DPI Project – Proposal Defense PowerPoint and Call
This project requires using the ATTACHED PowerPoint template to complete the assignment.
Please see the ATTACHED SAMPLE from a previous student
You will need to use the CORRECTED VERSION of Word document from the initial project submission ATTACHED
In this topic, you will participate with your full DPI committee in the DPI Project Proposal Defense call. This meeting requires that you present your revised DPI Project Proposal live in PowerPoint form as it stands at this time.
General Requirements:
Use the following information to ensure successful completion of the assignment:
· While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines.
· You are required to submit this assignment to LopesWrite.
Directions:
1. Using the “DNP Project Proposal Oral Defense Template” as your guide, create a PowerPoint presentation of your DPI Project Proposal, to be used during your DPI Project Proposal Defense call.
2. Present the revised Project Proposal PowerPoint to your full DPI committee.
You are required to complete your assignment using real-world application. Real-world application requires the use of current evidence-based data, contemporary theories, and concepts presented in the course. The culmination of your assignment must present a viable application in a current practice setting.
Improving Medication Adherence in Diabetic Patients in Home Health Care Settings Submitted by
Bola Odusola-Stephen
Direct Practice Improvement Project Proposal
Doctor of Nursing Practice
Grand Canyon University
Phoenix, Arizona
December 10, 2020
GRAND CANYON UNIVERSITY
Improving Medication Adherence in Diabetic Patients in Home Health Care Settings
by
Bola Odusola-Stephen
Proposed
December 10, 2020
DPI PROJECT COMMITTEE:
Mary Guhwe, DNP, Manuscript Chair
Bamidele Jokodola, RN, MSN, FNP, CMSRN, DNP, Committee Member
Full Legal Name, EdD, DBA, or PhD, Committee Member Comment by Author: Need to remove this as well as the footer
Abstract
Home-based healthcare is useful in managing some conditions as it is cost-effective and is known to improve the quality of life and longevity of patients. Home-based care is known to improve the mortality of patients due to the mental well-being associated with home-based care such as independence, mobility and the comfort of family and home. While beneficial, it can also be detrimental to patients if mishandled resulting in fatalities and complications in patients. Even though home-based care is popular and cost-effective, the adherence to medication by patients is unknown thus this project hopes to find out if educating patients undergoing home-based care improves their medication adherence. The project also aims to find out if family-led strategies lead to better medication adherence in home-based diabetes patients. Attachment and social cognitive theories will be used as the theoretical framework for this study. The project will be conducted in Urban Texas and will include 50 patients undergoing home-based care. Medical records of diabetes patients undergoing hospital-based care will also be reviewed for comparison. A standard questionnaire as well as the Morisky Medication Adherence scale (MMAS-8) will be used to collect data from patients. Data will be analyzed using excel and SPSS. Descriptive statistics and inferential statistics will both be used in analyzing data, Factor analysis will be used to analyze the data from the MMAS-8 tool. Comment by Author: The DPI template has the correct format for the abstract. Please refer to that and adjust your abstract. For the proposal you obviously will not have the results yet but you can complete the rest of the abstract requirements using the correct format Comment by Author: Make sure you have a change theory as part of your theories. As I mentioned previously, you do not need both the attachment and social cognitive theories but it is difficult to pin point which as you have not yet clearly identified what your intervention is for the project
Table of Contents Table of Contents
Chapter 1: Introduction to the Project 1
Background of the Project 5
Problem Statement 6
Purpose of the Project 7
Clinical Question(s) 9
Advancing Scientific Knowledge 11
Significance of the Project 13
Rationale for Methodology 14
Nature of the Project Design 15
Definition of Terms 17
Assumptions, Limitations, Delimitations 20
Summary and Organization of the Remainder of the Project 23
Chapter 2: Literature Review 25
Theoretical Foundations 27
Review of the Literature 29
Theme 1 31
Theme 2 32
Summary 36
Chapter 3: Methodology 40
Statement of the Problem 41
Clinical Question 42
Project Methodology 44
Project Design 46
Population and Sample Selection 48
Instrumentation or Sources of Data 51
Validity 52
Reliability 53
Data Collection Procedures 54
Data Analysis Procedures 56
Potential Bias and Mitigation 59
Ethical Considerations 62
Limitations 64
Summary 66
References 68
Appendix A 70
Appendix B 72
Appendix C 74
