healthcare delivery and health professions education. Sandipbunaf Patet/DigilalViskin Veclvs/lie1l]i Images

3

4

Chapterl Setting the Stage for the Doctor of Nursing

In many ways, the DNP degree was designed to address the inadequacies and inequities of the current healthcare delivery system. The DNP-prepared nurse pos sesses advanced competencies for increasingly complex clinical, faculty, and leader ship roles; enhanced knowledge to improve nursing practice and patient outcomes; and enhanced leadership skills to strengthen practice and healthcare delivery. The original Essentials for Doctoral Education (AACN, 2006) domains reflect the interprofessional competencies identified in the lOM’s 2003 report on health professions’ education. Similarly, The Essentials include curricular content related to systems-based influences on individual and population well-being, healthcare delivery, and health outcomes addressed in the lOM reports (2001, 2003, 2011). The addition of a terminal practice degree in nursing also supports the goal set in the 2011 Future of Nursing report to double the number of doctoral-prepared nurses within the decade. This educational trend is consistent with other health

professions now requiring practice doctorates for evolving roles in complex health systems.

Applying a systems thinking mindset and systems-based practice principles to optimize and innovate health care in diverse settings are defining characteristics of DNP practice and important dimensions of systems citizenship, a term coined by organizational leadership expert Peter Senge (2006). Systems citizens understand how systems function, identify interdependencies within systems, and build collab orative partnerships to achieve desired outcomes (Gonzalo et al., 2022). DNP-prepared nurses have been called to lead and collaborate with other healthcare practitioners to transform health care. This was substantiated by the National Academies of Science (2021) (formerly the lOM) in the recently released The Future of Nursing 2020-2030 report that reinforced prior recommendations and reiterated nurses’ central role in addressing health inequities. It should be no surprise, then, that the decision to enter a DNP program marks the beginning of what will become a transformative experience for many students. The program is both challenging and rewarding. Through the process of personal development, one begins to recognize the need to view the world through multiple lenses, to continue the quest for new nursing knowledge, to apply that knowledge in a practice setting in a meaningful way, and to collaborate with other healthcare practitioners to meet the ever increasing and complex healthcare needs of the nation. It is The decision a journey where students travel conceptually from one place in their clinical practice to a new to enter a DNP place in practice. The insight gleaned through the process gives students a new frame of ref program marks erence to continue to build a more comprehen sive understanding of nursing praxis, which the beginning will ultimately benefit nursing as a profession of what will and society as a whole. It is important to recognize that the DNP become a degree continues to evolve and that all DNPprepared nurses need to influence the outcome. As transformative the degree continues to mature, the value-added experience for impact of the DNP-prepared nurse on health care delivery and health outcomes will be rec many students. ognized. Therefore, it is essential that DNP

Health Systems Science

5

students demonstrate that they are prepared for doctoral nursing practice through knowledge synthesis, skill refinement, and the completion of the DNP project. This is a critical point because completion of the DNP degree is only the beginning; continued practice scholarship is expected from all nurses prepared at the doctorate level. And the impact of this work will transform health care by addressing policy concerns, costs associated with healthcare delivery, the quality of care, as well as im proving the work-life balance of healthcare clinicians and staff. As systems citizens, DNP-prepared nurses (clinical scholars) will need to continue to identify the gaps between the current and the desired state of practice and implement evidence-based solutions. Through these efforts, society will continue to see the impact of practice scholarship and the associated benefit of the practice doctorate.

^ Health Systems Seience: The Path to Systems Citizenship for DNP-Prepared Practice Scholars The introduction of systems-based practice competencies to address care gaps and improve health outcomes has been a critical development in advanced nurs ing education. The development of the DNP Project discussed throughout this book demonstrates the knowledge and skill of DNP-prepared nurses to design high-impact systems and policy innovations that will transform health care. This cumulative scholarly work also demonstrates an emerging professional identity as a systems citizen that “. . . necessitates caring for and addressing insufficiencies in the system as obligatory aspects of the professional role” (Gonzalo & Ogrinc, 2019, p. 1429). The emergence of systems-related curricula to better prepare healthcare pro viders and practice leaders for expanded professional roles in complex health sys tems is occurring in other health professions as well. This educational paradigm shift will provide exciting opportunities for novel interprofessional approaches to improve health care (Gonzalo et al., 2017). In 2013, the American Medical Asso ciation introduced Health Systems Science (HSS) as the “third pillar” of medical education to complement traditional undergraduate medical education’s basic and clinical science pillars as part of the Accelerating Change in Medical Education Con sortium (Skochelak et al., 2021). Health Systems Science is “the study of how care is delivered, how healthcare professionals work together to deliver that care, and how the health system can improve patient care and health care delivery” (Gonzalo et al.,2021,p. 6). This integrated curriculum consists of three types of curricular domains: core functional, foundational, and linking. Core functional curricular domains consist of specific HSS content areas such as population health, health system improvement, and clinical informatics. Foundational curricular domains include HSS content ar¬

eas that are higher-order concepts that span multiple courses in health professions’ programs of study. Examples of foundational domain content includes, teaming, leadership, and advocacy. Finally, systems thinking, the linking curricular domain, provides the lens or mental model that connects specific HSS concepts (internal linking) with all other coursework including specialty nursing and foundational graduate courses (external linking) (Gonzalo et al., 2021).

6

Chapterl Setting the Stage for the Doctor of Nursing

The HSS curriculum framework nicely aligns with the original DNP Essen Competencies for Professional Nursing Education (2021) (see Chapter 2, Defining the Doctor of Nursing Prac tice: Historical and Current Trends, Table 2-2), offering a common framework to . catalyze [health professions’] education as well as health care delivery trans formation” (Gonzalo et al, 2020, p. 1363). It is also noteworthy that the concepts within these common HSS curriculum domains address the underappreciated in fluences that are critically important to optimal patient care. tial domains as well as the new AACN Essentials: Core

► The DNP Project Soon after students begin the doctoral program, they will start to work on the fi nal program deliverable: the DNP project. Each doctoral-level course provides an opportunity for students to gain new knowledge that will help them complete the project. Through this journey, students may refine original project ideas, or students may end up going in an entirely new direction. Be assured that this is part of the process. In the end, the DNP project will be a carefully selected project that not only meets program requirements, but also fulfills the student’s professional goals and the organization’s goals (where the project is implemented), as well as contributes to the Health Systems overall goals of the DNP-prepared nurse as a healthcare professional: to positively influence Science (HSS) health care now and in the future. As DNP-prepared nurses, the authors have is “the study completed multiple scholarly projects, have of how care is provided consultation services for many DNP programs across the country, and have con delivered, how ducted research to give us insight and perspec healthcare tive on the DNP-prepared nurse’s contribution

professionals work together to deliver that

care, and how the health

system can

improve patient care and health

care delivery" (Gonzalo et al., 2021, p. 6).

to health care. The authors want to share their

experience and personal insights regarding the topic of the DNP project. Our hopes are to help future DNP students on their journey, to be a guide on the side that lends a helping hand when needed. The goal of this text is to give the student a frame of reference when em barking on the DNP project. However, because there are virtually limitless DNP project ideas being developed, it is impossible to speak to the needs of each of these specifically. Therefore, this text was designed to include the potential requirements for the most comprehensive proj ect even though some DNP projects may not require such detail. This is not meant to suggest that all projects should mirror the examples pro vided; rather, this text is intended to be a ref erence or a framework that allows students to

choose items that will help inform their project

The Purpose of the DNP Project

7

and challenges students to consider new perspectives that foster creativity and the development of innovative ideas. At the same time, it is our hope that doctoral nursing educators, team members, and other healthcare professionals interfacing with DNP students find this text helpful when guiding DNP students through the scholarly project process. Developing the DNP project is not a linear process; it is created through a series of explorations that result in a comprehensive, well-thought-out project plan. As such, students should recognize that although the topics in this text are presented in a stepwise framework to help them through the process, some of the work may occur simultaneously because of the evolutionary nature of the project. Many different DNP programs are available across the United States. All of the programs meet the needs of the community they serve; however, they may accom plish this via different methods. As a result, program structures will vary, some may include a formal DNP project team, while others may use a completely different approach. For example, some universities may use a model that requires one faculty advisor and one faculty member from the university who serves as a team member, while others may include one faculty advisor and one representative from the com munity. The same is true regarding the final program deliverable requirements. In an attempt to better understand the characteristics of these programs, the authors have collaborated with many individuals either pro viding DNP education in programs throughout Developing the the United States or informing DNP education, such as the American Association of Colleges DNP project of Nursing (AACN), to better understand the needs of DNP students, faculty, and others is not a linear working with students to complete the DNP process; it is project. We have learned that DNP education and the recommended requirements of DNP created through projects and teams are continuing to evolve (see Chapter 2, Defining the Doctor of Nursing a series of Practice: Historical and Current Trends). Rec

ognizing this, the authors sought to meet the various scholarly requirement needs of these programs by providing a wide variety of op tions and perspectives for students to consider and reference where applicable. While there are many examples, templates, and other formats provided as tools for the journey, the intent is to give students options, not be directive.

explorations that result in a

comprehensive, well-thought-out project plan.

^ The Purpose of the DNP Project A debate has been ongoing for many years regarding what one should consider as scholarship, especially in academe. Many learned individuals have weighed in on this debate over the years, including Ernest L. Boyer, a well-knovm educator who at one point served as the U.S. Commissioner on Education. In 1990, Boyer, then president of the Carnegie Foundation for Advancement of Teaching, suggested that for “America’s colleges and universities to remain vital a new vision of scholarship

8

Chapterl Setting the Stage for the Doctor of Nursing

A scholar is a learned

person, who

is specialized in an area of

knowledge (“Scholar,” 2016).

The DNP project plays a very

is required” (Boyer, 1990, p. 13). It is clear that the scholarship debate began long before the DNP degree; however, since the introduction of this degree, the discussion has shifted to in clude practice scholarship. In an effort to contribute to the richness

of this dialogue, a discussion regarding the evolving scholarship of practice is provided in Chapter 3, Scholarship in Practice. For the purposes of introduction to the DNP project, it is important to recognize, from a very literal sense, that the term scholar is de fined as a learned person, who is specialized in an area of knowledge (“Scholar,” 2016). Tak ing this definition and applying it to the DNP project helps one recognize that this project provides the student with a vehicle through

important role

which one can demonstrate advanced knowl

in doctoral

with AACN, which believes that the final

education; it affords the DNP student

edge in a particular area. This is in alignment

DNP project should demonstrate “synthesis of the student’s work” and that it should lay the groundwork for future scholarship (AACN, 2006, p. 20). Certainly, the project should demonstrate the student’s achievement of the

American Association of Colleges of Nursing’s an opportunity (2021) The Essentials: Core Competencies for Professional Nursing Education, but more spe to launch cifically, the Advanced-Level Nursing Education Competencies. A detailed discussion regarding into scholarly these competencies and current trends in DNP practice. education is provided in Chapter 2. It should be clear that the DNP project is many things; a required program deliverable, the demonstration of doctoral competencies, and a means to achieve professional goals as well as the goals of the organization where the project is implemented. The importance of the impact of this work cannot be overstated. The DNP project is one mechanism for advanced practice nurses to contribute to the goals of the National Academies of Science (2021), The Future of Nursing 2020-2030 report, the Institute of Medicine (2001) Six Aims for Healthcare Improvement, the goals for Healthy People 2030, and finally, demonstrate the Quality and Safety Education in Nursing (QSEN) knowledge, skills, and attitudes (KSAs) that nurses must possess to deliver safe, effective care (Cronenwett et al., 2007). But to realize this impact, DNP students must be focused on delivering high-quality, relevant projects that can be sustained. In addition, it is expected that the project is only the beginning of many future scholarly contributions by the DNP-prepared nurse that lead to improvement in health care and add to nursing knowledge. Therefore, the DNP project plays a very important role in doctoral education; it affords the DNP student an opportunity to launch into scholarly practice. The DNP-prepared nurse will have many opportunities

Chapters at a Glance

9

10 transcend current barriers and positively impact health care in the United States as we know it today—to build a bridge between research and practice, as well as between theory and practice. These are indeed exciting times! In many ways, the creation of this text is an example of DNP scholarly work. The authors collaborated with thought leaders in the held, demonstrating the skills attained in Domain 6: Interprofessional Partnerships. Then, using the skills garnered in Domain 1.- Knowledge for Nursing Practice, the authors reviewed the current liter ature and resources available for students on this topic. The authors also collabo rated with other practice experts across the United States, considered their personal experiences as DNP-prepared nurses, and determined that a resource designated specifically for the completion of the DNP project would be a useful resource for DNP students, DNP faculty, and members of healthcare organizations. In essence, the authors formed a scholarsliip team and worked together to meet the perceived needs of DNP students in programs throughout the countr)' to pro\ide the final deliverable, which correlates with Domain 4: Scholarshipfor the Nursing Discipline.

k Chapters at a Glance The reader will note the text begins with an overview of the DNP degree, the his torical influences, and an introduction to practice scholarship. The remaining chapters align with the project development process framework: Problem identifi cation, assessment, project plan, implementation, and concluding with impact (see Figure 1-1).

The AACN (2021) Essentials/or Adv(mccc/-Lt’vel Nursing Education are refer enced in each chapter where they apply to the chapter discussion. As mentioned in the preface, the student will also note that significant points of the discussion

impact

r

Implementation

1

Project plan

Assessment

r ^ L J Problem ID

Figure1-1 The Doctor of Nursing Practice Project Framework

10

Chapterl Setting the Stage for the Doctor of Nursing

are highlighted throughout the chapter, and key messages are reiterated at the end of each chapter. To facilitate learning and to help move the student along in the develop ment of the DNP project, each chapter begins with learning objectives and concludes \vith an action plan and helpjul resources (where applicable). Finally, a dedicated toolbox is available online that includes tools and templates to support the DNP project process.

Section I: The Doctor of Nursing Practice Degree Every good framework begins with a solid foundation. To that end, the focus of the first section of this text is providing an overview of the DNP degree that includes the impetus to the degree, the purpose of the degree, historical and current trends affecting DNP education, as well as defining the purpose of the DNP project and the current view of potential projects. The student is reminded that both the practiceand research-based doctorate will need to collaborate to impact nursing and health care and that the collaboration between the two doctoral levels of preparation will determine the future of nursing and its impact on health care. The overall goal of this section is to help the student develop an understanding of the many forms of scholarship as it relates to the practice doctorate, to conceptu alize the types of projects that can be and are being considered by DNP students in programs across the United States, to examine potential topics of interest in relation to the appropriate level of scholarship, and to recognize the ultimate significance of the DNP project—to positively impact health outcomes and healthcare delivery, which in turn validates the effectiveness of the DNP-prepared nurse. To this last point, a recurring theme threaded throughout this new edition relates to the impact that DNP students and DNP-prepared nurses are making in their efforts to improve healthcare delivery and health care in the United States.

Section II: The DNP Project Section II is devoted to guiding the reader through the DNP project process. Beginning with Chapter 4, Population Health and Healthcare Policy, and continuing in Chapter 5, The Phenomenon of Interest: Leading to Problem Identification, the complex nature of nursing practice is discussed, as well as how practice provides many opportuni ties to explore nursing phenomena. With the focus on problem identification (see Figure 1-2), students are introduced to a variety of strategies to help them select a phenomenon of interest and to explore the topic comprehensively. The value of identifying a project that will lead to an improvement in clinical practice is stressed. Understanding this value is determined through a comprehen sive assessment (see Figure 1-3). In Chapter 6, the DNP student is introduced to elements of a scholarly project that need to be considered early in the development phase, including conducting a literature search, writing a literature review to sup port the value and/or the need to address the phenomenon of interest, performing an organizational assessment, considering system-level issues that contribute to or create healthcare delivery problems, formulating a problem statement, defining the project goal and project scope, developing a project framework, and project type. During this process the student \vill use business acumen, consider a financial anal ysis and the implications, as well as the use of data to validate the problem. Tools are included at the end of the chapter to help the student conduct the organizational as sessment, complete a literature search and review, and help guide the student in the conceptualization of the project plan through the use of the project plan template.

Chapters at a Glance

\

f

\

Organizational need

r ^

N

/ Policy need

identification ]

L

\

Professional need

J

Population need

Figure 1*2 Problem Identification

/■'

1

SWOT analysis/ significance of problem

\

f

Conceptual model(s)

r

^

Assessment

data

(informatics)

Figure1-3 Assessment

Literature

review

11

12

Chapterl Setting the Stage for the Doctor of Nursing

/ Team formation

f

r ^

/

Project plan

Project proposal

\

/

Align

\ \

!

Project

\

types

\

methodology/ evaluation

\ with project

Figure1-4 Project Plan

The project plan template provided as an example is fairly detailed to capture the el ements needed in a complex or comprehensive project. However, the student is reminded that ail the elements presented may not be applicable to every potential project. The focus of the next three chapters guides the students through key aspects to include in the project plan (see Flgurel-4), In Chapter 7, Aligning Design, Method, and Evaluation with the Clinical Question, identifying the appropriate approach to obtain data and the methods used to work wth the data received are explained. A more specific description is offered for program development and evaluation projects, as well as an expansion of project types to include health policy-related projects.

Since nationally, nurses are being called to actively collaborate within inter professional teams to improve quality, cost-effective, and efficient care and improve outcomes (lOM, 2003), another focus of this section is to help the student un derstand that (1) the DNP project provides one with an opportunity to attain and refine the competencies needed for collaborative team participationand leadership; (2) the DNP student will need additional resources to assist in assessing, plan ning, implementing, and evaluating the DNP project; and (3) this is best achieved through collaboration- In Chapter 8, The DNP Project Team: Preparing for Proj ect Implementation, the student is guided through these and other processes that influence the development and implementation of the DNP individual or group project by the faculty mentor and/or project team. The composition and roles of the project team, including the faculty mentor and other members, are reviewed. This information is important because project team dynamics, including making the most of team meetings and resources to form a cohesive and collegial team that

Chapters at a Glance

13

will work together, is vital to the student’s success in completing the DNP project. Further, the point is made that interprofessional, collaborative teams are needed to transform healthcare delivery, A broad overview of points to consider when prepar ing for project implementation is provided, such as taking into consideration the client and personnel, monitoring requirements, problem-solving/t roubleshooting demands, the need to communicate with key stakeholders, and the characteristics and skill set of effective leaders. Samples of a variety of tools are provided for the student to use throughout the DNP project development and implementation cycle to help ensure a successful outcome. Further, the value of the practicum is stressed in this section to help the student recognize (1) how the experience will support the development of DNP competencies and professional scholarly growth and (2) the potential to use the practicum in preparation for and implementation of the DNP project. The benefit of academic practice partnerships is introduced as an effective practicum mechanism to enhance learning for the DNP student and to assist orga nizations in reaching their strategic goals. In Chapter 9, The Proposal, there is a comprehensive discussion regarding how the DNP project proposal represents the student’s intellectual ability, knowledge in the subject area, and contributions to nursing as a profession. To help the student with the proposal writing process, information is provided to (1) help students recog nize early in the process when they may need some additional writing support, (2) in troduce the student to the components included in a sample project proposal, and (3) provide a reference for writing the DNP project proposal. The chapter concludes with considerations for human subject approval and submitting for grant support. This section concludes with a discussion on project implementation, stake holder collaboration via practice partnerships, and project evaluation (see Figure 1-5). In Chapter 10, Leading Implementation Through Collaboration, the

/

Driving

f competency

;

\ attainment *

r Implementation 'X

/

/

Project

evaluation

Stakeholder

(tools, finance,

collaboration

'v,^ustainability) X, Figure1-5 Project Implementation

14

Chapterl Setting the Stage for the Doctor of Nursing

authors expand on how effective collaboration is needed to ensure successful im plementation and how these concepts align with the new AACN (2021) Essential Competencies. For example, the implementation phase is an opportunity for the DNP student to develop competencies related to collaboration, quality, safety, inter professional partnerships, and personal and professional leadership that contribute to a successful project. As noted throughout many of the chapters, exemplars are included to illustrate key concepts. Finally, project management, process improve ment, and communication tools are available at the end of the chapter to facilitate project implementation and communication with stakeholders. Then in Chapter 11, Driving the Practicum to Attain Competency and Leverage Impact through the DNP Project, the authors discuss how the practicum is used as a unique opportunity to plan field experiences that support the development of the advanced nursing competencies and professional scholarly growth. The authors also revised the widely used DNP Student Competency Assessment Tool to align with the Essenliahjor Advanccd-Lcvcl Nursing Education (AACN, 2021). A new chapter focusing on evaluation methods based on project type rounds out this section. Chapter 12, Evaluating the Doctor of Nursing Practice Project, complements the content in Chapter 7. Topics include determining process and outcomes measures, selecting measures and measurement tools, data collection considerations, the analysis plan (e.g., inferential/descriptive statistics; content and/ or thematic analysis), and writing and displaying results.

Section III: Doctor of Nursing Practice Outcomes The last section of this text. Section 111. concludes by reaffirming the importance

of the DNP project with a focus on impact, and the need to disseminate the re sults (see Figurel-6). In Chapter 13, From Data to Knowledge: Disseminating the

.

DNP model

Impacts (follow % through from

\ evaluation)

Impact Value of

practice doctorate

scholarship

Figurel-6 Impact

Dissemination

Chapters at a Glance

15

Results, various formats for disseminating the results are reviewed, such as pub lic presentation, a defense of the project, a written manuscript for the university, and a manuscript submission to a scholarly journal. To this point, valuable in sight is offered on how to successfully submit a manuscript for publication. The importance of communicating and disseminating the results of the DNP proj ect is stressed not only because it may be a required program deliverable, but also because of the knowledge translation that occurs, benefiting both nursing as a profession and, even more broadly, the health of our nation. The student is reminded that the project is a product of DNP education that reflects the attainment of knowledge and skills that launches the DNP graduate into schol arly practice. The point is made, however, that it is important to recognize the need to evaluate the outcomes of this doctoral degree in nursing for effective ness in accomplishing the goals of improving the nursing professions and health care, and meeting societal needs. Recognizing that this will be an important focus for the DNP-prepared nurse, in Chapter 14, The Value and Impact of Practice Doctorate Scholarship, an evaluation strategy is proposed using a new framework based on the Actualized DNP Model (Burson, Moran, & Conrad,

2016). The concept of practice scholarship impact is explored highlighting the research of a global scholarship team. The authors discuss global impact, the value of a scholarship team, mentoring, and the impact of the DNP-prepared nurse. This chapter concludes with an exemplar that illustrates integration of advanced-level nursing competencies of an international nursing leader with global value and impact. Finally, in many of the chapters, there is an excerpt from the perspective of the DNP student regarding the topic of discussion in the specific chapter. For instance, in Chapter 5, The Phenomenon of Interest; Leading to Problem Identification, a student shares her experience of narrowing the topic related to her clinical exper tise, the societal need, data from the organization, and the evidence in the litera ture. There are additional DNP student project exemplars that highlight a variety of frameworks available at the end of the eBook.

These examples are included to show

case aspects of the DNP project, to show the potential for the DNP project as a program deliverable, to provide evidence of healthcare transformation, and to illustrate the impact of the practice doctorate in nursing. In addition, sustainable projects become the catalyst for on going practice change far beyond the original project. Although it is evident that these projects certainly contribute to the health of individual populations, as a whole, they demonstrate that nurses prepared at the doctorate level provide more than protection, promotion, and optimi zation of health and abilities; these nurses fa

cilitate healing and wellness through human connection. As a result of these efforts, society is beginning to see the impact of practice schol arship and the associated benefit of the practice doctorate.

DNP-prepared nurses are

demonstrating their value to

society through practice

scholarship that inn proves healthcare outcomes.

Chapter 1 Setting the Stage for the Doctor of Nursing

16

Summary The journey to the DNP degree may still be via a winding and rugged road; how ever, given the potential for DNP graduates to improve healthcare outcomes and to positively impact the nursing profession, these authors hope that more and more of our nursing colleagues recognize the value of doctoral education and join us on the journey. For the current DNP student, our hopes are that this text will provide a broad view of the DNP project and shed light on the DNP project journey. Finally, where healthcare reform is concerned, it is evident that the National Academies of Sciences, Engineering, and Medicine (2021) has recognized nurses as valuable players in this process. The physical, emotional, financial, and mental health toll humans experienced as a result of the COVID-19 pandemic brings this point into clear focus. DNP-prepared nurses are equipped with a unique skill set to respond to these and other healthcare challenges and crises with the care and compassion that is needed for all humankind. Therefore, it is time for nurses, espe cially DNP-prepared nurses, to see health care as something we shape—DNPs are called to lead and manage collaborative efforts with other healthcare practitioners to improve health care.

Do not go where the path may lead, go instead where there is no path and leave a trail.

—Ralph Waldo Emerson

Key Messages ●

The DNP degree emerged as a response to current healthcare delivery chal lenges, combining advanced nursing and health system competencies needed for complex healthcare environments. The decision to enter a DNP program marks the beginning of what will become a transformative experience for many students. Developing the DNP project is not a linear process; it is created through a series of explorations that result in a comprehensive, well-thought-out project plan. The DNP project is a required program deliverable that demonstrates achieve ment of doctoral competencies and advanced knowledge in a particular area. The DNP project is a means to achieve professional goals and marks the begin ning of many future scholarly contributions. The impact from this work will transform health care by addressing policy con cerns, costs associated with healthcare delivery, and the quality of care.

● ● ●

● ●

Action Plan-Next Steps 1. 2. 3. 4.

Consider the value of the DNP project. Open the mind to a variety of potential project topics. Take advantage of learning opportunities. Enjoy the journey!

References

17

References American Association of Colleges of Nursing (AACN). (2004). AACN position statement on the practice doctorate in nursing. http;/Avww.aacn.nche.edu/publicat ions/position/DNPposition statement.pdf American Association of Colleges of Nursing (AACN). (2006). The essentials of doctoral education for advanced nursing practice. http://www.aacnnursing.org/Portals/42 /Publications /DNPEssentials .pdf American Association of Colleges of Nursing (AACN). (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org/Port als/42/AcademicNursing/pdf /Essentials-2021.pdf Boyer, E. (1990). Scholarship reconsidered: Priorities of the professoriate. Carnegie Foundation for the Advancement of Teaching. New York, NY: John Wiley & Sons. Burson, R., Moran, K., & Conrad, D. (2016). Why hire a DNP? The value added impact of the practice doctorate. Journal of Doctoral Nursing Practice, 9(1), 152-157. Cronenwett, L., Sherwood, G., Bamsteiner, J., Disch, j., Johnson, J., Mitchell, R, & Warren, J.

(2007). Quality and safety education for nurses. Nursing Outlook, 55,122-131. Gonzalo, J. D., Chang, A., Dekhtyar, M., Starr, S., Holmboe, E., & Wolpaw, D. R. (2020). Health systems science in medical education: Unifying the components to catalyze transformation. Academic Medicine, 95(9), 1362-1372.

Gonzalo, J. D., & Ogrinc, G. (2019). Health systems science: The “broccoli” of undergraduate med ical student education. Academic Medicine, 94(10), 1425-1432. Gonzalo, J. D., Skochelak, S. E., Borkan, J. M., & Wolpaw, D. R. (2021). What is health systems science? Building an integrated vision. In S. E. Skochelak, M. M. Hammoud, & K. D. Lomis (Eds-in-ChieO- Health Systems Science (pp. 1-20). Philadelphia, PA: Elsevier. Gonzalo, J. D., Thompson, B. M., Haidet, R, Matm, K., & Wolpaw, D. R. (2017). A constructive

reframing of student roles and systems learning in medical education using a communities of practice lens. Academic Medicine, 92(12), 1687-1694. Gonzalo, J. D., Wolpaw, D. R., Cooney, R., Mazotti, L., Reilly, J. B., & Wolpaw, D. (2022). Evolving the systems-based practice competency in graduate medical education to meet patient needs in the 21st-century health care system. Academic Medicine, 97(5), 655-661. Institute of Medicine (US) Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press. PMID: 25057539

Institute of Medicine (US) Committee on the Health Professions Education Summit. (2003). Health

professions education: A bridge to quality. Washington, DC: National Academies Press, https:// www.ncbi.nlm.nih.gov/books/NBK221528 Institute of Medicine (US) Committee on the Robert Wood Johnson Foundation Initiative on the

Future of Nursing, at the Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. PMID: 24983041 Institute of Medicine (lOM). (2003). Health professions education: A bridge to quality. Chapter 3: The core competencies needed for health care professionals. Washington, DC: The National Academies Press. http://www.nap.edu/openbook.php?record_id=10681 &page=45 National Academies of Sciences, Engineering, and Medicine. (2021). The future of nursing 20202030: Charting a path to achieve health equity. Washington, DC: The National Academies Press. https://doi.org/10.17226/25982 “Scholar." (2016). In American Heritage dictionary of the English language. Fifth Edition. Copyright © 2016 by Houghton Mifflin Harcourt Publishing Company. All rights reserved, https-y/www .thefreedictionary.com/scholar Senge, .P (2006). Systems citizenship: The leadership mandate for this millermium. leader to Leade,r 41, 21-26. https://doi.org/10.1002/ltl.186 Skochelak, S. E., Hammond, M. M., Lomis, K. D., Borkam,J. M., Gonzalo, J. D., Lawson, L. E., & Starr, S. R. (2021). Health Systems Science (2nd ed.). AMA Education Consortium Philadelphia, PA: Elsevier.

CHAPTER 2

Defining the Doctor of Nursing Practice: Historical and Current Trends Dianne Conrad, Karen Kesten, and Lydia Rotondo CHAPTER OVERVIEW

The purpose of this chapter is to define doctoral preparation for nursing and describe nursing practice doctoral education and its role in transforming health care. The historical journey and current trends in doctor of nursing practice (DNP) education will be explored on how the practice doctorate is evolving to meet the competencies as outlined in The Essentials: Core Competencies for Professional

Nursing Education (American Association of Colleges of Nursing [AACN], 2021). CHAPTER OBJECTIVES

After completing the chapter, the learner will be able to;

1. 2. 3. 4.

Define "doctor of nursing practice." Describe the historical and current trends affecting DNP education. Differentiate between the research and practice doctorate degrees. Discuss how the practice-based doctorate and the research-based doctorate will collaborate to impact nursing and health care.

y Defining the Practice Doctorate in Nursing The time is now for the practice doctorate in nursing. Nursing education has evolved to meet the needs of society in preparing nurses throughout history. The emergence and dramatic growth of Doctor of Nursing Practice (DNP) programs in the United States reflect this country’s demand for highly competent providers to improve the health care of its people. ® Samfiphunur Patel/DigitalVisioii VedHs/Getty Images

19

20

Chapter2 Defining the Doctor of Nursing Practice

In 2001, the Institute of Medicine (lOM) outlined aims for healthcare improve

ment in Crossing the Quality Chasm: A New Health System for the 21st Century, which included care that is safe, effective, patient centered, timely, efficient, and equitable. To provide that care, the lOM (2003), in Health Professions Education: A Bridge to Quality, called for a change in how healthcare providers are prepared to meet these challenges. Healthcare providers in all professions are to attain the following core competencies:

● ● ● ●

Provide patient-centered care. Work in interdisciplinary teams. Employ evidence-based practice. Apply quality improvement.

●

Utilize informatics.

By 2011, the lOM’s report The Future of Nursing: Leading Change, Advancing Health responded with these key messages:

● ● ●

●

Nurses should practice to the full extent of their education and training. Nurses should achieve higher levels of education and training through an im proved education system that promotes seamless academic progression. Nurses should be full partners with physicians and other healthcare profes sionals in redesigning health care in the United States. Effective workforce planning and policy making require better data collection and information infrastructure.

In 2021, the renamed lOM, the National Academies of Medicine, released The

Future of Nursing 2020-2030 report that reinforced and expanded on prior recom mendations with an emphasis on achieving health equity for all. The report states that nurses “play a central role in addressing these inequities across the entire spec trum” (p. x). The DNP-prepared nurse is uniquely qualified to lead efforts in policy and advocacy to realize the 2020-2030 Future of Nursing goals. (See Chapter 4, Population Health and Healthcare Policy for more on Social Determinants of Health and attaining competencies in population health, policy, and advocacy.) These important documents reflect the changing societal needs for a highly educated workforce prepared to meet the complex challenges of health care in the 21st century and beyond. In addition, the nursing profession and nursing education has continued to evolve since the founding of modern nursing in the 19th century. External forces and internal influences within nursing have contributed to the emergence of the practice doctorate in nursing. As depicted in Table 2-1, nursing education reflects the maturation of a nascent discipline over nearly 150 years. In the 19th century, nursing education focused on defining knowledge and skills as a distinct discipline. The 20th century was characterized by the establishment of the philosophical and scientific basis for the discipline, especially in the later decades. Nursing education in the 21st century will require the adoption of transformative learning as a defining attribute of competency-based education (Frenk et al., 2010). Within a transformative context, emphasis is placed on knowledge mobilization and the demonstration of what students and graduates can do with what they know in novel situations and multiple practice settings. While transformative learning is a critical attribute for all professional nursing education, DNP-prepared nurses must be particularly skilled at analyzing and synthesizing knowledge that is adapted to local contexts. The DNP scholarly project is a summative exemplar of transformative

Defining the Practice Doctorate in Nursing

21

Table 2-1 Evolution of Modern Nursing Education DNP Education: Transformative Learning for the 21st Century Level of Learning in Nursing Education 19th Century

Informative

Defining knowledge and skills for modern nursing practice beginning with Nightingale's Notes on Nursing.

Formative

Explication of discplinary knowledge: advanced nursing education, emergence of nursing science and nursing theory, establishment of philosophical basis of the profession of nursing.

1860-1 St Nightingale school ’ opens in England

1873-1 St US professional

I

nursing education

i

schools

1

20th Century

1923-Goldmark report 1970-Lysaught report Mid-century nursing theorists

21st Century 2009-Carnagie study (Benner et al.)

Defining Attribute

Tranformative

Knowledge mobilization; shift from fact memorization

Future of Nursing reports

to searching, analysis, and synthesis of information;

(National Academy of

demonstrated IPP

Medicine)

competence, adaptation of evidence to local contexts.

Data from Benner et al.. 2009; Frenk et al.. 2010; Gebbie. 2009; Goldmark. 1923; lysaught. 1970: and Nightingale. I860.

Data from Benner. P.. Sutphen. M.. Leonard. V.. & Day. L. (2009. December 9). Educating nufses: A cell fonddicet transformation. San Francisco. CA: Jossey-Bass. Frenk. J.. Chen. L., Bhutta. Z.A.. Cohen. J.. Crisp. N.. Evans, t. Fineberg. H.. Garcia. P. Ke. Y.. Kelley. P. Zulfi qar A Bhutta. Jordan Cohen. Nigel Crisp. Kistnasamy.. B.. Meleis. A.. Naylor. D.. Pablos-Mendez. A.. Reddy. S., Scrimshaw. S.. Sepulveda. J.. Serwadda. D.. and Zurayk. H. (Dec 4.2010). Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world, lancet 376. 1923-1958. Gebbie. K.M. (2009). 20th-century reports on nursing and nursing education: What difference did they make? Horsing Outlook.

57.84-92. doi:10.1016/j.outlook.2009.01.006 Goldmark J. (1923). Horsing and nursing education in the united states: Report of the committee for the study of nursing education. Macmillan Company.

Lysaught J.P {WtilAnabstractforaction. New York. McGraw-Hill. Nightingale. F. (1860). Holes on nursing: What it is. and what it is not D. Appleton and Company.

learning in advanced nursing education reflecting doctoral nursing education that prepares individuals for advanced practice as systems citizens, practice scholars, change agents, and health equity advocates in the 21st century. Although the first doctoral programs in nursing focused on preparing research doctorates with the PhD degree, in 1990, Case Western Reserve University changed their Nursing Doctorate (ND) program to a post-master’s clinical doctorate. How ever, in subsequent years, the ND and Doctor of Nursing Science (DNSc) programs mirrored the research-oriented PhD degree in emphasis and content. The societal

22

Chapter 2 Defining the Doctor of Nursing Practice

call for addressing improving the practice-oriented health and safety issues by bringing evidence to practice was evident in the Institute of Medicine (lOM) reports of 2000 and 2001. The nursing profession and the American Association of Colleges of Nursing (AACN) responded with the development of the practice doctorate in nursing in 2004. In 2006, the AACN provided the roadmap for practice doctorate education with The Essentials of Doctoral Education for Advanced NursingPraclice. The purpose of practice-focused doctoral programs is to prepare experts in specialized advanced nursing practice, as defined by the AACN (2006). The programs are to focus heavily on innovative and evidence-based practice, reflecting the application of credible research findings. Since 2006, the Doctor of Nursing Practice degree has flourished and evolved, guided by societal needs and professional organizational leadership to identify com petencies necessary to produce graduates who are practice experts in nursing (see Figure 2-1). Competency-based education for nursing was emphasized in the Qual ity and Safety Education in Nursing (QSEN) project, led by Dr. Linda Cronenvveii, which identified the knowledge, skills, and attitudes (KSAs) that nurses must pos sess to deliver safe, effective care (Cronenwett et al, 2007). Competencies for emr)' into practice as well as advanced practice are now outlined in the updated Essentials: Core Competencies for Professional Nursing Education (AACN, 2021) according to 10

2Q22: Growtnia 407

DNP Programs, available, in all SO states and

O.C. {AACN. 2022) 2021: Future of f/urswff 20ZO-2030: MCN New

fssem/a/s{AACN.2021)

TS

1999-2001 lOMReports; ToSrr is Human: Building a Safer

Healtn System t2000,y Crossing the Quality Ctiasm (2001) 1990: Case Western

Reserve Unrvetsity ND program was changed from an entry-level program to a

. Protessional Organizations . Respond: NONPF In 2001 : developed Practice I Doctorate Task Force (2004); < AACN posidor) statement

: on DNP (2004)

post-master's

* AACN The Essentials of

clinical doctorate

! Doctoral Education for

I Advanced Nursing Practice {2000)

Figure2-1 Historical Evolution of Doctor of Nursing Practice Data from AACN I2C06.2021.20221; lOM I2D00.2901): NONPF (200AI.

Data from Amatican Association of Colleges of Nutsing lAACNI. [200il. the essemlals of doctoral educaliori for advanced norsing gractice. Petiieved fromtiltp://m'.aacnTiutsing.org/Portals/42/Publicat!on s/ONPEssentials.pdf American Association of College of Nutsing [AACNI. !202l). The essentials; Cote competencies for professional nursing education. Retrieved ticm ntips^/iww.aacnnursing o'g/Pottais/42/AcademicNutsing2|idlfE$sen iials-2CI2l pdl American Association of Colleges of Nursing 12022). 2021-2022 Cnrodment and Graduations in Baccalaureate and Graduate Programs in Nursing. Washington. 8C; American Assotiation of Colleges of Nursing Instituted Medicine IIOMI. 12000). To Err is Human; Buiding a Safer Health System. Kohn IT. Corrigan JM, Donaldson MS. editors. Washingtor IDCI; National Academies Press. PMIO; 2S07724S.

Institute of Medicine IIOM) (2001). Crossing ine quality diasm; Anew health system Icr the 21sl century. Washirgton, DC: National Academies Press. Reuieved from hI^l:’/llnWJ1adonalac^demies.orgPlffld/-/tnedia/Files/Repo(t%20Flles/200i/Ctossillg■ttl^0uality-ChasrT)/aua llty%2(l Chasm%202001lN70%2Gte]oa%20tirief.odf

Nal'ional Orgenlatlonof Nurse Practitiimer Faculties [NONPF! I20UI. Practice doctorate in nursing; Models, competencies, and the NQNPF peispectjve.

Defining the Practice Doctorate in Nursing

23

Domains that reflect the lOM and QSEN competencies. The Quadruple Aim pro posed by Bodenheimer and Sinskey (2014) outlines the goals of care for all health professionals to enhance the patient experience and improve population health, while reducing costs and preserving care team well-being. Health System Science (HSS) is an emerging curriculum in medical schools referred to as the third pillar of medical education to complement clinical and basic sciences (Skochelak et al., 2021). HSS is “the study of how care is delivered, how health care professionals work together to deliver that care, and how the health

system can improve patient care and health care delivery” (Skochelak et al., 2021, p. 6). HSS provides critical education related to the context for healthcare delivery in which effective interprofessional collaboration and communication are essential for high-performing teams within complex healthcare systems. The Health Systems Science domains (core, foundational, and linking) and topics align with QSEN and AACN competencies in nursing education, demonstrating the need to prepare all health professionals as systems citizens to achieve a reimagined healthcare system. See Table 2-2 for a comparison of lOM recommendations on healthcare im provement, the core competencies of healthcare professionals, the Health System Science Domains, the AACN Essentials: Core

Competencies for Professional Nursing Education with the Quadruple Aim Goals. The practice doctorate for nurses, the DNP, is a degree, not a role. There are many roles in advanced nursing practice. The AACN (2004) defined advanced nursing practice as:

The DNP is a

degree, not a role.

Any form of nursing intervention that influences healthcare outcomes for individuals or populations, including the direct care of individual pa tients, management of care for individuals and populations, administra tion of nursing and healthcare organizations, and the development and implementation of health policy, (p. 2) Therefore, advanced nursing practice encompasses such roles as nurse practi tioner (NP), clinical nurse specialist (CNS), certified nurse-midwife (CNM), nurse anesthetist, nurse administrator, nurse informaticist, and nurse health policy spe cialist. This list of roles is not inclusive because nursing entrepreneurs continue

to pioneer advanced nursing practice roles to meet patient needs in a variety of settings. However, the AACN (2004) has not recognized nursing education as a stand-alone advanced nursing practice specialty for DNP education. The AACN (2004) recommends that both DNP and PhD programs offer additional coursework in pedagogy and practica that would prepare graduates to fill the role of nurse educator.

There is a special definition of the roles of the advanced practice registered nurse (APRN). In 2008, a report titled Consensus Model forAPRN Regulation: Licensure, Ac creditation, Certification & Education was completed through the work of the APRN Consensus Work Group and the National Council of State Boards of Nursing APRN Advisory Committee (APRN Joint Dialogue Group, 2008). This group defined four specific APRN roles—certified registered nurse anesthetist (CRNA), CNM, CNS, and certified nurse practitioner—for the purpose of standardizing licensure lan

guage across the country. However, the group acknowledged that

Table 2-2 Comparison of Quadruple Aim, lOM competencies, QSEN, Health Systems Science, and AACN Essentials Core Competencies of Healthcare

Quadruple Aim (2014)

The Essentials: Core

Professionals

QSEN Competencies (Cronenwett et al.,

(lOM, 2003)

2007)

Health System Science Domains (Skochelalcetal., 2021)

Competencies for Professional Nursing (AACN, 2021)

! Encompasses the : integration, translation, and j application of disciplinary nursing knowledge and ways of knowing, as well

3

foundation in liberal arts and

^ natural and social sciences. Provide Patient-

I Patient-Centered Care

j Recognize the patient ' or designee as the i source of control and

: full partner in providing ' compassionate and I coordinated care based

engaging patients

I on respect for patient's preferences, values, and

to play and active

; needs.

role in their care to

improve outcomes. |

Patient Family and Community

I (Core Functional Domain) Focus on patient experience of care as well as patient's values, behaviors, and motivations for engagement in health care. Considers contextual influences

Domain 2: Person-Centered Care

] Focuses on the individual

I within multiple complicated I contexts, including family and/or important others.

Person-centered care is of patients' families and communities, healthcare delivery, clinical decision support. : holistic, individualized, just.

; documentation, and tech-related tools.

(D N

I disciplines, including a

Patient Experience Centered Care Providing a Identify, respect, and care about care experience that is quality, I patients' differences. patient-centered, I values, preferences, compassionate, i and expressed equitable, and safe, needs.

B)

Domain 1: Knowledge for : Nursing Practice

^ as knowledge from other

Enhance the

o

I respectful, compassionate, coordinated, evidence-

I based, and developmentally appropriate.

D Z!)

(Q

(D

O O n

o o

c

(Q

T) n o

(V

Improve

Provide Patient-

Population, Public, and Social Determinants

Population Health

Centered Care

Provide evidence-

Should include a

of Health (Core Functional Domain) Includes all issues related to public health,

based care

focus on population

improving the

health.

preventative medicine, and improvement strategies to address healthcare gaps. Includes assessment, monitoring, measurement of disease/injury prevention, and health promotion, and health outcome improvement at the population level.

health of a

population, focusing on prevention and reducing illness.

Domain 3: Population

! Health

i Spans the healthcare delivery continuum from prevention to disease management of populations and describes collaborative

activities with affected

■ communities, public health, I industry, academia, health

j care, local government j entities, and others for the

! improvement of equitable

j population health outcome.

I Employ EvidenceBased Practice

I Integrate best I research with 1 clinical expertise i and patient values

j for optimum care. I and participate

Evidence-Based

j Domain 4: Scholarship for

Practice (EBP) Integrate best current

{the Nursing Discipline I Involves the generation,

evidence with clinical

synthesis, translation, application, and

expertise and patient/ family preferences and values for delivery of optimal health care.

I dissemination of nursing i knowledge to improve health i and transform health care.

3) 3

3' to 3n>

n

o' Tithesis, the Essentials for Advanced-Level Nursing Education

64

Chapters Scholarship in Practice

Table 3-2 AACN Essentials: Core Competencies for Professional Nursing Education 1.

Knowledge for Nursing Practice

2.

Person-Centered Care

3.

Population Health

4.

Scholarship for the Discipline of Nursing

5.

Quality and Safety

6.

Interprofessional Partnerships

7.

Systems-Based Care

8.

Informatics and Healthcare Technologies

9.

Professionalism

10

Personal, Professional, and Leadership Development

Reproduced from American Association of Colleges of Nursing. (20211. The MCN Essentials: Core Competencies for Professional Horsing Education, http://www.aacnnursing.org.

are integrated and demonstrated (AACN, 2006, 2015a, 2021). The Essentials ex emplify a thoughtful contribution and roadmap of the competencies the nursing scholar must exemplify to have an impact on health care from a nursing perspective (AACN, 2021). The AACN Essentials are presented and described in Chapter 2, De

fining the Doctor of Nursing Practice: Historical and Current Trends, and are listed in Table 3-2. Doctoral coursework supports the AACN Essentials for Advanced-Level

Nursing Education and the development of the new knowledge and skill set for the DNP student. The coursework also offers the student an opportunity to explore their topic of interest within each of the Essentials. The DNP project incorporates practice and scholarship. There is an emerging realization that scholarship requires the integration of practice in a practice disci pline. The defining feature of practice is that it incorporates an intervention that influences an outcome. The expansive view of the AACN definition of nursing prac tice allows for the full impact of contributions from all avenues of advanced practice to positively influence the nation’s health system. The AACN (2004) definition of advanced nursing practice is

any form of nursing intervention that influences health outcomes for indi\iduals or populations, including the provision of direct care or manage ment of care for individual patients or management of care populations, and the provision of indirect care such as nursing administration, execu

tive leadership, health policy, informatics, and population health, (p. 2) Advanced nursing practice includes nurse practitioners, clinical nurse special ists, nurse anesthetists, nurse-midwives, nurse administrators, policy specialists, and informaticists.

What Quali^es as a DNP Project?

65

Earlier discussion in this chapter focused on the critical nature of scholarship in contributing to the knowledge base of nursing from a practice perspective. It becomes clear that the DNP project is much more than a mere demonstration of what the student has learned; it is a demonstration of how practicing nurse scholars can build new knowledge. The DNP project is an effort to build the bridge between research and practice, narrowing the gap that has existed there. This gap has pre vented nursing from contributing fully to the body of knowledge that is desperately needed to achieve the clinical effectiveness and

fiscal benefits so sorely needed in our healthcare system. The DNP project is a demonstration of how practicing scholarly nurses can build new knowledge. The DNP project contributes to the DNP’s

The DNP

project is a

understanding of practice knowledge gener

demonstration of

ation by the lived experience. The experience of the DNP project fulfills the transformation of the student to adopting a scholarly way of thinking. The transformed student approaches issues with a new and developed view that in corporates a broad skill set. It is practice schol arship that is embraced in the DNP project.

how practicing nurse scholars can build new

knowledge.