2
Revised 4/21/2020 by: Dr. Suzette Scheuermann (Please remove this footer)
Chapter 1: Introduction to the Project
Improving Medication Adherence in Diabetic Patients in Home Health Care Settings Comment by Author: You have numerous formatting issues throughout the proposal that need to get fixed. My advise is to use a new template and re-enter your information in the new template as the template is already formatted for you in APA format
It is important that there should be proper and effective medication to the patients that are living with diabetes especially those that are under home -based care. More than half of the population does not take the medicine as it has been prescribed and this in most cases is resulting in costly health care challenge. The poor medication taking habits and the lack of adherence to the medicine creates complex problems. It is important that those who are under home care based should work hard to ensure that the patients are taking medications as they are supposed to be so that they do not develop more complications as a result of not adhering to medication. There are key interventions that should be identified, and effective measures made from this. Comment by Author: Why? Comment by Author: Citation? This whole section has numerous sections that need citations. I have given you feedback previously that you need some assistance with writing/editing. Please see DC network for resources. Comment by Author: The healthcare workers? Probably better to name the group you are referring to avoid confusion with the patients
Some medical situations inevitably require home healthcare services, this is important since it can help especially a person who is aging manage diabetes. Home –based care is also important in managing health issues, which are chronic in nature and also important in assisting people to live independently. Home-based care is also helpful in a person who is recovering from medical setback. Some patients that are under home care based may be unable to recover as well because in some instances they may not get the correct guidance as compared to when they are in the hospital. Comment by Author: See comments about citations above
The project is about the strategies and the methods that home-based care patients should follow to improve their health especially in adhering to medication to ensure that they get maximum benefits of their home-based care. This is because it has proven to be a challenge to follow the right medication strategies when the person is under home-based care. Comment by Author: This is not correct. Please see previous feedback about this. Your DPI project should be translating evidence into practice and not generating new knowledge/research. Please also refer to the DPI template for all the components you need in your various sections of the proposal. It is important to avoid missing any items but also so you can stay focused in your writing and be clear
Background of the Project
Home-based healthcare has been around since 1909 (Choi et al., 2019). It was perceived as a cheaper way to take care of patients who would have the benefit of enjoying the comfort of home and save money that would be have used up in paying hospital bills. In the early 20th century, home-based healthcare was mainly practiced due to adversities, in that the patients practiced it due to insufficient funds to afford proper health care. It was also practiced due to hardships in accessing medical care (Choi et al., 2019). In the present times, however, it is practiced out of choice, after a patient has weighed their options. Some of the situations where a patient can choose to practice home-based healthcare are when a patient is elderly and prefers to get home-based care instead of hospital care since at home, they would be more independent than they would be in a hospital. Home-based care is ideal when the condition can be managed without admission to a hospital such as in patients who have diabetes or those with hypertension (Szanton, et al.., 2016).
There is also a high rise of lifestyle diseases and conditions, such as diabetes. These chronic disease conditions require that a person engages in self-care behaviours at home to keep the situation controlled and prevent complications. Diabetes, for example, requires a patient to keep checking their glucose level. Many patients who are under home-based care do not have sufficient knowledge of the requirements that diabetes treatment entails. They do not practice medication adherence, causing more health complications due to unmanaged health conditions. Home-based care can increase the mortality and morbidity of diabetic patients if it is handled correctly by ensuring that diabetes patients have sufficient knowledge of what is required of them in terms of adherence (Neupane, et al, 2017). Comment by Author: This statement is incorrect. How does home correctly rendered home based care increase mortality and morbidity?