^ What Qualifies as a DNP Project? The DNP project should encompass multiple aspects of the AACN Essentials for Advanced-Level Nursing Education. The project should be broadly practice based (refer back to the AACN definition of “practice”). A few topic examples include a project based on a population, health system, or policy issue. Some formats for the DNP project include quality improvement, demonstration projects, clinical inquiry, policy projects, or translation of EBP and program development and evaluation. The DNP student should reflect on life experiences, both professionally and per sonally, to understand the strengths and the passions that are already owned and can be used in building a strong scholarly project. Developing an understanding of the needs of the stakeholders within the context of an organization must also be considered (see information on conducting an assessment in Chapter 6, Validating the Problem and Conceptualizing the Project Plan). The DNP project has been reviewed in the literature and within various venues. The variability of projects has been noted, with the developing understanding that DNP projects must incorporate evidence synthesis, leadership, and measurement of outcomes (Brown & Crabtree, 2013; Grey, 2013; Kirkpatrick & Weaver, 2013; Roush & Tesoro, 2018; Terhaar & Sylvia, 2016). There has been further inquiry by the AACN in the development of appropriate criteria for DNP scholarship that will include aspects of practice knowledge gener ation and DNP accountability. In response to the variability in DNP education, the AACN commissioned the Implementation of the DNP Task Force (2015a) to outline recommendations for the DNP project (see Chapter 2, Defining the Doctor of Nurs ing Practice: Historical and Current Trends). DNP project elements, including plan ning, implementation, and evaluation components, must be considered to have the

66

Chapters Scholarship in Practice

desired impact. Projects should focus on changes that impact healthcare outcomes ei ther through direct/indirect care with a system or population focus. Implementation should be demonstrated in an appropriate area of practice and include an evaluation of processes and/or outcomes and a plan for sustainability (AACN, 2015a). As the student considers development of the DNP project, it is helpful to have consistent criteria applied. Waldrop, Caruso, Fuchs, and Hypes (2014) suggest an acronym of “EC as PIE” for criteria that include Enhancing outcomes (health/practice/policy), Culmination of practice inquiry, Partnership engagement, Implementing evidence, and Evaluation of outcome. The results of the work from the AACN task force on the

DNP project have given new direction to the criteria of the project, which serve to clarify consistency and rigor without impeding creativity (AACN, 2015a). Practice scholarship encompasses all aspects of the delivery of nursing inter ventions to have a direct impact on outcomes. If the DNP project is to have an impact on our healthcare system and the quality of care, it must be done within the context of outcomes. In considering projects worthy of such study, several questions can be asked: Is there a contribution to comprehensive quality health care? Are there specific benefits for a group, population, community, or policy? Does the project ad vance nursing practice at the local, state, and national levels? Is the project sustain able and cost effective? See Chapter 14, The Value and Impact of Practice Doctorate Scholarship, for a framework for evaluation of the DNP degree and outcomes.

^ CHrrent Views of the DNP Project Rigor of the DNP Project Rigor can be defined as a “systematic, logical, and thorough approach to the de sign and implementation of a project that addresses a significant problem and in cludes an evaluation process based on appropriate metrics, collected and analyzed using methods that provide a valid and reliable determination of project outcomes” (Roush & Tesoro, 2018, p. 2). Ongoing evaluation of DNP projects will shed light on the evolving educational needs that faculty must address in developing the DNP-prepared nurse. DNP knowledge generation and scholarship will continue to evolve in re sponse to society’s needs. As students contemplate the significance of the project for themselves, they should also consider the work that has been done to get nursing to this important crossroad. The DNP project will not only contribute to the student’s successful transition but will add to the knowledge base of nursing and impact nursing’s work from now and into the future.

^ Scholarship Beyond the DNP Project DNP student enrollment and graduation rates continue to increase (AACN, 2022). With the increase in DNP graduate numbers, we are now at a point in the DNP de gree trajectory where society is beginning to see the impact of practice scholarship and the associated benefit of the practice doctorate. Therefore, defining the schol arship of the practicing DNP is critical to ensure the impact of the work in clinical, political, administrative, and academic venues. Nurses who earned the DNP degree make a significant impact on the quality, efficiency, and effectiveness of health care

Scholarship Beyond the DNP Project

through their contributions in clinical prac tice, advocacy in health policy, implementa

The

tion and evaluation of EBP, and contribution to

DNP-prepared

nursing education (Edwards et al., 2018). The DNP-prepared nurse influences clinical prac tice, health systems, health policy, academia,

67

nurse is

as well as health economics, and information

becoming part

technology (Edwards et al., 2018; Paplham &

of the fabric of

Austin-Ketch, 2015; Terhaar et al, 2016). Academic educators

have

demonstrated

systems within

that DNP graduates hold competencies of com organizations, bining knowledge of clinical innovation with practice expertise to improve population and universities, and patient health outcomes (Berkowitz, 2015). A recent study of 306 practicing DNP nurses entrepreneurial found that most respondents agreed, or strongly efforts. agreed, that they attained knowledge and com petencies in translating research evidence into practice; synthesizing the literature to identify a solution for a practice issue; identifying, measuring, and/or evaluating outcomes; and designing and implementing quality improvement, EBP, and research (Kesien et al, 2021a). These findings are important because practice scholarship knowl edge and competencies are needed for nurses to serve as full partners in health care redesign and improvement efforts, as indicated in the NAM’s (2021) Future of l^ursing 2020-2030 report. Kesten and colleagues (2021b) surveyed DNP-prepared nurses in practice to rate their level of engagement in practice scholarship activities in the workplace since achieving their DNP degree. Survey respondents indicated the highest level of frequency of engagement in practice scholarship for evaluating current clinical knowledge, translating current best evidence in practice, and evaluating new care delivery strategies. Kesten et al. (2022) explored the perception of impact by DNP-prepared nurses and found that most respondents reported that their practice scholarship was somewhat, very or profoundly impactful on individual patients or populations, quality of care, and on the profession of nursing. The perception of im pact was reported by most respondents at the patient care level, on patient families, the system, the interprofessional team, and the community. The DNP project is the beginning of the trajectory of scholarship that will be continued by the DNP graduate. As the DNP-prepared nurse becomes part of the fabric of systems within organizations, universities, and entrepreneurial efforts, practice scholarship will need to be further developed in the multiple arenas where the DNP graduate impacts practice outcomes. The DNP-prepared nurse within organizations is driving scholarship to implement institutional policy change, funnel EBP to the bedside, and direct practice-based evidence to research. This DNP graduate leads teams and employs high-level interdisciplinary competencies to improve health systems and popula tions. Roles are continuing to evolve to incorporate the knowledge and skill set that the DNP-prepared nurse brings to advance quality efforts within organizations. It is crucial that the DNP-prepared nurse demonstrate the ability to successfully im pact outcomes related to leading system change, implementing policy change, and management of persons with multiple chronic conditions across sites and that the

68

Chapters Scholarship in Practice

impact is evaluated using outcome measures valued by organizations and the public (Brown & Crabtree, 2013; Redman, Pressler, Furspan, & Potempa, 2015). In addi tion, the DNP-prepared nurse within health policy scholarship is able to enhance the vision of emerging healthcare systems. The rigor of practice scholarship gives credibility to the DNP-prepared nurse and influences policy. The DNP-prepared nurse within academia is incorporating a practice model that influences tenure track (see Chapter 14, The Value and Impact of Practice Doc torate Scholarship). The scholarship of integration and application is an essential part of this model. As more and more DNP-prepared faculty members hold orga nizational appointments and provide consultation services, there will be a need to balance competing priorities. An emerging approach to engage both healthcare organizations and academic practitioners and researchers is the academic-practice partnership (APP). APPs are formalized relationships between an academic nursing program and care setting and may include other professionals, corporations, government entities, and foun dations. Some examples of academic-practice partnerships include those between schools of nursing and acute care settings, community-based settings, and long term care facilities (AACN, 2018). There is a need for alignment and integration of academic nursing with practice settings to advance health, health care, and trans formation. Academic and practice leaders can accelerate dissemination of shared knowledge, scientific inquiry, translational research, and policy advocacy that af fect health. Research conducted on successful partnerships reveals that they have a shared vision, common goals, ongoing commitment, shared knowledge, clear communication, and mutual respect (AACN-AONE, 2012). APPs are an important mechanism to strengthen nursing practice and help nurses to become well posi tioned to lead change and advance health, thus addressing the recommendations of the NAM Future of Nursing report. Both DNP students and graduates benefit from the development of the APP For students, a supporting organization with identified strategic goals that align with the DNP project can strengthen and sustain the project. For DNP graduates, ongoing practice scholarship is supported for DNP-prepared nurses in practice or academia that ultimately benefit patients and systems. Dr. Amy Manderscheid describes her experience implementing her DNP proj ect between the academic and practice settings (see Exemplar 3-1).

Exemplar 3-1 Leveraging Interprofessional Collaboration Between Academia and Practice Settings to Impact a Pediatric Quality and Safety Improvement Imperative Amy Manderscheid, DNP, RN, CMSRN The power of a collaborative partnership among academia and practice settings offers staggering outcomes when promoting a culture of high reliability, quality, and safety in a leading Midwestern pediatric hospital. This unique relationship is an exemplar of an innovative role of a DNP-prepared nurse who chose to engage with an interprofessional team of healthcare providers and leaders to address quality-based processes and communication gaps in preparation of seasonal high patient volumes. The purpose was to assess nursing perspectives regarding confidence, teamwork, communication, and elements attributing toward a culture

Scholarship Beyond the DNP Project

69

of safety, while leveraging in situ simulation to mitigate respiratory decline with interprofessional teams of nurses, physicians, and respiratory therapists. The setting for this work occurred in a large midwestern academic children’s hospital on an acute care medical-surgical 24-bed unit. This children's hospital is part of a large health system and is a level-one trauma center. Specifically, the patient population on this nursing unit consists of fairly complex medical patients with diagnoses including, but not limited to, respiratory syncytial virus (RSV), bronchiolitis, and pneumonia. Two pediatric interprofessional teams conduct bedside rounds, where providers openly discuss concerns, progress, and questions in partnership with patients and families as appropriate. Team members are primary responders when rapid response teams are notified to quickly assess a deteriorating patient, and participants in our team-based simulations. Because of the organizational commitment to safety and training, this initiative entailed use of the on-site pediatric simulation program with use of fully functional, advanced audiovisual equipment, computers, and software. Participants worked in patient rooms with equipment and supplies as three clinical simulations were offered to teams of nurses, respiratory therapists, and physicians. Simulations were offered twice per week across 8 weeks, timed specifically prior to the seasonal peak of respiratory illness. This design led to opportunities to enhance application of safety culture principles through simulation training, identification of opportunities to eliminate risks, enhancing strategies as highly functioning interprofessional teams, and increasing

proficiency in multiple unit (or specialty)-based scenarios. This approach is consistent with evidence-based practice, as simulation can lead to increases in the effectiveness of teamwork and communication,

which can result in a reduction in errors, cost, and mortality rates (Merchant.

2012). Furthermore. Bultas, Hassler, Ercole, and Rea (2014) examined the use

of high-fidelity simulation in the Pediatric Emergency Assessment Recognition Stabilization course. In this study, participants were able to maintain or increase their ability to recognize the deteriorating patient and felt more confident in their ability to recognize and treat the deteriorating patient (Bultas. Hassler. Ercole. & Rea, 2014). The utilization of an early warning system, along with the timely delivery of interventions, is crucial in the prevention of patient deterioration (Murray, Williams, Pignataro, & Volpe, 2015). The delay in the recognition and treatment of the deteriorating pediatric patient is a recognized cause of preventable cardiac arrest and mortality (Panesar et al.. 2014). Through use of the Plan-Do-Study-Act (PDSA) model (Associates in Process Improvement, 2018), in tandem with the Clinical Practice Model framework (Elsevier CPM Resource Center. 2011); respiratory-base d pediatric simulations: and questionnaires with physician, nursing, and respiratory therapist teams, outcomes suggest a strong impact on recognizing clinical signs of patient deterioration while promoting safety culture principles, team-based assessments, and communication standards. Questionnaires

included the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Culture Survey, in addition to an assessment of safety behaviors and use of organizational tools, including the Pediatric Early Warning System (PEWS). Response rates exceeded 60%. indicating committed, engaged interprofessional providers as the project was implemented. Positive outcomes resulted in eight distinct pre- and post-measurement areas, indicating a positive shift in the areas of nursing confidence and performance, teamwork, and communication standards consistent with safety culture

70

Chapters Scholarship in Practice

principles. Length of stay and number of transfers to the pediatric intensive care unit continue to be monitored. Secondary gains were highly valuable, including capturing candid moments of peer support and education, nursing and medical student obsen/ations, executive leadership support, as well as simulation debriefs led by attending physicians, nurse educators, and the simulation specialist to discuss evidence-based practice and safety culture principles. In conclusion, collaborations among practice and academia professionals may result in impactful patient and system outcomes as relationships are formed, patient care processes are examined, and action plans are implemented and evaluated. Furthermore, the return on investment with high-impact interventions,

learning, teamwork, and recognition of safety culture principles and behaviors may be palpable as patients, leaders, and teams experience changes in care standards, reimbursement models, and positive culture transformations in sustainment of being recognized as a high-reliability organization.

y Recommendations It is critical that the outcome-focused nature of practice scholarship be recognized as an effective means of knowledge development that contributes to the changes needed in our healthcare system. To reach these goals, utilization of all skill sets of DNP-prepared nurses is needed to effect change in populations, healthcare organizations, and policy. A word of caution is exercised in focusing too heavily on one advanced practice role or another. The strengths of nurse practitioners, nurse midwives, clinical nurse specialists, nurse anesthetists, nurse administra tors, informaticists, and policy experts will be required to meet the challenges that are before us.

There will be ongoing challenges to continue scholarship after attainment of the DNP degree to continue to impact health care. The DNP-prepared nurse will need to define practice scholarship more clearly for organizations and academia to carve out time for scholarship in their clinical role—^which ultimately is the purpose of the DNP-prepared nurse. There is a need to develop ways to categorize our knowledge development to further disseminate and build on practice-based knowledge. This work is already under way and is further discussed in Chapter 14, The Value and Impact of Practice Doctorate Scholarship. There is great value in the work of teams. PhD- and DNP-prepared nurses working together in scholarship teams will continue to evolve to advance the profession of nursing. Interdisciplinary and intradisciplinary relationships will be required to impact complex issues. Development of scholarship teams will in crease creativity, impact, and production. There is movement in group and team models for DNP projects. Each member of the group must meet all expectations of planning, implementation, and evaluation of the project and have a leadership role in at least one component of the project and accountability for a deliverable (AACN, 2015a). Working closely with PhD colleagues to further the work of scientific inquiry will build a nursing repository of knowledge that can be used to solve issues and is further discussed in Chapter 10, Leading Implementation Through Collaboration.

Action Plan—Next Steps

71

Impact The DNP nurse is prepared to answer the charge from the NAM for nurses to take their place at the decision-making table and to collaborate with other healthcare professionals to improve the health and health care of our nation. Practice scholar ship is the driving force that will disseminate practice-based evidence and support the developing success of the practice doctorate to close the gap between research and practice, thereby meeting societal needs of improved health for our popula tions. Dissemination of outcomes related to DNP-prepared nurses’ work wiU propel the influence and the impact forward. This dissemination is an obligation of the DNP-prepared nurse to society and results in a positive effect on health care.

Key Messages Scholarship is the mechanism that provides knowledge development within a

●

discipline. A broadening of the view of scholarship includes integration and application.

● ●

Practice scholarship embodies all aspects of nursing interventions that affect outcomes in individuals, populations, systems, and policy. The DNP project integrates and demonstrates the AACN Essentials for Advanced-Level Nursing Education. DNP project elements include plaiming, implementation, and evaluation com ponents that impact healthcare outcomes. The DNP project is also a demonstration of the effectiveness of the DNP-prepared

● ● ●

nurse.

Action Plan-Next Steps 1.

2.

Which AACN Essentials for Advanced-Level Nursing Education could be demon strated in your idea for a DNP project? Does the project idea consist of breadth and depth of knowledge within a de fined area?

3. 4.

Is there the potential for irmovation and creativity to affect an outcome? Is there the ability to expose the DNP project to public scrutiny and peer review?

5. 6. 7.

What type of scholarship is evidenced within the project idea—discovery/ integration/application? What aspect of practice is the focus—^individual, population, system, policy? Is there a contribution to comprehensive quality health care? Are there spe cific benefits for a group, population, community, or policy? Does the project

advance nursing practice at ^e local, state, and national levels? Is the project sustainable and cost effective?

11.

Is this topic of interest a need at the organizational level? What organizations are potential project implementation sites? Is there a planning, implementation, and evaluation component? How will this project impact healthcare outcomes? What areas of expertise and passion does the student bring that can be built

12.

What skill sets need to be developed to successfully implement the DNP

8.

9. 10.

upon? project?

72

Chapters Scholarship in Practice

References American Association of Colleges of Nursing (AACN). (1999). American Association ofColleges ofNurs ing position statement: Defining scholarship for the discipline of nursing. https:/Avww.professional nursing.org/article/S8755-7223(99)80068-4/pdf American Association of Colleges of Nursing (AACN). (2004). Position statement on the practice doctorate in nursing. http://www.aacnnursing.org(DNP/Position-St atement American Association of Colleges of Nursing (AACN). (2006). The essentials of doctoral education for advanced nursing practice. httpyAvww.aacnnursing.org^ortals/42/P ublications/DNPEssentials .pdf American Association of Colleges of Nursing (AACN). (2015a). The doctor of nursing practice: Current issues and clarifying recommendations. httpsy/www.pncb.org/sites/default/filea'2017-02/AACN _DNP_Recommendations. pdf American Association of Colleges of Nursing (AACN). (2015b). DNPfact sheet. http://www.aacnnursing .org/News-Information/Fact-Sheets/DNP-Fact-Sheet American Association of CollegesofNursing(AACN). (2018). De/iningscholarship/oracademic nursing.

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Boyer, E. (1990). Scholarship reconsidered: Priorities of the professoriate. Carnegie Foundation for the Advancement of Teaching. New York, NY: John Wiley & Sons. Brown, M. A., & Crabtree, K. (2013). The development of practice scholarship in DNP programs: A paradigm shift. Journal of Professional Nursing, 29(6), 330-337. https://doi.oig/10.1016/j .profnurs.2013.08.003 Bultas, M., Hassler, M., Ercole, R, & Rea, G. (2014). Effectiveness of high-fidelity simulation for pediatric staff nurse education. Pediatric Nursing. 40(1), 27-42. Bunkers, S. S. (2000). The nurse scholar of the 21st century. Nursing Science Quarterly, 13(2), 116-123.

Burson, R., Moran, K., & Conrad, D. (2016). Why hire a Doctor of Nursing Practice-prepared nurse? The value added impact of the practice doctorate. Journal of Doctoral Nursing Practice, 9(1), 152-157.

Cary, A. H., & George, G. (2011). The Doctor of Nursing practice (DNP). Oregon State Board of Nursing Sentinel, 30(1), 10-11. Draye, M., Acker, M., &r Zimmer, .P (2006). The practice doctorate in nursing: Approaches to trans

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Grey, M. (2013). The Doctor of Nursing practice: Defining the next steps. Journal of Nursing Educa tion, 52(8), 462-465. https://doi.oig/10.3928/01484834-20130719- 02

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Kitson, A. (1999). The relevance of scholarship for nursing research and practice. Journal ofAdvanced Nursing, 29(4), 773-775. Kitson, A. (2006). From scholarship to action and innovation. Journal of Advanced Nursing, 56(5), 435-572.

Levin, R. E, & Slyder,J. (2012). Evidence-based practice on the DNE Research and Theory for Nurs ing Practice: An International Journal, 26(1), 6-9.

Magnan, M. A. (2023). The DNP: Expectations for theory, research, and scholarship. In L. Chism (Ed.), The Doctor of Nursing practice: A guidebook for role development and professional issues (5th ed., pp.103-131). Burlington, MA: Jones & Bartlett Learning. McEwen, M., & Wills, E. M. (2018). Theoretical basis for nursing. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Melnyk, B. M. (2013). Distinguishing the preparation and roles of Doctor of Philosophy and Doctor of Nursing Practice graduates: National implications for academic curricula and health care systems. Journal of Nursing Education, 52(8), 442-443. Merchant, D. (2012). Does high-fidelity simulation improve clinical outcomes? Journal for Nurses in Staff Development, 28(1), E1-E8. Merriam-Webster's Collegiate Dictionary. (2021). Scholarship. Murray, j., Williams, L. A.. Pignataro, S., & Volpe, D. (2105). An integrative review of Pediatric Early Warning System scores. Pediatric Nursing, 41(4), 165-174. National Academies of Sciences, Engineering, and Medicine (NAM). (2021). The future of nursing 2020-2030: Charting a path to achieve health equity. Washington, DC; The National Academies Press; https://doi.org/10.17226/25982 National Institutes of Health (NIH). (2015). Fogarty International Center: Advancing science for global

health. https://www.fic.nih.gov/Pages/Default.aspx National League of Nurses (NLN) Board of Governors. (2018). Doctoral faculty collaboration in nursing education. http://www.nln.or^docs/default-source/default -document-library/dnp_2018 .pdf?sfvrsn=2 National Organization of Nurse Practitioner Faculties (NONPF). (2016). The Doctor of Nursing practice nurse practitioner: Clinical schola.r https://c.ymcdn.c om/sites/www.nonpf.org/resource /resmgr/docs/ClinicalScholarFlNAL2016.pdf Panesar, R., Polikoff, L. A., Harris, D., Mills, B., Messina, C., & Parker, M. (2014). Characteristics

and outcomes of pediatric rapid response teams before and after mandatory triggering by an

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elevated Pediatric Early Warning System (PEWS) score. Hospital Pediatrics, 4,135-140. https:// doi.oig/10.1542/hpeds.2013-0062 Paplham, .P & Atistin-Ketch, T. (2015). Doctor of Nursing Pracdce education: Impact on advanced nursing practice. Seminars in Oncology Nursing, 31(4), 273-281. Redman, R. W, Pressler, S. J., Furspan, E, & Potempa, K. (2015). Nurses in the United States with a practice doctorate: Implications for leading in the current context of health care. Nursing Outlook, 63,124-129.

Reed, R G., & Brewer, B. B. (2018). Generating knowledge in practice: Philosophical and methodolog ical considerations. In E G. Reed & N. B. C. Shearer (Eds.), Nursing knowledge and theory innova tion; Advancing the science ofpractice (pp. 167-186). New York, NY: Springer Publishing Company Reed, .P G., & Shearer, N. B. C. (2018). Nursing knowledge and theory innovation: Advancing the science of practice. New York, NY: Springer Publishing Company. Rolfe, G. (2018). Practitioner-centered research: Nursing praxis and the science of the unique. In Reed, E G., & Shearer, N. B. C. (Eds.), Nursing knowledge and theory innovation: Advancing the science of practice (pp. 63-81). New York, NY: Springer Publishing Company. Rolfe, G., & Davies, R. (2009). Second-generation professional doctorates in nursing. International Journal of Nursing Studies, 46,1265-1273. Roush, K., & Tesoro, M. (2018). An examination of the rigor and value of final scholarly proj ects completed by DNP nursing students. Journal of Professional Nursing, http^/www.doi.org /10.1016/j.profnurs.2018.03.003

Salmond, S. W (2007). Advancing evidence-based practice: A primer. Orthopaedic Nursing, 26(2), 114-123.

Smith, M. J., & Liehr, R (2005). Story theory: Advancing nursing practice scholarship. Holistic Nursing Practice, 19(6), 272-276.

Swanson, M., & Stanton, M. (2013). Chief nursing officers’ perceptions of the Doctor of Nursing practice degree. Nursing Forum, 48(1), 35-44. https://doi.oig^l0 .1111/nuf.l2003 Terhaar, M. E, & Sylvia, M. (2016, January). Scholarly work products of the Doctor of Nursing practice: One approach to evaluating sdiolarship, rigour, impact and quality. Journal of Clinical Nursing, 25,163-174. https://doi.otg/10.llll/jocn.13113 Terhaar, M. E, Taylor, L. A., & Sylvia, M. L (2016). The Doctor of Nursing Practice: From start-up to impact. Nursing Education Perspectives, 37(1), 3-9. Thoun, D. S. (2009). Toward an appreciation of nursing scholarship: Recognizing our traditions, contributions, and presence. Journal of Nursing Education, 48(10), 552-556. Velasquez, D. M., McArthur, D. B., & Johnson, C. (2018). Doctoral nursing roles in knowledge generation. In .P G. Reed & N. B. C. Shearer (Eds.), Nursing knowledge and theory innovation: Advancing the science of practice (pp. 47-62). New York, NY: Springer Publishing Company. Waldrop, J., Caruso, D., Fuchs, M. A., & Hypes, K. (2014). EC as PIE: Five criteria for executing a successful DNP final project. Journal of Professional Nursing, 30(4), 300-306.

Impact Implementation

Project Plan AsesmMl

Problem

SECTION II

Identification

Problem

Identification CHAPTER 4

Population Health and Healthcare Policy

CHAPTER 5

The Phenomenon of Interest: Leading to Problem Identification

77

,109

75

CHAPTER 4

Population Health

and Healthcare Policy Katherine Moran

CHAPTER OVERVIEW The goal of health policy is to find equilibrium between the competing forces in health

care to produce an optimal system iBodenheimer & Grumbach, 2020). The healthcare system in the United States (U.S.j has been in a state of unrest for years. The discontent lies primarily in the polarizing views of the predominant political parties. Finding a balance between achieving a basic level of equity for health services and paying for these services remains at the center of the polarity. Yet, managing these polarities is critical, as the outcome will ultimately shape the health of our nation. Doctor of nursing practice (DNPl-prepared nurses have the education, knowledge, and skills to sit at the table and actively participate in the discussions where healthcare delivery and population health decisions are being made. These practice scholars have advanced competencies in practice improvement, development of new innovations, testing interventions and care delivery models, evaluation of healthcare outcomes, expertise to inform health policy, and leadership in establishing clinical excellence (American Association of Colleges of Nursing [AACN], 2004), In the National Academies of Sciences. Engineering, and Medicine's

The Future of Nursing 2020-2030 report, nurses are recognized for their potential to address health equities and are challenged to "initiate work to develop a shared agenda for addressing social determinants of health and achieving health equity" [NAM, 2021, p. 357). DNP-prepared nurses and students have the potential to impact policy change at both the local and population level, DNP students with an interest in this work should consider a policy-focused project as a foundation for ongoing policy scholarship. The purpose of this chapter is to help the DNP student understand factors that impact the health of our nation, recognize areas where the student may facilitate change, and develop methods and attain competencies that can be used to make an impact. CHAPTER OBJECTIVES

After completing the chapter, the learner will be able to: 1. 2.

Identify key factors that impact the health of our nation. Analyze healthcare information, data, and outcomes to understand the clinical problem.

@ Sandipkumar Palel/DieitalVision Vectocs^Getty Images

77

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Chapter4 Population Health and Healthcare Policy

3.

Compare and contrast approaches to addressing disparities in health and

4. 5.

healthcare delivery in organizations (micro level), communities (meso level), and beyond (macro level). Acknowledge ways that the DNP student may facilitate change. Identify opportunities to attain policy-related competencies.

y Health Policy Historical Perspective The complexity of the U.S. healthcare system, as it is known today, has been years in the making. Political decisions that impacted the health of the country date back to the early 1900s. Therefore, to fully appreciate the multitude of factors that have impacted the health of the nation, one must consider the broad healthcare landscape; that begins with the macro level view. For example, in 2010 the Pa tient Protection and Affordable Care Act (ACA) was enacted into law with a goal of providing “numerous rights and protections that make health coverage more fair and easy to understand, along with subsidies (through ‘premium tax credits’ and ‘cost-sharing reductions’) to make it more affordable” (HealthCare.gov, n.d., para 1). Numerous controversies have surfaced since the implementation of the ACA—for example, the constitutionality of the individual mandateand Medicaid expansion. The important point to note is that prior to the implementation of the ACA, as a country, the U.S. was not realizing the health outcomes one would expect given the amount of money spent on health care annually; therefore, a concerted effort was made to improve outcomes. This was not the first attempt to reform health care in the U.S.—and will likely not be the last. The U.S. has had multiple failed attempts to reform health insurance programs over the course of history. For example, Theodore Roosevelt’s proposal for national health insurance in 1912; Franklin Delano Roosevelt’s pro posal for universal health insurance in 1933, which was dropped to win support for Social Security; in 1949 Harry S. Truman again proposed universal health care;

Lyndon B. Johnson’s proposal with the Social Security Act in 1965 that created Medicare and Medicaid; Richard M. Nixon’s proposal for universal health insur ance that would have required employers to offer affordable coverage to all; and Senator Ted Kennedy’s attempt to gain support for his single-payer health insur ance plan (Manchikanti et al., 2017). The reforms that paved the way for the ACA include Johnson’s mandate for his Great Society reforms in 1964 that promised to eliminate poverty and inequity in the United States and, in 1965, the establishment of Medicare (a federal health insurance program for people who are 65 years old or older, certain younger people with disabilities, and people with end-stage renal disease) and Medicaid (a state and federally funded health insurance program for low-income individuals and families) (The Gilder Lehrman, 2021); and finally, in 1997, the Children’s Health Insurance Program (CHIP) (a federal program that provides matching funds to states for health insurance to families with children) (Medicaid.gov, n.d.). Unfortunately, the cost-sharing provisions of Medicare have posed significant financial barriers for the elderly and disabled beneficiaries. Medicare has also had limited effectiveness because of the absence of long-term care services and pre scription drug coverage. An attempt to address lack of prescription drug coverage, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), became effective in 2006 and established the prescription drug benefit.

Health Policy Historical Perspective

79

Medicare Part D. As a result of Medicare Part D, outpatient prescription drugs are covered through private plans that contract with Medicare (Kaiser Family Foundation, 2019).

Medicaid has also had its share of controversy. For example, some believe that because of Medicaid there has been a substantial increase in use of health services

among low-income individuals. But, this does not mean that there is equity in access among socioeconomic classes. Access issues among low-income individuals remain, primarily due to the variability across states as it relates to the population covered by Medicaid (eligibility requirements) and the benefits offered (even though Med icaid is federally regulated, the states have significant latitude in administration). For example, in 2021 there were 12 states that had not adopted Medicaid expan sion, which left many indi\iduals without affordable coverage. Moreover, there are individuals who fall in a “coverage gap”—meaning they do not meet the Medicaid eligibility requirements in their state, yet their income is below the poverty level. Unfortunately, the ACA does not provide financial assistance for individuals below the poverty level, because the thought was these individuals would receive coverage through Medicaid (Kaiser Family Foundation, 2021). Moving forward, it will be critical that DNP-prepared nurses focus on system atically analyzing and evaluating the factors that impact access to care, the cost of care, health behaviors, and outcomes of care. However, to address the most pressing needs of society, an intentional effort is needed to understand and ultimately ad dress the “social determinants of health." The social determinants of health include

genetic as well as lifestyle and environmental factors, such as the availability of resources to meet daily needs such as housing, food markets, job opportunities, access to health services, and education (Shi & Singh, 2019), These factors have a huge impact on the health of our nation.

Population Health Perspective Having a clear understanding of the social determinants of health can shed light on how multiple social factors impact health and health care; but also, help the DNP student understand clinical problems from a macro perspective. Ponce and Ko (2014) indicate that the social determinants of health that have the most im

pact are those that cause stratifications in social position; for example, income/ income inequality, social status, race/ethnic composition, segregation, political power, and efvorable environmental exposures and assets provide advantages in some communities, but unfortunately, create disadvantage and produce inequities for others. It is important to note that these “disadvantages” accumulate over time and prevail over generations, and are, therefore, intractable without policy solu tions (Ponce & Ko, 2014).

Income disparity contributes to health both at an individual and community level. People with a higher income tend to live in a desired neighborhood, have access to better health care, and live in areas where there are more healthcare

providers and larger healthcare systems. Lower-income people tend to have fewer choices for specialty physicians and less access to care. Higher-income people also have more choices in health insurance and more options for where they would like to receive their care. These individuals tend to have higher social status and political power and have a direct influence on how healthcare dollars are spent (Ponce & Ko, 2014).

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Chapter 4 Population Health and Healthcare Policy

The social processes and subsequent varying levels of social capital (aspects of social life that promote working together to achieve shared objectives) found within a community have an impact on income inequality and segregation. Further, they can in turn lead to inequities in social class and position and, ultimately, different levels of community assets and opportunities. As noted by Ponce and Ko (2014), there is a potential for social capital to improve access to care by linking disadvan taged populations and healthcare resources. But they go on to say that this process could also augment the advantages more privileged groups already possess. They conclude that “government-level macroeconomic and social policies that reduce structural inequities may be more appropriate” (p. 149). Two important indicators of health status, morbidity and mortality rates, should also be reviewed to gain an understanding of the health of a population, especially vulnerable populations. Yancey, Bastani, and Glenn (2014) purport that minorities experience higher rates of morbidity and mortality. There has been a plethora of research around the experiences of racial and ethnic minorities in the United States that have been described in reports from the Institute of Medicine (lOM): Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (Smedley, Stith, & Nelson, 2003) and Crossing the Quality Chasm (lOM, 2001). Even with the spotlight on ethnic disparities in the U.S., there is still a long way to go to address these concerns, especially as it relates to overall health and life expectancy. For example, African Americans’ overall health and life expectancy are impacted the most. Contributing factors include the historical, political, policy, and

social treatment of people of color and/or ethnic backgrounds; socioeconomic sta tus (SES); behavioral risk factors; physical environmental influences; and socioenvironmental influences. This is particularly important to note when considering that disease burden has shifted from communicable to chronic diseases. Since chronic

conditions are primarily self-managed, and the ability to successfully self-manage is impacted by the above-mentioned factors, it should be no surprise that as a result of this shift, inequality in chronic disease burden is now e\4dent. Of note, obesity is identified as a major driver of chronic disease disparities. Here again, “lower SES is associated with obesity, but higher socioeconomic status is less protective against obesity for African Americans than for Latinos and whites” (Yancey, Bastani, & Glenn, 2014, p. 84). Socioeconomic status has the largest impact on racial and ethnic disparities. A lower SES (poverty) determines where a person lives, the amount of food avail able, the types of food available, the type of insurance a person has, whether a person will have access to health care, and the quality of the health care that is available in the community. As previously mentioned, African Americans are the most disadvantaged—reflecting centuries of exploitation and oppression, forced immigration, enslavement, and subjugation (Yancey, Bastani, & Glenn, 2014). In addition to SES position, other factors also have an impact on racial/ethnic differences in health status. For example, the cumulative effects of prolonged ex posure to individual stressors, long-term effects of an early childhood/prenatal en vironment of deprivation, and the reaction to macrosocial factors (i.e., marketing to children and adolescents that increases a desire for goods and services enjoyed by affluent whites that are beyond the means of working and middle-class families) (Yancey, Bastani, & Glenn, 2014). As noted by Bustamante, Morales, and Ortega (2014), addressing racial and ethnic disparities in health care is of growing impor tance; and the importance of recognizing these disparities has become even more

Health Policy Historical Perspective

81

evident as a result of the COVID-19 pandemic. Keep in mind that because the U.S. is ethnically diverse, one can expect to see suboptimal health status for a substantial portion of the population if disparities in health care (i.e., a difference in care that is not accounted for by a difference in access to care, personal preference, clinical need, or clinical appropriateness) continue in these populations. This could include discrimination at the system level (influenced by the structure of healthcare systems and the legal and regulatory environment), discrimination at the patient-provider

level (prejudice or implicit bias), or even patient factors that could have an impact on outcomes (perception of health status or psychosocial constructs, such as readi ness for change or perceived self-efficacy).

The Cost and Quality of Health Care Other important factors that contribute to healthcare outcomes are the cost and quality of health care. According to Claxton, Rae, Levitt, and Cox (2018), healthcare prices in the U.S. have increased (21.6%) more rapidly than general economic in flation (17.3%), especially for the privately insured. In fact, Schneider et al. (2021) from The Commonwealth Fund report that the U.S. spends more on health care compared to 10 other industrialized countries (see Figured-!). Further, there is wide variation in the prices paid for the same services based on geographic location in the U.S. (Claxton et al., 2018, para 1). For example, in patient care costs have risen approximately 13% for patients with private insurance. 18 16 -

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‘2019 data are provisional or estimated for Australia, Canada, and New Zealand. Data; OECD Health Data, July 2021.

Figure4-1 The Commonwealth Fund report on healthcare spending Reproduced from Schneider. £. C.. Shah. A., Ooty. M. M„ likkanen. R.. Fields. K. and Williams, R. 0. [20211. Hiim, HimWlI: KiftaSog Poortf: Hestth Care in the U.S. Compared to BtherHigh-lname Ceantrm. New York. NY: The Commonwealth fund. https7/doi.org/l 0.26099/01 OV-H208 with permission.

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Chapter4 Population Health and Healthcare Policy

compared to a 3% increase for patients with Medicare or Medicaid (Claxton et al., 2018). Also note that these increases are found in some common inpatient proce

dures, such as inpatient laparoscopic appendectomy prices and full knee replace ments, which have risen 136% and 78% (respectively) between 2003 and 2016 for large employer plans. This growth has been faster than general price increases (28%) over the same period. There is also significant variation in the average price paid for these same pro cedures in the U.S. According to Claxton et al. (2018), the average price paid by large employers for an admission for a full knee replacement in 2016 was $34,063; however, this ranged from $24,734 or less (approximately 25% of admissions) to $52,181 or more (approximately 10% of admissions). The same was true for lap aroscopic appendectomies. The average cost in 2016 was $20,192, ranging from $12,088 (approximately 25% of admissions) to over $35,308 (approximately 10% of admissions). And these costs varied across markets. For example, the national av erage was $34,063 for a full knee replacement in the U.S. in 2016. However, in the New York City area the cost was $50,000, which was more than twice the price of the same procedure in the Louisville, Kentucky, area ($23,000). These price increases are not unique to the inpatient setting. Escalation in costs was also seen for outpa tient office visits (69% increase) and lower back magnetic resonance imaging (MRI) costs (14% increase) during the same time period (Claxton et al., 2018, para 8). The reasons for these wide variations are multifaceted; for example, some of the variation may be due to geographic differences in insurance coverage or even cost of living. Another healthcare cost concern relates to the need to control pharmaceutical

costs while assuring access and measuring health-related quality of life (HRQL). Where pharmaceutical costs are concerned, Schweitzer and Comanor (2014) sug

gest that there needs to be a better understanding of (1) the relationship between drug price and quality, (2) how the quality of a drug is determined, and (3) the extent of competition in the pharmaceutical marketplace, including the breadth of these markets. To further emphasize the need to understand controlling pharma ceutical costs, in this year alone pharmaceutical makers have increased the price of 460 brand name medications by 4.9% according to an analysis based on Elsevier’s Gold Standard Drug Database and the CMS State Drug Utilization Database (Bean, 2022).

Prices to date have been positively affected by a drug’s efficacy and thera peutic advance, but to what degree has yet to be determined. For example, most consumers are aware that some of the increase in expenditures is likely related to pharmaceutical companies’ desire to recoup the costs associated with research and development. However, expenditures have also grown in part because of how inte gral pharmaceuticals have become to medical care (for preventing hospitalizations, improving outcomes, etc.), but currently no one has been able to account for qual ity improvement as it relates to price increases. Regarding quality control, the U.S. Food and Drug Administration (FDA) used a crude measure of improvement score in the past when a drug was seeking market approval. Now, the FDA does not use that mechanism; in fact, there is currently no “agreed-upon” measure of therapeutic improvement needed for new drugs. Finally, as pharmaceutical companies continue to consolidate in the marketplace, one must consider how competition will impact the market to determine the best course of action for creating public policies in this

industry (Schweitzer & Comanor, 2014).

The Potential Impact of the DNP-Prepared Nurse

83

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Overall quality of healthcare delivery also varies widely nationally As noted in two landmark reports from the lOM (2000, 2001), poor quality is a concern in the U.S. healthcare delivery system. To give context to this concern, consider the report from The Commonwealth Fund (Schneider et al, 2021) that ranked the U.S. last

in measures of equity, access, efficiency, and healthcare outcomes when compared to 10 industrialized countries (see Figure4-2). While the overall results are dismal,

the U.S. ranked second overall in care process. The United States must capitalize on its strengths and implement strategies to improve healthcare quality among all sectors of healthcare delivery.

y The Potential Impact of the DNP-Prepared Nurse The gravity of the overall condition of our nation’s health and the status of the healthcare delivery system can be overwhelming to consider; yet as a DNP student, there are things that can be done to address disparities in health and healthcare delivery in healthcare organizations (micro level), the community (meso level), and beyond (macro level). Healthcare professionals must use an unbiased lens to recog nize differences between communities, and as a community, take up the initiative to help others gain access to valuable resources. To begin, DNP students should ask themselves a few simple questions: How well is (are) the healthcare system(s) in the community doing delivering the care needed for the population it (they) serve? What services should be provided that are currently not available? Are there issues related to access to care in the community? Do all the individuals in the community have healthcare coverage? Do the indi viduals in the community understand what they can do to improve and/or main tain their health? Then, students should think about what is within their sphere

of influence and advocate for a change. For example, many agree that education and primary prevention are key to the health of our nation. And, that healthcare organizations should encourage families within the commu Remember, all

nities they serve to maintain a healthy lifestyle and provide education via a variety of innova tive formats, such as at a health-oriented gro

cery store or through vegetable vans in urban

change begins with one person.

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Chapter^ Population Health and Healthcare Policy

areas. This micro-level approach is an example of an initiative that the DNP student could take to address healthcare concerns at the local level. DNP students can take

the lead in introducing this type of advocacy 'work within organizations. Other examples include: working with the local health department (meso level) to address the disparities in the community by gearing the care that is pro vided to those who are underserved (e.g., a DNP project to begin an immunization clinic within a homeless shelter) or focusing on community health resources that incorporate education to teach young children about health and wellness. For ex ample, Food Corps (2018) incorporates agricultural education to demonstrate how growing fresh fruits and vegetables allows families a resource to cook healthy meals; this promotes nutrition using natural resources in the heart of the city. This national (macro-level) initiative can be used as an exemplar to improve the health of the population in cities across the United States. Another example of a macro-level ini tiative includes development of an evidence-based toolkit to inform teachers, staff, coaches, bus drivers, and other school professionals how to safely and effectively care for a child with diabetes in the school setting. This initiative began as a state effort, but was also adopted at the national level. These examples illustrate the work that has been done to date, but also sug gest that there is still much work to be done. Healthcare policies not only need to address access to care but must support and enhance communities to evolve into

places for all residents of the community to live healthy, active, and safe lives. But, to be successful in this endeavor, the nation must be able to identify, understand, and monitor progress in addressing disparities. To this end, healthcare professionals should advocate for vulnerable pop ulations and urge politicians to change this system. The DNP student should think about these policies through multiple lenses; this is a complex issue that requires a multi-system approach. Consider “noncompliant” patient behavior as

an example. What does the evidence show regarding noncompliant behavior? Can it be said that patients who do not comply with treatment do not care about their health? Or, could a reason for their noncompliance be related to the social determinants of health? According to Ponce and Ko (2014), the link between the social determinants of health and health outcomes is poorly understood because it is difficult to track outcomes over a person’s lifetime (where a person lives/ works), because some things are difficult to observe (capacity to cope with social stressors) and because it is yet to be determined how/if the availability and quality of healthcare links the social determinants of health with health outcomes. The

point is, policy should be viewed through a broad lens and one should consider what the evidence reveals. To do this effectively, advances in available data will be required and individual-level data will need to be linked with administrative data to determine how social determinants interact with the health system. At the end

of the day, policy changes must be focused on evidence (as limited as it may be) rather than political opinion.

^ Evidence-Based Health Policy Evidence-based public policymaking is a topic of increasing interest today, espe cially as it relates to how it will (or should) be used in the decision-making pro cess. The term evidence-based policy refers to the process “whereby policy decisions

Evidence-Based Health Policy

are informed by rigorously established objec tive evidence” (“Evidence-based policy,” 2018, para 1). While as healthcare professionals it makes sense to base decisions on evidence, the

The nature of DNP work

use of evidence in the policymaking process is

requires the

not as straightforward. For example, policies involve multiple social concerns that may have

recognition of

different evidence bases relevant to each one;

the context of

therefore, the act of policymaking requires po litical reasoning. There are also inherent politi cal biases that ultimately drive how evidence is

the problenn

interpreted and used (Parkhurst, 2017). Nev ertheless, one should not reject the importance

85

and assessment of facilitators

of evidence; instead, move forward to overcome

these challenges and include evidence in the policymaking process to meet societal goals. To accomplish this, Parkhurst (2017) suggests building systems to guide the use of evidence in the policymaking process to pro

mote the good governance of evidence. In other words, the DNP student must “ensure that

rigorous, systematic and technically valid pieces of evidence are used within decision making processes that are inclusive of, repre sentative of and accountable to the multiple social interests of the population served”

(p. 8). This requires a two-pronged approach. First, the DNP student must realize that pol

icy decisions require trade-offs between the competing interests. From this perspective, evidence serves as a tool of measurement by

and barriers

to achieving a desired state. This includes

engagement of stakeholders, collaboration,

and negotiation.

DNP-prepared nurses are

identifying who will benefit from different

perfectly suited

decisions that are made or what groups may

to establish

accrue (or lose) benefits over time. Parkhurst

aptly points out that evidence cannot dictate the right choice. As mentioned above, to de termine what is right or wrong requires polit ical reasoning. The second approach involves the consideration of the contextual structures

the good

governance of evidence.

where all political decisions take place. These structures have the potential to direct or constrain the range of policy choices and/or decisions.

This two-pronged approach aligns perfectly with the advanced skills and competencies that all DNP-prepared nurses acquire during their doctoral studies. These advanced skills and competencies can be used to assure that evidence is critically analyzed and that perspectives from consumers, nursing, other health professions, and stakeholders with competing values are included in the policy making process.

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Chapter 4 Population Health and Healthcare Policy

y DNP Essential Core Competencies Used to Advocate for Healthcare

Policy Change The core competencies for healthcare policy for advocacy in health care are inter woven within The Essentials: Core Competencies for Nursing Education (AACN, 2021), serving as a foundation to students’ learning. For example, as mentioned above, healthcare professionals must advocate for low-income individuals and urge politi cians to change the current system. This is consistent with the health policy concept described in the Essentials for Advanced-Level Nursing Education (AACN, 2021) that call for the nurses to advocate for social justice, equity, and ethical policies within all healthcare arenas. Further, the AACN (2021) specifically states that advanced-level nursing education programs should prepare graduates for practice in advanced nursing practice specialties, including health policy. This is further contextualized in the Essential 3 (Population Health) subcompetencies that specify advance prac tice nurses should (3.4g) design comprehensive advocacy strategies to support the policy process; (3.4J) assess the impact of policy changes; and (3.4k) evaluate the ability of policy to address disparities and inequities within segments of the pop ulation. When considering evidence, DNP-prepared nurses are adept at analyzing scientific data related to individual, aggregate, and population health and critically appraising existing literature and other evidence to determine and implement the best evidence (Essential 4-2). And when linking individual-level data with administra tive data to determine how social determinants interact with the health system, the

DNP-prepared nurse uses the competencies acquired in Essential 2-7 to first analyze the data to identify gaps and inequities in care, monitor trends in outcomes, and then informs key stakeholders what critical elements are necessary to the selection, use, and evaluation of this information (AACN, 2021).

► TheDNP Project and Health Poll^ The following health policy analysis is an example of how one could advocate for a change to address a population health problem. In this example. Dr. Sonya Kowalski addresses a food insecurity problem within a local community using Bardach and Patashnik’s (2020) A Practical Guide for Policy Analysis: The Eightfold Path to More Effective Problem Solving (see Exemplar 4-1).

Exemplar 4-1 Policy Analysis for Michigan Food Bank Food and Operations Support Funding Sonya Kowalski, DNP, APRN, ACNS-BC Economists declared an end to the "Great Recession" in the summer of

2009, yet over 60% of the employment shortfall that was caused by the recession remains, which requires a greater amount of government safety net spending (Fieldhouse. 2014). The persistent problem with unemployment and underemployment has led to an increase in food insecurity, which has

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been identified as a health problem nationally (Murthy, 2016). Food insecurity is categorized as low food security, which is the experience of insufficient food quality, variety, and desirability, or very low food security, which is described as disrupted eating patterns and reduced food intake by the U.S. Department

of Agriculture (USDA. 2016). The state of Michigan food insecurity rate in 2014 was 15.7% and the food insecurity rate for Wayne County was 22% (Gundersen.