This proposed project is looking to tackle an increase in the fatality rate of diabetic patients practicing home-based healthcare. Most of the fatalities are caused by medical non-adherence, caused by a lack of sufficient knowledge of home-based care related to diabetes and other conditions. Patients at home are unaware of the requirements for medication, dosages, and required follow-up. Comment by Author: Citation? Also, I gave you feedback on this. This is not the aim or purpose of your project. Need to really adjust this and edit for clarity and scholarly writing
Problem Statement Comment by Author: This needs significant editing. You need templated language that clarifies what your problem is. I have given feedback multiple times previously and you have it in the DPI template as well.
Even though home-based care has certain advantages such as increasing the mortality of patients and the mental well-being of patients, it also has challenges in its implementation and successful outcomes. The adherence rate of home-based care patients is unknown and the implementation of strategies to aid in adherence is also unknown. It is important to measure these strategies and also to evaluate the adherence success rate of home-based care patients as this could make the difference between life and death for the home-based care patients.
The quality improvement project aims to find out how many patients have the required knowledge about their medical conditions and how to manage them. This includes learning about the vital medication, the importance of medicine, and the expected outcome if they do not adhere to the medical recommendations regarding diabetes and other conditions. The intervention for this problem can be done before a person is given a go ahead of having home-based care. Patients should first be given knowledge and the tips that are required on adherence to medication so that their health can continue improving and not to deteriorate as happens in many people who undergo home-based care. The nutritionists will be in charge of the diet education while nurses and practitioners will be responsible in offering general healthcare education regarding diabetes and the right lifestyle changes have to be taken into account. Nutrition education will examine the types of foods to be consumed, amount and frequency with which they should be taken. Lifestyle education changes will examine the healthy life activities that diabetic patients ought to be involved with. Medication adherence will be measured using self-report questionnaires that will be given to patients and health care providers during data collection. The tool will involve asking patients questions about the missed doses within a specific period of time. For accuracy purposes, the patients will be asked about medication adherence in the last three days because asking for more than three last days will be difficult for the patients to recall.
Purpose of the Project
Comment by Author: This needs significant editing. You need templated language that clarifies what your problem is. I have given feedback multiple times previously and you have it in the DPI template as well.
The purpose of the project will be to determine medication adherence amongst home-based diabetes patients in Urban Texas. The project aims at determining the level of knowledge about diabetes and home healthcare requirements in 50 diabetes patients in Urban Texas. The project will focus on ways to reduce fatalities in diabetes patients under home-based healthcare. Many diabetes patients suffer due to medication non-adherence. This means that they do not follow the guidelines in managing their condition at home by the physician.
The main reason for medical non-adherence is the lack of knowledge of what they should do at home as healthcare measures to ensure they continue to improve their health. This could be due to home nurses’ failure to sensitize the patients on proper medication adherence or lack of proper follow-up through home visits.
The main aim of the project is to evaluate the implementations of some strategies which are important when it comes to defining clearly impacts that are present in case a person is on home-based care and the implications of not adhering to set times of taking medication
By conducting this project, the medical field can devise ways of ensuring that the useful information on diabetes management at home reaches everybody in Texas and other parts of the country. This should be incorporated in all systems like schools, workplaces, hospitals, and homes.
Clinical Questions Comment by Author: Put your PICOT question in this section and use that as your clinical question. Then add all the other information needed in the section based on guidance from the DPI template
Does Medication Adherence Education Increase Medication Adherence?
The project will focus on medication adherence of diabetes patients who are undergoing home-based care. The variables measured in this project will be adherence to medication and the outcomes of adherence or the lack of adherence in the patients and how this impacts home-based care. The project also hopes to understand the differences that are present in adherence to medication in diabetes patients undergoing home-based care as compared to those undergoing hospital-based care.