Dewey. Crumbaugh. Kato. & Engelhard. 2016). In February of 2017. the Michigan jobless rate was 5.3% compared to the

U.S. jobless rate of 4.7% (Michigan Department of Technology. Management & Budget. 2017). In 2014. the percentage of Michigan residents living in poverty was 16.2%. compared to the national poverty rate of 15.5% (Wisely & Tanner. 2015). The same year, the child poverty rate in Michigan was 22.6%. compared to the national child poverty rate of 21.7% (Wisely & Tanner. 2015). A poverty rate that is much higher than the unemployment rate indicates that Michigan has a higher number of working poor families compared to the national average, and these numbers have not been improving. The poverty rates for African American children have been as high as 47% in Michigan, with over 30% of Hispanic and Native American children. 15.6% of White children, and 13.7% of Asian

American children living in poverty (Ruark. 2015). These numbers indicate a greater number of people working but still in poverty among ethnic minorities. The majority of families who utilize food banks are considered the working poor. The working poor are employed but do not make enough money to pay all of their expenses. According to the Food Bank Council of Michigan (2015). “When families have to choose between paying for childcare, medications,

housing, and food, food is usually the first budget that gets cut” (para 2). The greatest factors that drive people into emergency feeding programs are housing, heating, and health care (Zimet. 2017). This indicates that, in addition to the working poor, homeless, disabled, ill. and elderly persons are also at high risk for food insecurity. Rent increases in areas with gentrification lead to food insecurity among people with limited incomes (Whittle et al.. 2015). Female-headed households have been found to have 75% greater chance of being food insecure than male-headed households (Jung, de Bairros. Pattussi. Pauli. & Neutzling, 2017). University students have been found to have between 12.7% and 46.5% incidence of food insecurity (Hughes. Serebryanikova. Donaldson. & Leveritt. 2011). Veterans who served from 1975 and after have been found to be at high risk for food insecurity (Miller. Larson. Byrne. & DeVoe. 2016). Food insecurity is also a problem in 14.1% of households with an active duty service member, with 4.7% reporting very low food security (Wax & Stankorb. 2016). Food insecurity is an important issue for multiple populations in Michigan and the U.S.

Negative health outcomes are associated with food insecurity, such as increased rates of asthma, hypertension, hyperlipidemia, diabetes, birth defects, mental illness, depression, suicidal ideation, and premature aging (Gundersen & Ziliak. 2015). These negative health outcomes, related to food insecurity, resulted in estimated direct healthcare costs and indirect

lost productivity costs of $160.07 billion in 2014. Additionally, an estimated $18.85 billion was spent in special education and school dropout costs related to food insecurity (Cook & Poblacion, 2016). Food insecurity in Michigan has recently increased due to the 2014 federal Farm Bill. The Farm Bill covered both agriculture and nutrition programs and [continues]

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Chapter 4 Population Health and Healthcare Policy

Exemplar 4-1 Policy Analysis for Michigan Food Bank Food and Operations Support Funding

[continued]

changes led to reduction in the Supplemental Nutrition Assistance Program (SNAP) in states like Michigan that did not increase funding into the federal Heat and Eat program. Some senior citizens saw their nutrition benefits drop to $16 per month (Tower, 2016). The state of Michigan recently allocated $6.8 million to restore approximately $76 per month for nutrition to these low-income families in the 2018 budget (Snyder, Galley, & Pscholka, 2017). The average SNAP benefit is $126 per person per month (Center on Budget and Policy Priorities, 2016). SNAP benefits are available to persons who are at or below 130% of the federal poverty level. In addition to the SNAP program, some programs to combat hunger provide cash assistance, such as Temporary Assistance to Needy Families (TANF), which has a 4-year limit; Supplemental Security Income; and federal and state earned income tax credits. Other nutrition programs include the national school lunch program and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (Schmidt, Shore-Sheppard, & Watson, 2015). However, in the U.S., 45% of the food insecure are above the SNAP threshold

and 26% are above the threshold for other nutrition programs (Gundersen, Dewey, Crumbaugh, Kato, & Engelhard, 2016). In Wayne County, Michigan, 17% of adults and 33% of children who are food insecure are above eligibility requirements for nutrition programs (Wayne Metropolitan Community Action

Agency, 2016). Many of these people with food insecurity utilize local food pantries and food banks to alleviate hunger (Feeding America, 2011). The local food pantries and food banks are unable to meet the needs of

the food insecure. The Michigan Department of Education has requested more community organization support for the summer food service program to help feed a half-million children over the summer (Ackley, 2016). Local food pantry operators indicate inadequate resources to expand their services. Local and regional nutrition support agencies have a mission to reduce food insecurity, but resource barriers prevent getting the food to the needy at a local, neighborhood level. A state grant program could help to alleviate some of the resource barriers of the food banks and pantries and allow for a greater distribution of food as a community health initiative. Literature Review

A literature review was conducted utilizing the Cumulative Index to Nursing and Allied Health Literature (CINAHL). The search terms used were policy, food

insecurity, populations, interventions, strategies, best practices, government funding, and risk factors. The search was limited to the last 5 years and articles were chosen for review based on likelihood of similarity to U.S. and Michigan populations, such as U.S., Canadian, and Australian populations. Food insecurity articles from poverty-stricken nations such as Ethiopia were not included for this policy analysis.

In addition to the CINAHL database, Google was also searched for information related to recent political events that would not likely yet be available in research journals. The websites of known hunger political action groups, such as the Michigan League for Public Policy, and food resource providers such as Gleaners Food Bank and The Food Bank Council of Michigan were also searched. The review of literature revealed a large amount of

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89

information based on the populations and numbers of people affected by food insecurity, such as children and ethnic minorities with poverty rates from 13% to 47% (Ruark, 2015), the working poor (Food Bank Council of Michigan. 2015), university students with poverty rates from 12.7% to 46.5% (Hughes. Serebryanikova, Donaldson. & Leveritt, 2011), and active duty military families

with 4.7% very low food security rates (Wax & Stankorb, 2016). The review of literature also revealed the reasons for food insecurity, such as issues dealing with housing, heating, and health care (Zimet, 2017) and the health outcomes that result from inadequate nutrition, such as increased rates of asthma, hypertension, hyperlipidemia, diabetes, birth defects, mental illness, depression, suicidal ideation, and premature aging (Gundersen & Ziliak, 2015). The food provider websites provided details regarding what is being done to combat hunger, such as retrieving usable and previously discarded food and assisting with the harvest of food that may have gone to waste and

donating food to emergency food providers (Forgotten Harvest. 2017); they also gave opportunities for donations and volunteer services (Forgotten Harvest, 2017; Gleaner’s Community Food Bank, 2017). There was very little information about comparison of effectiveness of interventions or adequacy of government policies that promote relief of hunger. There was no indication of best practices or benchmarks for hunger alleviation. Alternative Solutions to Address the Problem

The first alternative would be to do nothing. If the existing programs continue without intervention, then the poorest community members would still be provided with SNAP, limited TANF funds, and WIC. The working poor could continue to try to obtain food from available resources. The rate of food insecurity would likely remain the same unless more high-paying jobs are created. This solution would prevent a greater tax burden on those employed in

higher wage jobs. The poor may be encouraged to work more, or obtain higher education. What is likely to happen is an increase in the adverse health effects that impact the food insecure and an increased demand on the healthcare

system in the decades to come. The increased health-related costs due to food insecurity will likely rise from the 2014 $160 billion estimate. Another alternative could be to direct resources into the creation of higher

paying jobs. At the national level. President Barack Obama created 22.3 million jobs from the worst part of the recession until the end of his presidency, which is the second greatest numberof jobs created by any U.S. president (Amadeo, 2017).Althoughthe numberof jobs increased,the number of food insecure remains high. It is possible that this is because the populations who remain food insecure may be too young, too old. too ill to work; may be disabled and unable to work; or may lack the education or child care resources necessary to participate in the labor market. A third alternative would be to increase both federal and state funding for food assistance programs. Data from 2012 indicated that SNAP benefits lifted

10.3 million people out of poverty and 5.2 million people out of deep poverty in the U.S. (Sherman & Trisi. 2015). An increase in funding could lift even more people out of poverty. According to the president’s 2018 budget (Trump, 2017), the funding for U.S. food security programs, including WIC. will remain stable, while funding for foreign food aid will be decreased. According to Governor

Snyder s 2018 budget (Snyder. Galley, & Pscholka, 2017), the state funding that [contir)ues]

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Chapter4 Population Health and Healthcare Policy

Exemplar 4-1 Policy Analysis for Michigan Food Bank Food and Operations Support Funding

[continued]

had been reduced for the SNAP program in 2015 will be reinstated for qualifying Michigan residents in 2018. At this time, there are no budget appropriations for an increase in SNAP benefits, and since 2014 the average benefits per person have declined (USDA. 2017). In addition to lifting an increased number of people out of poverty, additional unexpected benefits of an increase in SNAP funding include: every $5 in new SNAP benefits generates $9 in total community spending; every additional dollar of SNAP

benefits generates 17 to 47 cents of new spending on food; and $1 billion in retail food demand by SNAP recipients generates about 3.000 farm jobs (USDA. n.d.). The final and recommended solution to the food insecurity problem is an implementation of policy that would allow for improved organization and utilization of existing resources. An analysis of local food providers indicated that the availability of food is not always consistent, convenient, or transparent. Food banks are available regionally, such as Forgotten Harvest and Gleaner's Community Food Bank. These food banks serve the population of food insecure and assist in supplying the local food pantries; however, transportation has been identified as a significant barrier (Wayne Metropolitan Community

Action Agency. 2016). Community stakeholders recommend a collaborative effort to meet families where they are and the utilization of community wide philanthropy and community mapping of available resources (Wayne Metropolitan Community Action Agency. 2016). A survey of the local food pantry operators reveals a reluctance to participate in a collaborative effort such as a coalition to increase food visibility and accessibility for the food insecure. The fear is that demand that will greatly exceed supply and rapidly overwhelm the available resources of food, storage space, and volunteers. This problem is not unique to the local area. In the state of New York, the Hunger Prevention and Nutrition Assistance Program (HPNAP) has advocated for policy and funding to increase access and improve infrastructure to get food to the hungry (Zimet, 2017). The HPNAP has provided funding to the Food Bank of Central New York, who provide food and operations support in the form of grants to local food pantries. The local food pantries have used the grant money to purchase freezers, refrigerators, and shelving that support their food distribution efforts. This model has been suggested to be "a model for

the nation" (lOM. 2011. p. 121). A similar policy for grant funding could help to improve food access for Michigan food pantries.

Analysis of Recommended Solution According to Zimet (2017). "Hunger, the lack of affordable housing, homelessness, and lack of access to health care are all interconnected and

must be addressed in a comprehensive manner" (p. 4). A policy for grant funding to assist food pantries in providing food to the hungry would only address the hunger aspect for the food insecure, which would be a weakness of the program. A strength of the policy would be that it makes use of existing resources and the grant costs would be significantly less than the healthcareassociated costs of doing nothing or the costs of increased SNAP benefits. The support of the local food banks would be a preferable solution than the solution to increase higher paying jobs because it would provide a more rapid benefit to the hungry and provide for those who are too young, too old. too sick, or disabled and unable to participate in the work force. The grant funding could

The DNP Project and Health Policy

help the local communities meet their mission goals and ethically provide needed assistance. In the HPNAP program, the grant awards are up to $3,000 or, if used for

the purchase of food service equipment only, may be up to $6,000. The equipment organization stops providing emergency food assistance. Eligible organizations are nonprofit, tax-exempt organizations that provide emergency food without cost to recipient to all persons must be transferred to the central food bank if the

in need without discrimination. Grant money may be used for direct service worker staff costs, food storage utility costs, dedicated space costs, supplies necessary for food provision, transportation costs to deliver food to the pantries, and food service equipment necessary for operations such as refrigerators, freezers, shelves, stoves, and cabinets, with prices based on two actual quotes for nonsale prices. The over $1 million dollars utilized for the program between 2004 and 2011 in New

York averaged about $150,000 per year in budget allocation (lOM, 2011). This policy has a relatively low-cost, simple structure and reasonable administrative burden and would be administratively feasible to implement in Michigan. Community stakeholders would benefit from the addition of infrastructure resources. The resources would allow for existing money to go toward food, which would increase availability for the food insecure. The resources would encourage collaboration, as the various food pantries could alternate the acquisition and transportation of low-cost food from the regional food banks, which would conserve both money and volunteer time. The availability of more food locally would benefit the food insecure unable to obtain transportation to the regional food banks. The grant monies could also be used to fund a small stipend for pantry workers, which may be appreciated and encourage participation in some organizations. Food insecure people who utilize food banks with adequate storage and refrigeration will benefit from a maximization of resource allocation through increased food choices compared to the limited canned and boxed food that is available without the resources. Increased access to fresh fruits,

vegetables, and milk may promote a healthier diet among the food insecure. Given the association between food insecurity and numerous poor health outcomes such as diabetes, obesity, depression, and hypertension, the cost of the grant program may more than pay for itself in reduced healthcare costs. Conclusion

Food insecurity has continued to be a public health issue, years after the end of the "Great Recession." Food insecurity affects many populations, including children, the elderly, the disabled, the ill. immigrants, military veterans, and military families. Food insecurity leads to numerous health conditions and increased healthcare costs. Racial and ethnic minorities have a greater risk of food insecurity, which leads to greater health disparities. Policies that reduce food insecurity have been successful in the state of New York and have the potential to be successful in Michigan. The policy to award grant money to organizations that supply emergency food is an example of a policy that can be adopted to maximize the use of existing resources without great expense. Assistance provided to community stakeholders can help to remove barriers to reducing food insecurity such as transportation and equipment costs. Available refrigeration and improved storage facilities can help food providers to improve both quality and quantity of available food, which may lead to improved population health outcomes and reduced health disparities. The policy to provide grant funding to organizations that provide emergency food is a good one. both ethically and financially.

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Chapter^ Population Health and Healthcare Policy

We are called to lead and manage

collaborative efforts with other healthcare

practitioners to improve

^ Your Health Policy aourney Why did you first become a nurse? Why did you want to become a DNP-prepared nurse? Many chose nursing as their life’s work because they want to “make a difference” in the lives of their

patients; they are “called to the profession.” There is no doubt that through one’s nursing education many things are learned, but what of ten stands out most are those things that didn’t come from a textbook: that there is something sacred in the relationship between the patient

and the nurse; that nurses do more than pro vide protection, promotion, and optimization of health and abilities—nurses facilitate healing delivery and the and wellness through that human connection. health of the And, with this trusted relationship comes re sponsibility, especially related to advocacy. populations we There are many opportunities for DNPprepared nurses to promote change in health serve. care through advocacy, leading inter- and in traprofessional collaboration efforts, engaging stakeholders, transforming systems to improve care, analyzing policies—and, there are numerous paths the DNP-prepared nurse could take to make an impact. Where healthcare reform is concerned, the lOM has recognized nurses as valuable players in this process. It is time for nurses, especially DNP-prepared nurses, to see policy as something we shape. There will be challenges; however, the good news is we are now at a point in the DNP degree trajectory where we are beginning to see the impact of practice scholarship, and therefore, the associated benefit of the practice doctorate. Those nursing-specific improved healthcare outcomes that have been demonstrated by DNP scholars not only validate the value of the prac tice doctorate, but also elevate the science-based practice skill set of the nursing profession. That is why it is important for DNP students to explore opportunities and expand their horizons as it relates to healthcare policy and the role of the DNP-prepared nurse.

healthcare

A Call to Action

Advocacy is the process of supporting a cause or defending/inter ceding on behalf of a person or group (“Advocacy," 2021, para 1). Advocacy is a core principle of the nursing profession. Nurses engage in advocacy as part of the role and responsibility— to advocate on behalf of those whom they have been contracted (by society) to provide care at the individual, family, community, or population level (Lewenson & Nickitas, 2020). Certainly, all nurses know the work of Florence Nightingale, the founder of nursing education programs, and perhaps Lillian Wald, who established public health nursing. These revolutionary nursing scholars set the stage for nurs ing advocacy work for years to come. Today, nurses remain uniquely positioned to advocate for the health of the populations they serve.

Advocacy Opportunities

In 2020, nurses again topped the Gallup

poll for the most trusted profession (Saad, 2021). With this honor comes the responsi bility to act. Nurses, especially DNP-prepared nurses, possess scientific nursing knowledge and experience that can be used to influence policy decisions (Porche, 2019).

^ Advocacy Opportunities DNP-prepared nurses can begin by advocat ing for the good of the nursing profession. For example, by addressing workforce issues, the increased need for minority representation in nursing, and title protection, to name a few. The plea to advocate is noted in the American Nurses Association’s (ANA) (2021) document.

Nursing Scope and Standards of Practice, as well as the ANA (2015) Code of Ethics, where the ANA calls for professional nurses to advocate for safe healthcare environments. These efforts

will ultimately positively impact the care nurses provide to their patients. As mentioned, nurses are uniquely equipped to advocate for patient populations. Nurses can advocate to address disparities in healthcare access, for better healthcare quality, lower costs, and even extended healthcare in

surance coverage. For example, nurses testified in Michigan on behalf of patients to expand Medicaid. Betty O’Connor-Rogers was one of the registered nurses that testified. She shared the following experience with the Michigan Competitiveness Committee in 2013:

93

DNP-prepared nurses must use

the skills and

competencies

acquired in doctoral study to lead system change to improve patient outcomes,

critically analyze health policy proposals, advocate for

social justice, and demonstrate

leadership as they sit at the table with other healthcare

professionals to

positively impact

I took care of a patient who had always been healthcare very self-sufficient. He ate right, exercised, never smoked—he took care of himself. He reform. was a trucker whose employer didn’t of fer health insurance, but he figured he was healthy and could do without. Then, he started having trouble breathing and when he finally went to the doctor he learned he had a genetic form of lung cance.r If they’d found it soone,r they might have been able to do something. During treatment he went through his entire savings to pay his bills, but when he had nothing left he stopped his chemo and passed away. It’s one of the hardest things I’ve ever had to work through. And Medicaid expansion would have helped him. (Smith, 2013, para 5)

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Chapter4 Population Health and Healthcare Policy

This is just one example of many testimonies from nurses that ultimately pushed the Michigan legislators forward to expand Medicaid.

^ The DNP Project and Advoca^ The following policy analysis project related to the mental health concerns of our nation’s youth by Dr. Caroline Kemp, led to an opportunity to testify in front of the Maryland Senate Education, Health and Environmental Affairs Committee. During her testimony. Dr. Kemp advocated in favor of a bill that would require a nurse in every school. In this example. Dr. Kemp uses Bardach and Patashnik’s (2020) Prac tical Guide for Policy Analysis; The Eightfold Path to More Effective Problem Solving to analyze state policy to support mental health services in schools. Dr. Kemp used her project findings to support her oral and written testimonies for the Senate Commit tee, as well as the House Ways and Means Committee. (See Exemplar 4-2.)

Exemplar 4-2 An Analysis of School-Based Mental Health Models and Policies to Identify Recommendations for Replication and Policy Change Caroline M. Kemp, DNP, FNP-BC I started to develop my project topic prior to the COVID-19 pandemic out of my deepening concern for the mental well-being of youth in the age of social media. As I worked on my project in 2021 and the spring of 2022, youth mental health concerns were notably exacerbated, largely by the pandemic. As a former school nurse and current college health nurse practitioner. I value the school setting as an avenue to increase access to health care and improve equity. Schools provide an opportune setting to deliver prompt preventative interventions to actively mitigate the youth mental health crisis today.

Purpose and Process The purpose of this project was to provide a multilevel policy analysis for the Center for School Health Innovation and Quality (a school health think tank hereinafter referred to as "the Center"! to identify policy recommendations for improving school-based mental health services and reducing inequities in care. The intent of this project was also to produce a set of guidelines on how to advocate for better policy on school mental health services. I followed Bardach and Patashnik’s (20201 Practical Guide for Policy Analysis: The Eightfold Path to More Effective Problem Solving to analyze Michigan’s state policy to support mental health services in schools, a district in Florida’s policy and model for mental health care based in schools, and a nurse-developed model for mental health care in a Pennsylvania elementary school. Bardach’s model lays the groundwork to address challenges, highlight successes, and identify health outcomes related to strong policy. The eight steps of this model are as follows. 1. Define the problem. First. I researched the need for policy analysis in relation to current trends in youth mental health concerns in the context of health disparities and especially in light of the COVID-19 pandemic. I performed a literature review that supported the need for giving greater attention to the problem of growing mental health concerns and highlighted the need to recognize detriments of social media.

The DNP Project and Advocacy

2.

95

Assemble some evidence. I researched current policies and models in the three areas of focus. I conducted interviews with five school nurse leaders

from the three geographical locations for their frontline perspective on successes and needs of school-based mental health care. 3.

4.

Construct the alternatives. Several policy options were formulated that could be effective in improving mental health of youth at different levels using the school setting and through collaboration with community organizations. Select the criteria. I utilized specific criteria to determine if the policy alternatives would help improve health equity, increase access to mental health care, and support comprehensive and sustainable school mental health models.

5. 6. 7.

8.

Project outcomes. I considered the impact of these policies and the potential outcomes if replicated in other settings in the U.S. Confront the trade-offs. Possible trade-offs were acknowledged including monetary obstacles, personnel limitations, and time constraints. Stop, focus, narrow, deepen, decide. I documented thoughtful and thorough analysis to aid policy makers and advocates in recognizing the need and characteristics of effective policy options to combat the youth mental health crisis. I also incorporated Kingdon's Three Streams Model (1995) in my discussion and recommendations for just and sustainable policies and how to advocate for such policies today. Tell your story. I presented my findings, recommendations, and guidelines for advocacy in various forums detailed below.

Outcomes

My guidelines on how to advocate for school-based mental health policy are

framed in Kingdon's Three Streams Model (1995) and focus on three categories: the current mental health crisis among youth that has been exacerbated by the pandemic, the role of the school nurse, and the "big picture," using the CDC's (2021) Whole School. Whole Community. Whole Child model. Below is a summary (see Table4-1) of my policy recommendations based on my policy analysis findings. Dissemination

I presented my project outcomes during public health week in April 2022 via a public national webinar sponsored by American Public Health Association with a question-and-answer period hosted by the Center's founder. The webinar broke a record for audience members in attendance that week, highlighting the need for mental health policy. It was also recorded and available to view online. The Center's board of directors are currently working on disseminating my findings and results to more schools and advocates across the country. I showcased my findings during a poster presentation at the Quality and Safety Education for Nurses (QSEN) International Forum in Denver in June 2022.1 plan to submit my manuscript for publication in an academic journal.

Personal Impact and Conclusion This project impacted me in many ways and reaffirmed my passion for influencing health policy as a DNP-prepared nurse. Working on this project empowered me to testify in front of the Maryland Senate Education. Health and Environmental Affairs Committee in favor of a bill that would require a nurse in every school. [continues]

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Exemplar 4-2 An Analysis of School-Based Mental Health Models and Policies to Identify Recommendations for Replication and Policy Change

[continued]

My oral and written testimonies for the Senate Committee, as well as the House Ways and Means Committee, were based on my project findings and the crucial role of the school nurse in combatting the youth mental health crisis. Investing in students' mental health can not only improve their present and future health outcomes and academic success, but it can also improve the functioning of the school, families’ well-being, and the health of the community at large. To have the best chance of overcoming the crisis among our youth, we must have comprehensive and equitable policies to support evidence-based mental health models in schools.

The opportunities to advocate are virtually limitless. There are also multiple approaches to advocacy. The DNP student could attend a legislator's local town hall meeting, a health policy advocacy day, or a legislative hearing where expertise as a healthcare provider could be shared. Advocacy opportunities also exist via professional organizations. For example, the American Association of Nurse Practitioners lAANP) has an Advocacy Center on their website where members can keep abreast of healthcare issues and legislation and assist with advocacy efforts through submission of expedited form letters that can

Table 4-1 Recommendations

Level of PoUcy/Model State

■

School

Tailor to reflect the

Start in the classroom and

allocated to each

specific needs of the student population. Fill gaps in care

Include equitable and flexible funding: baseline amount

■

District

include education

and debriefing

county or district,

based on available

related to social

then additional

resources in each

media.

funding based on a per-pupil ratio. Informed by a diverse advisory board: including

community. Include options for improving access

Prioritize family engagement.

to care, such

and staff wellness.

as UberHealth

Use screening tools

nurses, school administrators,

partnership and telehealth spaces in

that are modeled

school

the schools.

students.

Incorporate teacher

for reaching all

psychologists, state Medicaid

representatives, and a representative from a large health system in the state.

■

At all levels, reducing inequities should be prioritized while formulating policies and models.

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97

be sent to legislators at the state and national level (see vww.aanp.org for more information). The DNP student should checl< to see if there is a need for volunteers to sit on the policy or advocacy committee, or attend a march at the

state capital. Or, consider going to Capitol Hill in Washington, D.C., to champion a piece of healthcare legislation with a senator or representative! Data from Bardach. E., & Patashnik, E. M. [MO]. A prscticsl guide for policy 3nalysis: The eigtitMil path to more effective probtem solving. Thousand Oaks. CA; CO Press.

Legislators want to hear from their constituents. The following tips are pro vided to help the DNP student prepare for a health policy advocacy experience.

Calling a Representative ●

The DNP student should begin by introducing themselves and letting the rep

● ●

The student should tell the staffer that they are a nurse. Then, the student should tell the representative about their main concern and share any support from the literature that speaks to the significance of the issue. Take the time to share a personal or professional story that relates to the con cern. A story gives the problem context and will help illustrate the main point. It is important to share one’s vision. Tell the representative what is working or is not working, and what the representative could do to address the problem. Always remember to thank the representative and the staff for their time (ANA,

resentative or senator know that they are a constituent.

● ● ●

2017a).

Meeting With a Representative Setting Up the Meeting

●

Call the senator or representative’s office. Request a meeting with the repre sentative or their staff at the nearest district office and inform them about the

●

topic of concern. The staffer will provide the location for the closest district office. While an ap pointment may not be necessary, it will assure that there is someone available during the requested meeting time.

Preparing for the Meeting

●

●

● ●

The DNP student should prepare with background work before the meeting to find out where the representative stands on the issue of concern. For example, it will be helpful to know the committees they represent, their background, political party, and the position they generally take on issues. This information may be found on the representative’s website or through online press releases. VWite down an introduction plan. For example, the DNP student could include in formation about their background in nursing, perhaps the types of patients that they see or the classes they teach, etc. This information will be helpful for the staffers. Plan to ask questions to get to know the representative. This is a great way to develop rapport! It may be helpful for the DNP student to write down their “number-one” con cern. It is best to focus the discussion around what is most important; do not

feel compelled to speak to every issue.

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●

●

Chapter4 Population Health and Healthcare Policy

The representative probably does not know much about health care, so be ready for questions. Again, make sure to thank the representative and staff for their time and follow up with a brief email or letter outlining the points made during the discussion (ANA, 2017b; Turner, 2017).

Speaking at a Town Hall Meeting ●

●

●

●

●

●

Before attending the meeting, try to get an idea of what the tone of the event will be. To do this, contact the policy maker’s district office to see who is ex pected to attend and if anyone is expected to give a presentation. This will give the DNP student an idea for how to prepare their remarks. As mentioned above, the DNP student should prepare with background work before attending the meeting. This includes having accurate, timely, and rele vant information to share with the group and a plan to introduce their position as early in the meeting as possible. Share information about the meeting with others and encourage them to attend to show community support for the initiative. The goal is to get as many advo cates to attend the meeting as possible. The DNP student should be prepared to present their views with concise

points and support from the literature. These facts will help those attending the meeting understand and remember the main points. Remember to practice your message! The goal is to be as comfortable and con fident as possible when sharing concerns at the meeting. Finally, it is a good idea for the DNP student to leave written copies of their position with the policy maker, staff, and others who attend the meeting (American Public Health Association lAPHA], n.d.).

Writing a Letter to the Editor Writing a letter to the editor is a great way to shed light on an issue or concern. For example, the DNP student could address the editor to clarify facts or correct misstatements, to oppose or support current or proposed legislation, or simply to gain support from the community. Consider the following recommendations when writing a letter to the editor. ● ●

●

Be strategic in the timing of the letter. The editor of a newspaper will be cogni zant of topics that are currently in the news. Review the paper guidelines related to word count, format, contact informa tion, and delivery methods (email, etc.). The DNP student should follow these important requirements to assure their work is included in its entirety. When writing a letter, provide brief, but sufficient background information so that the readers understand the significance of the issue and how it may affect their lives and communities.

●

If the DNP student is responding to a previously published editorial, they should make sure to include this information in the letter. And conclude the

●

letter with their name and credentials, so that the editor (and audience) recog nizes that the student is a healthcare provider. The letter should be specific to a circulation area. Do not send the same letter

to multiple papers within the same geographic area.

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Writing an Opinion Editoriai An opinion editorial (op-ed) is different than a letter to the editor. First, it is gener ally longer than a letter and is published in a specific section of the paper reserved for opinions. Consider the following information when preparing to write an op-ed. ●

●

●

●

●

Begin with the end in mind! Since papers receive hundreds of submissions a week, the DNP student will want to start early and do their homework before submitting the op-ed. The DNP student should first check with the newspaper to see if they ac cept opinion pieces. For example, they should call the newspaper, introduce themselves, and tell the editorial page editor that they would like to submit an op-ed. Like a letter to the editor, it is important to follow any specific guidelines the newspaper may have for these types of pieces (e.g., word limit [usually around 650 words], how to submit the piece, the format, etc.). When the DNP student submits the op-ed, they should consider including a message to remind the ed itor about their conversation and why it is an imponant topic for their readers. Finally, the DNP student should remember to include their name, credentials, and perhaps a brief description of their area of expertise so that the editor rec ognizes the student’s level of knowledge on the topic. If the student doesn’t hear anything after about a week, they should reach out again to confirm the editorial page editor received the op-ed (APHA, 2016).

Writing a Policy Brief A policy brief synthesizes “existing research knowledge on a policy or practice issue of importance . . . and is written in language an interested non-expert would find accessible” (National Education Policy Center, n.d., para 1). It is a helpful tool that uses evidence to influence policy and practice. As the term “policy brief’ implies, the paper should be short (only two to four pages in length) and include a description and context of a problem and the rec ommended action. There are a variety of policy brief formats that can be used, but many include:

●

An introduction that includes a description of the problem and background

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The aim of the brief

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Potential approaches and solutions

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A conclusion

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The recommended option and implications

The goal of a policy brief is to communicate the right message to the right people at the right time; therefore, writing a policy brief requires use of the essential communication skills and competencies attained in doctoral education. Like writ ing a scholarly paper, the goal of a brief is to share the information. However, simply sharing the information doesn’t mean that it will be used in practice. So, the focus of a policy brief is to communicate information in a way that will be understood by those who read it, and subsequently used to make a change. For example, it could be a change in local regulations or state law; it could involve funding priorities, or ganizational practices, or even program implementation (Johns Hopkins Bloomberg School of Public Health, n.d.).

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Since the focus is on clear communication, it is important to know the audience. Before embarking on a policy brief, the DNP student should ask them self the follow ing questions: What do you know about the audience? Are they aware of the prob lem? Will they be open or resistant to change? This information will help the student identify the best message to use to engage and motivate them for change. Consider the following from Johns Hopkins Bloomberg School of Public Health (n.d.) when writing a policy brief. ● ●

●

Begin by writing the aim of the policy brief, because everything in the brief should directly relate to the aim. The aim should include one or two sentences. Next, focus on describing the problem and why it is relevant to the reader. Use data to describe the extent of the problem. When writing a policy brief it is important to give the right amount of background information to engage the reader, but not overburdenthem with informationthat is not directly related. So, unlike a scholarly paper where one might include an exhaustive literature review, with a policy brief only include information that is relevant and neces sary to make the case. In the next section, talk about solutions that have already been implemented and the effectiveness of the solutions.

●

Then, the DNP student should describe a few options that they are recom

mending for change with the pros and cons of each option; remember, not doing anything can be an option. ●

In the final section, describe the recommendation. It will be important for the DNP student to do their homework before writing this section—reach out to

the stakeholders to get feedback and gain support for the recommendation. The student’s recommended option should be backed by evidence and flow

logically from their argument. It should be very specific and clearly describe the action the student recommends and the anticipated effect, not be vague and left to the audience to interpret. The audience should clearly understand what the student proposes they do, as this may be the only part of the policy brief that someone reads.

●

Once the brief is written, the student will need to come up with a title that is

both engaging and informative. The title is very important. It should not only tell the reader what the brief is about, but also why they should read it.

Remember, a policy brief is intended to be read quickly and should provide the reader with information about the problem, the aim, and recommendation without

unnecessary verbiage. With this in mind, structure the brief to highlight key points and make it easier to read, for example, separate text into sections with headings, use bullet points, bar graphs, and figures where possible, use callout boxes, bold or italicized font, and plenty of white space Qohns Hopkins Bloomberg School of Public Health, n.d.).

Performing a Policy Analysis The puq>ose of a policy analysis is to “critically appraise the context in which an agenda, issue, or policy exists" (Porche, 2019, p. 189). The policy analysis pro cess involves interpretive analysis and the historical context of the policy from the macro-level (focusing on broad influencers, e.g., economics), meso-level (focusing on implementation and individuals and groups that develop policy), and micro-level

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(focusing on engagement between constituents and policy makers, including the beliefs and values that impact the process) perspectives. The policy analysis prod uct reflects the level of focus, purpose, and intent for conducting the analysis, and should include a clear description of the problem, potential solutions, courses of action and expected outcomes, and contextual understanding of the problem and policy (Porche, 2019).

There are multiple approaches that can be used as a guide to conduct a policy analysis (see Chapter 6, Validating the Problem and Conceptualizing the Project Plan, for examples of policy analysis approaches). The following policy analysis framework from Bardach and Patashnik (2020) is used to illustrate the process. It is not necessary to follow these steps in order or to include all steps in every analysis. However, the authors point out that although this is an iterative process, defining the problem is a good place to start and telling the story is generally the ending point. f. Define the Problem

This is where the problem is defined in quantitative terms; it is where the reason for the work is described. This baseline information should give the reader a sense of the magnitude of the problem and direction. The authors suggest beginning by thinking in terms of deficits and excess. For example, there are too many people dying in motorcycle accidents (a public problem) or the need for primary care practitioners in rural communities is growing faster than our ability to educate practitioners (indicating a potential breakdown in the education system, an equity concern for rural com munities, or both).

As mentioned, it is important for the DNP student to quantify how big the problem is to the best of their ability. In some cases, they may need to estimate the magnitude of the problem using a metric that provides a reference for the reader.

The example above, “too many people are dying in motorcycle accidents, is a con cern, but how big of a concern? To quantify this statement one could say, “too many people between 16 and 19 years of age are dying from motorcycle accidents,” or to further define it one could say, “there are more people between 16 and 19 years of age who died from motorcycle accidents in the past year than in the past 10 years combined.” This provides further context that will be beneficial later in the analysis. Finally, Bardach and Patashnik (2020) offer a word of caution: Do not define the solution into problem (a problem statement that includes the solution) and to be skeptical about causal claims (in other words, evaluate the evidence carefully). 2. Assemble Evidence

This step in the process requires an investment of time to gather data, but also time to reflect on the meaning of the data collected. Both are time-consuming processes. It is better to think before collecting, so that the student is sure that the data they collect are useful. In other words, the student will need data that are first a source of

information (data with meaning), but with the potential to eventually become evi dence (information that affects existing beliefs). This can be accomplished through a literature review, by surveying other best practices, or by using analogies from similar programs (e.g., comparing public to private sector, etc.). Finally, take the time to reach out to potential supporters, but also to potential critics to gain their perspectives. It is important that the student doesn’t ignore those who disagree with their view!

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5. Construct Alternatives (Policy Options That Can Be Used to Mitigate the Problem) Sian with a broad, comprehensive list of potential options. For example, the DNP student could start with the options that are currently being discussed, come up with a few on their own, and consider letting the present trend continue—meaning, to continue with the status quo. Once the student is satisfied with the list of alterna tives, they will need to narrow the list down to a few best options. With any “new” alternative, it is good practice to run it by a few interested stakeholders, so that the student is sure they are on target. 4. Select the Criteria In this section the DNP student should think about value judgments. In other words, the student needs to determine if the projected outcome of an alternative (this distinction is important to keep in mind) would be good or bad for the population, and therefore,whetherit would or would not be considereddesirable. Examples of evaluation criteria that are important to consider include ef ficiency criteria, such as cost effectiveness. Equity criteria may also be used to evaluate fairness across the populations and/or social justice. In addition, there are a variety of freedom criteria that may be considered, such as freedom to choose

(e.g., to wear a helmet when riding a motorcycle), privacy, security, and so on. Other practical criteria that may be used in the evaluation process include the legality or the political acceptability of a policy, and the degree of opposition and/ or lack of support.

Finally, Bardach and Patashnik (2020) point out that, to the extent that is possi ble, the criteria chosen should be characterized both conceptually and operationally

(typically quantitatively). To do this, specify the metrics that will be used to evaluate the criteria. For example, a qualitative metric may be to maximize the use of helmets when riding a motorcycle. The quantitative metric may be to reduce the death rate by 50% in individuals between 16 and 19 years of age dying in motorcycle accidents in the next 12 months.

5. Project Outcomes

Projecting the outcomes for each of the alternatives is the next step. Here are a few things to consider when projecting outcomes:

● ● ●

●

●

Be as realistic as possible; it is impossible to be completely sure about what the future will bring, but avoid being overly optimistic. Combine models and evidence to develop useful projections (e.g., a social sci ence model is used to determine whether something is “smart” practice). Choose a base case (common reference mark). For example, let’s say that there are currently 1,500 teens dying annually from motorcycle accidents. Based on alternative one, one could say that it is reasonable to expect this number to decrease by 750 (based on a 50% reduction proposed earlier). Determine what a break-even estimate would be (e.g., 100,000 helmets need to be donated by the end of the first year of the program to assure success). Reflect on scenarios that could cause the proposal to fail (think about the polit ical [and other] dangers associated with the implementation process).

Impact

● ●

103

Think about potential “undesirable side effects” (for example, if a policy is initi ated that mandates helmet use but then leads to overregulation in other areas). Use an outcomes matrix to compare the policy alternatives.

6. Confront Trade-Offs

Confronting the trade-offs involves looking at the projected outcomes for each al ternative, then, determining which offers the best “trade-off” for the good of the population. The best way to do this is to establish commensurability across the established criterion. Money is often used for this metric. While it is best to quan tify trade-offs whenever possible, sometimes it is not possible. In these cases, using rank order may help in the decision-making process. It goes without saying that this should be a thoughtful process, as the trade-offs may include some moral and/ or ethical components. 7. Decide It is now time to make a decision! Which of the alternatives

is the best option to

solve the problem? What will it lake to get it adopted? Remember to consider po tential resistance from stakeholders who are happy with the status quo or the possi bility that there is no one willing to step up to see this option through. 8. Tell Your Story

It is now time for the DNP student to tell their story to the identified stakeholders. To be effective, the student should make sure they know the audience and can easily tell their story using simple, down-to-earth terms. Then, choose a method to deliver the information that is appropriate for the identified stakeholders (e.g., oral or written form, such as the example provided earlier).

Summary As a practice scholar, the DNP-prepared nurse must bring evidence to practice to positively influence healthcare outcomes. This can be accomplished through advocacy efforts at the micro, meso, or macro levels. The AACN Essentials for Advanced-Level Nursing Education (2021) competencies and subcompetencies call for advanced-level nurses to advocate for social justice, equity, and ethical policies

within all healthcare arenas (e.g., AACN Essentials subcompetencies 3.4g, 3.4j, and 3.4k). As mentioned at the beginning of this chapter, DNP students with an interest in this work should consider a policy-focused project as a foundation for ongoing policy scholarship. Ultimately, DNP-prepared nurses are leaders of the nursing pro fession; therefore, they should consider policy/advocacy work as part of their role.

Impact ●

DNP-prepared nurses have the education, knowledge, and skills to sit at the table and actively participate in the discussions where healthcare delivery and population health decisions are being made.

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Chapter4 Population Health and Healthcare Policy

As the most trusted profession, nurses (especially DNP-prepared nurses) will be heard when they advocate for patients and populations at the local, state, national, and international levels.

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It is critical that DNP-prepared nurses continue to focus on systematically an alyzing and evaluating the factors that impact access to care, the cost of care, health behaviors, and outcomes of care.

Key Messages ●

Political decisions that impacted the health of the country date back to the early 1900s. To address the most pressing needs of society, an intentional effort is needed to understand and ultimately address the “social determinants of health.” Healthcare policies not only need to address access to care but must support and enhance communities to evolve into places for all residents of the commu nity to live healthy, active, safe lives. Even with the spotlight on ethnic disparities in the U.S., there is still a long way to go to address these concerns, especially as they relate to overall health and life expectancy. Other important factors that contribute to healthcare outcomes are the cost and quality of health care. The term evidence-based policy refers to the process “whereby policy decisions

● ●

●

● ●

are informed by rigorously established objective evidence” (“Evidence-based policy,” 2018, para. 1). DNP-prepared nurses are adept at analyzing scientific data related to indi vidual, aggregate, and population health and critically appraising existing literature and other evidence to determine and implement the best evi dence; therefore, they are perfectly suited to establish the good governance

●

of evidence.

DNP-prepared nurses are called to lead and manage collaborative efforts with other healthcare practitioners to improve healthcare delivery and the health of the populations that are served. Advocacy is a core principle of the nursing profession; therefore, DNP-prepared nurses should advocate for social justice, equity, and ethical policies within all

●

●

healthcare arenas.

Action Plan-Next Steps 1.

Consider how to address disparities in health or healthcare delivery in an organization (micro level), community (meso level), or beyond (macro level).

2.

3. 4. 5.

Determine which method to use to engage in the advocacy process (meet with a legislator, write a letter to the editor, write a policy brief, or perform a policy analysis). Do your homework (gather the evidence). Analyze the evidence. Engage stakeholders—advocate to address disparities and urge politicians to change the system.

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York, NY: The Commonwealth Fund. https://doi.org/10.26099/01DV-H 208 Schweitzer, S. O., & Comanor, W S. (2014). Promoting pharmaceutical access while controlling prices and expenditures. In G. Kominski (Ed.), Changing the U.S. health care system: Key issues in health services policy and management (pp. 269-304). San Francisco, CA: Jossey-Bass. Sherman, A., & Trisi, D. (2015). Safety net more effective against poverty than previously thought. Washington, DC: Center on Budget and Policy Priorities, http://www.cbpp.org/research/poverty -and-inequality/safety-net-more-effective-against-poverty-than-p reviously-thought Shi, L., & Singh, D. A. (2019). Delivering health care in America: A systems approach. Burlington, MA: Jones & Bartlett Learning. Smedley, B. D., Stith, A. Y., & Nelson, A. R. (2003). Unequal treatment: Confronting racial and

ethnic disparities in health care. Washington, DC: National Academies Press, https://doi.org /lO. 17226/12875

Smith, A. L. (2013). Nurses care, which is why they’re advocatingfor Michigan Medicaid expansion. hupV/ www.eclectablog.com/2013/07/nurses-care-which-is-why-theyre-advo cating-for-michigan -medicaid-expansion.html Snyder, R., Calley B., & Pscholka, A. (2017). A path toward our future—state of Michigan. FY 18 Executive Budget Presentation. httpsy/www.michigan.gov/documents /budget/FY18_Exec_Budget _550967_7.pdf Squires, D., & Anderson, C. (2015). U.S. health care fromaglobal perspective: Spending, use of services, prices, and health in 13 countries. New York, NY: The Commonwealth Fund. http://www.common wealthfund.org'publications/issue-briefs/2015/oct/us-health-care -from-a-global-perspective The Gilder Lehrman. (2021). Study aid: Great society leffslation. https://www.gilderlehrman.org /history-resources/teaching-resource/study-aid-great-society-legislation#:~:text=President%20

Lyndon%20Johnson%20announced%20his,of%20252%20his%201egislative% 20requests Tower, M. (2016, June 12). Seniors struggle to make ends meet in wake of SNAP food assistance cuts. Saginaw News, http://www.mlive.com/news/saginaw/index.ssl/ 2016/02/saginaw_seniors _struggle_to_ma.html Trump. D. (2017). America First: A budget blueprint to make America great again. Washington, DC:

Office of Management and Budget, http://www.budget.gov Turner, R. (2017). Meeting with your legislator: 10 tips to help you prepare for your meeting, https:// www.canr.msu.edu/news/meeting_with_your_legislator

108

Chapter^ Population Health and Healthcare Policy

U.S. Department of Agriculture (USDA). (n.d.). The benefits of increasing the Supplemental Nutrition Assistance Program (SNAP) participation in your state. Washington, DC: Author. https^Avww .snaptohealth.org/snap/the-real-benefits-of-the-snap-program/ U.S. Department of Agriculture (USDA). (2016). Definitions of food security. Washington, DC: USDA Economic Research Service, https://www.ers.usda.gov/topics/food-nutrition-assistance /food-security-in-the-us/definitions-of-food-security/ U.S. Department of Agriculture (USDA). (2017). National and/or state level monthly and/or annual data—Latest available month January 2017. Washington, DC: USDA; Supplemental Nutrition Assistance Program (SNAP). https://frac.or;^research/resource-library/snap-monthly-data-2017 Wax, S. G., & Stankorb, S. M. (2016). Prevalence of food insecurity among military households with children 5 years of age and younger. Public Health Nutrition, 19(13), 2458-2466. Wayne Metropolitan Community Action Agency (2016). 2016 Wayne County community needs assessment. Detroit, MI: Author. httpsy/idph.iowa.gov/Portals/l/userfiles/91/CHNA%26HIP /2016%20CHNA%26HIPsAVayne%20Couniy%20CHNA%202-29-16.pdf Whitde, H. J., Palar, K., Hufstedler, L. L., Seligman, H. K., Frongillo, E. A., & Weiser, S. D. (2015). Food insecurity, chronic illness, and gentrification in the San Francisco Bay area: An example of structural violence in United States public policy. Social Science and Medicine, 143,154-161. http://dx.doi.Org/10.1016/j.socscimed.2015.08.027 Wisely, J., & Tanner, K. (2015, September 17). Income rise helps poverty rate in Michigan. Detroit Free Press. httpy/www.freep.com/story/news/localAnichiga n/2015/09/16/poverty-falling -incomes-rising/32507559/

Yancey, A. K., Bastani, R., & Glenn, B. A. (2014). Racial and ethnic disparities in health status. In Kominski, G. (Ed.), Changfng the U.S. health care system; Key issues in health services polity and management (pp. 71-101). San Francisco, CA: Jossey-Bass. Zimet, S. (2017). Health budget hearing testimony. Albany, NY: Hunger Action Network of New York State, http://wvmnysenate.gov

Helpful Resources American Association of Colleges of Nursing (AACN), Government Affairs httpy/www.aacnnursing ■org/ American Association of Retired Persons (AARP) https://wvm.aarp. org' American Nurses Association (ANA) httpsy/www.nursingworld.oig/ American Enterprise Institute (AEI) httpsy/wvm.aei.org/ Brookings Institution httpsy/www.brookings.edu/ Cato Institute httpsy/www.cato.oig/ Centers for Disease Control (CDC) Health Disparities & Inequalities Report httpsy/vmw.cdc.gov /minorityhealth/chdireport.html Democrats Action Center https-y/wvm.democrats.oig/ Economic Policy Institute (EPI) httpsy/www.epi.org/ Educational Policy Institute http://wvm.educationalpolicy.org/ Health Affairs httpy/content.healthaffairs.org/cgi/changeuserinf o^asic Henry J. Kaiser Family Foundation (KFF) https://vmw.kff.org/heal th-reform/ Kettering Foundation httpsy/vmw.kettering.org/ Library of Congress httpsy/www.congress.gov/ National Academies of Sciences, Engineering, and Medicine httpy/www.nationalacademies.oi;^hmd/ National Institute for Public Policy (NIPP) http://wvm.nipp.org/ Office of Policy Analysis https://vmw.doi.gov/ppa Organisation for Economic Co-operation and Development (OECD) httpy/www.oecd.org/ RAND Corporation httpsy/www.rand.oig/ Republican National Committee (GOP) Action Center httpsy/www.gop .com/ Robert Wood Johnson Foundation (RWJF) httpsy/www.rwjf.org/ The Commonwealth Fund http://www.commonwealthfund.org/ 2020 Platform Comparison httpsy/downloads.frcaction.org/EF/EF18H 05.pdf

CHAPTER 5

The Phenomenon of

Interest: Leading to Problem Identification Katherine Moran, Rosanne Burson, Karen Mihelich, and Lydia Rotondo CHAPTER OVERVIEW

Nursing practice is guided by science and theory. Nursing, as a profession, historically has been considered a practice discipline that is complex, varied, and underdetermined. There is an inherent societal obligation for the nurse to use good clinical judgment based on evidence-based practice that is informed by research. The nurse must "attend to changing relevance as vi/ell as changes in the patient’s responses and nature of his clinical condition over time" (Benner et al.,

2009, p. xiv). How/ever, because practice in the individual case is open to variations that are not necessarily accounted for by science [underdetermin ed), the nurse must use clinical reasoning to select and use relevant science (Benner et al., 2009). This means that the nurse must be able to focus on complex, individual circumstances; recognize important changes/trends in the patient's condition; and use good clinicaljudgment when providing person-centered nursing care. This is exemplified within Domain 2 (Person-Centered Care) of the American Association of Colleges of Nurses (AACN) (2021) The Essentials: Core Competencies for Professional Nursing Education. It is also crucial that nurses recognize and respond to the dynamic interrelationship between the environment and an individual's response to illness or overall health status. Understanding the multiple influences that impact health (e.g., social determinants of health, access to care, health literacy) from a systems perspective is critical to professional nursing practice, as described in Domain 7 (Syslems-Based Practice) of the AACN Essentials. CHAPTER OBJECTIVES

After completing the chapter, the learner will be able to: 1.