The data will be collected from both patients and health care providers engaged in home-based care programs. The aim is to find out to what extent medication adherence is utilised and what strategies are in place to ensure that patients adhere to their medication. The project will also seek to understand if the patients have sufficient knowledge on medication adherence. The following questions will guide this quantitative project: Comment by Author: This is research. Remember only limit your project to translating evidence into practice. Be very clear about what your problem is , what your intervention is and what your outcome is. Then you can be a good position to edit your manuscript. If you continue to edit the manuscript without clarity on those things it will be difficult for you
1. Does education on diabetes increase medication adherence in diabetic patients in home healthcare?
2. Do family-led strategies lead to better medication adherence in home-based diabetic patients?
Advancing Scientific Knowledge
This quality improvement project will help ensure that there is sufficient information available for the public regarding diabetes and the recommended home healthcare requirements to manage the condition. Seeing that there are so many patients without the necessary information regarding diabetes and how to manage it, there is a need to diversify the sources of information on diabetes and manage it. Comment by Author: Citation?
Sensitizing the population on the importance of adherence to medical recommendations and finding alternatives for expensive home healthcare facilities will solve problems even in the future, ensuring that the fatality rate in-home healthcare drops significantly. Adherence to medication by diabetes patients has been shown to improve their lives and reduce the development of more complications and premature death of patients (Delameter, 2006). This project will improve the overall quality of life for both the patients and their caregivers. This quality improvement project is also a gateway to more sensitization to people. The information can be shared in institutions. Future generations will also benefit from the knowledge on how to implement effective home-based care strategies to improve medication adherence and reduce diabetes related fatality rates. Comment by Author: How is this related to your project since these patients are home health patients?
The project will fill the literature gap on adherence to medication by diabetes patients undergoing home-based care. This project aims to provide all the necessary information to all Texas people to people all around the world. This information should be accurate and certified medically so that it will help reduce fatalities among diabetic patients in home healthcare settings.
Significance of the Project
This project is significant in current times. With the rise in chronic diseases, many people are opting for home-based care and not getting their treatment from a healthcare facility and thus they must know the importance of medication adherence even at home. Also, with the COVID-19, many people are undergoing more home-based due to congestion in hospitals and to also reduce the risk of spreading COVID-19 to other patients (Choi, Choi, & Shon, 2019). This DPI project provides a scope upon the general level of knowledge about diabetes and home healthcare. By focusing on medication adherence, the fatalities in home-based management can be reduced thus making the project very important to the management of diabetes at home. Though the project focuses on diabetes patients, it gives insight into the gap in a lack of knowledge on medication adherence for home-based care for other conditions as well including hypertension, heart disease and presently COVID-19. Other scholars interested in projects of this nature regarding other conditions will know the factors to consider and what to expect. Comment by Author: You need to make more of an argument for this as this is not the focus of your project so need to develop this argument further. You immediate impact for the project is improve medication adherence which improves control of the condition and prevents complications
After following through with content on the different ways of adhering to medical recommendations, other researchers can come up with ways to provide more information on current conditions to ensure that there is enough information guiding patients on the care measures required for a healthy life. Some situations that need looking into in the future are hypertension, and COVID-19, which are very urgent currently. Comment by Author: This is not what your project is about so need to edit
Rationale for Methodology
The DPI project employs quantitative methodology. This is where I will employ questionnaire as a way of collecting information. The data collected will be quantitative in nature to establish the medication taking behaviours of the patients under home-based care. In addition to the questionnaire developed, the Morisky Medication Adherence Scale (MMAS-8) will be used to determine how effectively the patients are adhering to medication. The MMAS-8 is a tool developed and widely used to determine patients’ adherence to medication in different conditions. It is a tool that eliminates bias from the patients and health care providers by asking questions in a method that avoids ‘yes-saying’ by patients. Numerical data is important as it focuses on trying to reduce the number of diabetes fatalities in home-based healthcare. Comment by Author: Can not use first person in scholarly writing. Pleas edit Comment by Author: You can not develop your own questionnaire/instruments for your project. You will need t utilize an already evidence-based instrument/questionnaire Comment by Author: Citation?