2.

Understand the meaning of nursing phenomena in relation to the identification of issues that are in need of change. Consider personal practice interests and expertise in contemplating phenomena.

® Sandlpkmar Palel/DIgitalVisiofi Vectors/Galty Images

109

110

3. 4. 5. 6.

Chapter 5 The Phenomenon of Interest

Scan the literature for potential areas of interest. Evaluate potential nursing theories as a framework for the nursing phenomenon. Explore the phenomenon through patterns of knowing. Apply the process of concept analysis to the phenomenon or a characteristic of the phenomenon.

The complex nature of nursing practice provides many opportunities to explore nursing phenomena. The focus of this chapter is to explore phenomena of inter est for the Doctor of Nursing Practice (DNP) project. Nursing theory and nursing knowledge are briefly explored to help the DNP student understand the significance of nursing phenomena. Along with the guidance received from the advisor, a variety of strategies are introduced to help the DNP student select a phenomenon of inter est for the DNP project.

y The Expertise of Nursing Practice The nurse must

be able to focus

on complex, individual

circumstances;

recognize

important

changes/trends in the patient's condition; and

use good clinical

judgment when providing

patient-centered nursing care.

In 2011, the Institute of Medicine (lOM) and the Robert Wood Johnson Foundation (RWJF)

put forth a report that highlights the value of nursing and outlines the central role that nurses will play in the future health of our nation. In this report. The Future of Nursing: Leading Change. Advancing Health, nurses are called to lead and manage collaborative efforts with other healthcare practitioners to improve health care. Understanding the unique attributes of the ex pert nurse and expert nursing practice will help the nursing profession meet the challenges set forth by the Institute of Medicine (2011). Most recently, the National Academies of Sciences, Engineering, and Medicine (NAM) and RWJF released their third report titled The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity, calling on the profession of nurs ing to play a pivotal role in achieving health equity “built on strengthened nursing capacity and expertise” (NASEM, 2021, p. 1). According to Morrison and Symes (2011), expert nursing practice includes a degree of in volvement and engagement with patients that demonstrates intuitive knowledge and skilled know-how through knowing the patient, re flective practice, and risk taking. According to Benner et al. (2009);

Expert nursing practice occurs when the nurse is able to see the situation in alternative ways, either through introspection or by consulting others; allowing the nurse to realize the true meaning of the present and past

The Expertise of Nursing Practice

111

events. The nurse reflects on the goal or perspective that seems evident to them and on the action that seems appropriate to achieving their goal; referred to as deliberative rationality, (p. 16) This unique skill set places the practicing scholar in the best position to iden tify those areas of clinical concern that require further inquiry and/or improvement and to help ensure that the healthcare needs of patients within the community, organization, In this day of or healthcare unit are being addressed. Here is where interest is sparked and the nurse begins attention to to connect the clinical concern to a phenome non of interest.

The ability of the nurse to be intention ally present with the patient, seek to better un derstand the individual event, and collectively choose individualized interventions that are

unique for this patient at this time are the ul timate contributions that the nurse offers. This

hidden work is what influences the patient’s experience and often positively affects clinical outcomes. The profession has not articulated well the skill set nurses bring to the table that enhances the work that is done. This is partly because the relationship and caring aspect of

nursing has been seen as the soft side of nursing and historically is not valued as much as the science-based technical aspects. For example, within the advanced practice role, the perceived value from organizations and other practi tioners has been the utilization of the medical

model in providing care. Nursing care is not measured, although in fact that may be the very thing that assists patients in meeting outcomes. In this day of attention to person-centered care and outcomes, the aspects of care delivery that nurses provide by their inherent understanding and broad view of phenomena require further examination, demonstration, and dissemina

tion. These processes will serve to highlight the hidden work of nursing and to validate its im portance to the patient’s healthcare experience and outcome.

Another key dimension of providing personcentered nursing care is the consideration of the multiple determinants of health that shape the therapeutic relationship between nurse and client. By employing a systems perspec tive, nurses holistically analyze and integrate these potentially underappreciated influences

person-centered care and

outconnes, the

aspects of care

delivery that nurses provide by their inherent understanding of phenonnena require further exanni nation,

demonstration, and

dissemination. The hidden work of the nurse is

what influences

the patient's experience and often positively affects clinical outcomes.

112

Chapter 5 The Phenomenon of Interest

The DNP project phenomenon of interest must center on a

topic that is meaningful to the practice

on health—social, medical, economic, histor

ical, and structural—into professional nursing practice. Nurses also apply systems expertise as practice scholars to explore areas of practice inquiry to remove barriers to care, leverage re sources, and develop collaborative relationships to optimize care delivery and promote health equity.

^ Identifying the

doctorate

student and is

Phenomenon of Interest

what are the phenomena that are of interest to the DNP student? When asked this question individually, DNP students may have difficulty practice setting. adequately articulating the details of their inter est. Perhaps it is because they have not been able to completely understand the complexity, or maybe their interests are too broad and not sufficiently narrowed to begin to articulate intent. Although the student’s advisor provides direction and support as the student considers a variety of phenomena, it is a question that each student must answer individually. The DNP project phenomenon of interest must center on a topic that is meaningful to the practice doctorate student and is valued by the practice setting. Further, as mentioned, practicing scholars are in the best position to identify those areas of clinical concern that require further inquiry and/or im provement. Identifying the phenomenon of interest is the first step in developing the DNP project.

valued by the

What Is a Phenomenon?

While some students may start the DNP program with a good understanding of the phenomenon they want to explore, as mentioned, others may not yet have a phe nomenon in mind or they may not have a full understanding of what is meant by the term nursing phenomenon. To better understand what constitutes a phenomenon, it is important to understand the meaning of the word. According to Merriam-Webster, phenomenon is defined as “a fact or event of scientific interest susceptible to scientific description and explanation; an exceptional, unusual, or abnormal person, thing, or occurrence” (“Phenomenon,” n.d., para. 2). Nursing phenomenon, on the other hand, is described as “a type of factor influencing health status with the specific characteristics; aspect of health of relevance to nursing practice” (International Clas sification for Nursing Practice [ICNP], n.d., para. 1). Hence, the phenomena within the realm of nursing are complex in nature. These phenomena incorporate humans and their environment and relate to all aspects of human function as an individual, family member, or member of community—^within the context of the physical or biological environment and human-made environments of norms, attitudes, and

Identifying the Phenomenon of Interest

113

policy (ICNP, n.d.). Consequently, it is not surprising that many DNP projects deal with complex health-related issues that necessitate systems thinking to appreciate how elements of complex systems interact with each other (Sebastian et al., 2018; Christenbery, 2011). One way to approach identifying the phenomenon of interest is to consider the areas of the DNP student’s clinical expertise. Phenomenon identification de rives from a practice situation that resonates. Practice experience occurs between the nurse and the patient and occurs within a complex environment that can sig nificantly influence the therapeutic relationship as well as the delivery and out comes of care. Further, reflecting on aspects that the student has observed within a particular patient population may give some direction. The expert nurse draws on this understanding and has developed specific interventions that align with the known phenomenon. For example, in working with patients with diabetes who are in need of insulin initiation, the nurse notes that there are often multiple barriers. Patients may experience fear of insulin related to injections or hypogly cemia. The patient may have insidious thoughts related to feelings of failure and guilt for having not been perfect in their approach to lifestyle behavior change and other recommendations from the healthcare provider. Patients may have de creased self-efficacy or empowerment issues that limit their ability to self-manage and maintain motivation. There may be family history whereby a family member started insulin, and this appeared to contribute to their demise. Misunderstanding the other factors related to the family member’s experience can exacerbate the difficulty the patient experiences as they try to overcome this new hurdle. The expert nurse has the skill set to help the patient explore the specific barriers that are contributing to their inability to move forward, toward better glucose control and improved health. The identified phenomenon of barriers to insulin initiation may be the beginning of an intense exploration of the topic, resulting in an inter vention that improves outcomes for patients. This illustrates why it is important for the student to learn how to identify, then come to understand an issue, before starting the DNP project. The student should also consider asking if there is something about their practice setting that needs further inquiry. Perhaps a population of patients is not reaching their healthcare goals because of some common barrier, or a healthcare organization identifies a gap in providing cost-effective, quality care. In both of these examples, a clinical problem results in a trigger that leads to identifying a phenomenon worth exploring. This is what is meant by identifying a clinical problem in the context of the needs of the organization or population. Recognizing and understanding issues of concern within specific organizations is a skill set and competency that is expected from DNP students. This is a great opportunity for students to see system-level issues that contribute to or create healthcare deliv ery problems. For example. Domain 7, Systems-Based Practice, subcompetency 7.1g of the AACN Essentials for Advanced-Level Nursing Education prepares the graduate to “analyze system-wide processes to optimize outcomes” coupled with subcompetency 7.2h to “design practices that enhance value, access, quality, and cost-effectiveness” (AACN, 2021, p. 46). To better understand how to determine the needs of an organization or population see Chapter 6, Validating the Problem and Conceptualizing the Project Plan, for more information on conducting an organizational assessment.

114

Chapters The Phenomenon of Interest

^ Utilizing ^sterns Thinking to Explore the Phenomenon of Interest S^'stems thinking is the foundation of effective systems-based practice (Plack et al., 2018). Systems thinking is a competency and mindset that helps individuals to recognize the interrelatedness among a system’s component parts, the “. .. drivers, connections, and consequences of interactions at play. . .” that determine organiza tional behavior (Gonzalo et al., 2021, p. 22). DNP students must be able to evaluate how various components of a healthcare organization interact in order to develop successful and sustainable context-appropriate interventions that meet the needs of an organization or population. Therefore, utilizing a systems thinking frame work supports change agency and DNP practice scholarship. By applying Habits of a Systems Thinker (see Table 5-1), DNP students can critically examine potential phenomena of interest in complex health organizations for future practice inquiry. Other helpful strategies in identifying a phenomenon may be to cast a wide net and to think about areas of interest from a broad, general perspective. Multiple methods can be used to help the student identify a pertinent topic. For example, it may be helpful to review research reports found in the Cumulative Index to Table 5-1 Habits of a Systems Thinker Seeks to understand the big picture.

i ■

A Systems Thinker focuses on the larger picture as well as the details.

j

How can I maintain balance

between the big picture and important details? ■

What time frame should be

■

considered as I view the system? Am I keeping my focus on areas of influence, rather than on areas of concern that I cannot influence?

Observes how elements within

systems change over time, generating patterns and trends. A Systems Thinker sees change over time as the dynamics of a system.

■

Identifies and test assumptions.

■

What important elements have

i

changed in the system? ■ ■

I ■ Changes perspective to increase understanding. A Systems Thinker increases understanding by changing the way they view aspects of the system.

How have the elements changed over time?

■ ■

■

■

What changing elements represent

amounts and how quickly/slowly are they increasing or decreasing? What patterns or trends have emerged over time? Am I open to other points of view? How do different points of view influence the way I understand the system? Who should I approach to help me gain new perspectives on an issue? As I learn about new perspectives, am I willing to change my mind?

utilizing Systems Thinking to Explore the Phenomenon of Interest Identifies the circular nature

of complex cause and effect relationships. A Systems Thinker sees the

■ ■

■

interdependencies in a system and

115

How do parts affect one another? Where does circular causality/ feedback emerge? Is one feedback loop more influential over time than another? If yes. how?

uncovers circular causal connections, Considers how mental models affect

■

How are the current mental models

current reality and the future. A Systems Thinker is aware of how

hindering our efforts to achieve

beliefs and attitudes influence the way

desired results?

a system behaves.

(attitudes, beliefs) advancing or ■

How am I helping others see the influence that mental models have on

■

our decision making? How could my own mental models be barriers to what I am trying to achieve?

Considers an issue fully and resists the urge to come to a quick

■

conclusion.

■

A Systems Thinker takes the necessary time to understand the

dynamics of a system before taking

■

immediately? How can I help others to be patient while living with unresolved issues?

I ■ Where might a small change have a long-lasting desired effect?

■

How can we use what we know

■

about the system to identify possible leverage action? Are there other small changes that we have not yet considered that could bring us desirable results?

desirable results.

Recognizes that a system's structure

How can we manage the tension that exists when issues are not resolved

action.

Uses understanding of system structure to identify possible leverage actions. A Systems Thinker uses system understanding to determine what small actions will most likely produce

How much time do we need to allow for consideration of this issue?

generates its behavior.

■ ■

A Systems Thinker focuses on system structure and avoids blaming when things go wrong.

■

How do parts affect one another? How does the organization and interaction of the parts create the behavior that emerges? When things go wrong, how can 1 focus on internal causes rather than dwell on external blame?

Considers short-term, long-term, and unintended consequences of

■

consequences of the proposed action

actions.

A Systems Thinker looks ahead and anticipates not only the immediate

and what trade-offs should we consider?

■

results of action but also the effects down the road.

What are the unintended

■

What are possible long- and short-term consequences of the proposed actions? Are we willing to accept short-term pain for long-term goals? [continues]

116

Chapter 5 The Phenomenon of Interest

Table 5-1 Habits of a Systems Thinker Checks results and changes actions if needed: successive approximation. A Systems Thinker intentionally gathers information to assess

[continued]

What indicators will we expect to see as we look for progress? Have we scheduled time to pause and assess the effects of our current plan and take necessary action? When considering changes, are we accessing other systems thinking

progress before changing actions.

habits?

Surfaces and tests assumptions. A System Thinker actively tests theories and surfaces assumptions,

How do my past experiences influence the development of my theories and assumptions? How well does my theory or model

perhaps with others, in order to

improve performance.

i

match or differ from other views of

the system? When considering a possible action, do I and those I work with ask "What

if questions?

Recognizes the impact of time delays j ■ How can we identify the role of time when exploring cause and effect relationships. A Systems Thinker understands that often cause and effect are not closely related in time.

;

I" > i ■

delays in the effects we expect to see? If we make a change to the system, how long before we anticipate seeing the results that we desire?

What will be happening within the system during the time delay that could affect the results we desire?

Pays attention to accumulations and their rates of change.

■

What elements in a system can I see. feel, count, or measure as amounts

that change over time?

A Systems Thinker clearly identifies elements of the system that accumulate and change over time

■

At what rate do these accumulations

of measurable rates.

■

change? How does an accumulation impact other elements in a system?

■

How does one accumulation affect

the rate of change of another? Makes meaningful connections within and between systems.

■

A Systems Thinker sees how concepts, I facts, and ideas link together, which can lead to new learning, discoveries, ■ and innovations.

I

What are the relationships among the parts of the system and how do they affect the behavior of the system? How can recognizing the many aspects of a system create a better

understanding of the system as a

whole?

!■

How does understanding of one system transfer to understanding of another system?

Data from Water s Center for Systems Thinking (2022). https://waterscenterst.org/

Utilizing Systems Thinking to Explore the Phenomenon of Interest

Nursing and Allied Health Literature (CINAHL) database. Reviewing published reports could help the DNP student identify topics that need further exploration or studies that could be replicated on a smaller scale (to validate find

ings or increase generalizability). Scanning the table of contents of professional journals or even a professional organization’s website may help the student identify topics of con cern relevant to nursing. By way of example, a website to peruse regarding pertinent topics is the Doctors of Nursing Practice (https://www. doctorsofnursingpractice.org/doctoral-project -repository/), an online community of DNP grad uates and DNP students that highlights practice innovation and professional growth. At this beginning stage of discernment, a question the student should ask is. What is inter esting to me? A student should consider not just areas of interest but include areas of passion that will take the student through the journey and energize them to complete the process. Another important understanding for the student is that doctoral study is transforming and takes time. The initial topics of interest will most likely mot-ph as the student is exposed to new concepts in their educational program. The student will view the phenomenon through many new lenses, which will change the appearance of the original idea. This is a normal part of the process. The student will reflect continuously on the phenomenon, and it will gradually evolve into the DNP project. Examples of DNP phenomena of interest are provided in Table 5-2.

117

As the student

is exposed to

problenns and needs from a

local context, the student

should consider

phenomena that are contributing to the current outcomes the

organization is experiencing.

Often, looking at the issues from the lens of

phenomena can

be a driving force for innovation.

Table 5-2 DNP Phenomenon Topics Examples of DNP Phenomena of interest

■ ■ ■ ■ ■

Social determinants in chronic disease management Access and early integration of palliative care Retention of a millennial nursing workforce Impact of COVID-19 on practice Shared decision making and treatment adherence

■

Evaluation of unit-based care teams

■

Provider acceptance of patient portals

Data from Vanderbilt University School of Nursing. (2021). 2021 Doctor of timing Practice ScholatlyPwjects. Retrieved from https://nursing.vanderbilt.edu/dnp/pdf/2021Jnp_booklet-web.pdf

118

Chapters The Phenomenon of Interest

Once a broad category or area of interest is identified, the next step is to drill dovm to a more specific focus. This is crucial. Areas of interest that that are too are too broad or vague may become unmanage able, causing frustration and wasted time. Nar broad or vague rowing the focus gives the student the opportunity may become to demonstrate a comprehensive understanding of the topic. Remember, the DNP student must unmanageable, be able to successfully complete the project; an incomplete project does not inform nursing prac causing tice, and it does not equate to a valid program frustration and deliverable, which is required for graduation! To effectively narrow the focus, it is help wasted time. ful to start by reviewing what is already known about the topic and, conversely, what is not known about the topic. For example, perhaps the DNP student has a good under standing of the healthcare needs of the immigrant population, but now the student wants to focus on health promotion activities used by recent immigrants. This topic could be further narrowed to health promotion strategies used by iMtino women who emigrated to the United States from Latin America. One method used to narrow a topic is to ask the following questions: Who, what, where, and when? \Wio is the population of interest? What is it about this population that is interesting? Where is the population found? When did the obser\’ation occur? Is it a current or historical observ'ation or related to a specific period of life? As the subject matter moves from a broad category to a more focused topic, multiple potential elements of interest will begin to emerge. One word of caution is needed regarding narrowing the project focus: Care should be taken to prevent the focus of the project from being narrowed too much. If the topic is narrowed to very specific criteria, there is a real irsk that there will be no (or very little) information available in the literature to inform the project.

Areas of interest

^ Identification of a Problem or Concern Now that a topic has been identified, it is time to think about why this topic is important or what is it about this topic that is a concern. Is there a need to change nursing practice to improve patient outcomes in an organization or for a specific population? Is there an unmet societal need that may benefit from a policy initia tive? Does this concern occur frequently enough to warrant further exploration? What does the literature reveal about this topic? When reviewing the literature at this point in the project development process, the goal is really only to browse the literature in order to gain a general understand ing of the topic, determine how much work has been done, and determine if this is indeed something worth exploring further. If one determines that the topic is interesting, it is time to take it one step further— to begin to think about how to address this or if anything can be done about it. Finally, remember to consider the resources that will be needed to investigate this phenomenon. Reviewing the idea with an advisor will help the student identify potential bar riers and help the student determine the feasibility of implementing the project.

Using Nursing Theory to Explore a Phenomenon

119

important?

is it within the realm of

nursing to

Phenomenon

How frequently

address and is it a feasible

of interest

does it occur?

project?

What is

revealed about

this topic in the literature?

Figure 5-1 Process used to identify the phenomenon of interest

Remember, if the student is able to clearly articulate the value of the topic, imple menting the project is feasible, and there are nursing strategies that could be explored to address the concern, the topic is worth further investigation (see Figure 5*1).

^ Using Nursing Theory to Explore a Phenomenon Theory provides an orderly way to view phenomena. Nursing theory was initially developed to guide practice through the clarification of the nursing domain. The ory provided a way for nurses to convey professional convictions and gave nurses a means of systematic thinking about nursing practice (McEwen & Wills, 2019). Nursing theory is made up of concepts (words or phrases used to describe the concept) and propositions (statements that describe the relationship among the concepts) that help to explain a phenomenon of interest Oensen, 2015). Sometimes the term construct is also included in the description of a theory. A construct is used to describe something that is not directly or indirectly observed, such as social support (Schmidt & Brown, 2015). Theory can be classified based on scope/level of abstractness or type/purpose, as depicted in Figure 5-2. Level of abstractness refers to the complexity of the theory and the speci ficity or concreteness of the concepts and proposition (McEwen & Wills, 2019).

120

Chapter 5 The Phenomenon of Interest

Metalheory

Most abstract: explains the discipline of nursing

Grand theory

Middle-range theory

Microtheory

Least abstract and more

concrete; guides specific nursing practice

Figure 5-2 Levels of abstraction in nursing theory Oau from HcE«i«n. M. & Wills, E. H. (20191. Iheoieial 6sss la mmg ISth it.]. PMladelpliia, PA Wolteis Kluwt Neain/l

Williams & Wilkins

For example, grand theories are most abstract because they are used to explain the discipline of nursing and include very broadly defined to guide nursing concepts. The concept of liccikli, for example, practice, and is broad, with potentially broad interpretation. Nursing recognizes that the concept of health it provides encompasses more than simply the absence of disease. Health is a dynamic process that an orderly changes over time and can vary based on the in way to view dividual’s circumstances, experiences, and ex posures to internal and external environments. phenomena. Because this concept is complex and broad in scope, it is not easily tested. A few examples of grand theories include Dorothea Orem’s selfcare deficit theory. Rosemarie Parse’s theory of human becoming, and Imogene King’s open system theory. These theories provide a philosophical umbrella under which nursing practice functions. Many of these theories were developed in the last century and serve to create paradigms that support nursing practice. Grand theories are often the theories learned at the bachelor’s level of nursing. Unfortunately, the abstractness of the grand theory is often difficult for the novice nurse to integrate intentionally within their practice. For some nurses, the discon nect between theory and practice may start here and continue even as nurses ad vance in their clinical experience. Beginning DNP students often comment that they are unsure about the usefulness of theory to practice. If grand theories were pre sented as philosophies to novice nurses, perhaps the understanding of how practice is grounded would become clearer. Grand theories have been very important to

Theory is used

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121

nursing’s knowledge development and will continue to form a base on which theo ries specific to practice can build. The next level of abstraction in theory classification includes middle-range the ories. As the name implies, these theories are found in the middle of the ladder of abstraction (between abstract and concrete) and are more limited in scope than grand theories. As a result, middle-range theories tend to be more generalizable to nursing practice and can be tested. The focus for middle-range theories is on understanding nursing-related phenomena, so they are very useful for the scholarpractitioner. Some examples of middle-range theories include Nola J. Pender’s health promotion model, Merle Mishel’s uncertainty in illness theory, and E. Lenz and L. Pugh’s theory of unpleasant symptoms. The final level of abstraction includes practice theories. These theories are used to guide specific areas of practice; therefore, they are ver>' concrete and narrow in scope, and they include concepts that are measurable and easily tested (McEwen Wills, 2019). “Situation-specific theory” is another term that highlights practice theory, which focuses on the context in which the theory is being used. This type of theory, as the name implies, is specific to the situation and encompasses the partic ular needs of a unique group of patients. An example of a situation-specific theory is Ramona Mercer’s conceptualization of maternal role attainment/becoming a mother. Because situation-specific theory is within a local context and supports the use of evidence-based research that is appropriate to the situation at hand, DNP students find this appealing in practice. There is a fluid relationship among theory, research, and practice that is im portant to understand. Each informs and impacts the other (see Figure 5-3). The ory is validated through research, which can lead to further theory development. Both theoiy' and research are used to inform practice. Similarly, information gleaned through iheor>’ application in practice can inform theor)' development and/ or continued research. The symbiotic relationship among theory, research, and prac tice is important to recognize because of the potential opportunities for further study that can emerge when using theory to explore a phenomenon. This type of explo ration is valuable to nursing because of the potential to add to nursing knowledge. For example, complex patient care and social issues can be identified and sub sequently addressed using theory. From the perspective of a scholarly project, the DNP student can use theory to recognize the antecedents to health-related events that negatively impact a population (e.g., those events that lead to colon cancer in

>

'

Research

* Evaluate External

analysis

I environment I influences I ● Identify I potential

Opportunities

\

Threats

I opportunities

y and obstacles.

Figure6-1 An example of a SWOT analysis chart

One very important first step in performing a needs assessment is to create an assessment plan. To begin the process, have a clear objective in mind. As men tioned, think about what needs to be determined. The answer to this question es tablishes the direction the assessment will take and the questions that need to be asked to obtain the pertinent information. Finally, it also helps narrow the target audience. The next step involves identifying who would be best prepared to answer the assessment questions. Is it an individual or a group of individuals? If several individuals need to provide input, how will those individuals be chosen? Choos ing the appropriate indhiduals is important because a representative sample of the population is necessar)’ to ensure that the data captured are valid. A more detailed discussion related to identifying key stakeholders follows this section. Finally, once the DNP student identifies who is best equipped to answer the assessment questions, a decision will need to be made regarding how the data will be collected, such as via interviews, focus groups, or surveys, and how the results will be evaluated.

Interviews can be conducted in person, over the telephone, or through an inter net resource, such as Zoom. The advantages of interviews are that (1) the response rates tend to be higher compared to surveys, (2) respondents have an opportunity to ask questions to gain clarity on a question that they may have otherwise left blank, and (3) additional information is gained by observing the respondent, which can help in interpreting responses (Polit & Beck, 2021). Regardless of the technique used, the student will want to have a structured set of questions prepared that may include both closed- and/or open-ended questions. The key is to carefully construct the questions so that they are clear to the respondent; are sensitive to the psychological state of the respondent; and, when using questionnaires or surveys, are the appropri ate grade level and are presented in a meaningful order that encourages cooperation (Polit & Beck, 2021). Developing appropriate questions can be a labor-intensive pro cess. Therefore, the DNP student should allow time in the project schedule for survey development and testing to assure the best outcomes are achieved.

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A focus group or community forum serves the same purpose as an individual interview, except it is conducted with a small group of 5 to 10 people. When se lecting individuals to participate in the focus group, care should be taken to attract a diverse population with a broad view of the phenomenon of interest. The DNP student can choose to send an invitation to potential participants or may choose to invite participants in person; however, the student should also send a reminder prior to the event with the date, time, and location identified. During the focus group, the DNP student should guide or facilitate the discussion using the structured questions. It may be useful to solicit additional help to conduct the focus group in order to cap ture the responses from the participants and/or assist in facilitating the discussion. Surveys are used to gain quantitative data that are primarily closed ended, such as yesor-no answers, but may include a few openThe process ended questions to add clarity. As mentioned,

of conducting a needs assessment

is fairly

straightforward. First, determine what information

the DNP student should allocate sufficient

time for survey development and testing in the project plan. The advantages of using a survey format are that it provides anonymity for the respondent and can easily be dispersed via the postal service or electronically via email. An other advantage is that respondents can then answer the survey at their convenience; but the downside is the response rates tend to be low. Once the information is obtained, the data

who the best

are analyzed. The data analysis method used will be dependent on the types of questions that are asked, such as quantitative (closed-ended) or qualitative (open-ended) questions. DNP stu

person(s) Is to

determine the best method to use for data anal

is needed,

answer the

question(s), and how the data will be

gathered; then outline the data

analysis plan and determine how

you will share

the findings with the organization.

dents will want to consult with their advisors to

ysis. See Chapter 7, Aligning Design, Method, and Evaluation with the Clinical Question, for more detailed information on this topic. Once complete, the results of the analysis should be shared with the organization. Communicating the assessment results can be accomplished us ing a formal (presentation or white paper) or informal process (verbal communication), de pending on the student’s relationship with the organization and the preference of the organi zation’s key stakeholders (see Chapter 13, From Data to Knowledge: Disseminating the Results). Keep in mind that when the purpose of the assessment is simply to verify that the phenom enon of interest is worth exploring or to iden tify the perceived state of the phenomenon, a DNP scholar-created questionnaire will suffice. As mentioned, this type of assessment could be accomplished fairly quickly by conducting

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a small focus group or communiiy forum or by surveying a convenience sample of the target population. When the results of the assessment are the central purpose for the project, measures need to be taken to ensure that a valid and reliable tool is used to conduct the assessment and that appropriate statistical methodsare used to analyze the data. This type of assessment takes a considerable amount of time and resources to complete and may require institutional review board (IRB) approval (see Chapter 9, The Proposal). However, a comprehensive assessment, such as a community or organizational needs assessment, provides valuable data that describe the current state of the phenomenon of interest, how the proposed project could address the findings, knowledge of approaches that could be most effective, as well as the potential project impact (McCawley, 2009).

Developing the Problem Statement The definition of a problem, according to Merriam-Webster, is “a question raised for inquiry, consideration or solution . . . [orl an intricate unsettled question” (“Prob lem.” 2022, para. 1). Both definitions are fairly straightforwar d; they indicate that a question is involved. However, defining a problem statement has not been quite as forthcoming. In fact, it has not been consistently described in the literature. Some consider the purpose of the project and problem statement as one and the same, whereas others lump together the objective, hypothesis, or summary of the content as the problem statement (Hemon 6r Schwartz, 2007). In an attempt to bridge this gap, for the purposes of this discussion and in the context of the DNP project, a problem statement will encompass a phenomenon in need of inquiry that is examined in order to develop a potential sofuhon. The problem statement is an introduction to the intent of the project. It should include enough information for the reader to gain an understanding of the issues surrounding the phenomenon of interest and the reason the project was selected as an area of focus. The problem statement provides the background to the problem as identified through the organizational assessment and justification for investigating the phenomenon of interest, as demonstrated through the literature review. Hemon and

Schwartz (2007) indicated

that a problem statement should include four components: 1.

Lead-in

2. Declaration of originality 3. Explanation 4. Indication of the central focus (p. 308). Using this definition as a guide to formulate a problem statement, the lead-in should include information that helps to set the stage; it is the first introduction to the problem. To illustrate this concept, consider the following lead-in; Successful diabetes management in the primaty care setting is a difficult, cosily, and labor-intensive process that requires proven skills in lifestyle coun seling (Moran et al., 2011). The information

The problem statement

encompasses a

phenomenon in need of

inquiry that is examined in

order to develop a potential solution.

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Chapter 6 Validating the Problem

Articulating

the problenn statennent...

The goal is to identify an issue, describe

it clearly but succinctly, and

adequately articulate why it

is important that the problem be addressed.

provided in this lead-in introduces the audi ence to the phenomenon of interest: diabetes management in primary care. It also highlights the area of concern: multiple factors that make it difficult to provide successful diabetes man agement in this care setting. The lead-in statement is then followed by the declaration of originality, supported by in formation from the literature review. The intent

here is to substantiate the need for the inquiry

by identifying the void in knowledge or the gap between the current state of the phenome non and the desired state. Continuing with the previous case example, consider the following: Although many studies have proved the value of addressing the needs of people with diabetes in this care setting, there is a paucity of studies that look at clinically effective interventions or strategies in rela tion to cost (Moran et al., 2011). In this case, the

need for the investigation or declaration of orig inality is substantiated by the paucity, or scarcity, of studies available that look at interventions or

strategies in relation to cost in this care setting. Next, the explanation of the phenomenon should highlight the value of the project and/ or the benefits of investigating the phenomenon. The explanation of the purpose in the example centered on the need to improve diabetes clinical and cost outcomes in the primary care setting. Finally, the indication of central focus should tie all the

previously mentioned components together to form a complete package, which is accomplished by articulating and/or defining what the project will accomplish. To clearly communicate the central focus, consider beginning this concluding state ment by simply proclaiming the purpose of the project or study: “The purpose of this study was to implement and evaluate a care delivery model integrating the Reg istered Nurse-Certified Diabetes Educator in the Patient Centered Medical Home

to assist in achieving positive clinical and cost outcomes in diabetes care” (Moran et al.,2011,p. 783). Another approach that may be used to facilitate writing the problem statement is to begin by defining who, what, where, when, and why. In other words, who the problem involves, what the issue is, when and where the problem is occurring, and why it is important to investigate. It is important to clearly define who is affected by the problem; this infor mation will be included in the lead-in. Using the previous example, the specific group identified in the problem statement is primary care providers and their patients. The what and the where in this statement involve providing successful diabetes management for patients with diabetes within the primary care setting. This defines the boundaries of the problem. One can conclude that providing dia betes management for patients with diabetes in this specific care setting is difficult

and possibly not effective. Discussing the impact of the issue or why this problem is important would also be appropriate here. For example, one could link the

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153

phenomenon of interest with patient outcomes. In this case, including information in the literature regarding less-than-optimal overall glucose control in this care setting could be considered. This introduces the reader to the potential negative impact on the stakeholders, that is, patients with diabetes and their healthcare providers. One could even link the less-than-optimal clinical outcomes in this setting to the current cost of care of patients with diabetes. Regardless of the ap proach used, the goal is to identify an issue, describe it clearly but succinctly, and adequately articulate why it is important that the problem be addressed. Remem

ber, a well-written problem statement will engage the audience and leave them with a desire to read more.

Identifying Key Stakeholders Once the problem statement for the potential project is developed, it is critical to reach out to stakeholders. Identified through the organizational assessment, stake holders are those individuals or groups who touch the project in some way or have an interest in the project outcome. These indhiduals can affect or could be affected by the outcome of the project. The student should consider those individuals or groups who are invested from the micro and macro level because they can pro vide informed and unique perspectives on issues that may have otherwise been overlooked.

Examples of stakeholders may include ser vice users, mentors, colleagues, organizational leaders, and community organizations. In the diabetes management example, the key stake holders could include patients, families, health care providers, healthcare staff, healthcare institutions, payers, and even the community. Think about stakeholders who could benefit

from the project, those who may have to make changes to current processes as a result of the project, and those who have something to lose.

Stakeholders... are those

individuals or

groups who touch the

project in some

Determining the type of influence a stakeholder may have on the project’s success is critical.

way or have an

Positive influence stakeholders may be willing to champion the project or support the project

interest In the

in some way, whereas negative influence stake holders may be a restraining force.

project outcome.

Once all stakeholders are identified, con sider which stakeholders are vital to the success

of the project. These are the key stakeholders. The task at hand now is to determine what can be done to get stakeholder support or to reduce stakeholderresistance. This may include identifying the potential benefits of the project for certain stake holders, such as outlining the project costs and benefits and developing strategies to minimize any perceived negative impact by other stakeholders. This process may seem cumbersome and time-consuming, but it is a valuable use of time because it helps to garner support for the project and minimize poten tial roadblocks. Consider Pareto’s principle, or the 80-20 rule. It is very applica ble to planning the DNP project: 20% of the work consumes 80% of the needed

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Chapter 6 Validating the Problem

lime. Furthermore, identifying and engaging key stakeholders is a good use of time because stakeholders can provide objective guidance on project implementation, identify options and/or solutions to address identified issues, provide input in areas in which there is an information gap, or help identify specific resources that are available to support the project.

Creation of Innovation and Conceptualizing the Project Plan As the student continues to engage in the DNP Project process, they will develop an appreciation of doctoral work, which is not linear, but rather more circular or spiral in nature. Meaning, the student should expect that the cognitive work that occurs as they explore an area of interest will be reworked through the process of developing the DNP project- For example, the student’s phenomenon of interest undeniably continues to develop as they engage in the literature review and organizational as sessment. The phenomenon will continue to be contemplated, the proposal will develop, literature will continue to be reviewed, and the methodology for the design will evolve. This deeper understanding of the topic leads to new ideas and innova tions that could improve care or make a contribution to nursing. If one considers the DNP project development process holistically, it is very similar to the nursing process—assess, diagnose/determine the problem, plan how to manage the problem and measure the outcomes, implement the plan, then evalu ate (see Figure 6-2). All DNP projects should consider a planning, implementation, and evaluation phase (American Association of Colleges of Nursing [AACN], 2015).

Assessment

Evaluation

implementation

Figure 6-2 Nursing process

Diagnosis

Outcomes/planning

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155

The DNP student will select a phenomenon The DNP project of interest, identify a problem or opportunity for improvement, develop a clinical question, is the ultimate develop a project plan, implement the plan, monitor the implementation to ensure that the nursing practice process is working as intended, and then eval activity because uate the outcome to determine if the goal has been met. Indeed, the DNP project is the ulti It utilizes the mate nursing practice activity because it utilizes the nursing process at the doctoral level. nursing process Within each phase of the project plan de at the doctoral velopment process, the DNP student is able to use more concepts and expand their thinking level. to incorporate health systems and populations of patients. As previously outlined, in the as sessment phase, the DNP student explored the information at hand to ensure the goals and outcomes of the project are aligned with the organization’s strategic plan. Factors included in this phase are the neces sity that goals and outcomes of the project are aligned with the organization’s strate gic plan, development of project specifications, financial analysis (e.g., cost-benefit analysis), and the identification of the team that will be able to move the project for ward (Waxman, 2018). An assessment was critical and helped define the issues that will now guide decisions in the project planning phase. As mentioned, it is in this phase that the commitment of the organization to the project should be clarified. The diagnosis phase of the nursing process translates to the development of a problem statement based on all the information that was pulled together when the student identified the issues surrounding the problem. Here is where fram ing the problem occurs. The DNP student choses the appropriate data that high light the specific issues surrounding the problem and presents this information in a problem statement. In the next phase, the planning phase, the student 'will need to include the determination of potential alternative solutions 'with pros and cons. The student must describe how each solution will address the identified need and consider the

feasibility and impact potential of each solution. Creative thinking and innovative ideas are a part of this phase. For example, a cost-benefit analysis can be an effec tive tool to present the financial aspects of the project. In this analysis, the project team (1) identifies the costs of the project, (2) identifies the benefits, and (3) com pares costs and benefits. All potential costs of the project should be brainstormed to determine a project budget, which includes one-time costs such as equipment and training, as well as recurring costs such as payroll. Nonmonetary costs should also be considered and given a monetary value, such as the in-kind donation of the student’s time as the project manager or material items such as use of a personal computer or software applications. This may also include issues related to produc tivity, as well as risks to the project outcomes. Including the costs of not doing the project may be effective as well. In determining the benefits, accurate projection of revenue can be challenging. It is best to forecast using conservative figures. Dollar amounts on the intangible benefits need to be incorporated as well. Examples of benefits include direct profits, increased production, and increased employee/patient satisfaction.

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Chapter 6 Validating the Problem

Identify the optimal solutions based on analysis of the costs and benefits. There are many sample tools available to develop the cost-benefit analysis (Smartsheet, n.d.). Additional information on Cost-benefit Analysis Tools can also be found at the end of this chapter under the “Tools” section. As the team compares the costs and benefits, consider the time it will take for the benefits to repay the costs. The project plan is developed based on the identified optimal solution. If the project involves large sums of money, the team will want to consider net present value (NPV) and/or internal rate of return (IRR) to more accurately examine the financial decision (Mind Tools Limited, n.d.). The DNP student working with financial ex perts within the organization collaboratively prepares the assessment. In this way, the DNP student brings the understanding of the clinical environment and con sideration of aspects that will influence costs, while the financial experts can work with appropriate tools to determine calculations to support the project. The Sample Budget template provided at the end of this chapter (see “Tools”), may be a useful worksheet for the DNP student to outline identified program expenses and revenue. Exemplar 6-1 from Dr. Elizabeth Pohl describes how financial analysis can be used to make the business case for a program development project.

Exemplar 6-1 Sickle Cell Disease: Development of an Acute Pain Management Program in an Outpatient Hematology/Oncology Practice Elizabeth Pohl DNP, RN, AGNP-C

The title of my DNP scholarly project was Sickle Cell Disease: Development of

an Acute Pain Management Program in an Outpatient Hematology/Onc ology Practice. This project came about through collaboration with an organizational

partner who cares for adults with sickle cell disease (SCD) in the outpatient setting. The organizationwas consideringthe developmentof a SCD acute pain program, but needed guidance. First, they needed to determine if evidence-based guidelines for SCD acute pain management programs existed in the scientific literature. Second, they wanted to know if a SCD program would be feasible from a financial perspective in the outpatient setting. The methodology for the program development project was aided first by utilizing the McKinsey 7S Model in the organizational assessment (Waterman. Peters. & Philips, 1980). This model focuses on structure, systems, style, staff, skills, strategy, and superordinate goals that contribute to effective organizations. This framework helped me to identify weaknesses and strengths of the organization and how the organization was separate from, but strongly connected to, other community partners in the area who provided care in large acute care centers. A review of the current scientific literature guided recommendations for the program development project and these findings could also be tied back to the 7S Model. For example, results of the literature review showed that all studies employed at least a part-time social worker in the acute pain management programs; however, social work staff were not present in the benign hematology office of the project setting. Systems and structure were also important considerations as most acute pain programs in the literature were tied to large medical centers with quick access to emergency care should patients become medically unstable. The literature review also demonstrated how these programs were able to reduce emergency department visits and inpatient days by quickly and thoroughly treating acute SCD pain at its onset in the outpatient setting.

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157

The framework for this program development project was the Consolidated Framework for Implementation Research (CFIR) (Damschroder et al.,

2009). There are multiple components of this implementation model but understanding the “inner setting" and "outer setting" were the most important concepts to consider for this project. The "inner setting" includes the organization’s culture, networks, and affiliations. The “outer setting" includes the economic and social context in which the organization resides. Utilizing CFIR and applying it to the findings of the organizational assessment became crucial as the business plan for the acute SCO pain management program was developed (Damschroder et al.. 2009). The interaction between the inner and outer setting needed to be considered to assure project success. The business plan for this program development initiative, which included a financial analysis, was the most crucial component for future program implementation and long-term sustainability. The organization provided reimbursement information for specific billing codes across their four major payers and their current payer mix was determined through chart review and organizational reports. The business case was created based on three potential scenarios to estimate potential profits and expenses to the outpatient clinic:

1. a very modest increase in acute pain visits to the hematology clinic (leading to the same decrease in emergency department [ED] visits as pain was relieved in the outpatient clinic). 2. a moderate increase in pain visits, and 3. an aggressive increase in pain visits.

The decrease in ED visits assigned to the aggressive case were the values most often cited in the literature when acute pain management programs were instituted in the outpatient setting. Many of the outpatient clinics studied had access to code teams from the hospital or were very near to an ED should a patient become unstable. Our hematology clinic was not. and it was at least a 15-minute drive to the nearest ED. Therefore, it was posited that pain treatment in the hematology clinic should be more conservative and some patients may still need to be referred to the ED,

To create the business case, costs were assigned to each ED visit and inpatient days as indicated in recent literature. The hematology clinic also provided their reimbursement rates for common ICD-10 codes used for acute pain management visits for their three main insurance payers. Across all three business case scenarios, the increase in patient visits to the hematology clinic did not generate enough projected revenue to offset the operational costs of the acute pain management program. This is the micro view. However, when the business case for the program was analyzed from a macro or systems view, the implementation of the program would lead to a large cost savings for the insurance payers and acute care providers in the community, which was accounted for in the Cost-Savings Analysis. The Consolidated Statement of Operations showed a net loss for the organization to run the program alone, but the Business Plan with Cost-Savings Analysis showed significant cost savings to the community partners by treating pain in the outpatient setting and preventing emergency department visits and hospitalization. The proposed Business Plan with Cost-Savings Analysis demonstrated the need for this organization to create financial partnerships with payers to sustain the acute pain management program. Although the Business Plan with Cost-Savings Analysis was a crucial component of the deliverables of the scholarly project, other supporting

158

Chapter 6 Validating the Problenn

deliverables were needed to create tailored program development that would be sustainable for the organization. There were three major themes of the deliverables: quality monitoring, fiscal responsibility, and quality care delivery. The deliverables included are outlined in Table 6-2.

The project met the required academic rigor of a DNP project as it integrated implementation frameworks, organizational assessment frameworks, and was strongly rooted in the biopsychosocial model to strategically meet a problem for the organization. For the organizational stakeholders, the project's goals were met as they were given access to the Microsoft Word documents or Excel workbooks populated with the data outlined in the deliverable. At this time, the organization plans to implant this

program development initiative; however, due to dynamic conditions within the organization an implementation date has not yet been determined. References Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R.. Alexander, J. A., & Lowery.

J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science: IS, 4/50). https://doi.org/10.1186/1748- 5908-4-50 Waterman, R. H.. Peters. T. J.. & Phillips. J. R. (1980). Structure is not organization. Business Horizons. 23(3), 14-26. https://d0i.0rg/l 0.1016/0007-6813(80)90027-0

Table 6-2 Program Development Toolkit Components Guiding Component

Toolkit Component

Quality Monitoring

■ ■ ■

Billing and coding worksheet. Data collection and analysis tool populated with pre-implementation data. Sustainability plan and implementation recommendations.

Quality Care Delivery

■ ■

Organizational policy. Evidence-based care flow for triage and analgesia administration.

Fiscal Responsibility

■

Handoff tool tailored for acute SCD pain.

■

Patient and family education.

■

Business plan, pro forma budget, and cost-savings analysis.

note: Toolkit components support the development of a sickle cell disease acute pain management program in an outpatient hematology practice.

Part of the planning phase will also include planning for implementation— developing the project plan and determining outcome measures and metrics for the project. Well-defined outcomes and metrics are developed prior to implemen tation. When outcomes are specific, meaningful, and measurable, expectations of the project are described.

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159

Evaluation incorporates the measurement of all metrics/identifie d outcomes.

Successful outcomes deliver a recognized and successful project (see Chapter 12, Evaluating the DNP Project, for detailed information on methods used to evaluate the project). Table6-3 identifies the various components in each phase.

Table 6-3 Developing Project Innovations Phase

Tools

Assessment

SWOT analysis Force field analysis Community analysis Needs assessment

Organizational data Diagnosis

Framing the problem Problem statement

Planning

Potential alternative solutions

Cost-benefit comparisons Optimal solution identified

Plan for implementation (project plan) Metric/outcome development Implementation

Project plan in process

Evaluation

Metrics

Satisfaction [patient/staff/providerl Clinical outcomes Cost outcomes

Other measures

To help the student envision a project plan, a project plan template in an anno tated format is provided in the “Tools” section at the end of this chapter. The student should keep in mind that this is just one of many project plan formats available. It is best to check with the DNP project team or project faculty mentor to determine the format used by the university or college prior to beginning the planning process.

Determining Project Coals

Project goals

A goal is “the end toward which effort is di rected” (“Goal,” 2022, para.l). In the case of the DNP project, it is what the student strives to achieve. Project goals describe what the stu dent intends on delivering within the context of the project. Generally, a project’s overall goal is relatively high level, though it should provide enough information to define when the project is complete. The project goal is the underpinning for decision making.

describe what

the student

intends on

delivering within the context of

the project.

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Chapter 6 Validating the Problem

When considering poiemial project goals, think visionary! Perhaps the goal is to achieve a specific milestone, to test a hypothesis, to share insights or discoveries learned through the process, or to improve a process or outcome within an organi zation. For example, perhaps after conducting an organizational needs assessment the student identifies that there has been a steady increase in the number of medica tion administration errors occurring in the medical intensive care unit (MICU) over the past 9 months. After sharing this information with the organization, a decision is made to investigate the cause, determine the best course of action, and finally, implement a quality improvement project with the aim of reducing the medication error rate in the MICU, The possibilities are limited only by imagination and avail able resources, including time. To this last point, it is crucial that the chosen project goal be achievable within the prescribed DNP program lime frame; otherwise, there is a very real risk of not meeting program deadlines, which could result in failure to progress.

Once the goal has been identified, the next step is to define it. When artic ulating the goal of the project, clarity is the key. It is vital that the goal be clearly identified to ensure that everyone knows what event will mark the completion of the project. From here, the student can work backward to identify the in terim goals (or objectives) that must be met in order to achieve the final desired outcome.

Defining the Project Scope The project scope includes all the work that needs to be accomplished in order to fulfill the project goals. It helps to define when the project begins and when the proj ect ends. To define the project scope, the student will need to consider the bound aries of the project. This includes identifying what will and will not be included (features and functions), along with identifying the deliverables. Defining the project scope early on in the process helps the student during the implementation process. It is much easier to determine what is relevant to the project and what is not when clear boundaries have been identified up front. In the medication administration error scenario, the scope is defined by unit (MICU) and only includes medication errors. In this case, the scope may also include all three shifts, and it may include parenteral and oral medications, etc. To this last point, it may be easier for the student to un derstand all the dimensions of the project if the various components are diagrammed or graphed; this gives a visual representation of the project scope. When defining the project scope, consider the following: What will make this project The project personally meaningful? Certainly, the ultimate goal of the DNP project is to provide a me scope includes

all the work that needs to be

accomplished in order to fulfill

the project goals.

dium for the student to demonstrate achieve

ment of the AACN (2021) Essenhais that focus

on advanced-level nursing education, which translates to an outcome that directly or indi rectly benefits society. This is of great signifi cance, and as such, what is and is not included

in the project should be determined by the student after assessing what is of most value. This process fosters personal investment in the

Developing the DNP Project

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outcome and makes the entire project more meaningful to the student. After all is said and done, the student owns the project and is responsible for achieving the deliverables.

Once the scope of the project is clear, the objectives of the project should be defined. This will help keep the project on track, clarify any assumptions, and avoid any unintended surprises. Objectives should describe what will be done (a measurable component) and when it will be completed. There may be a wide variety of types of objectives, depending on the type of DNP project. For exam ple, in the medication administration error scenario, the DNP student conducts a root cause analysis and determines that there is a system issue that is contributing to the increase in medication administration errors in the MICU. As a result of

these findings a plan is developed, based on best practice, to address the prob lem. An example objective for this quality improvement project could be; Amend the current medication administration policy and procedure to include safety checks and medication administration safe zones to decrease medication administration er rors within 3 months after the new policy has been implemented. An objective could include cost metrics, technical processes, or other measurable success criteria as indicated by the project. The key is to be as specific as possible. The student must accurately capture the conditions that are necessary to achieve the project’s overall goal. One final point: the student will want to carefully consider the DNP program deliverables in the project goals and objectives (see Chapter 13, From Data to Knowledge: Disseminating the Results, for more information on program deliverables).

Determining the Theory and Framework The next step in the process is to articulate the necessary features or functions that are required to meet the objectives. To begin, the student will need to outline the implementation process. Using a conceptual framework may be helpful in this phase of project development because it assists in identifying and categorizing the various components of the project. A conceptual framework is a “group of concepts that are broadly defined and systematically organized to provide a focus, a ratio nale, and a tool for the integration and interpretation of information” (“Conceptual framework,” 2018, para. 1). The Donabedian model is an example of a conceptual framework that focuses on three main categories: structure, process, and outcome (Donabedian, 1988). Using this framework, the student is able to identify all the concepts that affect the project structure (the setting in which the project will be im plemented and who will be involved in the project), the process (what will be done and how it will be delivered), and, finally, the outcome (what will be measured, reviewed, or assessed).

The Donabedian model is just one example of a conceptual framework; there are many to choose from. Vogel et al. (2018) describe how they used the health belief model (HBM) as a framework to guide a quality improvement project to im prove human papillomavirus (HPV) vaccination among young males. For example, the authors capitalized on the parents’/guardians’ desires to avoid adverse outcomes for their children by offering HPV education, which then increased their perceived seriousness of this condition. Since the likelihood of increased vaccine uptake was dependent on the parents’/guardians’ overall perceived benefits outweighing the perceived barriers, education proved to be helpful. In this example, each of

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the HBM core components was considered in relation to HPV vaccination uptake among males in their target population. In addition to a conceptual framework, the student will also need to consider a theoretical framework to help inform and/or guide the project. As indicated in Chapter 5, a theoretical framework is used to guide the student’s perspective by further defining the project variables, identifying the known relationships among variables, and providing a framework for examining outcomes. Theory helps to explain or predict the relationships around the phenomenon of interest. If this is the case, the student and the student advisor need to determine the framework(s)

that best capture the components of the student’s scholarly project. More detailed information regarding the implementation process is covered in Chapter 8, DNP Project Team: Preparing for Project Implementation.

Improvement Science Since many DNP projects are focused on improving processes and outcomes in practice, it is important to understand what is meant by improvement science or quality improvement and how implementation science may be used to impact these outcomes. The Health Resources and Services Administration (HRSA) (2011) de

fines quality improvement as a systematic and continuous process that leads to mea surable improvement in healthcare services and the health status of targeted groups. Further, because a health organization’s quality is linked to the organization’s service delivery approach or underlying systems of care, the principles of quality improve ment should focus on the systems/processes of care, the patients, the care team, and the use of data to drive change (p. 1). Using the prior discussion of Donabedian’s (1988) framework to address the medication errors in the MICU, the key components of the organization’s systems, processes, and outcomes of care can be depicted. For example, the organization’s system or structure would include resources (infrastructure, people, materials, tech nology), the process would include what is done and how it is done, and the outcome would include the results of the care provided (patient satisfaction, change in health behavior and health status). The organization’s resources and processes need to be evaluated together in order to improve the end result. While the structure and resources for an organization are generally easy to recognize, it may be difficult for some organizations to identify their processes because of the complex nature of health care. To better understand the processes used within an organization and the subsequent impact on outcomes, a process map can be used to diagram the events that lead to an outcome. A process map typically includes identifying and mapping the sequence of activities involved in a particular outcome (which includes identifying what is performed, who performs it, when it is performed, etc.). Following this process allows one to visualize op portunities for improvement. See “Tools” at the end of this chapter for an example of a Process Map. When evaluating outcomes, one measure of quality that is of particular im portance in health care is the degree to which the patient’s needs are met, such as access to care; culturally sensitive and equitable care; and patient safety. It should be no surprise that in order to meet the patient’s needs effectively and to continue to improve quality, it takes an interprofessional team. According to HRSA (2011), the healthcare team has the knowledge, skills, and experience to make needed and

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long-lasting improvements. It is because of the unique perspectives from each team member that creativity and innovation evolve. The DNP student engaged in this process vnW have an opportunity to demonstrate leadership competencies in facili tating the work of the interprofessional team. The importance of this role cannot be overstated, because behind every effective team is an equally effective leader who is able to organize and facilitate the work of the team. Finally, the team will need to use data to drive the change. This will include quantitative data (frequencies) for measurement of change but also qualitative data to provide context for the needed improvements (HRSA, 2011). Determining what is most important to measure can be difficult. For this reason, HRSA (2011) rec ommends beginning with standardized performance measures, which are derived from practice guidelines that are designed to measure systems of care (see Agency for Healthcare Research and Quality [AHRQ] Clinical Guidelines and Recommendations, www.ahrq.gov/professionals/clinicians-providers/guidelines-recom mendations/). Good performance measures should be relevant, measurable, accurate, and feasible. The data should be collected at established intervals and then analyzed to determine opportunities for change.

Implementation Science A developing interprofessional research field in health care is implementation science research, also known as dissemination science or health services research. The focus

of implementation science research is identifying and implementing best-practice approaches to health care in a variety of healthcare settings with an ultimate goal of improving outcomes. According to the Fogarty International Center (2018), imple mentation science is:

... the study of methods to promote the adoption and integration of evidence-based practices, interventions, and policies into routine health care and public health settings. Implementation research plays an import ant role in identifying barriers to, and enablers of, effective global health programming and policymaking, and leveraging that knowledge to develop evidence-based innovations in effective delivery approaches, (para. 1) There is an increasing need for this type of research in health care to improve outcomes. It is well-known that there is a gap that exists between research and practice, which has resulted in a delay in adopting evidence-based approaches that have been proved to positively impact healthcare outcomes. Implementation sci ence research holds promise for bridging this gap. This can be accomplished in a variety of ways, such as by using scientific methods to compare evidence-based interventions, develop new approaches to improve healthcare delivery, evaluate a population-based intervention, improve program quality and performance, or iden tify strategies that promote the integration of evidence into practice. An example of a model that addresses integration is Rogers’s diffusion of innovation theory. Rogers (2003) explains that diffusion, which is “the process by which an innovation is communicated through certain channels over time among the members of a social system” (p. 5), occurs when there are key characteristics present in an innovation. These include (1) relative advantage, which is the degree to which an innovation ap pears better than the alternatives (measured in terms of economics, social prestige.

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convenience, and satisfaction); (2) compatibility, which is the degree to which the innovation is seen as consistent with existing values, previous experiences, and needs of those who would adopt it; (3) complexity, which is the degree to which the innovation is seen as difficult to use or even understand; (4) trialability, which is

the degree to which an innovation could be experienced or experimented with on a limited basis; and (5) observability, which refers to how visible the results of the innovation are to those likely to adopt it (Rogers, 2003). However, because this field is still evolving, there is a need to recognize how

implementation science research differs from other forms of research. Scientific rigor must be balanced with the need to conduct research in real-world settings. It is important to keep in mind that implementation science research may not pro duce results with the same precision as other forms of research; however, that does not mean that implementation science research is not of high quality. Therefore, implementation science should include the elements of good science, such as data collection and analysis methods that are replicable and available for public review, propositions that are logical and lead to falsifiable hypotheses, and methods that are evaluated by subject matter experts (Quality Enhancement Research Initiative [QUERI], 2014a).

The DNP student embarking on a project focusing on implementation of ev idence into the clinical setting and/or evaluation of the implementation process should consider an implementation framework to help guide them. For example, the Iowa model of evidence-based practice to promote quality care is useful be cause it includes steps to accomplishing a change in practice (Titler et al., 2001). The model incorporates the patient, the provider, and the social system. Through a series of steps, the practitioner identifies either a problem-focused trigger or knowledge-focused trigger that indicates the need for change. Another example of a model that may be useful for implementing evidence into practice is the QUERI (Quality Enhancement Research Initiative) (2014b). This six-step model includes (1) selecting conditions based on patient populations that are at high risk of disease and/or disability; (2) identifying evidence-based guide lines and/or best practices; (3) measuring existing practice patterns and outcomes; (4) implementing improvement programs; (5) assessing feasibility, implementation, and impacts of the program on the patient, family, and system; and (6) evaluating the impact of the program on health-related quality of life. Finally, formative or process evaluation is a component of implementation sci ence that focuses on the process of implementation, rather than the outcomes of implementation. The information gleaned through formative evaluation also con tributes to the overall understanding of project outcomes. Through formative evalu ation, an understanding of the context (where the project is implemented) can help mitigate barriers to implementation and provide insight to factors that will assure sustainability. Data collection methodologies used in formative evaluation include both quantitative measures (e.g., a scale to assess readiness to change) and qualita tive measures (e.g., open-ended questions used to gain insight to project facilitators and barriers) (QUERI, 2014c).

These examples illustrate how DNP-prepared nurses as well as DNP students may use implementation science methods to explore a clinical concern and be in cluded as part of implementation science research teams, as the DNP competen cies (which are rooted in quality improvement) are in perfect alignment with the requirements for implementation science research.

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> Defining the Project Type The DNP project can lake many forms (see Box 6-2). The boundaries for the project are determined by the DNP program requirements. While all projects will exemplify some of the AACN Essentials for Advanced-Level Nursing Education, such as interpro fessional collaboration or use of data and informatics, they may not exemplify all of the Essentials.

Box 6-2 Examples of DNP Projects Quality improvement Translating evidence into practice Clinical or practice-based inquiry Healthcare delivery innovation Program development and evaluation Demonstration project Healthcare policy Generating new evidence or knowledge

Quality Improvement The definition of quality as it relates to health care is subjective; it differs based on who is defining it. For the patient, quality may include accurate, skillful, and compassionate care. Healthcare providers, on the other hand, may define quality as achievement of the desired health outcome, whereas healthcare payers (health insurance companies) are likely to include some aspect of cost effectiveness. Quality improvement projects in health care encompass those efforts that seek to improve services for the future. According to the Institute of Medicine (lOM), healthcare quality is defined as “the extent to which health services provided to individuals and patient populations improve desired health outcomes. The care should be based on the strongest clinical evidence and provided in a technically and culturally compe tent manner with good communication and shared decision making” (Peerpoint, 2012, para. 1). The lOM (2001) summary report Crossing the Quality Chasm outlines six aims for improvement that are built on the need for health care to be; 1. 2. 3.

4. 5.

6.

Safe: avoiding injuries to patients from the care that is intended to help them. Effective: providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit. Patient-centered: providing care that is respectful of and responsive to individ ual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions. Timely: reducing waits and sometimes harmful delays for both those who receive and those who give care. Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energyt Equitable: providing care that does not vary in quality because of personal char acteristics such as gender, ethnicity, geographic location, and socioeconomic status, (p. 3)

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Quality Improvement Focus As mentioned, healthcare quality improvement projects generally focus on analyz

ing elements of specific areas of performance in order to gain some measure of improvement. Given the current focus on healthcare quality by the National Acade mies of Sciences, Engineering, and Medicine, the DNP scholar is well positioned to influence healthcare quality at the micro level (reducing medical errors on a specific care delivery unit) and/or macro level (leading efforts to reduce infant morbidity and mortality at the state level).

Quality Improvement Methods Several different quality improvement methods have been used effectively in the in quality improvement projects are presented in Chapter 12, Evaluating the Doctor of Nursing Practice (DNP) Project.

healthcare arena. A few of the most common tools used

Evaluating the Doctor of Nursing Practice (DNP) Project The following are a few examples of the quality improvement methods used by DNP scholars:

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●

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FADE model: Focus (define the process that needs improvement). Analyze (collect the data and analyze). Develop (determine the plan of action). Execute (imple ment the plan), and Evaluate (measure the change and continue to monitor). Model for Improvement: A framework developed by Associates in Process Im provement (Langley et al., 2009) that is used by the Institute for Healthcare Improvement (IHI) to guide improvement work. The model includes three focus questions: 1. What are we trying to accomplish? 2. How will we know that a change is an improvement? 3. What changes can we make that will result in improvement? By asking these questions, the organization is actually setting aims, establish ing measures, and selecting changes. The changes are then tested using sev eral PDSA cycles (see below). After refining the change using the PDSA cycle, the change is then implemented on a broader scale and is eventually spread through other parts of the organization. Shewhart Cycle: Uses rapid cycles of improvement until an optimal process is reached. This model uses the PDSA cycle to test change—Plan (plan a change). Do (implement the plan). Study (analyze the results), and Act (take action based on the results).

●

Six Sigma: Focuses on identifying and eliminating defects in a process in or der to reduce variability and improve outcomes. This model uses the DMAIC strategy—Define (define the opportunity for improvement, the project goals, and the key stakeholders). Measure (determine what to measure and collect the data). Analyze (analyze the data to determine the root cause). Improve (im plement a solution and continue to collect data to evaluate the outcome), and Control (develop and initiate a monitoring plan).

Other Quality Improvement Considerations The goal of this chapter is to provide a broad overview of the types of DNP projects currently being developed, not to provide specific instruction on how to conduct

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these types of projects. Students who choose to complete a quality improvement project as evidence of their scholarly work need to be aware of quality improvement requirements. For example, the Standards for Quality Improvement Reporting Ex cellence (SQUIRE) 2.0 guidelines (2015) focus on the “use of formal and informal theory in planning, implementing, and evaluating improvement work; the context in which the work is done; and the study of the intervention(s)” (Ogrinc et al., 2015, p. 501). Selecting a mentor with expertise in quality improvement is desirable.

Nursing Research While it is recognized that DNP students will primarily be focused on projects that improve practice and will therefore be using quality improvement frameworks, there is also a recognition that some students will choose to engage in implementa tion science research or other forms of research to improve practice. For this reason, information that is important for the DNP student to consider related to research is included. Research, in general, is defined as as inquiry that is aimed at finding and/or interpreting facts, which may lead to new or revised theories or laws based on these findings, or application of the new or revised theories or laws (“Research,” 2022). When considering the more specific nature of nursing research, Houser (2018) defined it as a “systematic process of inquiry that uses rigorous guidelines to produce unbiased, trustworthy answers to questions about nursing practice” (p. 5). Research Focus

The National Institute of Nursing Research (NINR), an organization dedicated to improving the health and health care of Americans through funding of nursing re search, “supports and conducts clinical and basic research and research training on health and illness, research that spans and integrates the behavioral and biological sciences, and that develops the scientific basis for clinical practice” (NINR, 2016, p. 6). This could be accomplished through clinical problem analysis, knowledge generation (especially when collaborating with PhD colleagues), or translating evi dence into practice.

Research Question As mentioned at the beginning of this chapter, a method often used to develop a good clinical and/or research question is the PICOT approach. For example, a clini cal question using the PICOT format could be; Do patients with type 2 diabetes who attend a 6-week diabetes management program experience lower HbAjc results than those patients who do not attend the program? In this case, the P indicates patients with type 2 diabetes, the I is a diabetes management program, the C represents patients who do not attend the program, the O is the HbAic results, and the T is 6 weeks. This format helps the scholar focus on elements of the question that are of interest (Brown, 2018; Polit & Beck, 2021). Research Method

The research methods may be qualitative (when the goal is to understand the lived experience around the phenomenon of interest), quantitative (when the goal is to test a hypothesis, measure a phenomenon, or examine how the phenomenon of interest works), or a mixed method (both quantitative and qualitative).

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Research Design The research design may be nonexperimental (descriptive, correlational, predictive, or quasi-experimental design) or experimental (used to test cause and effect) in na ture. The design is determined based on the research question or purpose, the avail ability of subjects and time frame, the skills of the researcher, ethical factors, amount of control required, the resources available to conduct the study, and expectations of the audience for research (Houser, 2018). The overall study plan—the details of how the study will be conducted—^will be determined by the research design. Other Research Considerations

1. The institutional review board QRB). Before beginning a research project, ap proval is required from the university’s IRB and/or from the review board where the study is conducted. The IRB, an independent ethics committee, comprises a group of individuals who “oversee all research involving human subjects and ensures studies meet all federal regulation criteria, including ethical standards” (Houser, 2018, p. 482). Applying for and receiving IRB approval can be a labor-intensive and time-consuming process. Once the application for IRB ap proval is submitted, it can take anywhere from several weeks to several months to receive approval, depending on the type of review (expedited or full review). See Chapter 9, The Proposal, for more information regarding submitting for IRB approval. 2. Time and resources. Because of the short time frame associated with the typ ical DNP program, the student will need to choose a project with a fairly well-defined scope to complete the DNP program requirements on time. Not only does the actual study need to be com pleted on schedule, but the analysis and

The institutional

review board... oversees

all research

involving hunnan subjects and ensures that

interpretation of the results need to be con ducted and the final documentation (i.e., a research report) produced. In cases in which the project is large or complex, some DNP programs have allowed DNP students to

complete the project together or group proj ects, with each student being responsible for specific elements of the project. 3. Expertise. If research is the focus of the DNP scholarly work, the student should work with a study team and/or individual

studies meet

researcher with expertise in conducting research (see Chapter 7, Aligning Design,

all federal

Method, and Evaluation with the Clinical

regulation

mining the data).

criteria

and ethical

standards.

Question, for information on collecting and

Pilot study A pilot study, also known as a feasibility study, is a smaller study that is done to determine if a larger study is practical and/or achievable. A pilot

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study could be done to ensure validity and reliability of instruments and data col lection procedures, or to assess costs, efficiency, and/or accuracy (Houser, 2018). A pilot study conducted to determine feasibility should replicate the larger study as closely as possible (i.e., setting, intervention, data collection, and analysis).

Pilot Study Focus A pilot study is useful because it can identify areas of concern around a study design that can then be fixed before implementing the study on a larger scale. For instance, there may be issues with the randomization process of participants or with the data collection procedure. A pilot study can also be used to determine if the level of intervention is appropriate (e.g., length of the intervention) or to see if the intervention causes adverse effects. Using the case example presented earlier, a pilot study was used to determine if providing diabetes education, management, and support using a registered nursecertified diabetes educator would be cost effective and improve clinical outcomes.

Pilot Study Methods and Design The methods and design used in a pilot study are analogous with those of a larger research study.

Other Pilot Study Considerations A pilot study can be especially helpful for a student because it provides some re search experience. It also allows for preliminary testing of a hypothesis and, as mentioned previously, it can help reduce unanticipated problems in the main study; this may save time and/or money if procedural issues inherent in the study design are discovered before it is implemented on a larger scale. 1.

2.

3.

The institutional review board. If the pilot study involves human subjects, ap proval from the university and study setting IRB may be required. Remember that it may take anywhere from several weeks to several months to receive IRB approval (depending on the type of review), so careful planning is essential. Time and resources. Although a pilot study can be completed in significantly less time than a large study, a fair amount of time is still required to complete the study in its entirety, including the analysis and interpretation of the results and final documentation. Again, careful planning is essential. Expertise. As mentioned, if research is the focus of the DNP scholarly work, the student should work with a study team and/or individual researcher with expertise in conducting research.

Healthcare Delivery Innovation The current U.S. healthcare system is at a crossroads. New methods for care delivery

and approaches to disease management are being evaluated to determine if there is a more cost-effective means to meet the healthcare needs of the population. The focus is shifting from acute, episodic care to prevention, paying particular attention to community and primary care. Clinical teams are exploring the benefits of rede fining care around medical conditions. For these and other reasons, DNP healthcare delivery projects are also popular choices for scholarly work. These projects often include an intervention or innovative approach to healthcare delivery that has an ultimate goal of positively affecting outcomes.

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Healthcare Delivery Innovation Focus The focus may include designing and evaluating new models of care, imple menting and evaluating evidence-based practice guidelines, integrating telehealth into chronic disease management, or even redesigning care delivery systems in resource-poor settings. The potential projects in this category are extensive. The DNP student may consider using an implementation science or quality improve ment approach when addressing these types of practice projects. Healthcare Delivery Innovation Methods The method used to deliver the project is dependent on the focus. For example, a DNP student embarking on a quality improvement project may use quantitative methods to answer the clinical question but may also want to consider quali tative methods to provide additional clarity. Projects that organize care using a team approach are gaining momentum because payers are looking for ways to improve clinical outcomes and efficiency. For example, the DNP student could choose to partner with a hospital- or community-based organization to coordi nate delivery of care. Certainly, collaborating vidth other healthcare providers in the area or even health payers can be an effective approach when implementing a scholarly project.

Other Healthcare Delivery Innovation Considerations

When considering implementation of a healthcare delivery innovation, regardless of the specific type of project or methods used to implement the project, there should be a focus on the cost effectiveness of the innovation as well as the clinical

effectiveness. For instance, in the case study that was used to illustrate how to write a problem statement, the focus of the study was on implementing clinically effective interventions or strategies in the primary care setting to address the needs of a diabetes population. However, the authors chose to also include the cost as sociated with implementing this type of intervention. The results were that the model was both clinically and cost effective in the population studied (Moran et al., 2011). In the end, the authors were able to make a business case for imple menting the registered nurse-certified diabetes educator in the patient-centered medical home.

Healthcare Policy Analysis Healthcare policies must be evaluated frequently to ensure that they are still rele vant to society, that is, they continue to meet societal needs. Policy analysis helps with this process. The DNP student who engages in healthcare policy analysis within a scholarly project works to evaluate the historical evolution of the policy and determines if there is still congruence within the cunent social context. If there is incongruence, the results of the analysis may be used for policy modifi cation recommendations (Porche, 2019). The policy analysis may be the first step in formulating a project plan to address the healthcare needs identified.The DNP project should include planning, implementation, and evaluation components to address policy needs identified in the analysis to impact healthcare outcomes (AACN, 2015).

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Healthcare Policy Analysis Focus The intent of the analysis may be descriptive, to describe how and why the policy came to be and to describe the current state of a policy, or it may be prescriptive, to consider what could occur if a proposed policy is implemented.

Healthcare PolicyAnalysis Methods Multiple approaches can be used in policy analysis depending on the impetus for conducting the analysis (i.e., qualitative or quantitative). The DNP student may decide to use one of the following models, as outlined by Porche (2019); however, keep in mind there are other models that are not described here: ● ● ●

● ●

Eightfold path uses a problem-solving process to clarify the problem and iden tify solutions. See Chapter 4, Population Health and Healthcare Policy, for an example of a policy analysis using the eightfold path model. Participatory policy analysis (PPA) is used to ensure that the ideals of democracy are included in policy alternatives. Logical-positivist model uses a deductive reasoning approach to analyze a policy (hypothesis testing). Forecasting model focuses on the assessment of technology adoption. Political feasibility model focuses on the fit of the policy with the values/interests of stakeholders.

● ● ●

Economic viability model involves analyzing policies from an economic and financial perspective. Value analysis model looks at the values that are important in policy (e.g., access, efficiency, privacy, consent, etc.). Five “E” model uses five variables to analyze a policy: (1) effectiveness, (2) efficiency, (3) ethical considerations, (4) evaluating alternative options, and (5) positive and feasible recommendations for change.

Other Healthcare PolicyAnalysis Considerations

Policy analysis can focus on micro-level issues (efficient allocation of resources) or macro-level issues (structural focus, sociocultural issues). The policy analysis pro

cess can use a variety of methods to obtain relevant data. However, conducting the analysis is only one part of the picture. Disseminating the results of the analysis to the appropriate stakeholders is a critical component of policy analysis; it is a part of the implementation and evaluation portion of the DNP project.

Program Development and Evaluation Programs that are developed to address health and healthcare needs are of critical importance and essential to the health of our nation. Gaps in healthcare access or delivery across the nation have been addressed through implementation of a variety of healthcare programs. They can be complex and multifaceted or relatively simple, such as providing health education to a community. Program Development and Evaluation Focus The types of programs that DNP scholars could potentially develop are vast and wide reaching. A DNP program development and evaluation project may include an

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intervention that involves planning and implementing activities that will ultimately improve the health of a specific group or decrease known health problems within a community (“Program development,” 2018). The process involves identifying a gap in care, developing a program that is evidence-based to address the need, and finally, evaluating the outcome.

Program Devetopment and Evaluation Focus Methods Methods used for program planning and evaluation are variable but may include items such as surveys, individual interviews, and, more recently, focus groups. As mentioned, focus groups comprise individuals who represent a defined target pop ulation. These and other methods are used to gather information to determine the program needs, participant satisfaction, policymaking, organizational development, and outcome evaluation. Irrespective of the method used to glean the desired in formation, it is imperative that the expectations are clear to the participants and the purpose well articulated. Other Program Development and Evaluation Focus Considerations

The DNP student embarking on a program development and evaluation project may benefit from the guidance of an expert in program development, implementa tion, and evaluation, especially as it relates to their area of interest. It may be helpful to include such an individual on the DNP project team (if applicable). It is also recommended by the AACN (2015) Implementation of the DNP Task Force to in clude an organizational mentor as part of the project team to be a liaison tvithin the organization. Acting in this capacity, the mentor could open doors to key personnel and inform the project from the organizational perspective. Clearly, the potential project options for the DNP scholarare boundless.In fact, there are many more options than are listed within this chapter. When considering the options, the key is to focus on a phenomenon that meets the needs of society and/or an organization, is interesting, and in which the DNP scholar has sufficient expertise; to choose a project that will result in a personally meaningful outcome (because the time commitment to complete scholarly work is significant); and to develop a network of support in areas in which the DNP scholar has limited knowl edge. There are many outstanding exemplars of DNP scholarly work. Consider the work by Dr. Rachel Cardoza, which involved a practice innovation that focused on vulnerable underserved palliative populations and a funding plan for expansion of services into the community (see Exemplar 6-2).

Exemplar 6-2 A Standardized Palliative Care Referral Workflow and Educational In-Service at an Outpatient Congestive Heart Failure Clinic Rachel Cardoza, DNP, RN, AGNP-C

The DNP project starts with trying to change the world and ends with what will be meaningful and sustainable work. As a DNP student, choosing an organization for project work is key to the success and sustainability of scholarly work. Entering into my project. I knew I had interdisciplinary DNP project champions that included nursing, social work, and physicians who would support and adapt to the

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scholarly needs and help me identify areas for change, growth, and improvement. As a DNP student, the academic practice partnership in palliative care highlighted not only an emerging specialty but also the product that a DNP-prepared nurse practitioner can provide. Palliative Care, as a specialty, is less than 10 years old in this organization. Palliative Care is supportive, person-centered care for those with life-limiting illnesses and incorporates care aligned with patient preference and also comfort management. It is not hospice care, but the specialties often align closely due to many of the interdisciplinary certifications. My project allowed me to establish a foundational relationship to work toward innovative practice change improving palliative care practice at the individual and system level. My DNP project work included a focus on vulnerable, underserved, palliative populations and a funding plan for expansion of services into the community. Fast forward 3 years, my DNP student project blossomed into a new position as a palliative care nurse practitioner. The position involved patient care, building on DNP scholarly work, but also continuing to change practice, mentor future DNP students, and demonstrate the added value of a DNP-prepared nurse. As a DNP-prepared nurse, I understand the importance of measuring process and outcomes to easily demonstrate the benefits of change. A key strategy that I used, and now all DNP students within this organization use, involved identifying key stakeholders and leaders within the organization. Once those key personnel were identified, it was important to understand what they valued in terms of data, finances, and outcomes, so that I could build a business

case for expansion and improvement of palliative care services and develop a plan for a successful project within the organization. I became employed as the first DNP-prepared nurse in palliative care shortly after completion of my DNP project work. My new DNP position included program development, which led to an opportunity to secure $400,000 in philanthropy funding from the organization’s foundation to support practice

change. The need for a DNP Project succession process (to continue the work I had started) was identified after reviewing referral patterns and issues in a small population. A second DNP student was able to expand on my work in a more profound way because of the relationships and value that had already been established. The job description grew over time based on the work of the DNP students who followed and came to fruition within two successive

years of my original DNP scholarly work. This DNP F*roject succession process continues today. Two successive years of students have started their DNP scholarly experience in this setting and former DNP students; are seeking employment opportunities as a result of their project work. The more the organization understood the role of the DNP-prepared nurse, the more impact was realized as these nurses worked to improve practice within the organization. The DNP students were deliberate in measuring quality with each successive project; these measures included decrease in hospital utilization and increase in median hospice length of stay. Next came the dissemination of the results of DNP work as both a

student and employee at National Home-Based Services and Hospice and Palliative Conferences, which was enhanced because of the skills attained

as a DNP-prepared nurse and the focus on interdisciplinary project team partnership. Ultimately, this DNP work aligns with the Institute of Healthcare Improvement’s (2018) "triple aim" and with what some organizations have adopted as the "quadruple aim," which includes improving quality, controlling costs, enhancing patient and family experience, while supporting clinical staff satisfaction (Bodenheimer & Sinsky, 2014).

174

Chapter 6 Validating the Problem

Impact ●

Project planning leads to a successful DNP project. This process requires care ful alignment with the needs of the organization, appropriate identification of priority practice concerns, assessment of the barriers and facilitators to imple mentation and factors that will assure sustainabihty, and careful selection of the best method and/or approach to use to both address the practice concern and to evaluate the outcome.

Key Messages ●

The literature review is a method used to support the value of and/or the need to study the phenomenon of interest. The assessment can lead to the identification of a gap in the current state of a phenomenon or help validate current perceptions. The problem statement encompasses a phenomenon in need of inquiry that is examined to better understand the phenomenon in order to develop a poten

●

●

tial solution.

●

When articulating the problem statement, the goal is to identify an issue, de scribe it clearly but succincdy, and adequately articulate why it is important that the problem be addressed. Stakeholders are those individuals or groups who touch the project in some way or have an interest in the project outcome. Use the nursing process at a doctoral level to refine your innovation and project plan based on assessment data. Project goals describe what the student intends on delivering within the con text of the project. The project scope includes all the work that needs to be accomplished in order to fulfill the project goals.

● ● ●

●

Action Plan-Next Steps 1. Conduct a literature review.

2. 3. 4. 5. 6. 7. 8. 9. 10.

Conduct an organizational assessment. Wite the problem statement. Identify key stakeholders. Identify alternative solutions to the identified problem. Choose the best solution as the project focus. Conceptualize the project plan. Define the project goals and scope. Select a project theory and framework. Determine the project type.

Tools

OrganizationalAssessment Tools Assessment tools include those items that help the student organize thoughts and

work through conceptual ideas, as well as in the decision-making process. The fol lowing tools can be used early in the project planning phase.

Tools

175

Evaluating the organization in which the project will take place is a helpful exercise in project planning. Identifying the organization’s strengths, weaknesses, resources, and other attributes can help in planning and implementing a project smoothly and successfully. Table 6-4 lists resources for choosing an appropriate organizational assessment aid. Table 6-4 Organizational Assessment Tools Tool

Description

Resource

Free

Website with tools for

Management Library

evaluating and improving organizations

httpsV/managementhelp .org/aboutfml /diagnostics.htm https://managementhelp.org /organizations/index.htm

Reflect & Learn

Organizational assessment frameworks, including:

Frameworks

■

http ://www. ref lectlearn .org/discover/frameworks

Universalia Institutional and

Organizational Assessment Model IlOA Model) ■

A Causal Model

of Organizational Performance & Change (Burke & Litwin Model) ■ ■

The Seven-S Model The Marvin Weisbord Six-Box

Model (Weisbord's Model)

■ Reflect & Learn Self-Assessment Tools

Open Systems Model

Over 60 tools for various types of http://reflectlearn.org organizational self-assessment: /discover/self-assessment

■

By type of organization (profit, non-profit, donors/ grantmakers, governmental

-tools

agencies/organizations) ■

By area of the Universalia

lOA Model (organizational capacity, external environment, organizational motivation, organizational

performance) Canadian International

Developmental Agency

Organizational Assessment Guide presents a framework for conducting assessments and guidelines for shaping execution

http://documents .reflectlearn.org/Offline %20Docs%20for%20

Your%20lntroductory%20 Guide%20to%200A/OA

%20Guide-E.pdf American

Communication Climate

https://www.cuanschutz.edu

Medical

Assessment Toolkit (C-CAT)

/centers/bioethicshumanities /research/c-cat

Association

176

Chapters Validating the Problem

Tools to Help Define the Problem The student will want to summarize assessment data

to get a comprehensive view of the true components of the problem. The following tools will assist in gathering the data accurately and simply. Check Sheet

The check sheet is used to gather data about a process. The user typically places a check mark on the sheet to indicate observation of a specific point in a pro cess, A check sheet can be customized to meet the specific needs of a project (see Figure6-3).

Checkpoint one Step/item 1 Step/item 2 Step/item 3 Stepfltem 4 Step/item 5 Step/item 6

Checkpoint two Step/item 1 Step/item 2 Step/item 3 Step/item 4 Step/item 5 Step/item 6

Checkpoint three Step/item 1 Step/item 2 Step/item 3 Step/item 4 Step/item 5 Step/item 6

Figure 6-3 Check sheet Rt{(0dund mitti pemisskm fisn Dl Mxros. tiRpu'/mw.qinixiDs.com

Fishbone Diagram The fishbone diagram is also known as the cause and ejjea diagram or the fshifeawa diagram, and is used to identify potential causes of a problem or to help the team members when they are having difficulty coming to a conclusion (see Figure 6-4), To use a fishbone diagram, the team must first agree on a problem statement, Cause

Effect

Materials

Why? ^ Why? ^ Why? ^

Process/methods

Why? ^ Why? ^ Why? ^

Problem statement

Why? ^ Why? Why?

People

Figure 6-4 Fishbone diagram Reproduced wtd petirission froiri Ql Macros. http://wiw.i|imacro icom

Machines

Tools

177

which is captured on the horizontal center line running through the diagram. The team then begins to brainstorm ideas about the cause of the problem. These ideas are captured on vertical lines running into the center (problem) line. As more and more ideas are added to the figure, it begins to take on the appearance of an arrow, or fishbone (hence the name). If it is difficult for the team to generate ideas, headings can be used to facilitate the process (e.g., materials, process/methods). As the team continues to drill down, subcategories that further describe the prob lem are generated. Another use for tools is to present data, including assessment or evaluation data, in a powerful and efficient manner, Basic graphs, such as bar graphs, will highlight differences between groups or categories. Other examples include radar or spider charts, frequency histograms, line graphs, pie charts, and run charts. A few specific examples follow. Histogram A histogram is a bar graph that is used to illustrate the frequency distribution of a phenomenon. It is a rough estimate of the probability distribution of the given variable. For example, Figure 6-5 Illustrates the frequency distribution of patient arrivals in the emergency department over a period of time. In the example in Figure 6-5, time is used as the variable.

Arrivals to the emergency department 7

□ Arrivals 6 -

Poly, (arrivals)

5 -

D

a m < (U

c Q)

o’

Data

Multiple options Surveys,

Collection

Literature search

standardized

Multiple options Surveys, check sheets, process flow diagrams,

instruments,

Literature review

System/stakeholder assessment

Baseline and/or post

Multiple options to measure the program's needs, and impact

assessment

System/stakeholder

cause-and-effect

measures,

diagrams, clinical

implementation

assessment, resource

registries

record reviews or

measures of outcomes

review, surveys,

or database

data extraction, interviews, observations,

relevant to the practice guideline integration

interviews, focus groups, program costs

Interviews, focus groups Cost-benefit analysis

and measures for the

focus groups, key informants, system/

focus groups

review

System/Stakeholder

execution, outcomes,

physiologic

extraction, interviews, observations,

Literature search and

specific program goals

stakeholder assessment

Data

Analytics

Specific to the Specific to the clinical question quality issue i Quantitative and or hypothesis Emphasis on I qualitative quantitative I techniques and qualitative I Run charts Pareto charts 1 techniques; fiscal analyses Statistical process Process and outcome

evaluation for

I

intervention and

implementation projects

i

Practice Guideline

Development Evaluation of evidence

strength: Quantitative Data Levels of evidence: l-VII

measure processes and outcomes that can

include quantitative and qualitative techniques

and financial analyses

I

Emphasis on evaluation of evidence, quantitative and qualitative j techniques: fiscal analyses

Co

5

(Melynk & FineoutOverholt, 2015) Levels of evidence (Johanna

control I Fiscal analyses

Diverse approaches to

I

D

Briggs Institute [JBI],

(t) o>

2014)

3

Grades of recommendations

(JBI. 2014)

8

M

[continues]

N

[continued]

Table 7-1 DNP Project Approaches Category

Research/PracticeBased Inquiry

Quality Improvement (Qi)

Evidence-Based Practice

Program Development and Evaluation (PD/PE)

(EBP)

Health Policy

? o 3U

TJ

Qualitative Data

CERQual [Confidence in Evidence from Reviews

>

of Qualitative Research.

IQ

2018; www.cerqual.orgl.

D D

Guideline Assessment

in

AGREE-II. n.d.lwww

a

.agree.trust .orgl

v>

(D

Practice Integration I

Evaluation (D

Analysis of achievement of designated outcomes with quantitative, qualitative, and fiscal technique Intersections

Research informs QI.

QI informs EBP.

rr

o Q.

Q.

PD/PE informs and identifies ' opportunities for

EBP informs QI.

EBP, and program, QI can identify needs ' EBP evaluation identifies evaluation.

tor research

New research can

gaps in EBP

and program development, i QI can generate new

reviews.

I

be initiated from

Interprofessional

knowledge.

collaboration.

1 Interprofessional !

collaboration.

research, EBP. and QI.

need for additional

Interprofessional

research.

EBP can guide program development and

£U

I

'

collaboration.

Health policy work influences and

c Q)

continued research,

o

QI and program

development/

evaluation.

evaluation.

Interprofessional

Interprofessional

collaboration.

collaboration.

2001; U.S. Department of Health and Human Services [DHHS], 2009 and 2011.

fij

T>

Need top management support for the project before implementation; otherwise, the resources needed for the project are in jeopardy.

A

o A CU

a D

IQ

Students should relate how the project fits the mission of the organization.

3 TJ A

Communicate the project purpose and goals clearly to all of the stakeholder’s (they are more likely to support the project when they have a clear understanding of the project goals).

Management support, mission, and schedule

Project planning

Develop a project schedule that sufficiently and realistically outlines the stages of the implementation process, including all activities, milestones, and team member roles and responsibilities in relation to time to complete.

3 A 0>

o

O c IQ

o o 0)

cr o

Figure10-2 Project planning

Q]

o D

Collaboration

●

Current practice

●

New evidence

●

Intervention

●

Considerations

●

Recommendations

311

Finally, the doctoral student should develop a project schedule that sufficiently and realistically outlines the various stages of the implementation process, includ ing all actmties, milestones, and team member roles and responsibilities in relation to the lime needed for completion. The project schedule will be a useful document to help the student manage and meet the project deadlines. See the Resources sec tion at the end of this chapter and Chapter 8, The DNP Project Team: Preparing for Project Implementation for examples of a project schedule and other tools to facilitate project implementation. A vast amount of resources are available to assist the DNP student in the plan

ning and implementation phase of the DNP project. This chapter provides only a sample of the potential tools available for use; a wealth of additional information is available via online and project management textbooks. Students should check with an advisor or their DNP project team to identify any necessary resources that may be available through the university at no or reduced cost.

^ Collaboration Collaboration within and across professions and with team members from var

ious groups can ensure optimal success in operationalizing the project. For ex ample, AACN’s Domain 6 addresses interprofessional partnerships and identifies interprofessional collaboration (IPC) as an important process needed to meet this Essential. However, it is important to keep in mind that collaboration is integrated, or inter woven, in other Essentia! domains, making it a critical activity required to achieve compe tencies in several Essentia! domains (AACN,

2021). This section will delve more deeply into collaboration, various types of collabo

rative experiences, and professional partner ships that the DNP student may conduct and establish while designing and implementing

Collaboration within and across

professions and with team

the project. The process of developing the DNP project

members from

will require collaboration with members of the nursing profession as well as other health pro

various groups

fessionals. Members of the team a DNP student

can ensure

gathers to complete a DNP project may include,

optimal

but are not limited to, nursing and other disci plinary faculty project team members, organiza tional leadership, healthcare workers, business and management personnel, experts in infor matics, statisticians, and patients who are part of the intervention.

success in

operationalizing the project.

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ChapterlO Leading Implementation Through Collaboration

Collaboration is an important and critical concept in healthcare practice, edu cation, and research. The Quality and Safety in Nursing Education Institute (QSEN, 2022) identified teamwork collaboration as one of six competencies with specified knowledge, skills, and attitudes to support collaboration. The QSEN work, which aims to improve quality and safety in healthcare systems, requires collaboration for intraprofessional and interprofessional teams to function effectively. Additionally, national federal regulations have also focused on collaboration, issuing possible financial penalties for organizations that fail to document physician and nurse col laboration (Emich, 2018). As the DNP student works on project implementation collaborating with multiple disciplines and professions, it is also important to con sider collaboration expectations of various organizations, agencies, and accrediting bodies (e.g.. The Joint Commission, Magnet, AACN, and Liaison Committee on Medical Education).

Definitions

To understand and operationalize collaboration, it is beneficial to consider the ori gin and use of the term. Collaborate, the root word of collaboration, stems from the

Latin word collabratus, meaning to labor together and it refers to working “jointly with others or together especially in an intellectual endeavor” (“Collaborate,” 2018, para. 1). Collaboration typically refers to a process that emphasizes joint involve ment in activities, but in health care, includes communication and decision making and is often equated with a union or partnership that has mutual goals and commit ments (Henneman et al., 1995). Green and Johnson (2015) described collaboration

as a well-defined, mutually beneficial relationship between two or more organiza tions with the purpose of achieving common goals. Ash et al. (2017) noted that the concept of collaboration in successful business and management fields includes strategic alliances and interpersonal networks that can be transferred to the health

sector. The process of collaboration includes communicating, cooperating, trans ferring knowledge, coordinating, problem solving, and negotiating. Collaboration can occur within the framework of formal and informal teams that the DNP student

may encounter during the DNP project processes. DNP students may work with

formally identified teams during the project, such as their project team or other teams consisting of professionals and paraprofessionals within the clinical site to enhance project success. Students may also use the same skill set in communicating and working with informal team members such as statisticians or other experts

needed for consultation on specific aspects of the project. The terms interdisciplinary, interprofessional, multiprofessiona l, and multidisci plinary have been used interchangeably in the literature and often refer to types or processes within teams (Nancarrow et al., 2013). Using the terms interdisciplinary or multidisciplinary can limit the concept to knowledge ascribed to a particular discipline. The terms interprofessional or multiprofessional offer a broader defini tion than interdisciplinary. Interprofessional or multiprofessio nal collaboration refers to the interactions between and among two or more individual professionals who may represent a particular discipline or branch of knowledge, but who additionally

bring their unique educational backgrounds, experiences, values, roles, and iden tities to the process. Collaboration with other professionals is enriched when there is shared or overlapping knowledge, skills, abilities, and roles (Ash et al., 2017QSEN, 2021).

Collaboration

313

To summarize, in this text, interprofessional collaboration will be the term used outside of the nursing pro fession. Similarly, the concept of intraprofessional collaboration is considered interac tions among colleagues within the nursing profession who share nursing professional education, values, socialization, and experience. Though the terms intraprofessional and interprofessional are preferred terms for the work, the term interdisciplinary may be used at times to accurately cite work from other authors. to refer to interactions with other health team members

Partnerships Collaborative partnerships that allow interaction between and among health profes sionals to share ideas and knowledge and participate in shared decision making can

improve quality and cost-effective care. Domain 6 of the AACN Essentials (2021) document describes interprofessional partnerships as “Intentional collaboration across professions and with care team members, patients, families, communities, and other stakeholders to optimize care, enhance the healthcare experience, and strengthen outcomes” (p. 11). The AACN (2021) further identified interdisciplinary collaboration as a “group of healthcare providers with various areas of expertise” (pp. 60-61), who work together toward their clients’ goals, while referring to inter

professional as collaborative engagement of two or more professions or profession als. DNP students may develop interprofessional, intraprofession al (within one’s discipline), or paraprofessional partnerships (AACN, 2021). There are important benefits associated with establishing unique types of partnerships, particularly for the DNP student who may conduct projects within community settings. Addition ally, there may be a spectrum of community health workers (CHWs) who are often crucial to project design and implementation. Olaniran et al.’s (2017) systematic review described paraprofessionals as CHWs with some secondary education and subsequent formal pre-service training, and who are often in paid positions. The DNP student may encounter different and unique paraprofessionals , whose de gree of education, service training, and salary status may vary depending on the organization/setting.

The Committee on the Future of Nursing 2020-2030 reported a vision for nurs ing leadership that requires nurses to collaborate with others to successfully imple ment change. The DNP project is an excellent opportunity to provide this evidence. Without a doubt, collaboration is central in project design and implementation. The AACN (2021) describes four competencies and several subcompetencies that the advance nursing practice student is required to exhibit. Competencies include: ● Communicate in a manner that facilitates a partnership approach to quality care delivery;

●

Perform effectively in different team roles, using principles and values of team dynamics;

● ●

Use knowledge of nursing and other professions to address healthcare needs; and Work with other professions to maintain a climate of mutual learning, respect, and shared values.

Subcompetencies at the advanced level (i.e., doctoral students) describe how

the student achieves the competency (AACN, 2021). Each student is responsible for understanding and explaining involvement and achievement of the competen cies and subcompetencies using language that is pertinent and measurable. As the

314

ChapterlO Leading Implementation Through Collaboration

student works on project design and implementation, it is prudent to become cog nizant of the competencies and subcompetencies within Domain 6 and to identify how these will unfold and be measured in the project. See Chapter 11, Driving the Practicum to Attain Competency and Leverage Impact Through the DNP Project, for a tool to assess progression of competency attainment.

^ Models/l=rameworks Supporting Collaboration Healthcare systems have encountered significant and burdensome challenges, par ticularly since the COVID-19 pandemic began. The pandemic drastically affected the ways that health and health care were visualized by patients and providers. One critical and highly valuable collaborative partnership that has lacked significant at tention is the partnership between patients and providers. There is a strong need to improve patient, family, and community involvement in a person’s health. The DNP student must think innovatively to design a project with effective approaches and strate One critical and gies for individuals and healthcare systems that meet the demands for person-centered care,

highly valuable

collaborative

partnership that has lacked

significant attention is the

partnership between

patients and providers.

while minimizing costs, and reducing treatment burdens for patients and communities. Thus, DNP students who apply a model or framework

lens can better understand, assess, design, im plement, and evaluate projects. Yet this period in history is different, such that prior models and frameworks may no longer apply, especially in light of our recent healthcare challenges and the overwhelming costs of care to systems and society (Lachman & Nelson, 2021). No longer is the focus on simply managing disease, while ignoring health promotion, particularly within the context of chronic conditions. Though there are numerous models and frameworks to guide partnership collaboration, a few are provided here for the student’s consideration within the

context of partnership collaboration.

Co-production Model One of nursing’s greatest attributes is recognizing the inherent value of the relation ship with patients in delivering health care. Batalden (2016, 2018) and others (Lach man & Nelson, 2021) propose that the phenomenon co-production of health is a way

of thinking that provides high-value health care to produce optimal outcomes in indi vidual and population health. In this model, Batalden (2018) describes co-production

of health as the “interdependent work of users and professionals who are creating, designing, producing, delivering, assessing, and evaluating the relationships and ac-

tions that contribute to the health of individuals and populations’’ (p. 2). The goal of a co-production model is for the patient and provider to co-create value in health care.