According to Creswell &Creswell (2017), a quantitative methodology is best suited for projects that require data in numerical form. This is to know the interventions that are happening to those who are under home based care to ensure that the strategies are working, and mortality rate of such people are reduced.
The information is then analyzed using quantitative methods and represented in charts and graphs. The conclusion on the findings is then drawn from the analysis of data, after which recommendations are thought of and implemented to curb the problems in scope.
Nature of the Project Design
This project will adopt the quasi-experimental design in that it deals with a random population that will be targeted will be all the stakeholders that have interacted with those patients that are in health care basis, and the DPI research project does not happen in a controlled environment. This design is more cost-effective than the actual experiment project design. In this project, the sample population is diabetes patients in Texas. The questionnaires, both the MMAS-8 scale and the questionnaire developed by the researcher, provide insights into the information intended for collection, thus providing accurate findings. Another mode of data collection used in this project surveys involves the diabetic patient or their caregiver to answer some questions related to diabetes, medical adherence, and home healthcare. Comment by Author: This is not really true. There is no requirement for randomization in quasi experimental design Comment by Author: The writing here needs editing for grammar and flow. Also please see prior feedback about removing any references of research a it pertains to the project. Comment by Author: Citation? Comment by Author: Only use evidence based instrument which you have provided as the MMAS so do not include caregiver interview etc that pertain to research
The project will use the data collected through the course time allocated. A detailed analysis of the data will be done, the date represented for interpretation, after which solutions to the research problem will be solved and tackled. It is a very descriptive project aimed at unravelling some of the truths that are not too obvious to develop solutions that are well needed in the current times. Comment by Author: If you are going to discuss data analysis then you need to just state what specific statistical tests you will run and what specific data you will analyze. This section is very vague and unclear as there are lot of research related statements
The research designs will help in the smooth process of data collection, analysis, and conclusions, which will help draft the recommendations for a healthy life for diabetic patients in Texas and possibly in the world who practice home-based healthcare.
Definition of Terms
Medication adherence:
This is the extent to which a patient, caregiver, or home nurse follows the recommended guidelines on managing a medical condition.
Home-based healthcare
Refers to the medical care given to a patient in the comfort of their home instead of going to the hospital.
Facilities
A thing, place, or person necessary to make the home healthcare process for a person with diabetes easier for both the patient and the caregiver.
Diabetes
A medical condition that is characterized by high sugar levels in the blood. It can be managed with drugs and insulin.
Assumptions, Limitations, Delimitations
This project assumes that medical non-adherence by diabetes patients’ is caused by a lack of sufficient knowledge on the matter. Education in the area as well as providing information on managing diabetes from home will solve the problem. It is also assumed that after education, the patients will automatically practice medical adherence because the knowledge will be easy to understand and the benefits of adhering to medication will be outlined to patients thus, they should be able to implement the knowledge. It also assumes that many people practicing diabetes home healthcare cannot afford the required facilities and equipment for treatment and care which is why they chose home-based care in the first place. Additionally, this project assumes that all patients and their caregivers are literate. Therefore, they can understand the physician’s diabetes and home healthcare recommendations for a long healthy life. Comment by Author: This is not correct as home health is not based on financial limitations bur rather other factors Comment by Author: Why are you assuming literacy when there is literature evidence that the average patient education material needs to be at the 5th grade level?
The project is limited because it focuses on only diabetes home-based care and does not consider patients undergoing home-based care who have different conditions. The project is also limited to an urban location and thus Texas state only and further limited to Urban Texas thus excludes rural Texas patients who may have different needs or challenges related to medication adherence. The project will also be limited to medication adherence of home-based care patients and does not cover other aspects such as mental health and health related quality of life of the patients. The project also includes all diabetes home patients, even those who are not necessarily ill and who are only practicing home-based care due to old age. In this case, the data may be a little imbalanced since it may record diabetes fatalities of patients who succumb to old age as a medical non-adherence fatality. Comment by Author: This is not a limitation as your population is diabetic patients in home health
Delimitations in this project include the project areas namely adherence and diabetes patients. The project will only collect data from diabetes patients and will only be interested in their medication adherence. The project study area is also only being conducted in an urban Texas area in the South East Unites State thus it will exclude patients from other states as well as rural rural locationsTexas.
The findings of the project will be applicable to medication adherence in patients with other conditions who are undergoing home-based care. They will also be applicable to all patients with diabetes throughout the country who are in the home-based care program to help them better adhere to medication and reduce the number of fatalities associated with the home-based health care programs.
Summary and Organization of the Remainder of the Project
Chapter one provides support for the assessing of interventions and their effectiveness especially those that are in home-based care, (Creswell & Creswell, 2017). This will bring about changes in the quality of life for people practicing diabetes home-based care not just currently during the COVID-19 pandemic but also in the years to come. People need to know the importance of medical adherence since it provides a chance to improve a patient’s quality of life. Chapter two will review literature both theoretical and empirical on the variables home-based healthcare, diabetes and also medication adherence to give the project a literary and empirical framework on which it will be based.
Chapter three will discuss the research methodology employed in the project. This will include research design, the target population, sample size, data collection tools, data analysis, reliability and validity of research instruments and ethical considerations when collecting data. Chapter four will present research findings and discussion of the findings. This will include both descriptive and inferential data analysis as well as discussions of the findings. Chapter five will present conclusions and recommendations drawn from the project.
Diabetes patients should also be enlightened on maintaining a healthy lifestyle and managing the condition at home (Choi et al., 2019). The data collected will make it easier to spot the problem and the gap, and therefore come up with ways to bridge it. One way to bridge the gap and reduce home-based healthcare fatalities of patients with diabetes is by providing adequate information on the management of diabetes at home. All the people involved in the home healthcare provision process should be sensitized to the significance of medical adherence. Comment by Author: See previous feedback on this
The projects also include data collection, where the data is presented and analyzed. The data gives insight into the situation, enabling ease of discussion of solutions and recommendations to increase medication adherence in home-based healthcare, which will reduce fatality rates of diabetic patients in home-based healthcare.
Chapter 2: Literature Review
Diabetes is a medical condition that is characterized by high sugar levels in the blood. It can be managed with drugs and insulin. Blood sugar serves as the major producer of energy in the body. Any condition interfering with blood sugar levels and mechanisms would bring about disruptions to the normal body activities. Optimal diabetes control usually needs patient associated engagement in various types of self-care associated activities, including the adherence of patients to the identified medication associated regimens along with adjustments to various lifestyle associated modifications and even the monitoring of the blood glucose associated levels, (Jajarmi, et al, 2019).
Since diabetes is a lifestyle disease, it can be easily prevented and avoided by making lifestyle changes. Managing the disease can also be made easier by making lifestyle changes as well as adhering to medication. This is important since it will help in avoiding of many challenges and complications that may arise from diabetes. one of the most problematic issues associated with home care for the patients suffering from Diabetes is Adherence to medications. According to Bonney (2016), patients usually take their identified medication as is …
DNP Project
Proposal Defense Template
1
Build the presentation
Use the information from your DPI Project Proposal Template document as the base.
Edit down your proposal presentation.
Summarize Chapters 1-3.
Include Appendix A.
Check…and Double Check
Timing: The Proposal Defense presentation should be no longer than 30 minutes.
Be sure you have the approval of your DPI Chairperson and Committee for everything in the presentation; if you are unsure of something, clarify it prior to your defense call.
Practice multiple times.
Format
DO:
Use this GCU slide layout.
Use an easy to read font size.
Use figures and tables.
DO NOT:
Do not add slide transitions, animation, or sounds that are distracting.
Do not crowd slides with excessive text.
Oral Presentation
Create notes in your presentation of the points you want to cover in your oral presentation of each slide.