Models/Frameworks Supporting Collaboration

315

based on the premise that professionals and end users (i.e., patients) can leverage their collaborative partnerships. The co-production model is especially meaningful for DNP students who are striving to meet the Essentials (AACN, 2021) criteria in Domain 6, which emphasizes partnership collaboration and shifts the focus of care from passive patienthood (Swenson et al., 2010) to the collaborative partnership of provider and pa tient. Additionally, Elwyn and colleagues (2020) explain that co-production encour ages patient resilience and autonomy; saves time for patients, caregivers, and health systems; and lowers costs for society and communities as a whole. The principles of a co-production model encourage patients, their caregivers, and providers, to form a collaborative partnership in a co-production cycle that includes co-assessing, co-deciding co-designing, and co-delivering one’s care. The take-away in the co-production model of health and healthcare policy is that it is co-developed with people, rather than for peo ple (Steen & Brandsen, 2020). This framework merits consideration in DNP projects where the student is working to increase value in health care for patients, caregivers, communities, providers, and systems, regardless of setting.

Interprofessional Collaborative Practice Model As the DNP student strives to meet the Domain 6 subcompetency that requires

directing interprofessional activities and initiatives, several interprofessional frame works and models may offer specific skills associated with interprofessional collab orative practice (ICP). One ICP framework (Stutsky & Laschinger, 2014) offers the DNP student insight into key collaboration strategies within the context of an inter professional project. This ICP framework focuses on assessing personal and situa tional factors in ICP relationships and examining the outcomes, or consequences of ICP. For example, an ICP framework requires that project processes include explor

ing organizational work behaviors and attitudes, as well as patient outcomes (p. 2). This framework, like others, requires that the DNP student bring strong relational skills such as cooperation and communication (AACN, 2021). TeamSTEPPS® TeamSTEPPS® is another interprofessional collaborative model and system devel oped by the Agency for Healthcare Research and Quality (AHRQ, 2022) and by the Department of Defense (DoD). Most helpful with this model are fully devel oped solutions for implementation of the model, for example, a training kit, cur riculum, coaching and measurement tools, as well as videos and other supporting materials that could be readily applied in a project. This work is based on more than 30 years of scientific research and the resources are readily available, making the TeamSTEPPS® model a potentially valuable contribution to collaborative work in a project.

The RWJF (2015) has identified exemplar healthcare organizations that have embraced interprofessional collaboration and published best practices in their re port Lessons from the Field: Promising Interprofessional Collaboration Practices. Key findings from the report show that successful interprofessional collaboration mod els include:

● ●

Putting patients first. Demonstrating leadership commitment to interprofessional collaboration as an organizational priority through words and actions.

316

Chapter 10 Leading Implementation Through Collaboration

Creating a level playing field that enables team members to work at the top of their license, know their roles, and understand the value they contribute. Cultivating effective team communication. Exploring the use of organizational structure to hardwire interprofessional practice.

► Components of Collaboration

in the DNP Project: Who, What, Where, When, and How To explore the components of collaboration with different professionals and mem bers of scholarly project teams, the framework of Who, What, Where, When, and How will be used.

With Whom to Collaborate?

when the DNP student gathers resources needed for the scholarly project, who will be needed to assist in assessment, planning, implementing, and evaluating the pro cess may include members from the nursing profession, that is intraprofessional, as well as members from outside the profession, or interprofessiona l, including patients and populations served. Intraprofessional Collaboration

The DNP student will find resources within the profession from both faculty and other nursing professionals in the clinical setting. Nursing faculty are the primary role models and resources for collaboration for the DNP student. The Task Force

on

the Implementation of the DNP recommended a doctorally-prepared faculty mem ber to help guide the student (AACN, 2015). Cronenwett and colleagues (2011) described the optimal learning environment for DNP students as “one in which doctorally-prepared faculty members are actively engaged in teaching, clinical practice, translational science and systems improvement, preferably within an envi ronment characterized by robust interprofessional learning opportunities” (p. 14). Identifying faculty as mentors as well as content and research consultants in iden tified areas of the project is important early in the DNP project work. These faculty members may also serve as part of the DNP project team to guide the work of the student during the project. Carlson et al. (2017) outlined the value of PhD- and DNP-prepared faculty member collaboration, along with the organizational repre sentative in project teams, to provide an environment that:

1. Leverages the potential of both DNP- and PhD-prepared faculty members’ knowledge and expertise 2. Encourages mutual respect and a vibrant intellectual community 3. Promotes the scholarly formation of students while exemplifying the value of collaboration, (p. 4)

DNP students collaborate with their PhD-prepared nursing faculty, but the po tential for collaboration between nursing PhD students and DNP students provides a multifaceted approach to healthcare problems. For example, Dowling-Castronovo

Components of Collaboration in the DNP Project

(2018) suggests that DNP-PhD collaborations innovate research, education, and practice. The interaction between the research and practice degrees in nursing can be applied to projects in which research questions are generated by the practice doctorate from clinical questions and then tested in the practice environment for application and evaluation with the assis tance of the research doctorate. The process can be reversed in that the nurse researcher

coming from a particular field of interest can enlist the aid of the practice doctorate in the clinical environment to test theor)' In all, the nursing profession benefits from the collabo ration of the practice and research doctorates in the generation of knowledge applied to evidence-based practice. The opportunities for intraprofessional collaboration also occur with other nurses in

Who will be needed for

the scholarly project team can include members from

the nursing profession as well as members

from outside

the clinical setting where the scholarly project takes place. DNP students can model doctoral nursing leadership skills with other nurses—

the profession.

such as nursing administration, nursing staff, and nursing informatics expens involved in

The nursing

their project—and include them in their project team when appropriate. DNP students in ad ministrative advanced practice roles can influ ence institutional policy with projects, such as

benefits from

instituting a new program to benefit a specific population. For example, the administrative DNP student might gather a team of nursing administrators, clinicians, and other depart

ments, such as pharmacy and information tech nology, to inform a project aimed at serving the local uninsured population. DNP students can model leadership behaviors in a project pro

posal for their university and present the proj

317

profession the collaboration

of the practice and research doctorates in

the generation of knowledge

ect to the board of the institution to implement the innovative change.

applied to

Interprofessional Collaboration Many health professional programs are now collaborating to educate students to learn

practice.

evidence-based

with, about, and from others from outside their own profession. Interprofessional education is the interactive learning and collaboration of students from different

health and social professions “for the explicit purpose of improving interprofes sional collaboration or the health/well-being of patients/client s (or both)” (Reeves et al., 2013, p. 4).

318

ChapterlO Leading Implementation Through Collaboration

To fully operationalize the concept of interprofessional collaboration in prac tice, the Robert Wood JohnsonFoundation(RWJF) (2015) states that:

Effective interprofessional collaboration promotes the active participa tion of each discipline in patient care, where all disciplines are work ing together, fully engaging patients and those who support them, and leadership on the team adapts based on patient needs. Effective inter professional collaboration enhances patient- and family-centered goals and values, provides mechanisms for continuous communication among caregivers, and optimizes participation in clinical decision-making within and across disciplines. It fosters respect for the disciplinary contributions of all professionals, (p. 1)

Additionally, as the project plan becomes clearer, it will be important to col laborate with content experts and with the identified DNP project faculty men tor (see Chapter 8, The DNP Project Team: Preparing for Project Implementation). DNP students should assess the areas in which they have expertise and the areas in which a content expert may be required. It

An innportant

part of doctoral work is

collaboration, which assists

the student in

growth and adds to the richness of

the project.

may be helpful to consider the multiple aspects of the general plan in the assessment. For ex ample, in a health policy project, the DNP stu dent may be a content expert on the impact of the advanced practice nurse (APN) in reduc ing costs in transitional care. In addition, the

DNP student may have considerable expertise interacting with legislators on this same topic. However, the DNP student may need assistance in the area of policy development. If this is the case, the DNP student could seek out a policy expert to further explore the content required for the project and its success. An important part of doctoral work is collaboration, which assists the student in growth and adds to the richness of the project.

What Type of Information Is Needed? what type of information is needed to complete the DNP project? Answering this question may involve investigation and study in other disciplinary fields as well as developing professional collaborative partnerships. Information needed for suecessfully implementing the project includes identifying and filling gaps in knowl edge. The DNP student may need to look outside the nursing profession to other disciplinary fields for answers. Business, management, and statistical professionals, as well as professionals in other healthcare disciplines may offer other types of in

formation that the DNP student may require. For example, should a student wish

to explore the feasibility of purchasing new equipment to relieve pressure ulcers in hospitalized patients for use in a safety study, the DNP student may need to gather

information from equipment vendors, budget office personnel (for funding), and

clinicians who may use the equipment on the clinical units. In this case, DNP stu dents need a broad lens to explore their chosen field of study, and to narrow down

Components of Collaboration in the DNP Project

319

the clinical question. Gathering the resources and interacting with other members of an identified team provide an opportunity for the DNP student to practice intra professional and interprofessional collaborative competencies, including leadership and communication skills. Faculty mentors and the DNP student’s project team can assist in identifying and linking the student with the appropriate resources needed to inform the project. Students will continue to perfect these skills and competen cies as the project matures in the context of their clinical practicum experiences. For example, in preparing for the DNP proj ect regarding the use of standardized nursing What type of language in the electronic health record (EFIR), independent study was needed in the area of information nursing standardized language, healthcare in formatics, and the development and function of is needed to the EHR (Conrad et al., 2012). This preparation

involved collaborating with nursing informatics experts in an independent study class, as well as working with information technology experts at

complete the

a national conference of EHR vendors. Nursing

Answering

informatics is a rapidly developing field, and the independent study allowed an in-depth explo ration of the current status of the visibility of

nursing practice reflected in electronic docu mentation. Learning the new technical language of information technology allowed dialogue with EHR vendors to understand how advanced

practice nurses can be involved in asking for the tools, such as reference terminologies avail able in EHRs, to reflect nursing language and

nursing care. This DNP project was published in the Journal of the American Academy of Nurse Practitioners (Conrad, Hanson, Hasenau, & Stocker-Schneider, 2012).

DNP project? this question

may Involve Investigation and study in other disciplinary fields as well

as developing

professional collaborative

Professional Collaborative

Partnerships

partnerships.

One area that is critically important in the DNP

project focuses on the intentional collaboration in professional partnerships to ensure accurate information to inform the process (AACN, 2021). Partnership defi nitions focus heavily on the ways that two or more people work together toward

a mutually defined purpose while establishing interpersonal relationships (Gallant et al., 2002). D’Amour and colleagues (2005) agree with the prior definition around interpersonal relationships but emphasize the need for authentic and constructive collegial-like relationships. Accentuating relationships within a partnership ap proach is significant since it is compatible with the Essentials (AACN, 2021) Domain 6 sub-competencies regarding communication and respect for diversity, equity, and inclusion within partnerships.

To effectively achieve improved health outcomes, the DNP student interfaces with multiple types of partnerships at several different levels. There will be opportunities

320

ChapterlO Leading Implementation Through Collaboration

CO establish, manage, evaluate, and sustain practice partnerships between community health care, or primary care centers, and academic settings. Regardless of the location or setting, the student brings a foundational knowledge of team dynamics to the partnership settings. However, during the project, DNP students effectively lead part nership work, as they identify collaborative goals, collegial ambitions, and expected contributions of the partners as the parmers move toward managing and directing roles, strengths, limitations, and resources for the collaborative work. As leaders, DNP students will demonstrate mutuality, respect, and the acceptance of cultural differences within and among specific partnerships. Ultimately, while leading collab orative partnerships, students learn that what can be achieved together is greater than what either partner could achieve alone (Pusa et al., 2021). Creating, leading, and sustaining collaborative partnerships requires an intentional plan, accompanied by expert leadership skills. This work is not for the “faint-of-heari,” but for the student who persists, there is significant potential to increase the quality and access to health care, to change policies, and to diminish costs.

When and where to

Where and When Does Collaboration Take Place?

When and where to implement the change may

implement the

be influenced by the DNP student’s collaborat

change may

nization. Ash et al. (2017) cautioned that even

ing team based on the assessment of the orga

be influenced

a desirable change can meet resistance by the team members and other members of the orga

by the DNP

nization. DNP-prepared nurses must be change agents for successful collaboration and under

student's

stand and apply various change theories to ac complish collaborative team goals. Gathering the team together, particularly in the planning and implementation phases of the project, will likely take place during the practicum experience in the facility/community chosen to implement the DNP project. During this time, the DNP student will use the organi

collaborating team based on the assessment of

the organization.

zational evaluation techniques learned in DNP

core courses, leadership skills and knowledge, and implement change theory tech niques if the project involves a practice inten-ention.

How to Accomplish a Successful DNP Project Using

Collaboration

The DNP project allows the DNP student to practice and attain competencies

on

how to lead a collaborative team.

The DNP student can address the following factors to assist the team to achieve the DNP project goals:

●

Shared purpose, goal, and buy-in of members: The DNP student must be clear on articulating the purpose of their project in relation to the benefits to the patients, members of the team, and organization.

Components of Collaboration in the DNP Project

●

●

●

●

3ZI

Reciprocal trust in team members: The DNP student will utilize the practicum experi ence in the organization to foster a culture of trust and transparency. Recognition and value of the unique role or skills each team member brings: Respect for team members and modeling this behavior

The DNP project

by the DNP student allows for successful interaction with and among team members. Functioning at the highest level of skill, abil ity, or practice: The DNP student has the opportunity to utilize clinical expertise in formulating and implementing a scholarly practice innovation and can model the aim

and attain

of the Future of Nursing’s (lOM, 2010; NAS, 2021) call for nurses to practice to the full extent of their education and training.

team.

allows the DNP student

to practice

competencies on how to lead a collaborative

Clear understanding of roles and the responsibilities of team members to meet goals: The DNP student must use high-level communication skills throughout the

project to ensure that each team member understands their role in completing the project. This can decrease conflict and uncertainty among team members and enhance timely completion of the project. ●

●

Work culture and environment that embrace the collaborative process: The DNP student’s evaluation of organizational culture and environment is necessary to

identify barriers to implementing and completing the project and enlist the help of the team to overcome the barriers. Collective cognitive responsibility and shared decision making: The DNP student is the leader of their project team but must enlist the aid of team members for timely and appropriate decision making during all aspects of the project process.

DNP students can use these principles of integrated clinical models and in terprofessional collaborative best practices during their practicum experiences and in implementing their DNP projects. Dr. Abby Winterberg illustrates the value of leadership and interprofessional collaboration in a project involving information technology in Exemplar 10-1.

Exemplar 10-1 The Impact of Interprofessional Collaboration and Information Technology Innovation to improve Healthcare Outcomes

Abby Winterberg, DNP, APRN, FNP-BC As a nurse practitioner in a pediatric pre-anesthesia consult clinic. I am passionate about ensuring that each patient has the best perioperative experience and outcome. With my prior background as a research assistant in the basic sciences, I aspired to not only deliver exceptional care, but also to develop new solutions that would improve patient experiences, quality of care, and outcomes. The DNP program offered the perfect opportunity to develop skills for my ideal role through mastery of the DNP Essentials.

particularly interprofessional collaboration and information technology.

322

ChapterlO Leading Implementation Through Collaboration

My DNP project focused on the development and implementation of an electronic tool for documenting pediatric behavioral responses to anesthesia inductions (Winterberg et al., 2018). This initially seemed like a simple challenge with a straightforward solution. In reality, effective execution of the project required in-depth knowledge of the scientific literature, collaboration with experts in the field of anesthesia, development of staff education, partnering with a PhD researcher to develop a staff survey/metrics, and collaboration with our electronic health records team. The interprofessional approach to development was successful, as the electronic tool we developed (the Child Induction Behavioral Assessment) was subsequently validated and continues to be a sustainable method for electronic documentation eight years after implementation. I wanted to continue the type of work I was doing during the DNP program after graduation, but found there was no role in my department for an advanced practice registered nurse (APRN) doing this type of work. Toward the end of my doctoral program. I requested a one-on-one meeting with the anesthesia chief. I shared the in-depth project work that was completed during my DNP program and highlighted the skills that could benefit our department. I expressed my desire to continue working in our department, but that I aspired to have a combined role in clinical care and quality improvement/research. After a few additional discussions with the anesthesia chief and our director of

research, we created an innovative role for an advanced practice DNP-prepared nurse. Since graduating in 2015.1 have been principal investigator on eight grants that have spanned many clinical-practice focused projects. Projects have included conducting multiple studies, including validation of the Child Induction Behavioral Assessment (CIBA) tool and product development-focused research. Research studies have been accomplished through partnerships

with PhD-prepared scientists, statisticians, and anesthesiologis ts with expert practice knowledge.

In 2020. the CIBA validation study was published in the journal Anest/ies/a

& Analgesia (Winterberg et al.. 20201. This publication brought CIBA to the

attention of a team at the Hospital for Sick Children in Toronto. Canada. This team was already working with the electronic health record company (Epic) to create a standardized induction assessment form and asked to include

CIBA as a part of this new form. CIBA was subsequently incorporated into the standardized induction form, licensed to Epic and adopted at over 100 medical centers across the United States and multiple centers internationally.

The standardized induction form provides a method to monitor induction interventions and outcomes. Future work will use these data to develop

quality benchmarks and evidence-based guidelines for pediatric induction interventions. The CIBA project highlights the importance of disseminating

DNP projects through publication in order to build the scientific literature. Additionally, this work highlights how continuation of a DNP project and DNP role development after graduation can lead to multi-center collaboration,

widespread implementation, and practice changes. Through working on the CIBA project. I recognized that despite existing interventions, many children were highly anxious during anesthesia induction. My knowledge of the research literature and existing best practices led to a novel idea for developing a digital product to improve pediatric inductions—a breathingcontrolled gaming app/device. This patent-pending gaming device is designedto easilyengagechildrenin the processof anesthesiainduction through breathingcontrolled gameplay (Winterberg et al.. 2022). My team is currentlyworking

Operationalizing the Project Plan

323

to make the product available to other hospitals through commercialization. Developing a new app/device required many internal and external collaborators, including team members with expertise in product design, videography. engineering, computer programming, and marketing. While working with colleagues from many different professions. I have often had to learn new skills and adapt to using new technologies. I also had to develop creative ways to share my ideas. My DNP program placed a strong emphasis on the use of technology in our coursework. making the process of learning new technologies second nature. The ability to quickly learn new technologies, particularly different apps. has

been exceptionally useful. Apps have enabled me to create short movies, develop animations and storyboards, and even learn basic computer coding skills to

create a prototype app. The technology and informatics skills acquired during my DNP program have undoubtedly enabled success in my current role. The unique preparation acquired during the DNP program enables DNP-prepared nurses to be leaders and strong collaborators across many disciplines. As front-line clinicians. DNP-prepared nurses have an optimal

vantage point to develop and implement innovative solutions to complex healthcare challenges. The competencies and skills learned during the DNP program are key components that allow clinicians to adapt and effectively lead in an ever-changing technological and healthcare environment.

^ Operationalizing the Project Plan The next step in operationalizing the project plan is the action phase of the project implementation process (Pinto & Slevin, 1987) (see FlgurelO-3).

The Client Personnel, and Technical Skills The next two factors to consider in the operationalization phase of project imple mentation relate to human resources. These include the client (defined as anyone who has an interest in the result of the project) and personnel recruitment, selec

tion, and training (Pinto «Sr Slevin, 1987). First, consider the client’s needs. The

student needs to make sure that the end users (i.e., key stakeholders or those who

will be affected by the outcome of the project) are consulted during this process to help inform the project. See Chapter 6, Validating the Problem and Conceptualizing

the Project Plan for more information on identifying key stakeholders. Next, the

student needs to gather the team. What is most important to note about the team is the need to select the right person with the right skill set for the right Job. Certainly, the team includes the student’s project faculty mentor and practice mentor, but

the team may also include additional members whose primary responsibilities are

implementing various aspects of the project. For example, certainly it is important to have the technology available to support the project, but it is also important that team members possess the ability to use technology to successfully meet the project goals and objectives. In addition to having the right skill mix, team members also need to be com

mitted to the project. When commitment is lacking on the part of any team mem ber, the project outcome can be negatively impacted. Once the team is gathered, it is time to prepare for training. As mentioned earlier, most projects will require some

w N

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Project Status Report

341

References Arthur, J. (2011). QI macros example book. Denver, CO: KnowWare Iniemalional. Balanced Scorecard Institute, (n.d.). Balanced scorecard basics, https://balancedscorecard.org/bsc -basics-overview/

Chapman, A. (2011). Six Sigma definitions, history, overview. Businessballs. https://www.businessballs .com/performance-management/six-sigma/ McLaughlin, D. B., & Hays, J. M. (2008). Healthcare operations management. Chicago, IL: Health Administration Press.

Pinnacle Enterprise Group. (2012). Lean and Six Sigma, http://www.pinnacleeg.com/shp-lean-and -six-sigma.php/page/services/service/lean-and-sbt-sigma QI Macros. (2012). The shortcut to lean Six Sigma ersults/http://www.qimacros.com

CHAPTER 11 Et

‘A

Driving the Practicum to Attain Competency and Leverage Impact Through the DNP Project Amy Manderscheid and Rosanne Burson CHAPTER OVERVIEW

The practicum is a unique opportunity to plan field experiences that support the development of advanced nursing practice and professional scholarly growth. Practicum experiences provide an opportunity to apply, integrate, and amalgamate the Essentials: Core Competencies for Professional Nursing Education (AACN, 20211 necessary to demonstrate achievement of desired outcomes within advanced nursing practice.There is also the potential to use the practicum in preparation for implementation of the DNP project. This chapter presents a process to focus and

organize plans for an effective practicum with the designed outcomes to ultimately achieve impact. The practicum plan is driven by the DNP student's identified needs in collaboration with faculty and mentors. CHAPTER OBJECTIVES After completing the chapter, the learner will be able to: 1.

2. 3.

h.

Assess professional growth needs in relation to the Essentials for Advanced-Level Nursing Education and the project needs. Develop objectives for the practicum to successfully attain goals for professional development. Identify an appropriate site and effective mentor for the practicum in collaboration with the faculty. Use the opportunities within the practicum for professional growth and to prepare for DNP project implementation.

® Sandipkumar Palel/DigitalVisioit Vectjis/Getty Imsgss

343

344

Chapter 11 Driving the Practicum to Attain Connpetency

^ Praeticum Purpose As the time for the practicum course approaches, DNP students may be at very different points in their preparation for the DNP project. The DNP student may have developed a keen view of the phenomenon and reviewed many aspects of the literature surrounding the phenomenon. There may be an understanding of the clinical question and the process that will be used for outcome improvement. Some of the integral structural parts of the plan may be in place, such as potential nursing theories that will support the project, or there may be some early thoughts on the methodology that will be utilized in the DNP project. At this point in the curriculum, the student may have completed some of the DNP program coursework, which undoubtedly strengthened the student’s skill set related to the Essentials for Advanced-Level Nursing Education (AACN, 2021). The student should also be deciding on a project type and considering all the compo nents that will be required to complete the project successfully. It is important that the student understand that the DNP project team members and faculty support are available for assistance. (See Chapter 8, The DNP Project Team: Preparing for Project Imple mentation, for specific information related to The practicum is relationships with the project team members.) The practicum is another opportunity for an ideal location the student to hone skills within the Essentials for to build the Advanced-Level Nursing Education (AACN, 2021). However, practicum activities can also be used required skill set to further networking relationships and assess the organizational climate as a precursor to the of the student implementation of the DNP project. The practi cum is an ideal location to build the required and develop the skill set of the student and develop the setting for setting for the the project. This field time is also an opportunity

project.

to showcase the abilities of the DNP student and

market the potential of DNP education to assist organizations in transition driven by data.

k Identifying the Setting The DNP student should consider the potential setting of the DNP project as they

plan for the practicum. It may be beneficial to consider a setting in alignment with the role or specialty of the DNP degree the student has chosen. For instance, a project that will improve the quality of care delivered to ventilated patients in the intensive care unit will require an acute care setting. In this case, there are several questions to consider before embarking on the practicum experience. Such as, is the student specializing in health systems leadership or acute care advanced practice nursing? Does the student have access to an acute care organization? The student may be working within an acute care organization, or they may have a professional contact within another organization. Some universities have been strengthening their practice partnerships to enhance

learning for DNP students and commit to strategic organizational goals related to

Identifying the Setting

345

health care. This approach provides an environment and key stakeholders who are committed to the project. Academic practice partnerships are intentional relationships based on shared vision, goals, knowledge, and respect (AACN/American Organization

of Nurse Executives [AONE], 2012). Chapter 3, Scholarship in Practice, discusses academic practice partnerships in more detail. The academic practice partnership creates a system for doctoral nurses to achieve their goals for project development, implementation, and evaluation within the practicum and during project completion. It is important for the DNP student to have a full understanding of the college or university-

It is important

requirements of the practicum. Some universi ties do not allow practicum hours within the or ganization of their place of work; others require

for the student

that the student not work within the confines of

to have a full

their current role in the organization. Each practicum setting choice has distinct positives and negatives. A practicum in an orga nization of which the student is not a member

or employee offers a new lens that can broaden

understanding of the project topic. The DNP student may identify issues within the practi cum organization that align with the student’s experience, or issues may be considerably dif

understanding of the college or university requirements of

the practicum.

ferent as a result of the Organizational Assess ment. The organization may benefit from a fresh pair of eyes viewing areas in which the organization has an interest, as well as expert hours offered to work on these specific aspects of the organization. If the student is completing a practicum within their organization, one can assume that a relationship and a level of trust has developed. The student may have knowledge of the environment and different departments to work with to complete practicum and project objectives. Although this knowledge is helpful, it is import ant for students to separate themselves from their usual workday competencies. The student should keep in mind that it may be difficult for others with whom the student works to relate to the student in another capacity. Regardless of employment status, the bulk of the practicum can be positioned in the organization where the DNP project will be implemented. Understanding the organization and developing relationships and trust are critical features that will help the student successfully implement the project. Caution should be ex ercised, however, because the organization and the student may have competing goals. Further, the practicum design should incorporate specific experiences and deliverables that will give the student the opportunity to demonstrate the devel opment of relationships and networks to facilitate the DNP project. For instance, as discussed in Chapter 9, The Proposal, identifying the institutional review board (IRB) representative and spending time asking specific questions related to the or ganization’s IRB application process will help the student develop a collaborative relationship and smooth the way for this part of the process. As part of the Essentials for Advanced-Level Nursing Education, students who actively engage throughout the practicum may find experiences and opportunities meaningful (AACN, 2021). Finally, the student must remember several items. The student is demonstrating the Essential Competencies for Advanced-Level Nursing Education to the organization.

346

Chapterll Driving the Practicum to Attain Competency

The student Is

dennonstrating the Essential

Connpetencies for Advanced-

Level Nursing Education to

the organization, and nnay serve as a role model

that inspires the development

of potential suitable roles for

DNP-prepared

and may serve as a role model that inspires the development of potential suitable roles for DNPprepared nurses. The student is marketing not only their self, but also the value-added benefits of the DNP-prepared nurse. Expect many oppor tunities within the practicum to discuss what the DNP-prepared nurse is and why the student has chosen this path. Preparing an “elevator speech” ahead of time can assist the student to respond in a logical, consistent, and concise manner. It is necessary to be able to respond in various time frames—a very short one-minute response, as well as responses that are afforded more time. A student may identify the need for an in dependent study to become further immersed in a specific topic. For example, a DNP stu dent may complete an informatics independent study to become more fully informed regarding available software and information technology (IT) issues to implement a project. As the DNP student considers the project scope, the realiza tion of the need for additional understanding of informatics may evolve. Many DNP programs have elective courses built into the curriculum

and encourage independent studies that will ul timately strengthen the project.

nurses.

An assessment

of the student's current skill set

prior to the onset of the practicum Is essential in

developing a

practicum plan that will address

strengthening core

competencies.

^ Matching Student Competency with Project Needs An assessment of the student’s current skill set

prior to the onset of the practicum is essential in developing a practicum plan that will ad dress strengthening core competencies. A rec ommended approach is to review each of the Essentials for Advanced-Level Nursing Education (AACN, 2021) to identify specific areas for one’s professional growth. For example, consider Domain 8; Informatics and Healthcare Tech

nologies. One of the identified competencies supports the use of technology for communica tion and documentation between the team mem

bers (AACN, 2021). The student may choose to design a plan for the practicum hours that will incorporate experiences to strengthen this core competency by spending time within the

Matching Student Competency with Project Needs

347

Informatics or Information Technology departments, or with an informatics nurse or team. Additionally, a student may also identify Domain 7: System-Based Practice to develop competencies that incorporate the ability to develop cost-effective care and sustainability (AACN, 2021). As a result, the student may choose to meet with leaders who design, operate, and are responsible for their department financial plan to fur ther understand healthcare costs, reimbursement,and the value of teachnology with efficient and effective care, as it relates to the project and other domains and Essentials. In addition to identifying learning needs for the student, an assessment of the competencies that will be needed specifically for the DNP project assists in designing the practicum. For example, the student may determine that outcome data for a pop ulation will need to be extracted as a step in the project. So, within the practicum, the student will want to identify a specific outcome or deliverablethat will assist in the progression of the project. Examples of de liverables may include defining data sets that are Move through applicable for the DNP project, or it may be iden tifying and working with the data or information

technology department within the organization. Both of these outcomes will assist in moving the project forward through the practicum. The student should move through each of the Essentials for Advanced-Level Nursing Educa tion (AACN, 2021) domains, competencies, and subcompetencies to determine what additional experiences will be needed for the project, differ entiating current student strengths from compe tency areas that will be attained in the practicum (see Table 11-1). In this table, column 1 describes the domain

for this Essential. The next column displays the AACN Essential competency statement, followed by the Advanced-Level Nursing Education (AACN, 2021) subcompetency. Next, the DNP student completes a self-rating of their current compe tency on a scale based on Benner’s (1984) nov ice to expert 1-5 competency levels. The student

then indicates in the following column whether this particular skill set is needed for the practicum, project, and/or included in SMART objectives. Lastly, the student is able to include pertinent, helpful notes in the final column. The complete competency assessment for practicum design tool template is available electronically via the link in the Resource section at the end of this chapter. It includes all the Essentials for Advanced-Level Nurs ing Education and related competencies. Once students have worked through all the Essentials for Advanced-Level Nursing Education domains, competencies, and subcompetencies in relation to the self-identified learning needs

each of the

Essentials for Advanced-Level

Nursing Education

domains,

competencies, and sub

competencies to determine

what additional

experiences will be needed

for the project, differentiating areas of student

strength with what will need

to be pursued in the practicum.

Table 11-1 Competency Assessment for Practicum Design

OB

Indicate if included

Advanced Level Domain

Competency Statement

1.

Knowledge

1.1 Demonstrate an

for Nursing

understanding of the discipline of nursing's distinct perspective and where shared perspectives exist with other

Practice

Nursing Education Sub-competencies

DNP Student

in practicum/project

Competency Rating

SMART goals

5

*

l.le Translate evidence

from nursing science as

o

Notes

3" Oi

●o (D

D

5


1) to optimize health system performance

The Importance of Evaluation

369

The Triple Aims

ffl To improve the experience of care Iquality/satisfaction], ff2 To improve the health of populations. 03 To reduce cost.

Figure12-1 The Triple Aims Data from Befwyk. D. K.. Nolan. T. W.. & Wtiittirgton. J [2008!. Tfie triple aim: Care, health, an

and improve the lives of patients (Berwick et al., 2008; IHI, n.d.).

Pursuit of the aims is challenging, as health care is complex and most problems are multifac eted and difficult to improve. Improvement can be attained through use of evidence-based solu tions and evaluation (Sherrod & Goda, 2016).

There is a plethora of scientific evidence that can be used to optimize health system performance. But how does one know if an

Improvement can be attained

through use of evidence-

based solutions and evaluation

evidence-based solution works? And how can

(Sherrod & Goda health systems make intelligent choices about which evidence-based solutions are likely to 2016). work within their setting? Embracing a practi cal, robust evaluation methodology can lead to improvement in health care that is measurable and sustainable (Shaughnessy et al., 2018). Systematic use of evaluation has solved many problems and helped count less healthcare systems do what they do better, Evaluation has changed dramati cally with new methods and approaches that can be used in diverse populations and settings. IHI calls this the science of improvement, an applied science that emphasizes innovation, rapid-cycle testing in the field, and spread in order to learn what changes, in which contexts, to produce improvement (Deming, 1986; Institute for Healthcare Improvement [IHI], n.d., Science of improvement). ● ●

It combines expert subject knowledge with improvement methods and tools. It is multidisciplinary, drawing on clinical science, systems theory, psychology, and statistics.

●

It includes identifying a clear aim for the improvement desired and an evalua tion plan, which includes measurement.

An important element of the science of improvement is learning from data over time to detect improvement. The Model for Improvement is often used to guide cycles of testing in the field. The use of the science of improvement requires the highest level of scientific knowledge and clinical practice expertise (http://www.ihi,org), As stated in Chapter 2, Defining the Doctor of Nursing Practice; Historical and Current Trends a DNP-prepared nurse is a clinical practice scholar who possesses the knowledge and skills to improve

370

Chapter 12 Evaluating the Doctor of Nursing Practice (DNP) Project

patient and system outcomes within health care. To validate the scholar’s knowledge and skills, a DNP project is completed. One component of the project is evaluation of an improvement in a process, policy, or outcome in health care.

The difference

between nnaking a change and nnaking an innprovennent is

distinguished by

evaluation (Sylvia &Terhaar, 2018).

^ WhyDoan Evaluation? The difference between making a change and making an improvement is distinguished by evaluation (Sylvia & Terhaar, 2018). If the im provement is not measured, one does not know if it improved. Evaluation within a DNP proj ect allows a student to demonstrate the current

status, set goals for the future, and monitor the effects of improvements as they are made. How does one know if the DNP project leads to im provement? Simple—evaluation.

i A Framework to Guide an Evaluation Plan The Centers for Disease Control (CDC) Evaluation Framework provides a prac tical, nonprescriptive, ordered process to design an evaluation plan (Milstein et al., 2000).

The framework contains two dimensions: steps in the evaluation process and standards for “good” evaluation. The six interconnected steps (Table 12-1) are actions that should be a part of evaluation planning, and are completed in sequence, as earlier steps provide a foun dation for subsequent steps. The 30 standards (Table 12-2) are organized within four groups to assess whether an evaluation plan is well-designed in a DNP project. Utility standards establish boundaries for the evaluation. Feasibility standards ensure that the eval uation makes sense and that the steps in the plan are both viable and pragmatic. Propriety standards ensure that the evaluation is ethical, conducted with regard for the rights and interests of those involved. Finally, accuracy standards ensure that the evaluation findings are considered correct. Table 12-1 CDC Evaluation Framework Steps in the Evaluation Process Step 1

Step 2

; Engage stakeholders to be a part of the evaluation to ensure their : unique perspectives are understood. When stakeholders are not ■ involved, evaluation findings are often ignored, criticized, or resisted.

Describe what is being evaluated, the core components to make the change, its stage of development [new and untested or well used), and

j how it fits within the context (setting and participants); and expected I outcomes (e.g., reduced falls, increased timely appointments).

A Framework to Guide an Evaluation Plan

steps

371

; Focus the evaluation design by planning. State the purpose: to gain j insight; improve how things get done; or determine what the effects are. I Identify the design: experimental (e.g., compare a randomly assigned I group who took part in a walking program with those who did not); [ quasi-experimental (e.g., patients who took part in a diabetes program ; compared to those on a waiting list); a comparison within a group over i time (e.g., over 5 years); or observational comparison within a group to i describe what happens (e.g., pre/post-comparison of fall rates).

Step 4

Gather credible evidence that is believable, trustworthy, and relevant counts as "evidence." Select measures during planning. Measures may be short term or long term, and several should be selected. Data sources may be people (e.g., surveys), documents (e.g., chart audits), or observations (e.g., watch hand washing). Selecting multiple sources provides an opportunity to include different perspectives and enhances evaluation credibility. Identify the amount of data to be collected, the time period

i to answer the clinical question, thinking broadly about what !

; I I

! collected, and how it will be gathered. Step 5

i Justify conclusions. Evidence must be carefully considered from I different perspectives to reach conclusions that are substantiated. ! justified, and linked to the data. This includes values held by i stakeholders to judge whether a project is "successful," "adequate." or "unsuccessful."

Step 6

Ensure use of evaluation findings for decision making and subsequent action. Prepare for use of the findings—begin during planning and continue throughout the evaluation.

Data from Berwyk. D. M.. Nolan. T. W.. & Whittington. J. (2008). The triple aim: Care, health, and cost. Health Maifs, 27[i]. 759-769; Institute for Healthcare Improvement. (n.d.), IHI Triple Aim. http://wwv.ihi.org/Engage/lnitiatives/TripleAim/Pages/default.aspx

Table 12-2 CDC Evaluation Framework Standards for “Good Evaluation” Utility

Stakeholder identification of those involved in or

standards

evaluation, so their needs can be addressed.

affected by the

Evaluator credibility to assure those conducting the evaluation are trustworthy and competent, so that the evaluation will be generally accepted as credible. Information scope and selection identification, so data collected i addresses the clinical question and is responsive to the needs of patients and stakeholders. Values identification, so the procedures and rationale to interpret the findings are described and the basis for judgments about merit and value are clear.

Report c/ar/fy should clearly describe what is evaluated, the context, purpose, procedures, and findings to ensure the report is easily understood.

[continues]

372

ChapterIZ Evaluating the Doctor of Nursing Practice (DNP) Project

Table 12-2 CDC Evaluation Framework Standards for “Good Evaluation"

[continued]

Report dissemination midcourse, so intended users can use findings in a timely fashion.

Evaluation impact reported in ways that encourage follow-through by stakeholders.

Feasibility Practical procedures to keep disruption of everyday activities to a standards i minimum while needed information is obtained.

I Political viability planned with anticipation of the different interests of I various groups, i Cost effectiveness of the evaluation should be efficient and produce i enough valuable information that the resources used can be justified.

Propriety \ Service orientation designed to help an organization effectively serve

standards | the needs of all of the targeted participants. Formal agreements on what is to be done, how. by whom, and when, in writing, so that those involved are obligated to follow the agreement.

i Rights of participants respected and protected. Human interactions respect basic human dignity and worth, so ' participants do not feel threatened or harmed.

Complete and fair assessment, recording strengths and weaknesses, allowing strengths to be built upon and problem areas addressed. Disclosure of findings and limitations of the evaluation are accessible to everyone affected by the evaluation.

^ Conflict of interest dealt with openly and honestly, so the evaluation ^ process and results are not compromised. ! Fiscal responsibility, evaluators' use of resources should reflect

^ accountability and be prudent and ethically responsible.

Accuracy j Documentation should be clear and accurate, so that what is being standards I evaluated is clearly identified. Context in which the project takes place should be examined, so that likely facilitators and barriers are identified.

Describe purpose and procedures in enough detail that they can be ; evaluated. Defensible information sources should be described

in enough detail that the adequacy of the information can be assessed.

Valid information gathering procedures should be chosen or developed and implemented in such a way that they will assure that the interpretation is valid.

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373

Reliable information gathering procedures should be chosen or developed and implemented to assure that the information obtained is sufficiently reliable. Systematic information is review of any errors found, and how they are corrected.

Analysis of quantitative information data from observations or surveys—should be appropriately and systematically analyzed, so that evaluation questions are effectively answered. Analysis of qualitative information, which is descriptive from interviews and other sources, should be appropriately and systematically analyzed so that evaluation questions are

I effectively answered. ; Justified conclusions reached in an evaluation should

be explicit, so

■ stakeholders can understand their worth.

Impartial reporting procedures should guard against the distortion caused by feelings and biases of people involved in the evaluation, : so reports reflect the findings. Meta-evaluation is evaluation against own data and pertinent ' standards, to examine strengths and weaknesses.

,L..,

Data from Milstein, B.. Wetterhall, S.. & CDC Evaluation Working Group. (20001. A framework featuring steps and standards for

program evaluation.//ea/tt/Vomof/dn/’racf/a./Ol. 221-228. https://doi.Org/10.1177/1524B3990000100304

The framework guides users to plan an evaluation that is useful, feasible, ap propriate, and accurate, answering the questions: What is the best way to evaluate? What is learned from the evaluation? Now that a basic understanding of the steps in the evaluation process and the standards for “good” evaluation are known, it is im portant to understand the types of evaluation and how to select which type should be used in which circumstance.

k Types of Evaluation In order to plan the evaluation within the DNP project in accordance with the most appropriate approach, it is necessary to understand the different evaluation types. There are two main types of evaluation, formative and summative, and each type is used for a different reason (Figure 12-2). Formative evaluation ensures that an intervention is feasible, appropriate, and acceptable before it is fully implemented. There are two reasons formative eval uation is conducted:

1. When a new intervention is being developed to assist in the early phases of development so that early improvements can be made. Some examples are: Was it feasible to deliver the intervention to patients or within the setting? Was the intervention or program appropriate for the patients? Did patients accept the inter vention or program?

374

Chapter 12 Evaluating the Doctor of Nursing Practice (DNP) Project

● Used during development or Formative evaluation

\N \

modification.

>

● Informs goal achievement or ways to improve.

\

Summative evaluation

●

Examines data to determine

outcomes and impact of an improvement.

Figure12-2 Types of evaluation

2, When an existing inien'ention is being adapted or modified. Adaptation or modification, adding to or removing a part of an intervention that already ex ists, is usually done so that it fits the needs of patients (e.g., able to read educa tion handouts) or the healthcare system (e.g., fits into workflow of nurses). An example is: Did the same outcome occur when volunteers were used instead oj nurses to deliver the intervention or program? Process or implementation evaluation determines whether the intervention components were implemented as intended and resulted in expected outputs (e.g., effectiveness, improved quality of care, improved safety, and cost reduction or ben efit). To obtain the results on the use, some of the following questions are usually answered.

● ● ● ● ● ●

Who (e.g., patients, nurses, techs) used the intervention, program,or policy? What (e.g., reduced BP or wait time) did the intervention, program, or policy do? When (e.g., on Monday, weekly) did the intervention take place? Where (e.g., at home, at hospital) did the inter\^ention, program, or policy take place? What are the barriers (e.g., too much information) and facilitators (e.g,, incen tive to use) to implementation of the intervention, program, or policy? Did the established intervention or program change over time (e.g., only half of education materials used)?

● ●

Were there inefficiencies (e.g., nurse took 2 hours rather than 20 minutes) in delivery? Were inter\'ention or program components accurately portrayed for replication elsewhere?

Examples of process or implementation evaluation include; Did the intervention or program meet the goal for usage? Did patients receive the specified number of home visits in the inien'ention or program? Summative evaluation provides information on an intervention’s effective ness and efficiency and information related to the implementation process (e.g., as

Types of Evaluation

375

expected, cost, or impact). Summative evaluation is conducted after the completion of development, and during and after implementation. There are several reasons summative evaluation is conducted and four are discussed.

Outcome or effectiveness evaluation is used to measure the effect of the inter vention on the target population or on the health system, assessing the progress in the outcomes that the intervention is to address. Outcome and effectiveness eval

uation often includes short-term, intermediate, and long-term results. Outcome or

effectiveness evaluation is usually used to determine one of three things: 1. To decide whether the intervention, program, or policy affected patient outcomes.

2. To determine changes in comprehension, attitudes, behaviors, practices, or workflow.

3. To establish and measure clear benefits of the intervention, program, or policy. Examples of outcome or effectiveness evaluation include the following: Did patients report the expected changes after completing the intervention or program? What are the short-term, intermediate-, and long-term results of use of the new policy? Economic evaluation is used to determine if the cost of providing the inter vention, program, or use of a new policy outweighed the expenditures, called

cost-benefit or a reduction in cost, thus known as cost effectiveness. Often, re

turn on investment (ROI) is calculated by subtracting the initial value of the cost of the investment (e.g., implementation costs of intervention, program, or innovation) from the final value of the investment (which equals the net return), then dividing this new number (the net return) by the cost of the investment, then finally, multiplying it by 100 (Table 12-3). Examples of economic evalua tion questions include: What was the cost of delivering the intervention or program? What were the savings after providing the intervention or program? Were costs reduced overall from prior years? V^at is the ROI of a new telemedicine platform and staff to support care? Did use of the new school-based violence prevention program reduce security officer cost? Impact evaluation is used to assess an intervention, program, EBP, or poli cy’s ability to achieve its ultimate goal. Impact evaluation focuses on long-term, sustained change as a result of the intervention, both positive (e.g., saved costs) and negative (e.g., increased wait time) and intended (e.g., reduced BP) and un intended (e.g., increased anxiety and depression). Impact evaluation is usually

Table 12-3 Return on Investment

Final value (net return) of investment = $500,000 Minus initial cost of investment

$250,000 = $250,000

Divide by final value Multiply by 100

$250,000/$500,000 = 50% ROI

376

Chapter 12 Evaluating the Doctor of Nursing Practice (DNP) Project

used to determine one of two things: how the intervention influenced policy; and how those who received the intervention compared to those who did not receive it. Examples of impact evaluation questions include: Whs there an improvement in patient or system outcomes? Did the new policy contribute to a change in the outcomes or impacts? Were there any unintended consequences of the intervention, program, or new policy? Once the student understands the different types of evaluation, then a determi nation can be made of what type of evaluation method fits the DNP project design, methods, and clinical question.

k Evaluation for Research or improvement Two types of evaluation are typically utilized in health care: one is the evaluation for research (e.g., designing and testing a new intervention) and the other is evaluation for improvement (e.g., implementing in a new setting or program/policy). However, evaluation for research is very different from evaluation for improvement (Table12-4). Practice scholars review research within the scientific literature (e.g., meta-analysis, systematic reviews, randomized controlled trials) that can be used as a basis for an improvement in a DNP project. If a project is using evidence from the literature that has never been used in the type of setting where the project is being conducted (e.g., literature is in acute care and will be used in primary care) or with a new population (e.g., literature is in age 20-30 years old and will be used with older adults [65 years old or older]), both formative and summative evaluation should be conducted

simultaneously. This approach will provide information on usage of the intervention, program, EBP or policy in a new setting or population and if it was effective. Selection of the type of evaluation to conduct—formative, summative, or both—depends upon what the project entails (Table 12-5). Each project type

Table 12-4 Purpose, Tests, Biases, Data Collection, and Duration of Evaluation for Research and Improvement Evaluation for Research Purpose i To discover new

Evaluation for Improvement To generate new knowledge in practice.

' knowledge, Tests

j One large "blind" test.

I Many sequential, observable tests.

Biases

' Control for as many

i Stabilize biases from test to test.

biases as possible. Data

Gather as much data as

^ possible. Duration i Takes long time to obtain i results.

i Gather just enough data to learn; ; complete another cycle if needed.

Small tests of change accelerate the ' rate of improvement.

Reproduced from Institute for Healthcare Improvement, (n.d.l. Science of impfovement: EstaUishing measures, http://wvw.ihi.org /resources/Pages/KowtoImprove/ScienceoflmprovementEstablishingMe asures.aspx

Table 12-5 Type of Formative and Summative Evaluation, When to Use, What It Shows, Why It Is Useful, and Common Project Type Type of Evaluation

When to Use

What it Shows

Why It Is Useful

Common Project Types

■

■

Allows for

Program Development/

modifications to

Evaluation [PD/PEl

Formative Needs Assessment

During development of a program or design of an intervention.

When an existing program or intervention is being modified or adapted. When an existing program or intervention is being used in a new setting or with a new population.

Whether the proposed program or intervention is likely to be needed, understood, and accepted by the population or health

be made to the

plan before full implementation begins.

system for which it is intended.

■

■

rn

§ c

Q

Maximizes the

O 3

The extent to which an

likelihood that

evaluation is possible, based on the goals and objectives.

the program or

S'

intervention will

to fD

succeed.

Co

0)

Q o

Process Evaluation:

1.

Implementation Evaluation

2.

Program Monitoring

As soon as program

■

How well the program or

■

intervention is working.

or intervention

implementation begins. During operations of an existing program or

■

The extent to which the

intervention.

■

program or intervention is being implemented as designed. Whether the program or

Provides an early warning for any problems that may occur.

■

Quality Improvement (Ql)

3o

Evidence-Based Practice

3

(EBP)

Program Evaluation [PEI

tj o

Allows monitoring of how well the program

3

intervention is accessible

or intervention is

3

and acceptable to its target population or health system.

working.

fD

W

Iconf/nuesl

3

w

s| 00

Table 12-5 Type of Formative and Summative Evaluation, When to Use, What It Shows, Why It Is Useful, and Common [continued]

Project Type

o

Summative

3OJ

Outcome Evaluation;

After the program has

1.

Effectiveness

contacted at least one

Evaluation

person or group in the target population.

2.

Objective-Based

■

Evaluation

The degree to which the program or intervention is having an effect on the target population behaviors or health systems operations.

■

Tells whether

Research/practice-

the program or intervention is being effective in meeting

based Inquiry

Quality Improvement (Ql)

its needs.

(EBP)

Evidence-Based Practice

Program Evaluation (PE) Economic Evaluation;

1.

Cost Analysis

2.

Cost-effectiveness

At the beginning of a program or intervention. During the operation of a program or intervention.

Evaluation 3.

Cost-Benefit

4.

Analysis Cost-Utility Analysis

●o o N m < 0)

c Q)

3 IQ

Provides managers and funders a way to

Program Development/ Evaluation (PD/PE)

ID

intervention and their costs

assess cost relative

Policy Assessment (PA)

D

(direct and indirect) compared

to effects. “How much

to outcomes.

bang for the buck?"

What resources are being used in a program or

■

O n

o o

z c cn

Impact Evaluation

■

During the operation of an existing program or intervention.

■

At the end of a program or intervention.

■

The degree to which the program or intervention meets its ultimate goal.

■

Provides evidence

Policy Assessment (PA)

3

n n

(D

O

5 Tl fD n

Designing an Evaluation Plan

379

discussed in Chapter 7, Aligning Design, Method, and Evaluation with the Clinical Question, (research or practice-based inquiry; QI, EBP, PD/PE, or PA) could fit any type of evaluation approach (needs assessment; process, outcome, economic, or impact evaluation); it just depends on what the project entails. It is useful to know that if an outcome evaluation is conducted, a process or implementation evaluation should also occur. If the outcome evaluation shows that the program or intervention did not produce the expected results, it may be due to an implementation issue or the project timeframe (e.g., did not allow adequate time to examine the change after implementation). Table 12-5 can be used to guide student selection of the type of evaluation that fits the project design, methods, and clinical question.

V Designing an Evaluation Plan Getting Started In Chapter 7, Aligning Design, Method, and Evaluation with the Clinical Ques tion congruence of the DNP project design, method, and evaluation with the pur pose, objectives, and clinical question were discussed, with a variety of project approaches. The DNP project design and methods are usually explicated prior to getting started on the evaluation plan. Questions to consider when designing an evaluation plan include; 1. What will be evaluated?

2. Is improvement being evaluated? 3. Will the evaluation be formative or summative?

4. What criteria will be used to judge performance of the project? 5. What standards of performance on the criteria must be reached for the project to be considered successful?

6. What evidence will indicate performance on the criteria relative to the standards? 7. What conclusions about the project are justified based on the available evidence?

8. Does the evaluation align with the project design and methods?

To clarify the meaning of each question, examine the answers to these ques tions for Get a Vox, a hypothetical program to increase vaccination rates. 1. What will be evaluated? A program focused on increasing vaccination rates through public education and intervention. 2. Is improvement being evaluated? Examined the number of vaccines completed. 3. Will the evaluation be formative and/or summative? Summative, as the interven tion is established and being conducted in a setting (community clinic) and population (adults) that is not new. 4. What criteria will be used to judge performance of the project? The number of eligi ble adults who review educational materials online after receiving information from the clinic and the percentage who are vaccinated. 5. What standards of performance or criteria (e.g., what is the goal or the number to be achieved) that must be reached for the project to be considered successful? Eighty percent of adults in the clinic reviewed the educational materials online and 50% were vaccinated within 6 months.

380

6.

Chapter 12 Evaluating the Doctor of Nursing Practice (DNP) Project

What evidence will indicate performance on the criteria relative to the standards? Number of logins to determine how many adults reviewed educational materi als and rate of vaccinations in 6 months.

7.

What conclusions about the project are Justified based on the available evidence? Are the rates of vaccination due to Get a Vox or something else; or, if no or insuffi cient change was seen, should the program change, or has enough time passed

8.

Does the evaluation align with the project design and methods? Measures were quantitative so design and methods aligned with evaluation.

to see results?

Answering these eight questions provides the information needed to begin to formulate an evaluation plan.

The DNP Project Aim Guides the Evaiuation Plan In Chapter 6, Validating the Problem and Conceptualizing the Project Plan, the DNP project problem statement flows from the key stakeholders, organizational assessment, and literature review, and it is described as a global aim that an swers the question, “What is the ultimate goal of the project?” For infection control practitioners, a relevant aim would be to eliminate hospital-acquired infections. For public health nurses, a relevant aim would be to attain a childhood vacci nation rate of 80% among children. The global aim leads to a clinical question, which often includes an outcome. An example of a clinical question is: “Will use of an evidence-based fall prevention bundle lead to fewer hospital falls?” To gauge progress toward the DNP project aim, the student must conduct an evaluation to consider how they will know if a change is an improvement and mea sure several factors. For example, after implementing the fall prevention bundle, the evaluation would answer the following questions: 1. Did rate of falls among hospitalized older adults decrease? 2. Did the education on how to use the fall prevention bundle reach enough hos pital staff to be an effective implementation strategy? 3. Did the fall assessment, done daily, identify those who might have a fall? 4. Was the use of a gait-belt for ambulation, hourly rounding, and regular toilet ing the reason falls decreased? 5. Was the referral to, and use of, physical therapy the reason falls decreased?

The Project Aim Guides Identification of Measures to Evaluate

The aim and clinical question for the project should guide identification of the measures to evaluate. Table 12-6 displays improvement measures to consider and provides some examples of different types of projects. Baseline measurement of data or the current status of a measure within a pop ulation or organization of interest must be examined to inform the DNP project aim and clinical question. Baseline data informs the organization whether improve ment is needed and after implementation, if improvement was attained. It can also provide an indication as to what is important to the health system. Baseline data (Figure 12-3) should be collected for an adequate length of time to understand the current system, with consideration to context, to determine the appropriate time frame (Shaughnessy et al., 2018).

Designing an Evaluation Plan

381

Table 12-6 Improvement Measures Measure

Definition

Examples

Outcome

Relation of the project aim to performance of population or system under study.

■

For Ql: Number of falls per 1,000 patient days in acute care hospital over 12 months.

■

For policy assessment: Injury rates from non-use of seat belts.

Process

Completion of an activity relating to the project.

■

For program development/ evaluation: Percent who

■

completed 12-week 3-mile walking intervention. For policy assessment: Percent who used school-

based violence prevention actions. Balance

(unintentional

consequences)

Potential way the project might have an unintentional, negative impact on a different part of the system.

■ ■

For Ql: Employee falls from a hand sanitizer spill. For policy assessment: Increases in arrest of

intimate partner violence victims as a result of a new

arrest policy.

Change

Use of implementation strategies relating to the project.

■

For EBP: Percent of RNs

■

who completed education on use of practice guideline. For policy assessment: Number of teachers who use school-based violence

prevention policy.

Rate of delirium in hospitalized 70+ adults who had a fall (2016 and 2017)

60.0% -ooo>o

(D

55$$$5$$$$5 Rate — Mean

Upper control --- Lower control

Figure12*5 Control chart: X- and Y-axis and median Data fiom Institute (or Healthcare Improvement |n.d.). Conlnl chiits. http7/wvm.ihi.org/education/IHI0penSchool/resources/Pages/ AudioandYideo/VlIhiteboardlXaspx

Table 12-7 Whole System Measures to Assess Health System Performance on the Triple Aims Subdomain

Measure

Definition

Individual

General health

Self-rated general health (Excellent, Very Good, Good, Fair, Poor)

Health

Healthy

Overweight/

Behaviors

obesity Optimal lifestyle metric

Percentage of overweight or obese adults

Percentage of adults who do not use tobacco, are physically active, eat five fruits and vegetables daily, and have limited use of alcohol

Community Well-Being and Health Equity

Social support

Self-reported extent to which people have the social and emotional support they

need (Always. Usually. Sometimes. Rarely. Never)

Disparities in infant mortality rate

Difference in death rate for infants under

age of 1 year between white, non-Hispanic women and non-Hispanic black women. non-Hispanic Puerto Rican women. nonHispanic American Indian or Alaskan Native women

Designing an Evaluation Plan

Subdomain

385

Measure

Definition

Disparities in high school graduation rate

Difference in percentage of high school students graduating in four years between: di students who do not have disabilities and students with disabilities; (21 students with

limited English proficiency and students without limited English proficiency; (31 students from low-income families and

students not from low-income families; (4)

white, non-Hispanic students and black and Hispanic students; and (5) white, nonHispanic students and Hispanic students

Experience of Care Domain Measures Access

Timely ambulatory care

Percentage of patients who answer "Always" to Clinician & Group Consumer Assessment of Healthcare Providers and System |CG-

CAHPS®) questions on their ability to get urgent care, routine care, or needed information from a physician's office Prevention

Childhood immunization

Safety

Hospital-acquired conditions

Serious

. reportable events (SREs)

Percentage of children receiving recommended vaccines by age 3 Rates of select conditions in acute hospitals (e.g.. select infections)

care

Number of SREs [categories include surgical or invasive procedures, product or device events, patient protection, care management, environmental, radiologic, potential criminal)

Appropriateness , Preventable and hospitalizations

illnesses or chronic conditions that are

Effectiveness

preventable through effective ambulatory

Rate of hospital admissions for certain acute

care (e.g., diabetes, dehydration) Patient-

Patient-clinician

Centeredness

communication satisfaction

Percentage of patients reporting the highest level of satisfaction with their provider's communication

Per Capita Cost of Care Domain Measures Affordability

Unmet

healthcare needs

Societal

Footprint

' Healthcare cost

per capita

Percentage of patients who either did not receive care due to cost in the past 12 months or delayed care due to cost in the 1 past 12 months Sum of public and private healthcare expenditures divided by size of population

Reproduced from Martin. L., Nelson, E., Rakover, J„ & Chase. A. IZ016). Whole s^tem meesufesI.D: A compass for health system leaders. Cambridge. MA; Institute for Healthcare Improvement.

386

Chapter 12 Evaluating the Doctor of Nursing Practice (DNP) Project

inpatient and outpatient (Martin et al., 2007; Martin et al., 2016). A Whole System Measures approach is based on the following principles: ●

Balance: The measure set must address each of the

three elements of the Triple

Aim (health, care, cost) and balance the current needs and future direction of

●

● ●

the system. Parsimony: To maintain a systems perspective, a small set of measures is required. Alignment: Builds on established metrics so as not to duplicate efforts. Usefulness: Useful to health system leaders and boards to drive improved per formance; signal stability, improvement, or decline; and had a track record of use.

●

●

Consensus: Health system leaders, quality improvement professionals, and evaluation experts have knowledge in this area to be shared. Adaptability: Empirical validity is essential to work in the present environment and to account for the ever-changing healthcare landscape.

The measures supply healthcare leaders and other stakeholders with data that enable evaluation of quality and value that are not disease- or condition-specific to complement other measures to inform strategic quality improvement planning. Whole System Measures may be used within a DNP project.

Use of Multiple Measures (Indicators) Use of multiple measures is needed for most improvement efforts: outcomes mea sures, process measures, and balancing measures (IHI, n.d.. Science of improvement: Establishing measures). Consider each category of measures: outcome, process, bal ancing, and change measures. This will ensure that an accurate picture of the effects of the improvement from the DNP project have been examined. To provide a deeper understanding of each type of measure, a description is provided and examples by project type are shown in corresponding figures. Outcome measures evaluate the patient’s health and capture the system per formance (Figure 12-6). They answer the question: “What are the end results of the DNP project?” The outcome flows from the project aim and clinical question. Process measures are the workings of the healthcare system (Figure 12-7). Process measures are those that capture the changes the DNP project efforts make to the inputs or steps that contribute to the system outcomes. When working with process measures, it is important to focus on the processes that directly con tribute to the outcome that is desired. It is beneficial to link a process measure to an outcome measure. An example is measuring the percentage of time staff adhere with the clinical guideline on vaccinations and then number of children vaccinated.

Balancing measures determine whether changes designed to improve one part of the system are causing new problems in other parts of the system (Figure 12-8). An example is when a new change improves staff satisfaction, yet decreases patient satisfaction.

Change measures are those that are collected with each test of change that is carried out during implementation of the improvement (Figure 12-9). Often, the

Designing an Evaluation Plan

■

387

For research/practice-based inquiry: Percent of patients with hemoglobin Ale

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Q

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2

3

4

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9

10

11

T

12

13

14

Week

Figure12-16 Before/after hours to complete lab test— Scenario two. Data from Institute for Healthcare Improvement. |n.d.l Run chat tool. http7Avww.ibi.or9/tesources/Pages/rools/RunCh3rt. aspx

pre-change cycle time (Figure 12-18). The results may be due to a Hawthorne effect, whereby an initial improvement is observed due to particular attention to the measures, but later when focus on the change decreases, the cycle time reverts to the original process levels. The changes have not resulted in sustain able improvement. If given just the numbers for Weeks 4 and 11, it may appear

406

Chapter 12 Evaluating the Doctor of Nursing Practice (DNP) Project 10

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2

3

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5

6

7

T—I

8

9

10

1—r

11

12

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13

14

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Figure 12-17 Before/after hours to complete Lab test— Scenario three. Data fnm Institute far Healthcare Improveffient. (n.d.|. RandmttxL http^/imwjM.ofs/resnurces/l^es/Ioots/RunChaitas^

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4

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Figure 12-18 Before/after hours to complete lab test— Scenario four. Data from Institute for Healthcare Impnnemenl |n.d.L Amcterf A»f. http://mmv.ihi.or9/resaurces/P3ges/rools/RunChattas 1n

that the change resulted in an improvement. When data for all 14 weeks are reviewed, it is clear the improvements after the change is made (i.e., in Week 8 through Week 11) are not sustained and it can’t be assumed the change in Week 11 is a result of the change. A run chart can be used to display any measure over time and is very easy to develop (e.g., within Microsoft Word or Excel). Its simplicity makes the run chart

Analyzing and Displaying Results of the Evaluation Plan

407

a powerful tool and one of the most useful for understanding and communicating variation. Here are some of the reasons to depict measures on a run chart (IHI, n.d., Run chart tool): 1. 2. 3.

Run charts can help explain baseline performance and identify opportunities for improvement. They can help determine if a change is an improvement. Once an improvement is made, the run chart can be used determine if gains made are sustained.

4.

A run chart can be used to look at any type of measure over time. For example, falls, CLABSI infections, length of stay (LOS), counts, and percentages.

Run charts engage leadership and staff

Run charts can also be a powerful tool for engaging leadership and staff. Without a clear picture of the actual outcomes, it is difficult to create a real desire for change or action around an issue. Quite often, staff are shocked when they are shown the performance of an organization over time and in a way that tells a story, which in turn can generate support for change. Also, it is difficult for leadership to create the business case for investing time and resources in an initiative without first understanding the current system performance. Utilizing run charts to tell the quality story gets everyone on the same page and clears the path for improvement to begin.

Analyzing and Understanding Run Charts Variation

One of the key strategies in improvement projects is to control variation. There are two types of variation: common cause and special cause. Driving to work is a form of variation that many people experience. For example, a daily commute can take between 45 minutes and 60 minutes. There is 15 minutes of variability for extra traffic or having to stop at all the stoplights along the route. This is common cause variation. Special cause variation is that snowstorm that causes the normal com mute to take 120 minutes.

Common cause variation is inherent in a system (process or product) over time, affecting everyone working in the system and affecting all outcomes of the sys tem. A system that has only common cause variation is said to be stable, implying that the process is predictable within statistically established limits. Differences over time are due to chance rather than predictable influence on the system. Common cause does not mean good variation—^it only means that the process is stable and predictable. For example, if a patient’s systolic blood pressure is usually around 165 mmHg and is between 160 and 170 mmHg, this might be considered stable and predictable but it is also completely unacceptable. Special cause variation is not a usual part of the system (process or prod uct), does not affect everyone, and arises because of specific circumstances which are not necessarily predictable. For example, special cause variation may be the impact of a flu outbreak on infection rates or the sustained impact of a targeted improvement activity to improve hand hygiene compliance. In the same way that common cause variation cannot be regarded as “good” variation, special cause variation should not be viewed as “bad” variation. One could have a special cause

Chapter 12 Evaluating the Doctor of Nursing Practice (DNP) Project

408

that represents a very good result (e.g., a low turnaround time), which one would want to emulate. Special cause merely means that the process is unstable and unpredictable. A system that has both common and special cause variations is called an unsta ble system. The variation may not be large but the variation from one time period to the next is unpredictable. Understanding the distinction between common and special cause variation is essential to developing effective improvement strategies. When aware that there are special causes affecting a process or outcome measure, it is appropriate and usually economical to identify, learn from, and act based on the special cause. Often this action is to remove the special cause and make it difficult for it to occur again. When the special cause is due to a targeted activity that pro duces a favorable outcome, the appropriate action is to make it a permanent part of the process. Because variation is normal and constant, data must be plotted over time to be useful (Langley et al., 2009). It is only by plotting data over enough time—both before and after a planned change is implemented—that one can judge whether the variation is random or forms a pattern that indicates that a meaningful change has occurred.

There are four signals of non-random change or special cause that one should look for on run charts. If you do not see evidence of one of these signals, then your data is exhibiting common cause variation. Finding one or more of these signals suggests that further analysis and interpretation by the team members is required in order to understand the causes or factors influencing the change. Keep in mind that not all common cause variation is good, and not all special cause variation is bad.

Signalh Shift A shift signaling change is six or more consecutive points above or below the me dian (Figure12-19). Values that fall directly on the median are not included in this count and neither break nor add to the shift.

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Analyzing and Displaying Results of the Evaluation Plan

409

Signal 2: Trend

A shift signaling a trend is five or more consecutive points going up or down, ex cluding the starting point (Figure 12-20). Where the value of two or more consec utive points is the same, only include one in the count. For quality improvement, either there is a trend or there is not. Charts are

not described as “trending.”

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ChapterIZ Evaluating the Doctor of Nursing Practice (DNP) Project

or too many runs may indicate the pattern is non-random. See Perla, Provost, and Murry (2011) for instructions on determining if there are too few or too many runs in the data.

Signal 4: Astronomical point An astronomical data point is one that is an obviously different value (Figure12-22). Anyone studying the chart would agree that it is unusual. Every data set will have a highest point and a lowest point, but this does not necessarily make these points “astronomical.” It is worth understanding the cause of the astronomical point but not necessarily to react to it. Understanding the reasons for this point will help the team emulate it if it is positive and avoid or address it if it is negative. As special causes are identified and removed or exploited, the process becomes stable. Deming identified several benefits of a stable process (Deming, 1986):

● ● ●

The process has an identity; its performance is predictable. Costs and quality are predictable. Productivity is at a maximum and costs at a minimum under the system.

The effect of changes in the process can be measured with greater speed and reliability. ● ●

PDSA tests of change and more complex experiments can be used efficiently to identify changes that result in improvement. A stable process provides a sound argument for altering specifications that can not be met economically.

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412

Chapter12 Evaluating the Doctor of Nursing Practice (DNP) Project

Female 90%

Nurse gender

Figure 12-24 Example of a pie chart on demographic

Report on the Results of the Improvement Usually, multiple figures are utilized to describe the DNP project findings (e.g., reduced falls, adverse events, or cost; improved vaccination rates, or medication adherence rale) of an improvement project. The evaluation plan figures can be used to tell the story of the DNP project. Each figure needs an explicit title describing the topic of interest (e.g., pain, strokes, falls, adverse events, vaccination rates); the statistic used to describe the findings (average [mean), percent, number, etc.); the time period (year, months, days, etc.); and the median (run chart) or mean (control chan). The value of the data (minutes, occurrences, percentages, etc.) needs to be described so that those who view the figure can understand what is being shown. A stand-alone and understandable depiction of what occurred prior to and after implementation of an improvement project is needed to report on the results of an improvement.

The results of a DNP project to reduce the door to test time for stroke patients in an emergency department is shown in the control chart in Figure 12-25. In addition to displaying results of the DNP project within figures, as shown in Table 7-4 in Chapter 7, Descriptive or Inferential Statistics, such as a paired t-tests, repealed measures ANOVA, and Chi-square analysis are utilized, as appropriate to the clinical question and type of data collected, to report the statistical analysis findings from the improvement.

To tell a complete story of the evaluation of the DNP project, it is important to graphically depict the results of the improvement and report on the statistical differ ences between prior to and after implementation of the intervention, EBP, program, or policy.

Impact

30

413

Average door to test time minutes in stroke patients pre- (2020)/ post- (2021) implementation and the median

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Figure12-25 Example of results of an improvement project on door to test time in stroke patients

Summary In summary, a systematic approach to gather the “proor or evidence that a DNP project was effective so that the results of the DNP project are valid and reliable and are reported in an understandable way to audiences of interest carmot be overstated. This chapter provided general methods for evaluating a DNP project to match the project goals, context, design, and what is being evaluated. Proj ect evaluation contributes to the DNP-prepared nurse developing competency as

a practice scholar. Specifically, this chapter applies to Domain 4 of the AACN (2021) Essentials for Advanced-Level Nursing Education, 4.1h “Apply and critically evaluate advanced knowledge in a defined area of nursing practice” and 4.1j “Dis cern appropriate applications of [quality improvement, research, and] evaluation methodologies.”

Impact The rigor of the evaluation plan will assure that the DNP project results are re ported in a scholarly and understandable manner as well as enactment of the Es sentials competencies specifically stated in Domain 4, Scholarship for the Nursing Discipline.

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Chapter 12 Evaluating the Doctor of Nursing Practice (DNP) Project

Key Messages ●

The DNP project evaluation should be based on the best-practice standards for evaluation.

●

●

●

The evaluation plan should identify why the evaluation is being undertaken, to measure the performance of a program or intervention or for improvement of a population or system outcome. The evaluation should determine if the issues or opportunities identified in the clinical question have been impacted or addressed. The evaluation plan should identify the type of evidence that would be suffi cient for the DNP project and the projects stakeholders to form a conclusion or judgment.

Action Plan-Next Steps 1. Design an evaluation plan that aligns with the project aims, clinical question, project type, design and methods, and stakeholder desires. 2. Formulate a table of measures that includes data that is able to be collected

and meaningful and will support the formation of a conclusion or judgment. 3. Utilize run charts or control charts or other appropriate tools to depict a pro gram or intervention improvement of a population or system outcome.

References American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https;//www.aacnnursing.org^orta ls/42/AcademicNursing^pdf /Essentials-2021. pdf Berwick, D. M., Nolan, T. W, & Whittington, J. (2008). The triple aim; Care, health, and cost. Health Affairs (Project Hope). 27(3), 759-769. httpsy/doi.org/10 .1377/hlthaff.27.3.759 Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science: IS, 4(50). https^/doi .org/10.1186/1748-5908-4-50

de Barros, L. B., Bassi, L. C., Caldas, L. .P, Sarantopoulos, A., Zeferino, E., Minatogawa, V, & Gasparino, R. C. (2021). Lean healthcare tools for processes evaluation: An integrative review. International Journal of Environmental Research and Public Health, 18(14), 7389. https://doi. org/10.3390/ijerphl8147389

Deming, W Edwards. (1986). Out of the crisis. Cambridge, MA; Massachusetts Institute of Technology Center for Advanced Engineering Study Donaldson, M. S., Corrigan, J., & Kohn, L. T. (1999). To err is human: Building a safer health system. Washington, DC: National Academy Press. Helfrich, C. D., Li, Y. E, Sharp, N. D., & Sales, A. E. (2009). Organizational readiness to change assessment (ORCA): Development of an instrument based on the Promoting Action on Research in Health Services (PARIHS) framework. Implementation Science, 4(38). httpsjVdoi. org/10.1186/1748-5908-4-38

Gatchel, R. J. (2004). Comorbidity of chronic pain and mental health disorders: The Biopsychosocial perspective. American Psychologist, 59(8), 795-805. https://doi.org/10.1037/0003-066X .59.8.795

Institute for Healthcare Improvement, (n.d.). Control charts, http://www.ihi.org/education

/IHIOpenSchooI/resources/Pages/AudioandVideo/Whiteboardl3.aspx Institute for Healthcare Improvement, (n.d.). IHI triple aim. httpy/www.ihi.org/Engage/lnitiatives /TripleAim/Pages/default.aspx Institute for Healthcare Improvement, (n.d.). Measure run charts. http://www.ihi.org/Engage /lnitiatives/TripleAim/Pages/default.aspx

References

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Institute for Healthcare Improvement, (n.d.). Run chart tool. http://www.ihi.org^resources/Pages /Tools/RunChart.aspx Institute for Healthcare Improvement, (n.d.). Science of improvement, http://www.ihi.org/about /Pages/Scienceofimprovement.aspx Institute for Healthcare Improvement, (n.d.). Science of improvement: Btablishing measures, http:// www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementEst ablishingMeasures .aspx

Institute of Medicine (US) Committee on Data Standards for Patient Safety, Aspden, E, Corrigan, J.

M., Wolcott, J., & Erickson, S. M. (Eds.). (2004). Patient safely: Achieving a new standard for care. Washington, DC: National Academies Press (US). Langley, G. L., Moen, R. D., Nolan, K. M., Nolan, T. W, Norman, C. L., & Provost, L. R (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). San Francisco, CA: Jossey-Bass. Martin, L., Nelson, E., Rakover, J., & Chase, A. (2016). Whole system measures 2.0: A compass for health ^stem leaders. Cambridge, MA: Institute for Healthcare Improvement. Martin, L. A., Nelson, E. C., Lloyd, R. C., & Nolan, T. W (2007). Whole system measures. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement. Merriam-Webster. (n.d.). Concept definition. InMerriam-Webste.rc omdictionary. httpy/www.merriam -webster.com/dictionary/concept Milstein, B., Wetterhall, S., & CDC Evaluation Working Group. (2000). A framework featuring steps and standards for program evaluation. Health Promotion Practice, 1(3), 221-228. https:// doi.org'lO. 1177/152483990000100304 Perla, R. J., Provost, L .P, & Murray, S. K. (2011). The run chart: A simple analytical tool for learning form variation in healthcare processes. British Journal of Medicine Quality and Safety. 20, 46-51. https://doi.org/10.1136/bmjqs.2009.037895 Provost, L. R, & Murray, S. (2011). The health care data guide: Leamingfrom data for improvement. San Francisco, CA: Jossey-Bass.

Rossi, .P H., Lipsey, M. W, & Freeman, H. E. (2004). Evaluation: A systematic approach. Thousand Oaks, CA: Sage Publications. Schwandt, T. A. (2009). Toward a practical theory of evidence for evaluation. In S. I. Donaldson, C. A. Christie, & M. M. Mark. (Eds.), What counts as credible evidence in applied research and evaluation practice? Cpp. 197-212). Thousand Oaks, CA: SAGE Publishing. Schwarzer, R., &Jerusalem, M. (1995). Generalized self-efficacy scale. In J. Weinman, S. Wright, & M. Johnston (Eds.), Measures in health psychology: A user’s portfolio. Causal and control beliefs (pp. 35-37). Windsor, UK: NFER-NELSON. Shaughnessy, E. E., Shah, A., Ambroggio, L, & Stable, A. (2018). Quality improvement feature series article 1: Introduction to quality improvement. Journal of the Pediatric Infectious Diseases Society, 7(1), 6-10. https://doi.org/10.1093/jpids/pix061 Sherrod, B., & Goda, T. (2016). DNP-prepared leaders guide healthcare system change. Nursing Management. 47(9), 13-16. https://doi.Org/10.1097/01.NUMA.000049 1133.06473.92 Sylvia, M. L., & Terhaar, M. E (2018). Clinical analytics and data management for the DNP (2nd ed.). New York, NY: Springer Publishing. VHA National Center for Patient Safety. (2014). Falls toolkit, https://www.patientsafety.va.gov /professionals/onthejob/falls.asp World Health Organization (WHO), (n.d.). Folls.httpsy/www.who.in t/news-room/fact-sheets/detail /falls

Ziafati Bafarasat, A. (2021). Collecting and validating data: A simple guide for researchers. Advance. Preprint. https://doi.Org/10.31124/advance. 13637864.v2

Impact Implementation

/

/ ■t

r /I Problem

SECTION VI

\

Project Plan

'

s

Identification

Impact CHAPTER 13

CHAPTER 14

From Data to Knowledge: Disseminating the Results

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The Value and Impact of Practice Doctorate Scholarship

439

417

CHAPTER 13

From Data to

Knowledge:

Disseminating the Results Rosanne Burson and Catherine Corrigan CHAPTER OVERVIEW

Some of the first items that Doctor of Nursing Practice [DNPl students should consider as they prepare for the project are the required deliverables within the specific DNP program. Keep the end goal in mind. What are the requirements for graduation in relation to disseminating the results of the DNP project? Some type of dissemination will be required, although there is variability across programs. The requirements typically include a public presentation, a defense of the project, and a written manuscript for the college or university. A journal article may also be required. Finally, there should be dissemination of the project outcomes as an executive summary or a written report designed for use within the organization that supported the project (Davis et al., 2021). Each of these formats will require very different approaches; they need to be considered early to avoid unnecessary rework. This chapterwill review the various options that can be developed as part of disseminating the results of the DNP project. Dissemination is a critical component of nursing scholarship. Nursing scholarship is the discovery, translation, application, and integration of new knowledge to improve health outcomes and transform health care (American

Association of Colleges of Nursing [AACNj, 2021; Burson. 2020). It is essential that DNP-prepared nurses engage in practice scholarship as leaders of the profession and within the interprofessional team to address inequalities and provide optimal care (AACN, 2021). It is through dissemination that collective knowledge becomes wisdom within the profession, DNP-prepared nurses embrace innovation in nursing practice scholarship, add value to the nursing profession and optimize outcomes [Kesten et al., 2021). The Essentials for Advanced Level Nursing Education (AACN. 2021) highlight nursing scholarship in domain 4, In order to disseminate outcomes and quality improvement practices, elements of expert communication skills and techniques using a variety of modalities with diverse audiences are required (AACN, 2021) and will be reviewed throughout this chapter.

® SaodipkufTiar Patel/OigitalVisiwiVecWGetty Images

419

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Chapter 13 From Data to Knowledge: Disseminating the Results

CHAPTER OB3ECTIVES After completing this chapter, the learner will be able to: 1. 2. 3.

Identify the available options for disseminating the results of the DNP project. Discuss recommendations for effective public presentations. Review pointers for manuscript submissions and how to address reviewers’ feedback.

4.

Demonstrate the significance of communicating and disseminating the results of the DNP project to advance the scholarship of nursing.

^ What Are the Deliverables? Dissemination of the findings from evidence-based practice and research to improve health outcomes is described in The Essentials: Core Competencies for Professional Nursing Education (AACN, 2021). The use of evidence to improve practice or patient outcomes is highlighted by deliverables prior to graduation in a DNP program. A deliverable is a term used in project management to describe a tangible or intangi ble object produced as a result of the project that is intended to be delivered to a customer (Cutting, 2008). DNP deliverables are documentation of evidence-based inquiry that can impact safety, patient outcomes, quality, and cost (Becker et al., 2018). As mentioned in Chapter 2, Defining the Doctor of Nursing Practice: Histor ical and Current Trends, some recommended deliverables (AACN, 2021) include:

● ● ●

● ● ●

Publishing in a peer-reviewed print or online journal. Poster and podium presentations. Presentation of a final written product or verbal executive summary to stakeholders at a local, state, or national meeting, and/or the practice site/ organization leadership team. An educational presentation/development of a webinar presentation or video. A podcast—oral presentation to the public at large. Development and presentation of a digital poster, grand rounds presentation, and/or a PowerPoint presentation. It is critical that the DNP student under

It is critical that the DNP student understands

the expected time frame from

completion of the final deliverables to

graduation.

stands the expected time frame from comple tion of the final deliverables to graduation. For example, when must the project be completed to be eligible for graduation? When must all deliverables be accepted by the project team, and graduate or nursing school, to be ready for graduation? Can deliverables, such as a final presentation, be completed after this date? The DNP program team may require that the full

project team or faculty mentor, sign off on all written work, or that the work be submitted

to the college or university and/or a journal at a defined deadline prior to graduation, while allowing the presentation to occur at project completion.

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421

^ Public Presentations Public presentation of the DNP project may be a graduation requirement, so be sure to have a thorough understanding of the requirements of the specific DNP program. The public presentation may occur as a proposal prior to the start of the project or as a presentation after the completion of the project. The overall look of the presen tation changes on the basis of its timing (before or after the project is carried out). A presentation that occurs prior to the project is often considered a verbal de fense of the project. A verbal defense includes: ●

Introduction

●

Background to the problem

●

Literature review

● ● ● ●

Clinical question Project plan (may include budget) Methodology Projected sample requirements

●

Tools for evaluation

● ●

Expected implementation process Time for questions and comments from the audience

See Chapter 9, The Proposal, for details in preparing the proposal. Sometimes the defense occurs in front of the project team only, and team members can add sug gestions, ask questions, and finally approve the defense. The proposal may also be a

public defense. In this format, there is often a public declaration of the presentation, with an invitation from the college or university to interested audiences to attend. Following the presentation, the audience ask questions and may make additional comments. Audience members may consist of nursing faculty from the university or other universities, faculty from outside the school of nursing, graduate program faculty, deans from various colleges within the university, students from various pro grams, interested persons from healthcare organizations, or other interested parties. A presentation that occurs after the project is completed has the purpose of disseminating results, so it will also include project results; an interpretation of the results; sustainability, recommendations, and implications for practice. Forums used for disseminating results include conferences sponsored by the university, or podium and poster presentations outside the university in various local, regional, or national venues, including within the organization where the project was carried out.

Regardless of the timing or the place, there are a few items to consider in rela tion to the development of the presentation. The DNP student should understand:

●

The purpose of the presentation (defense of the proposal vs. dissemination of results).

● ●

The makeup of the audience attending the presentation. When the presentation should occur during the education

● ●

The time allotted for the presentation. The required format of the presentation.

process.

The student will work with their DNP project team to negotiate a date for the defense. Several meetings with the DNP project faculty mentor, or project team, can be expected as the student fine tunes their writing and develops all components

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Chapter 13 From Data to Knowledge: Disseminating the Results

of the project. The evaluation of the final DNP project is the responsibility of the faculty (AACN, 2021); hence, the faculty mentor will confirm with the project team that the student is indeed ready to defend. In preparing the presentation, it is important to know the time allotted and the presentation format. A typical time allotment is 30 minutes, with an additional 30 minutes for questions. It can be challenging to focus on the high points of all the work that has been done in this brief time frame (Miquel et al., 2018). A PowerPoint format can assist the presenter in staying focused on the points that must be con sidered and presented. PowerPoint Pointers

In preparing a PowerPoint presentation, there are a few standard expectations to consider.

1. Express appreciation to the agencies, the project team members, and others who have been instrumental to the project. 2, Identify grant support or other funding sources, if any. 3. Cite sources on your slides and list references at the end. 4. Use graphs and charts (rather than tables) to make a point. 5. Use a simple design with clear 32-point font or larger; use the 6*6 rule as a guide, meaning no more than 6 words per line and no more chan 6 lines per slide; use the same design, font, and color for all slides. 6. Do not crowd slides with too much information—the fewer words the better.

7. Avoid using more than 2 slides per minute. 8. Follow the topic items to keep the presen

The depth of knowledge regarding the

topic ... will enhance the

presentation far beyond the features of PowerPoint.

tation on track.

9. Practice to stay in the time frame available. Remember that although competency in developing a slide set is important, the PowerPoint presentation is just a tool to assist the presenter in providing information to the group. The way the presenter stands, their voice, eye contact, and professional attire contribute to the entire package (Blome et al., 2017). The depth of knowledge regarding the topic, sup ported by the literature, as well as the creativity of the innovation and attention to the detail of

the project plan, will enhance the presentation far beyond the features of PowerPoint.

Podium Presentations and Posters Other mechanisms for disseminating the results of the DNP project include podium presentations and posters. Typically, more poster presentations are scheduled at a conference venue than podium presentations in order to provide more opportuni ties to disseminate creative work (Berg &r Hicks, 2017). For either format, the presenter must submit an abstract to the conference re view committee and have it accepted prior to being permitted to present. Aligning

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423

the abstract with the objectives of the conference will improve opportunities for successful submission and acceptance. In addition, the author should carefully fol low submission guidelines that are described by the conference planners. The pro cess of preparing for either method is summarized as follows: 1. Identify which conference would be most appropriate for the presentation. 2. Read/evaluate abstract submission guidelines regarding the format, word lim its, space constraints, and deadline. 3. Most abstracts are submitted online, where the abstract is cut and pasted into a text box, or uploaded as an attached document. 4. Be concise in the message, which should be carefully thought out. 5. The title should represent the content. 6. Project abstracts usually contain five sections: ● Background/Problem: Introduction to the topic and what is currently known.

● ●

Objective: The aim or purpose of the project. Methods/Approach: How the purpose has been addressed and the ratio nale for that method.

●

●

Results/Outcomes: Present pertinent results in text or table/figure (graphs preferred) and indicate the method used for data analysis. Conclusions/Implications: Focus on the response to the objective and how it fits in with future practice and policy if indicated. (Berg & Hicks, 2017; Tribe & Marshall, 2020).

There are a few key recommendations to consider for podium and poster pre sentations. First, have a good understanding of the time allotted for the presenta tion. Always consider the audience and the purpose in developing the presentation. Poster presentations are short, typically 10 to 15 minutes. The following points are recommended for podium presentations: 1. Use a clear voice audible voice; a soft monotone voice can reflective negatively

2. 3. 4. 5. 6. 7. 8. 9. 10.

on the presentation (Abutiheen, 2017). Make eye contact with people in the audience (Blome et al., 2017). Present concisely and specifically indicate each section of the presentation. Share the most important objectives and results. Relegate background information to 1 or 2 points. Use graphic representation (preferably graphs) of results. Avoid “busy” tables that take too long for the audience to absorb. Always take the time to discuss the limitations of the study. Rehearse the presentation with enthusiasm and excitement (Blome et al., 2017). Request faculty and/or peer review prior to the presentation, for both the slide set and the actual presentation.

A poster is a presentation that provides a visual means of communicating information and should be visually appealing while transferring knowledge and stimulating discussion (Berg & Hicks, 2017; Tribe & Marshall, 2020). For poster presentations, the visual aspect is critical for success and is prepared with two areas in mind: content and display. For poster content, use the same title as the abstract. Material should be or ganized, concise, and free of spelling or grammar errors. When considering the display, it is recommended to use the “10-10 rule.” Keep in mind what a participant

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can look at in 10 seconds from 10 feel away (Persky, 2016). Color, layout, and well-placed graphs can be instrumental in attracting participants to the poster. Other conference specifications to consider include: 1. Poster format and size—freestanding or attached to a wall or corkboard or digital image projection (this information is available on the conference webpage). 2. Location of the posters—conference room, hall, or lobby. 3. Number of posters/presenters; number of conference attendees. 4. Bring copies of abstracts, contact information, push pins, and business cards. 5. Know dates that the poster must be delivered by and when delegates can visit

during the conference at which time you can stand by

your poster to answer

questions and receive feedback (Berg & Hicks, 2017; Tribe & Marshall, 2020). 6. Recording deadlines if the poster is to be digitally presented. There are multiple poster templates available online, as well as companies that will produce a poster at a reasonable charge. Consider the type of material for the poster. If traveling a distance and using the poster several times, consider a cloth poster that can be rolled up in the suitcase. Some conferences are moving to electronic posters to provide more space. Bring a backup Keep in digital file of your poster to the conference

nnind what

a participant

reviewing a poster may look at in 10 seconds

from 10 feet away.

Podium

and poster presentations are a connection

to other

opportunities that can

occur through networking.

in case of technical difficulties. Be sure that

poster submissions meet all requirements of the specific conference that is being attended, especially in relation to formatting criteria, which can include PowerPoints, website live demonstration, and other web-focused media (Tribe & Marshall, 2020).

Podium and poster presentations are im portant, because they are great ways to dissem inate information in areas of practice. These types of presentations can be a precursor to a journal article or a follow-up to the article. Another feature is that podium and poster presentations are a connection to other po tential opportunities that can occur through networking. For example, one of the authors of this book was invited to be a guest lecturer at a DNP program to present poster material to a leadership class because of a conversation with a professor who attended a poster session at a national conference. Including your contact in

formation in a handout and/or having business cards available are great tools for networking with those interested in your topic. Finally, pre sentations are another aspect of scholarship that can be used for promotion and tenure evalua tion for individuals working in academia.

Executive Summary

425

V Portfolios A portfolio may be used to enhance an expected deliverable within the DNP program, although it may not be considered as a DNP project (AACN, 2021). A portfolio is a compilation of documents that demonstrates student learning accomplishments. Portfolios can be used to assess if learners have met the required competencies and overarching program outcomes (Melander et al., 2018). It is recommended that the portfolio documents, the final practice synthesis, and scholarship include the impact or effect on practice. Examples of portfolio artifacts can include pilot studies, program evaluation, quality improvement (QI), evaluation of a new practice model, consulting projects, integrated research reviews, and manuscripts submitted for publication. Reflections may be a portion of the portfolio that exemplify synthesis of the Essentials for Advanced-Level Nursing Education (AACN, 2021). It is important, however, that the student is provided with clear direction (preferably in the form of a rubric) for the portfolio content. Aligning the content with the Essentials is also recommended (Melander et al, 2018).

Once again, it behooves the DNP student to be aware of this requirement early in the program. Knowledge of the required documents for the portfolio helps the DNP student to begin preparation throughout the educational process and saves tremendous time from having to rediscover the needed documents at a later date.

k Executive Summary The executive summary is another efficient and impactful written method of dis semination that may be used to present the project outcomes to members of the organization where the project was carried out. A useful guide to writing executive summaries by the Navy and Marine Corps is available online (https://www.med. navy.mil/sites/nmcphc/Documents/environmental-programs/riskcommu nication/

Appendix-E-Guide-to-Writing-Effective-Executive-Summary.pdf.). The executive summary is typically 1 to 2 pages long and is a great tool to have available with an oral presentation. It could also be used as the basis of an abstract for future conference presentations. The format of the document will include:

● ● ● ●

Description of the current status of the topic and why change is needed Presentation of the project details and how it aligns with the organization’s goals, objectives, mission, vision, and values Market analysis findings Implementation process

●

Evaluation metrics

●

Project outcomes as related to metrics:

● ●

●

Clinical

●

Financial

●

Satisfaction

● Other metrics as identified in the evaluation plan Sustainability Implications

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y Written Manuscript Understanding the written requirements of the college or university will be im portant for graduation as well. Written manuscripts will have requirements related to format and submission. Often there is a required due date for the manuscript to be ready for graduation—this may be several weeks prior to actual graduation, so planning is essential. Be sure to get a list of the submission requirements. Manu script submission requirements may include specific formatting such as that of the American Psychological Association (APA), as well as how the manuscript should be submitted, such as hard copy, bound, or digitally prepared. For some programs, a requirement for graduation is submission of an article for publication, which integrates well with the purpose of the DNP to dissemi nate evidence-based practice. Even if it’s not a requirement for graduation, DNP students and graduates need to have a commitment to publishing. Disseminating results provides others with information that is needed for evidence-based practice and success for other writers to build on. Scholarly dissemination is an important aspect of developing future scholarship, becoming part of a network of scholars (Carlson et al., 2017), and substantiating the rigor of doctoral level work. Rigor includes strict adherence to methodology and data-driven measurementand anal ysis to inform quality and improve health outcomes (Costa et al., 2020; Root et al, 2018). The process of moving from data to meaningful nursing knowledge can be explained in the Data, Information, Knowledge, Wisdom (DIKW) pyramid (see Figure 13-1). Data provides the basis for “information” which is data organized into a meaningful context. Moving up the pyr amid is “knowledge”—know-how or ability to use the data and information. Finally, “wisdom” Scholarly adds value by combining knowledge and expe dissemination rience to justify decision-making for the com

is an important

aspect of

developing future

scholarship,

mon good (Fricks, 2019). Replication of best practices in varied clinical environments closes the gap between research and

implementation in practice, thus building practice knowledge. Consider some nontraditional means of disseminating practice knowledge as an ex pression of scholarship, for instance, social media blogs using Twitter, or establish a website to share your project findings (Milner et al, 2019).

becoming part of a network of

scholars, and

substantiating the rigor of doctoral level work.

y aournal Submissions Reasons to write for publication include: 1. Dissemination of evidence

2. Sharing initiatives and innovation with others

3. Keeping nurses/healthcare stakeholders updated

4. Communicating research findings

Process for Journal Submissions

427

A Wisdom

● What is best in the application of knowiedge to action ● Adds value, understanding, integration, foresight

Knowledge

● Know-how of applying information, or skill ● How is the information applied to achieve specific goals?

Information

● Organize and interpret the data into meaningful information (for a specific purpose)

Data

● Items needed for analysis ● Raw data collected from the DNP project

Figure 13-1 DIKW pyramid Repieduceil ftom Ccirrissn, C.. Moran, K.. Kesien. K.. Conrad, 0., Hussey, .P, Manderscheid, A. &PohL E, I2II221.

Competency-based education and entiusIaM! professional actriities: An electronic dlnical tradeng system solution, CW: Cotiiporaa; lnftmibcs.

5.

6. 7.

pemHiig

Developing the science base of nursing Directing the future of the profession Communicating the importance of clinical practice findings to build evidence (Oermann & Hays, 2018)

Too often, the journal submission is the last item on the list separating the DNP student from graduation, if this is a requirement of the college or university. If this submission is considered in the planning phase, it will be done well and there will be an improved opportunity for successful publication of an article on the DNP project. However, there are many considerations in transitioning the manuscript of a project to a suitable article for publication.

y Process for Journal Submissions Understanding the process for peer-re\newed journal submissions is essential for the prospective author. When an article is submitted, the editor will review it to determine if it aligns with the aims of the journal and/or interests of the readership. The editor will send out a call for a panel of reviewers with expertise that matches

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the manuscript, such as expertise on the topic and/or the manuscript design. Some times obtaining a reviewer may be a challenge. Reviewers are very busy; even once assigned, it may take some additional time to complete the review. Peer reviewers have an allotted time period to complete the review, which is typically 2 to 3 weeks. The reviewers will send back comments, as well as an opin ion of acceptance, nonacceptance, or acceptance with revisions. The editor then compares the comments, reads the article in more depth, and makes a decision. The editor will write a summary letter, collating the comments from the reviewers. The minimum time for turnaround is 6 to 8 weeks; however, it could take 3 months or longer, depending on the journal. It behooves the author to speak with colleagues who are experienced with publishing to identify journals that may be more responsive. Some journals have been known to hold onto articles for 1 to 2 years after acceptance. So, tapping into the “writing grapevine” prior to submis sion is in the author’s best interest. Another tactic is emailing the editorial office to find out the percentage of articles chosen for publication, how long the review pro cess is, and how long after acceptance that articles are generally published. This in formation can be obtained prior to a query letter, and put in a file for future review, prior to actual submission to the journal. Another area to explore is the journal’s use of unsolicited manuscripts, meaning manuscripts not requested by the editor; rather, they can be considered based on the writer’s own scholarship. Some journals only publish solicited articles (authors are asked by the journal personnel to create a manuscript); others publish a combination. Not many articles are accepted as written. The article may be accepted with minor revisions, the article may be sent back to the writer asking for revision and resubmission of the manuscript, or the article may be rejected. Authors are en couraged to revise their manuscript when revisions are requested, because both the wTiter and the journal have already invested significant time in the endeavor. When revising the manuscript, the author should respond and detail what has been incorporated into the revision. However, if the writer does not agree with the rec ommendations, they need to provide a rationale for why they disagree. Once the editor receives the revised manuscript, they may send the article back out to one or two reviewers. Keep in mind, the author may even need to revise the manuscript again. The article may be rejected even later in the process if the author and review ers cannot agree on revisions.

There are many journals and many opportunities to submit a well-written manuscript. The author must be thoughtful and spend the time to research the best fit for the article, including the possibility of journals outside of nursing.

^ Tips for Successful 3ournal Submission Recognizing that students sometimes struggle when preparing a manuscript for submission to a peer-reviewed journal, this section will review tips for journal submission.

Understanding the process and gaining important pointers for manuscript sub mission will assist the author in producing a polished paper and provide a smoother journey to publication. Each of these recommendations will be explored further in this chapter.

Tips for Successful Journal Submission 1.

429

Choose the journal carefully based on its mission, readership, and types of articles.

2. 3.

4. 5.

Match the manuscript to the journal. Follow all author guidelines for: ● Manuscript style and format ● Abstract guidelines ● Development of tables, figures, and graphs ● Supplemental data files Expect recommendations from reviewers and be willing to resubmit. If needed, develop writing skills by using writing resources.

Choose the Journal Carefully Based on Its Mission,

Readership, and Types of Articles A place to begin the search for an appropriate journal is to peruse journals that were included in the literature review for the project and scan journals that have published articles on topics that are related to the DNP project. A helpful tool to use when considering potential journals for an article is the Joumal/Author Name Estimator (Jane): http://jane.biosemantics.or g/. This tool al lows the author to submit an abstract or keywords, and then, based on the informa tion retrieved, provides the author with a list of journals that have accepted similar topics. The author can then access the recommended journals to review the types of articles that those journals have published. The impact factor, often abbreviated IF, is a measure of the frequency that ar ticles from the journal are cited, which reflects the journal’s importance. The Uni versity of Virginia Health System website gives a step-by-step direction on how to identify the IF of journals of interest: https://guides.hsl.virg inia.edu/faq-jcr. Most journals outline specific requirements for a manuscript in an information (guidelines) for authors section of their website. The author should look at the mis sion and/or vision statement of the journal, the type of topics in the journal’s call for papers, and the journal’s reader audience, all of which will identify the level of content that is required. Questions to ask include: Does the journal publish articles like the manuscript in hand? For example, is this a research article, a case study, or quality improvement article? Does the journal target the population the author would like to reach?

Select 4 or 5 journals based on the type of journal, the articles in the journal, and its readership and audience, and then write with those journals in mind. Re member, the submitted manuscript must be consistent with the journal’s mission. Focus on the journal’s target audience by reviewing recent issues of the journal to identify topics of interest and depth of content. Another aspect of the journal review is getting a sense of timing. In other words, what else has been published in this journal and other journals on the topic? How does this manuscript add to the body of nursing knowledge? The editors are not just trying to fill space; rather, they are highlighting an issue that is of interest to the audience and is important for building nursing’s body of knowledge. It is plausible that the student’s article could be con sidered a follow-up to articles already published on the topic; however, the topic should not be overdone (i.e., there are too many recent similar articles). The author may not know what is in the pipeline, but a review of recent articles in the journal may give perspective on what topics have already been published. A query letter

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to the editor of the journal the student is considering, may provide insight into what the editor is looking for in unsolicited articles and if the proposed manuscript would be a match for the readership. To appeal to the audience, the topic should be well developed, and the manuscript should have good readability.

Match the Manuscript to the Journal The university requirement for the DNP project may differ from manuscript for mat. For example, if the article was originally developed for an academic setting, it must be rewritten to fit the journal author requirements. As the author aligns with specific journals, consider what they want to present to the world. Does the project have a clinical or quality focus; does it fit into a specialty journal? Is the topic appro priate for the chosen journal? For instance, if the article is more about the process than the disease state, consider a journal focused on quality. In preparing the manuscript for a specific journal, write the article specifically for that journal. The title is critical—does it say what the article is about? In other words, the portrayal of content in the title is important. Other questions to ask include;

● ● ● ●

Does the article align with the journal’s mission? Is the topic timely and innovative, or is it a twist on an older topic? Is the article unique? Is there consideration of the journal article categories such as case studies, feature articles, or briefs?

Follow All Author Guidelines

It is important to follow all the recommended author guidelines for: ● ● ● ●

Manuscript style and format Abstract guidelines Development of tables, figures, and graphs Supplemental data files

When choosing a journal for submission, be sure to follow the author guide lines explicitly in relation to format, font, citations, and length of article. It is im portant to write to match the journal, which includes the length of paragraphs, headings, and depth of content. The final product should look like a paper that would fit in that journal. It may be helpful to review the table of contents of the journal to assist in this process. Most journals will have guidelines for various types of submission. The author should identify the specific type of article that they plan to submit and follow those specific guidelines. Here is an example of the requirements within a specific journal: authors.jbleaming.com.

Expect Recommendations from Reviewers and Be Willing to Resubmit Many authors have had their work rejected or had to undertake a major revision at some point in time. The writer should expect direction or clarification and give themselves permission to grieve—this is a normal process related to the sense of

Tips for Successful Journal Submission

431

ownership of an article. One should also expect good feedback and recommenda tions from the reviewers. Take all the input and move forward with a meaningful response to the reviewers and thank them for their feedback. Address each item separately and indicate if changes were made; if no changes, then provide the ra tionale for preferring to leave a particular item as is. Setting up a table with the re viewers’ comments in one column and how they were addressed in anothercolumn provides clarity for the writer to address the feedback as well as for the editor who will receive the response to the reviews. The writer should appreciate the opportu nity for improvement, make the requested revisions by the due date, and resubmit the manuscript.

Understand Why the Manuscript Was Turned Down Take a deep breath and objectively consider the comments from the editor and the reviewers. If the comments indicate that the manuscript is well written but is not a match for the journal, the writer needs to resubmit to a more appropriate journal. If there are content or writing recommendations, the author should take the feedback and make changes to strengthen the article before submitting it to another journal. Also, time and resources from the journal have gone into the author’s article review, so be sure to follow through and resubmit the manuscript if changes are required. For instance, an author may not follow the previously discussed recommendation of using a specific reference style like the American Medical Association (AMA) or American Psychological Association (APA) format. Or perhaps the topic was not innovative, or the new practice initiative was limited by a brief intervention pe riod with unsustainable outcomes. Sometimes articles have errors in references,

which raises a flag about the content. Or references may be incomplete, incorrect, or too old. It is recommended that others, such as a faculty mentor or other faculty, read the paper before submitting. Another suggestion is to get an editor to assist with writing. The next step is to take the reviewer comments, incorporate the relevant ones, and send the manuscript to the next journal on the list. Less than one-half of au thors resubmit. Be persistent in making revisions and keep submitting the article. There are over 500 nursing and healthcare journals with plenty of opportunity! However, after four rejections, the author may need to reframe the topic. Consider the recommendations and add a twist. Perhaps not enough preliminary work was done. It is also important to think about the project design. Most DNP projects are not appropriate for research-oriented journals. However, journals focusing on qual ity improvement, innovation, or evidence-based practice may be a great fit.

Develop Writing Skills It is important for students, faculty, and advisors to recognize the need to rework the article for publication versus an academic manuscript. Keep in mind, the editor is evaluating the author’s writing skills from the first contact. There are specific clues that the editor keys into from the writer. For example, how does the query letter read in relation to composing a sentence? Does the DNP student’s skill and content level match other manuscripts in the journal? Did the author pay close attention to methodolo©^ and design; this will also be assessed very carefully by the re\iewers. It may be helpful to read articles in other journals to see how others are developing

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Chapter 13 From Data to Knowledge: Disseminating the Results

and presenting case studies, for example. Alternatively, consider a literature search on how to write for publication. Nurse Author and Editor (www.nurseauthoreditor. com) offers articles and tips on writing (e.g., present sections in the manuscript that are based on research guidelines if the manuscript is a research article or perfor mance improvement guidelines for QI manuscripts). Finally, find a mentor for authorship. This should be someone who under stands what mentorship entails. The mentor does not have to be geographically located near the writer—mentoring can occur via the Internet. If the writer does not have a mentor in mind, consider academic connections or contacting professional nursing organizations that have journals. Often colleges and universities have writ ing centers or other mentoring support. Some have resources to match new authors with senior writers, or they may even have a formal mentoring program. It may be helpful to offer to be a reviewer to learn about clear writing and publishing; writing skills improve the more one writes. Mentors can be of tremendous help in the area of scholarship, networking, and dissemination skills (Gonzalez & Firmell, 2020).

Online Manuscript Submission Most journals will have an online submission process. Be sure to follow the direc tions explicitly. Typically, the article will be submitted in separate documents that include the title page, abstract, body of the manuscript with references, tables, and figures. The directions will include whether the manuscript should be sent in PDF or another format. Each of these components may have word limits. Using a tool like Microsoft Word’s word count feature can ensure that the submitted piece is well viathin the specified limits. There may be a letter to the editor submission area as well, where the author highlights why this is an important article to consider. Fi nally, make sure to plan for enough time to upload the submission accurately. Other Journal Considerations Another area to consider prior to journal submission is using a plagiarism program like SafeAssign (www.blackboard.com/safeassign/index.html). There are many pla giarism programs available for use. For example, journals may first submit the man uscript through a program like iThenticate (www.ithenticate.com/). If the results are unfavorable, the manuscript may be rejected before the editor does an initial review. Even when references are cited correctly, a percentage over a predetermined level suggests that the article is not original material. For example, too many direct quotes will increase the percentage level. The writer should strive for a result less than 15% using SafeAssign.

k Summary In summary, an important aspect of journal submission is communicating the writer^ experience or findings to contribute to the body of knowledge within nursing and health care. Collectively, the value of DNP-prepared nurses’ work will be discussed in the final chapter (Chapter 14, The Value and Impact of Practice Doctorate Scholarship). In addition, there is great personal value in submitting for publication. This includes development of the author’s own knowledge, personal satisfaction, sharing

Summary

433

with a wider audience, and the potential benefits of promotion and tenure in a uni versity setting for a faculty member (Oermann & Hays, 2018). When a manuscript presents timely and important content that is of interest to the journal’s readership, and is in the appropriate style, the opportunity for publication becomes a reality! The importance of dissemination to nursing scholarship cannot be overstated. It is this contribution to knowledge that differentiates the doctorally prepared nurse. Dissemination allows for sustainability of the work within the organization and opens the door to evolution of the work outside the organization. Dissemina tion elevates the knowledge from a specific arena to development of a network of scholars who can learn and grow from each other, which further develops knowl edge and wisdom. The following excerpt by Dr. Doug Dascenzo describes his dissemination expe riences with his DNP project (see Exemplar13-1).

Exemplar 13-1 Using Virtual Remote Monitoring as an Alternative Observation Method for Suicidal Patients

Douglas R. Dascenzo DNP, RN, CENP The overarching aim of my scholarly project was to determine if Virtual Remote Monitoring (VRM) is an acceptable alternative to the constant observation method traditionally deployed for suicide watch, which includes the assignment of an individual sitter to each suicidal patient until active suicide precautions are discontinued. A quality improvement project conducted by Kroll et al. (2019) at Brigham and Women’s Hospital was selected for replication. The target population included adult suicidal patients at low or moderate risk and low impulsivity residing on general medical floors outside the inpatient psychiatric unit. Outcomes were compared using VRM vs. in-person sitting. The replication study I conducted validated the absence of any adverse events associated with VRM, rendering it a safe and effective alternative observation method. Furthermore, 16 weeks of data collection revealed a net

annual cost savings of $357,000 resulting from decreased sitter use. While nurses preferred in-person sitting to VRM, the decision to apply VRM was more effectively guided by criteria for use rather than nurse preference. According to Edwards (2015), dissemination of knowledge is an essential precursor to practice change. There are multiple ways in which this can be accomplished. Allow me to describe how my project impacted an entire healthcare system. The first opportunity was to present an overview of this work to the academic community and others supporting my learning. I subsequently closed the loop with the Institutional Review Board to fulfill a reporting requirement, as well as to indicate whether additional data would be collected, the scope of the

work expanded, and/or the project concluded. This work began as a quality improvement initiative in the acute care hospital for which I am the accountable executive for nursing operations. The parent company of the hospital had already approved the use of VRM for adult patients at low and moderate risk for suicide but had not issued any additional guidance. Having previously met resistance to this proposed change of practice among the psychiatrists who attributed increased and unnecessary risk to VRM, it was clear that a thoughtful and well-orchestrated approach would be necessary to secure buy-in and support for the change.

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I established a stakeholder's group that met weekly to share what we learned collectively about VRM from multiple sources, but also to drive the practice change locally. The stakeholders included the medical director of psychiatry, nursing director of behavioral health, clinical nurse specialist, director of logistics, director of information technology, and nurse educator. In addition, I included the principal investigator at Brigham and Women's Hospital who was successful at implementing VRM for this specific patient population. The group established a suicide watch protocol listing inclusion and exclusion criteria for VRM based on the original work of Kroll et al. (20191 but customized it to meet the specific requests of the stakeholders. In addition to the use of the abbreviated Columbia Suicide Severity Rating Scale (C-SSRS) (The Columbia Lighthouse Project. 2016) to screen for suicide risk, the SafeT (Ryan & Oquendo, 2020], an evidence-based suicide risk stratification tool, was also utilized

to stratify suicide risk following a positive suicide screen. The Behavioral

Activity Rating Scale (BARS) (Simpson. Pidgeon. & Nordstrom. 2017) was incorporated to measure impulsivity as an extra criterion to assure suitability for VRM. The protocol assigned role and responsibilities for initial assessment, re-assessment, and notification of changes. In addition, the clinical house supervisor established and led a daily 5-minute huddle to review the status on suicide watches, including outstanding SafeT and BARS assessments and/or reasons for in-person sitting over VRM, all of which became part of our daily standard work to ensure sustainability. While engaged in the implementation phase of this project, it was discovered

that a suicide risk category was being prematurely assigned to a patient based solely on a positive suicide screen or abbreviated C-SSRS; this abbreviated C-SSRS had been incorporated into all workflows in the electronic health record (EHR) where suicidality was assessed. A request for an enterprise-wide change in the EHR logic was submitted and approved to include the SafeT and avoid an erroneous classification of suicide risk, and subsequent assignment of an improper observation method. Additionally, an opportunity became evident to consider expanding this quality improvement work and became the focus of another DNP project. Emergency department patients commonly wait hours to days for the county to render a definitive care disposition, which consumes excessive amounts of sitter resources around-the-clock. In this way, dissemination becomes a catalyst for ongoing improvement. A poster presentation of my scholarly work was accepted by the Institute for Healthcare Improvement. The theme of the annual symposium was patient safety, so the focus of this project aligned perfectly. I selected the use of technology to enhance patient safety as one of the pre-established subheadings. Finally. I submitted an abstract of my work and conducted a 10-minute podium presentation at the National Doctor of Nursing Practice Conference. This not only prepared me to summarize salient features of my project, but also connected me to other colleagues with similar clinical practice interests. References Edwards, D. J. (2015). Dissemination of research results: On the path to practice

change. Canadian Journal of Hospital Pharmacy, 65(6): 465-469. https//doi. org/10.4212/cjhp.v68i6.1503 Kroll, D. S.. Stanghellini, E., DesRoches, S. L.. Lydon, C., Webster. A.. O'Reilly. M.. Hurwitz, S.. Aylward, P. M., Cartright, J. A.. McGrath. E. J.. Delaporta, L., Meyer, A. T, Kristan, M. S.. Falaro, L. J.. Murphy, C., Karno, J.. Pallin, D. J., Schaffer. A..

Action Plan-Next Steps

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Shah, S. B., Lakatos, B. E., Mitchell, M. T., Murphy, C. A.. Gorman, J. M.. Gitlin, D. R, & Mulloy, D. R (2019). Virtual monitoring of suicide risk in the general hospital and emergency department. General Hospital Psychiatry. https://doi.0rg/lO.IOI6/j. genhosppsych.2019.01.002 Ryan, E. R, & Oquendo, M. A. (2020). Suicide risk assessment and prevention: Challenges and opportunities. Focus W[2], 88-99. https://doi.0rg /IO.l 176/appi. focus.20200011

Simpson, 5., Pidgeon, M., & Nordstrom. K. (2017). Using the Behavioral Activity Rating Scale as a vital sign in the psychiatric emergency service. Semantic Scholar, https:// www.semanticscholar.org/paper/Using-the-Behavioural-Activity-Rat ing-Scaleas-a-in-Simpson-Pidgeon/c5d1dcf2e90e7a3c783133043866c7573f10cc0d #pa per-header

The Columbia Lighthouse Project. (2016). The Columbia protocol for healthcare and other community settings, https://cssrs.columbia.edu/the-columbi a-scale-c-ssrs/ cssrs-for-communities-and-healthcare/#filter=.general-use.englis h

Impact ●

An important aspect of DNP sdiolarsliip is the dissemination of work that is being carried out in practice. Work that is appropriately disseminated strengthens practice-based evidence. It is through dissemination that the value of practice knowledge and the impact of the practice doctorate in nursing is understood.

● ●

Key Messages ●

The DNP student should understand all the college or university requirements for disseminating the results of the DNP project and the importance of includ ing organizational stakeholders. The results of the DNP project may be disseminated in verbal presentations, such as an oral defense, or podium or poster presentations. The results of the DNP project may be disseminated in written documents that are submitted to the university or as a manuscript submitted to an appropriate journal. Consider the executive summary format to disseminate project outcomes to the organization where the project was implemented. Follow all specific guidelines for verbal or written dissemination. Plan for the time it takes to develop and submit the results of the DNP project. Consider manuscript submission to a journal, even when it is not a graduation

● ●

● ● ● ●

requirement.

Action Plan-Next Steps 1. 2. 3. 4. 5. 6.

Know the requirements for communicating the results of the DNP project. Plan how the results of the DNP project will be disseminated. Develop a timeline to incorporate the planned communication. Consider journal submission of a manuscript, even if it is not a requirement. Review potential journals for the manuscript. Write the manuscript with the journal in mind.

7. Happy writing!

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References Abutiheen, A. A. K. (2017). PowerPoint presentations in medical conferences in Iraq. (A Qualitative Study). Middle East Journal of Family Medicine, 15(1), 32-41. American Association of Colleges of Nursing (AACN). (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.oig/ Store/product-info/productcd /PUB.NEWESSENTIALS

Becker, K. D., Johnson, S., Rucker, D., & Finnell, D. S. (2018). Dissemination of scholarship

across eight cohorts of doctor of nursing practice graduates. Journal of Clinical Nursing 27(7-8), e 1395-el401. https//doi.org/10.1111/jocn. 14237 Berg, J., & Hicks, R. (2017). Successful design and delivery of a professional poster. Journal ofthe Amer ican Association of Nurse Practitioners, 29,461-469. https//doi.org/10.1002/2327-6924.12478 Blome, C., Sondermann, H. & Augustin, M. (2017). Accepted standards on how to give a medical research presentation: A systematic review of expert opinion papers. GMS Journal for Medical Education, 34(1). https//doi.oig/10.3205/zma001088 Burson, R. (2020). Scholarship in practice. In K. Moran, R. Burson, & D. Conrad (Eds.), The Doctor of Nursing Practice Project: Aframovorkfor success (3rd ed., pp. 39-64). Burlington, MA: Jones & Bartlett Learning. Carlson, E. A., Staffileno, B. A., & Murphy, M. .P (2017). Promoting DNP-PhD collaboration in doctoral education: Forming a DNP project team. Journal of Professional Nursing. https//doi .org/10.1016/J.profnurs.2017.12.011 Corrigan, C., Moran, K., Kesten, K., Conrad, D., Hussey, R, Manderscheid, A. & Pohl, E. (2022). Competency-based education and entrustable professional activities: An electronic clinical tracking system solution. CIN: Computers, Informatics, Nursing, 40(7), 429-434. DOI: 10.1097 /CIN.0000000000000924

Costa, L. L, Bingham, D., Storr, C. L., Hammersla, M., Martin, J., & Seckman, C. (2020). Develop ment of a DNP measurement grid to increase the rigor of doctor of nursing practice students’ data collection and analysis methods. Journal of Professional Nursing, 36(6), 666-672. https// doi.org/10.1016/J.profhurs.2020.09.006 Cutting, T. (2008). Deliverable-based project schedules: Part 1. Project-Management.com. http://www . pmhut.com/deliverable-based-proJect-schedules-part-1 Davis, C., Garrett, C. D., Grigsby, S., Shipley, R., Chapman, B., & Kelley, C. B. (2021). All about the DNP project. American Nurse. https://www.myamericannurse.eom/dnp-proJect-fundamentals/# Fricke, M. (2019). The knowledge pyramid: The DIKW hierarchy. Knowledge Organization, 46(1), 33-46. https//doi.otg/10.5771/0943-7444-2019-1-33 Gonzalez, Y., & Finnell, D. S. (2020). Promoting and supporting a doctor of nursing prac tice program of scholarship. Journal of Nursing Education, 59(9), 526. https/Zdoi.org /10.3928/01484834-20200817-10

Kesten, K., Moran, K., Beebe, S. L., Conrad, D., Burson, R., Corrigan, C., Manderscheid, A., &

Pohl, E. (2021). Practice scholarship engagement as reported by nurses holding a doctor of nursing practice degree. Journal of the American Association of Nurse Practitioners. https//doi ,org/10.1097/JXX.0000000000000620 Melander, S., Hampton, D., Hardin-Pierce, M., & Ossege, J. (2018). Development of a rubric for eval uation of the DNP portfolio. Nursing Education Perspectives. https//doi.oig/10.1097/01.NEP.OO 00000000000381

Milner, K., Zonsius, M., Alexander, C., & Zellefrow, C. (2019). Doctor of nursing practice project

advisement: A roadmap for faculty and student success. Journal of Nursing Education, 58(12), 728. https//doi.org/10.3928/01484834-20191120-09 Miquel, J., Sanuna, E, Barrera, A., & Torrens, C. (2018). How do we deliver our findings? Analy sis of podium presentations at shoulder meetings. Journal of Orthopaedic Surgery and Research, 13(1). https//doi.org/10.1186/S13018-018-0942-7 Navy and Marine Corps Public Health Center, (n.d.). A guide to writing an effective executive sumrrmry. https://www.med.navy.mil/sites/nmcphc/Documents/environmental-pr ograms/ riskcommunication/Appendix-E-Guide-to-Writing-Efrective-Executiv e-Summary.pdf

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Oermann, M. H., & Hays, J. C. (2018). Writing/or publication in nursing (4th ed.). New York, NY: Springer Publishing.

Persky, A. M. (2016). Scientific posters: a plea from a conference attendee. American Journal of Pharmaceutical Education, 80(10).

Root, L, Nuftez, D. E., Velasquez, D., Malloch, K., & Porter-O’Grady. T. (2018). Advancing the Rigor of DNP Projects for Practice Excellence. Nurse Leade,r 16(4), 261-265. https/Zdoi.org /10.1016/j.mnl.2018.03.013 Tribe, R., & Marshall, C. (2020). Preparing for a conference, doctoral or professional presentation. Counselling Psychology Review, 35(2), 30-39.

CHAPTER 14 A.

The Value and Impact of Practice Doctorate

Scholarship Karen Kesten and Dianne Conrad

CHAPTER OVERVIEW

Throughout this text, the doctor of nursing practice [DNP) project has been highlighted as an important product of DNP education that reflects the attainment of the competencies that launch the DNP graduate into scholarly practice. However, it is also important to recognize that the practice doctorate degree for nursing will need to be evaluated for effectiveness and value in accomplishing the goals of improving the nursing profession, health care, and society. Therefore, the impact of the practice doctorate is defined in this context as a powerful effect of something, especially something new, such as a change in practice and/or sustained change in practice [Cambridge Business English Dictionary. 2011). To begin this process, an approach to evaluation of the practice doctorate is proposed using the Actualized DNP Model that focuses on structure, process, and outcome measures (Burson, Moran, & Conrad, 2016). Current evidence-based trends reflected in DNP practice as well as DNP exemplars applying the model have led to the evolution of the model to the Actualized DNP Framework. In this final chapter, the value and impact of practice doctorate is explored in the context of the revised Actualized DNP Framework. Finally, an exemplar by Dr. Minna Miller illustrates how the competencies attained in advanced nursing doctoral education are reflected in her DNP practice and scholarship as an international nursing leader. CHAPTER OBJECTIVES After completing this chapter, the learner will be able to:

1. 2.

Discuss the impact of the practice doctorate on the nursing profession, health care, and society. Explain the evaluation of the impact of the DNP in terms of the structure of DNP education, the process of advanced nursing practice, and the various types of outcomes expected as illustrated in the Actualized DNP Framework.

® S3ndipl>iiiTi3( Patel/DigiUlVisioiiVecUus/GeltylmajK

439

440

Chapter 14 The Value and Impact of Practice Doctorate Scholarship

The DNP degree

3.

is reflective of

the rigorous

4.

education that students receive

to be high-quality clinicians, leaders In

interprofessional healthcare team

delivery, and contributors to

the redesign and improvement of healthcare

delivery models (National

Organization of Nurse Practitioner

Faculties, 2015,

para. 4).

Review how contributions to the literature

and practice are made by DNP-prepared nurses, beginning with the DNP project as a launching pad to practice scholarship. Evaluate how DNP-prepared nurses add value and impact to the nursing profession and society.

As discussed in Chapter 2, Defining the Doc tor of Nursing Practice: Historical and Current Trends, the DNP educational program is the foundation for the practice doctorate and is built on the American Association of Colleges of Nursing (AACN) Essentials: Core Competen cies for Professional Nursing Education (2021). The DNP project reflects the culmination of the attainment of the Essentials for Advanced Level Nursing Education by the DNP student. How ever, the ultimate impact of the DNP graduate on nursing as a profession, health care, and so ciety continues to evolve.

Montgomery and Porter-O’Grady (2010) summarize the value of the scholarly project in DNP education by stating that it “provides students with an opportunity for rigorous and scholarly development of a clinical issue, demonstrating the ability to apply knowledge, translate learning and exhibit evidence-driven outcomes in their areas of practice exper tise” (p. 45). In 2011, Marie Annette Brown challenged DNP graduates to complete the DNP project to accomplish multiple goals, such as: ●

Building student expertise in practice inquiry.

●

Contributing to advancing and improving care in institutions, local communities, and

all types of healthcare settings by affecting ● ● ●

care delivered and assisting agencies to innovate better models of care delivery, thus improving outcomes of care. Contributing to advancing the practice of registered nurses (RNs) and ad vanced practice registered nurses (APRNs). Contributing to the nursing profession and nursing science. Contributing to practice inquiry, translational science, and comparative effec tiveness research.

The completion of the DNP project prepares the graduate for the art and science of practice scholarship, as well as to contribute to the body of transla tional research knowledge and clinical practice knowledge development for the

The Actualized DNP Framework

nursing profession. The ultimate value and im pact of practice scholarship in advanced nurs ing will be reflected in a variety of healthcare

441

The DNP project reflects the

outcomes.

culmination of

^ The Actualized

the attainment

DNP Framework:

of the Essentials

Continuous Quality

for Advanced-

Improvement of the Degree, DNP Graduate Practice,

Level Nursing Education.

Outcomes, and

Impact As the practice doctorate continues to mature, the present and future of the DNP de gree and its impact on health care and society can be examined in the context of The Actualized DNP Framework, expanded from the original core model developed by Burson, Moran, and Conrad (2016) (see Figure 14-1). The revised Actualized DNP

Framework illustrates the relationship of the critical features of DNP education and practice that produce quality outcomes to improve health care at multiple levels. Ultimately, the outcomes lead to impact on society and the nursing profession. The attainment of the Essentials (AACN, 2021) begins the cycle and produces a nursing practice doctorate with critical competencies in advanced practice, leadership, pol icy, population health, and informatics who can apply evidence-based practice and expert care in the clinical arena. Through the use of leadership skills in traditional and innovative roles, implementation science, and interprofessio nal collaboration, the practice doctorate uses an evidence-based practice application component to gen erate new knowledge in practice, developing practice-based knowledge. This is the added value and impact that the DNP-prepared nurse brings to health care with improved quality outcomes in patient care, population health, systems, and policy, to fulfill the goals outlined in the proposed Quadruple Aim (Bodenheimer & Sinsky (2014) and the Future of Nursing 2020-2030. The Framework is continuous and ongoing, as generating practice-based knowledge then informs the core competen cies for nursing education needed for the practice doctorate, hence completing and continuing the cycle. The threefold approach to assessing the value and impact of the practice doctorate acknowledges the linkage between all the components: Good structure leads to good process, which in turn increases the likelihood of good outcomes, as demonstrated by Donabedian (1988) in his classic approach to quality improve ment. In assessing the impact of the DNP degree now and in the future, the struc ture of how DNP students are prepared and educated, the process of how care is delivered by the DNP-prepared nurse, as well as the outcomes of that care and how it impacts patients and society can be explored. These elements reflect the core of the Actualized DNP Framework. However, research regarding the outcomes and

442

Chapter 14 The Value and Impact of Practice Doctorate Scholarship

I

Evidence-based

M

knowledge

Advanced nursing knowledge

A

Innovative advanced

DNP

C

practice roies

competencies

T

\

P

I I

Generation of practicebased knowledge

c,o

Patient '< ■

Population

>.

Quality outcomes V

System-


k

k

Quality outcomes

>

▼

j System-^

■►Policy

When organizations value practice scholarship, the opportunities for Quality outcomes are specific

the DNP-prepared nurse to use

and measurable In context of

acquired doctoral-level competencies

parent, population, systems and policy. Impact of outcomes

to translate evidence to practice,

affect society and the nursing profession

systems change, and improved quality outcomes are more likely to be realized

Figure 14*4 The Actualized DNP Framework Developed Py Dosanne Bursoti. Kathetioe Motan, Dianne Conrad. Karen Kesten. Catherine Corrigan. Amy Mandetscheid. Sarah Beehe & Karen Mihelich. Data from Burson, R.. Moran. K.. & Conrad. D. [201dl. Why hire a doctor ol nursing practice-prepared nurse? The value-added impact t>l the practice doctorete. Jouwal ol te/CEffll. 162-167.

and intentional evaluation by the profession. How the DNP graduate will affect pa tients, populations, systems, and policy will need systematic evaluation focusing on the impact and outcomes realized in practice. The ultimate value and impact will be the change in how health care is delivered and how the health of society is improved by innovative DNP-prepared nurses’ practice.

Global Impact of the Practice Doctorate Practice doctorate education and advanced practice is now recognized imemaiionally. DNP-prepared nurses from the United States are collaborating with other coun tries in global teams to advance the profession. Combining the expertise of individual DNP-prepared nurses and PhD colleagues, working in interprofessional teams, has the potential to transform health care with the formation of knowledge networks to advance care delivery and the nursing profession. Opportunities to present at inter national conferences and publications regarding the value-added impact of the prac tice doctorate are evolving as DNP practice scholarship is disseminated. An exemplar

464

Chapter 14 The Value and Impact of Practice Doctorate Scholarship

of the practice doctorate approach to promoting advanced nursing practice in Ire land by DNP-prepared Fulbright scholars with the help of a global team is presented in an article in the International Nursing Review (Conrad et. al., 2020). Dr. Minna Miller was one of the first DNP-prepared graduates in Canada. She shares the story of her DNP journey in Exemplar 14-3, beginning with attaining

Exemplar14-3 Minna K. Miller, DNP, MSN, BA, RN, NP(F), FNP-BC, FAANP

My Doctor of Nursing Practice (DNPI journey started in 2011 as I had just completed the didactic portion of the Post-MSN Family Nurse Practitioner (FNPl certificate program at Western University of Health Sciences in Pomona, California. I was encouraged by the Family Nurse Practitioner program director to apply to the DNP program. To my surprise, I was accepted, and graduated from the program in 2015. My capstone project process was a transformational experience. It laid the foundation for all future research/proje ct work and gave me the confidence to serve and lead locally and globally to advance the nurse practitioner (NP) role and the profession. The project focused on evaluation of patient satisfaction with NP care at an NP-led Pediatric Primary Care Clinic, the first of its kind in Canada, at a Children's Hospital in British Columbia IBCI, Canada. The organization was within the Provincial Health Services Authority, where I had just started my first full-time NP role in 2012. The project evolved over the course of the DNP program as I completed coursework related to DNP Essentials (AACN, 2006). It included an extensive literature review on patient satisfaction, related conceptual frameworks and models of care, and outcome measures specific to NP care in primary care settings (DNP Essential #1 Scientific Underpinnings for Practicel; organizational assessment utilizing Johnson's (2001) microsystem assessment tool; Root Cause Analysis (Kelly, 20111 and recommendation for a change in the form of a pilot study (PDSA cycle). Before a pilot study of patient satisfaction with NP care could be undertaken, it was necessary to decide on an appropriate measurement instrument. This led to a review of 34 previously identified tools (Essential #3, Clinical Scholarship and Analytical Methods for Evidence-Based Practice). While these tools were designed to evaluate patient satisfaction with NP care, I discovered that they did not capture the uniqueness of NP care as a mixture of nursing and medical models. This realization led me to do a concept analysis on "patient satisfaction with NP care" to clarify the concept. The concept analysis, using Walker and Avant's (2010) approach, revealed an empirical referent. Client Satisfaction Tool by Bear and Bowers (1998) as a suitable measurement instrument for the proposed pilot project. The project involved multiple stakeholders within the organization, including the NPs and medical office assistant at the pediatric primary care clinic; primary care NP lead for the hospital who was my DNP mentor; chief nursing officer; continuous quality improvement director; and NP professional practice leader for Provincial Health Services Authority (Essential #5 Interprofessional Collaboration for Improving Patient and Population Health Outcomes). The pilot project yielded excellent positive results. The organization subsequently purchased the rights to use the Bear and Bower's tool across the health authority in a variety of settings to evaluate patient satisfaction with NP care. Evidence of patient satisfaction with NP care can support funding for additional NP positions. NPs from the primary care clinic have since been invited to expand service delivery

The Impact of the DNP Graduate in Practice

465

to subspecialty clinics, including dermatology clinic, chronic pain service, and a full-time NP at the asthma clinic.

As one of the first DNP-prepared NPs in British Columbia, I have had many opportunities to positively impact NP role development and advancement in the province. In 2014,1 was invited to participate in the Ministry of Health Provincial Privileging Standards Project, NP Privileging Expert Panel. This led to development of privileging standards and a dictionary for nurse practitioners that made it possible for NPs to admit and discharge patients to and from the hospital, a landmark advancement of the NP role in British Columbia IBC). NPs are now considered medical staff in BC with physicians, dentists, and midwives. I also became an active member of the BC NP Association and was selected to chair

the communications committee for a 2-year term, leading foundational policy work within the organization. In 2016,1 was invited to be the vice-chair of the NP Standards Committee for the College of Registered Nurses of British Columbia. The plan during my service focused on the review and revision of the NP scope of practice document with the inclusion of controlled drugs and substances prescribing, medical assistance in dying, opioid agonist prescribing, and the development of the scope of practice document for the new Neonatal NP role. As a DNP student, I made a goal to submit one abstract each year to an international conference and one abstract to a regional/national conference. In 2014,1 traveled to Helsinki, Finland (my home country) to present for the first time at the International Council of Nurses, Nurse Practitioner/Advanced Practice Nurse Network conference. I had never heard of the Network before

and became intrigued by this network of thousands of NPs/APNs from around the world. I decided to join the Network and have been actively involved since then. In 2016, the Network conference was held in Hong Kong, where I had the opportunity to present my doctoral project work and join the Network's Health Policy Subgroup. Within the year, I became the co-chair of the Health Policy subgroup, and more recently have served as the project coordinator for the Network. It has been a tremendous opportunity to connect with colleagues from around the world, to lead and participate in global APN-related research in the Anglophone Africa Advanced Practice Nurse Coalition Project, and even Co-Chair the Scientific Program Committee for the Network's 2021 International Conference (what a learning curve!]. Through my work with the ICN NP/APNN, I met many wonderful, experienced NP scholars from the United States, and decided to join the American Association of Nurse Practitioners (AANP) in order to access the

plethora of resources available to members. It was a privilege to be asked to join the international committee and to participate in the International Ambassador program as a mentor, and applicant reviewer, to be an abstract reviewer for the National Conferences, and to be invited to speak at these conferences as well. I was honored, as the first Canadian NP. to be inducted as

a fellow in 2017 and have since then successfully nominated two Canadian NP colleagues who are now fellows. I am so grateful for my DNP faculty mentors and my capstone supervisors, who believed in me and kept me focused, and for my DNP/NP colleagues around the world for the opportunity to learn, share, lead, and serve together. The DNP journey has forever changed the lens through which I view everything I do as I intentionally seek to apply the DNP essentials in advanced practice, education, research, and leadership. Minna K. Miller. DNP. MSN. BA. RN. NP(F), FNP-BC. FAANP

466

Chapter 14 The Value and Impact of Practice Doctorate Scholarship

competencies of DNP education; applying the competencies in innovative roles; and ultimately influencing patient, system, population, and policy outcomes in Brit ish Columbia in Canada and internationally The impact of her v^ork on society and the profession continues as she applies her DNP competencies as an international nursing leader.

^ Summary The practice doctorate in nursing is evolving to meet the needs of the society it serves. Evaluation of this preparation for nurses at the practice doctorate level requires scru tiny and systematic evaluation to assess its value. The Actualized DNP Framework is a guide to assess the impact of the DNP education, projects, and irmovative practice roles to produce outcomes. Assessment of the DNP degree is needed to determine the quality of education delivered and to produce practitioners who are prepared to deliver high-quality, innovative, evidence-based care. Assessment of the impact of outcomes achieved with patients, populations, systems, and policy is also needed to evaluate the DNP-prepared nurse at multiple levels. This will be an ongoing process that will improve the quality of education and care delivered, as well as impact out comes for society. It is an exciting time for nursing to take an active part in transform ing health care. Donabedian (1988) acknowledges the journey with the statement, “I hope it is clear that there is a way, a path worn rather smooth by many who have gone before us. I trust it is equally clear that we have, as yet, much more to learn” (p. 1748).

Key Messages ● ●

The DNP project reflects the culmination of the attainment of the Essentials: Core Competencies for Advanced-Level Nursing Education. Evaluation of the impact of the DNP-prepared nurse can be assessed using the Actualized DNP Framework.

●

●

● ●

DNP education provides the structure for developing an advanced nursing role as well as developing scholarly practice competencies through the completion of the DNP project. Innovative healthcare delivery in advanced nursing practice roles is the process through which the DNP-prepared nurse will impact evidence-based practice. Assessment of the impact of outcomes achieved with patients, populations, sys tems, and policy is needed to evaluate the DNP-prepared nurse at multiple levels. The value and impact of DNP practice will be realized in improved policy outcomes, improved patient outcomes, improved population outcomes, and improved system outcomes.

Action Plan-Next Steps 1. Successfully complete your DNP project. 2. Disseminate the results of the project. 3. Use the competencies gained in attaining the Essentials of DNP education in an advanced nursing practice role to impact healthcare outcomes.

References

467

4. Continually articulate, define, and promote the value-added impact of the DNP-prepared nurse to practice leaders, colleagues, and society. 5. Transform health care!

References American Association of Colleges of Nursing (AACN). (2006). The essentials of doctoral education for advanced nursing practice. httpsvywww.aacnnursing.oi@Portals/42 /Publications/DNPEssentials.pdf American Association of Colleges of Nursing (AACN). (2015). The doctor of nursing practice: Cur rent issues and clarifying recommendations. httpsy/www.aacnnursi ng.org4*ortals/42 /DNP/DNP -Implementation.pdf American Association of Colleges of Nursing (AACN). (2021). The essentials: Core competencies for professional nursing education. httpsy/www.aacnnursing.org/AACN- Essentials American Association of Colleges of Nursing (2022). 2021-2022 enrollment and graduations in bac calaureate and graduate programs in nursing. Washington, DC: Author. Auerbach, D., Buerhaus, E, Skinner, L, & Staiger, D. (2017). 2017 data brief update: Current trends of men in nursing. Bozeman, MT: Montana State University, httpy/healthworkforcestudies.com /publications-data/data_brief_update_current_trends_oLmen _in_nursing.html Auerbach, D., Martsolf, G., Pearson, M., Taylor, E., Zaydman, M., Muchow, A., . . . Dower, C. (2014). The DNP by 2015: A study of the institutional, political, and professional issues that facilitate or impede establishing a post-baccalaureate doctor of nursing practice program. Boston, MA: RAND Corporation. httpsr/Avww.rand.or^pubs/research _reports/RR730.html Bear,M.,&rBowers,C.(1998).Usinganursingframeworktomeasureclients atisfactionatanuise-managed clinic. Public health nursing, 15(1), 50-59. httpsy/doi.oi;^10.1 11L5.1525-1446.1998.tb00321.x Beeber, A., Palmer C., Waldrop J., Lynn, M., & Jones C. (2019). The role of doctor of nursing practice-prepared nurses in practice settings. Nursing Outlook, 67(4), 354^364. https://doi .org/10.1016/j.oudook.2019.02.006. Bodenheimer, T., & Sinsky, C. (2014). From triple to quadruple aim: Care of the patient requires cate of the provider. Annals of Family Medicine, 12(6), 573-576. Broome, M. E., Riner, M. E., & Allam, E. S. (2013). Scholarly publication practices of doctor of nursing practice-prepared nurses. Journal of Nursing Education, 52(8), 429-434. Brown, M. A. (2011, January). Advancing practice through the DNP capstone. Paper presented at American Association of Colleges of Nursing Doctoral Conference, San Diego, CA. Burson, R., Moran, K., & Conrad, D. (2016). Why hire a doaor of nursing practice-prepared nurse? The value-added impact of the practice doctorate. Journal of Doctoral Nursing Practice, 9(1), 152-157. Cambridge Business English Dictionary. (2011). Cambridge University Press. Chism, L. A. (2019). The doctor of nursing practice: A guidebook for role development and professional issues (4th ed.). Burlington, MA: Jones & Bartlett Learning. Clark, R. C., & Allison-Jones, L. (2011). The doctor of nursing practice graduate in practice. Clin ical Scholars Review, 4(2), 71-77.

Conrad, D., Burson, R., Moran, K., Kesten, K., Corrigan, C., Hussey, E, & Pohl, E. (2020). The practice doctorate approach to assessing advanced nursing practice in Ireland. International Nursing Review, 67(4). httpsyydoi.org^lO.lll.inr.12624 Doctors of Nursing Practice, Inc. (2022). History, https://www.doctorsofnursingpractice.org /about-us/history/ Donabedian, A. (1988). The quality of care: How can it be assessed? Journal of the American Medical Association. 260,1743-1748.

Fang, D., & Zangaro, G. A. (2022). Completion and attrition of DNP students of the 2006- 2015 ma triculating cohorts. Nursing Outlook, 00(00), 1 9. httpsy/doi.org/10.1016^ .outlook.2022.01.004. Fontaine, D. K., & Langston, N. .F (2011). The masteris is not broken: Commentary on “The doctor of nursing practice: A national workforce perspective." Nursing Outlook, 59, 121-122. https:// doi.org^l0.1016/j.outlook.2011.03.003 Institute of Medicine (lOM). (2003). Health professions education: A bridge to quality, http^/www.nap .edu/openbook.php?record_id=1068l&page=45 Johnson, J. K. (2001). Clinical microsystem assessment tool. https://clinicalmicrosystem.or^ploads /documents/mictosystem_assessment.pdf

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Chapter14 The Value and Impact of Practice Doctorate Scholarship

Kelly, D. L. (2011). Applying qualify management in healthcare—A fystematic approach (3rd ed.). Chicago, IL: Health Administration Press. Kesten, K., & Hoover, S. (2022). Doctor of nursing practice scholarship dissemination through an open access repository. Journal of Professional Nursing (under review). Kesten, K., Moran, K., Beebe, S., Conrad, D., Burson, R., Corrigan, C., Manderscheid, A., & Pohl, E. (2022a).DriversforseekingtheDNPdegreeandcompetendesacquiredasrep ortedbynursesinpractice.JoumaloftheAmericanAssociationofNursePractitioners,34(l), 70-78. https://doi.org/10.1097 /JXX.0000000000000593. Kesten, K., Moran, K., Beebe, S., Conrad, D., Burson, R., Corrigan, C., Manderscheid, A., & Pohl, E. (2022b). Practice scholarship engagement reported by nurses holding a Doctor of Nurs

ing Practice degree. Journal of the American Association of Nurse Practitioners, 34(2), 298-309. httpsy/doi.oig/10.1097>gXX.0000000000000620 Kesten, K Moran, K., Beebe, S., Coniad, D., Burson, R., Manderscheid, A., Pohl, E, & Corrigan, C. (2022c). Impact of practice scholarship as perceived by nurses holding a Doaor of Nursing Practice degree. Journal ofNursing Administration 52(2), 99-105. httpsy/doi.org/ 10.1097/NNA.0000000000001109 Kipnis, D. G., Palmer, L. A., & Kubilius, R. K. (2019). The institutional repository landscape in medical schools and academic health centers: A 2018 snapshot view and analysis. Journal of the Medical Library Association 107(4), 488-498. http://jmla.pitt.edu/ojs/jmla/article/view/653 Montgomery, K. L, & Porter-O’Grady, T. (2010). Innovation and learning: Creating the DNP nurse leader. Nurse Leade,r 8,44-47. https://doi.org'10.1016?j.mn/2010 .05.001 National Academies of Sciences, Engineering, and Medicine. (2021). The future of nursing 2020-2030: Charting a path to achieve health equity. >A^hington, DC: The National Academies Press, https:// doi.oig/10.17226/25982 National Organization of Nurse Practitioner Faculties (NONPF). (2013). DNP NP otoBat Process and approach to DNP competency-based evaluation. https-y/www.nonpf.org/general/custom.asp?page=27 National Organization of Nurse Practitioner Faculties (NONPF). (2015). Sample curriculum templates for practice doctorate education, https://www.nonpf.org/resource /resmgr/DNP/NONPFDNPS tatementSept2015.pdf National Organization of Nurse Practitioner Faculties (NONPF). (2016). White paper: The doctor of nursing practice nurse practitioner clinical schola,r https://www.nonpf.org /resource/resmgr/docs /ClinicalScholarFlNAU016.pdf National Organization of Nurse Practitioner Faculties (NONPF). (2018). The doctor of nursing prac tice degree: Entry to nurse practitioner practice by 2025. htipsy/www.nonpf .org/resource/resmgr /dnp/v3_05.2018_NONPF_DNP_Stateme.pdf Nelson, J. M., Cook, .P E, & Raterink, G. (2013). Nursing practice capstone process: Program matic revisions to improve the quality of student projects. Journal of Professional Nursing, 29(6), 370-380. httpsy/doi.org/10.1016/j.profhurs.2012.05.018 Peterson, K., & Stevens, J. (2013). Integrating the scholarship of practice into the nurse academi cian portfolio. Journal of Nursing Education and Practice, 3(11), 84-92. http://dx.doi.otg/10.5430 ^nep.v3nllp84 Pritham, U. A., & White, R (2016). Assessing DNP impact: Using program evaluations to capture healthcare system change. The Nurse Practitioner, 41(4), 44-53. Redman, R. W, Pressler, S. J., Furspan, R, & Potempa, K. (2014). Nurses in the United States with a practice doctorate: Implications for leading in the current context of health care. Nursing Outlook. 63(2), 124-129. Roush, K., & Tesoro, M. (2018, March). An examination of the rigor and value of final schol

arly projects completed by DNP nursing students. Journal of Professional Nursing, httpsy/doi .oig/10.1016^ .profhurs.2018.03.003 Scholarworks ©UMassAmherst. httpsy/scholarworks.umass.edu/nursin g_dnp_capstonedndex.html. Accessed 19 November 2021.

Terhaar, M. E, & Sylvia, M. (2015). Scholarly work products of the doctor of nursing practice: One approach to evaluating scholarship, rigour, impact and quality. Journal of Qinical Nursing, 25, 163-174, httpsy/doi.org/10.1111/jocn.l3113 University of San Francisco Scholarship Repository, https://repository.usfca.edu/dnp/. Accessed 19 November 2021.

Walker, L. O., & Avant, K. C. (Eds.). (2010). Strate^esfor theory construction in nursing. Upper Saddle River, NJ: Pearson.

Index Note: Page numbere followed by b.J, or £ indicate materia! in boxes, figures, and tables, respectively. American Association of Nurse Anesthetists

A

(AANA), 43

AACN. See American Association of Colleges of Nursing AANA. See American Association of Nurse

American Medical Association (AMA), 5, 431

Manual of Style, 277 American Psychological Association (APA), 261,426,431

Anesthetists

abstract/executive summary, 265-266 abstractness levels, in nursing theory, 120-121

academic practice partnerships, 345 Accreditation Commission for Education in

Nursing (ACEN), 443 accuracy standards, 370, 372-373t active voice, 279

Actualized DNP Model, 62-63, 63/ advance care planning, 133 Advanced Level Nursing Education Essentials competencies (AACN), 308 advanced nursing knowledge. 62 DNP education, 442-453

format, 280-281

analysis procedures. 275-276, 275t annotated bibliography, 279 APA. See American Psychological Association appendices, 278 application scholarship, 58, 6l£ APRNs. See advanced practice registered nurses

areas of interest, 118

article submissions, for publication. See also journal submissions assessments, organizational, 146-147 Associates in Process Improvement, 166 attributes, 130

advanced nursing practice defined, 23, 38, 64 roles of, 23

advanced nursing practice roles, preparation for, 447, 448-4501

advanced practice nurse (APN), 318 advanced practice registered nurses (APRNs). 44 Clinical Training Task Force report, 35-36 advocacy defined, 92

DNP Project, 94-103

healthcare policy and core competencies, 86 opportunities, 93-94 tips. 97-103

Agency for Healthcare Research and Quality (AHRQ), 315 AGREE II instrument, 217

bachelor of science in nursing (BSN), 241 background and significance, importance and,266

balanced scorecard. 208, 335-336, 335/ balancing measures, 386, 387/ being measured, define, 392 Bloom’s taxonomy, 359 Blue Cross Blue Shield of Michigan Foundation Student Award, 284 Boyer, Ernest L, 7, 55 bricoleur, concept of, 60, 6l£ Brown, Marie Annette, 440

BSN, See bachelor of science in nursing Business Source Premier, 142b

AMA. 5ee American Medical Association

American Association of Colleges of Nursing (AACN), 7, 22. 23, 35-36, 38, 55, 440-444, 447, 451

AACN-AONE principles, 41