Except for specific content, such as clinical questions, do not just read the slides. Paraphrase in a conversational, yet professional manner (the result of practice, as per the prior slide).
Your oral presentation should explain or expand upon what is on the slides; it should not reiterate the content.
Title Page
Start with a title page that uses the title of the DPI Project
Investigator’s Background
What qualifies you to do this project?
Credentials
Experience
Etc.
BE VERY BRIEF.
Topic Background
Why this topic?
History
Need
What needs(s) in practice does the research identify? What need will your project address and implement?
You can use more than one slide to address each of the categories.
Problem Statement
Your problem statement should clearly and explicitly state the reasons you are doing your study.
The purpose of this study is to…
Importance of the project
How might your project impact the field of study or health care outcomes?
How could it impact your work as a professional?
What else is significant?
Theoretical Foundation
If it is discussed in your project, include a slide on the philosophical orientation.
For example: critical theory or social constructivism
clinical Questions
Number your questions to facilitate easy reference during discussions with the committee members.
Methodology
Define which major category of methodology you implemented for your project.
Include your rationale as to why your chosen methodology is appropriate to your clinical questions?
Cite relevant methodology literature in support of your choice of methodology.
Specifics on Methodology
Depending on your choice of methods, you may need
to outline specifics such as (including but not limited to):
Variables—PICOT
Participants—number, how selected, IRB considerations, demographics
Reliability and validity
Methods of data collection
Data analysis
Limitations
You may need multiple slides for these categories.
References
List only those cited in the DPI Project Proposal Defense presentation.
One slide should be sufficient.
(Everything else is included in your manuscript.)
Thank You
Thank the members of the committee.
references
California State University, Fullerton, College of Education, Educational Leadership. (n.d.). Preparing a PowerPoint for your dissertation defense. Retrieved from http://coeapps.fullerton.edu/ed/eddstudents/documents/DissertationDefense_ppt_guidelines11-28-10.ppt
The Impact of implementation of code blue nurse champion for cardiac arrests
By: Beverly Holland, MSN, MBA, RN, NEA-BC
DNP 960
Project lead
Registered nurse with 34 years in acute care hospital settings
20 years in leadership roles
Clinical Education Department director
Involvement in ministry wide quality improvement, for example:
Code Blue committee
New employee orientation and Transition into Practice (TIP) RN onboarding
1/8/2021
B.Holland.DNP960.Oral_Defense
2
Background
Cardiovascular disease is the primary cause of death resulting in 840,768 deaths in the United States (US) in 2017, with 379,133 due to cardiac arrest (Varini et al., 2019).
An estimated 209,000 in hospital cardiac arrests (IHCA) occur each year in the US, with a survival rate of 24% (Andersen, Holmberg, Berg, Donnino, & Granfeldt, 2019).
Impacting factors for survival include:
skilled front line response by bedside nurses
skilled resuscitation team,
prompt initiation of cardiopulmonary resuscitation and defibrillation, and
organizational structures to support resuscitation care (Guetterman et al., 2018).
1/8/2021
B.Holland.DNP960.Oral_Defense
Cardiovascular disease (CVD) is a primary cause of death in the United States. In-hospital cardiac arrest (IHCA) events pose a significant risk for patients. Survival and favorable outcomes for IHCA events are highly dependent on factors such as having a skilled resuscitation team in-house, prompt initiation of cardiopulmonary resuscitation (CPR) and defibrillation and established organizational structures to support resuscitation care. The Institute of Healthcare Improvement (IHI) recognizes the need for having a safety measure to assist healthcare professionals at the bedside in the prevention and identification of patient deterioration (IHI, 2008). Current evidence illustrates the variability in cardiac arrest survival in and out of the hospital, demonstrating a substantial opportunity to save lives (Bhanji, Finn, et al., 2015).
3
Background (cont.)
Determinants for survival
Provider level
Early defibrillation
High quality CPR (Bhanji, Donoghue, et al., 2015).
Nurses as first responders
Delay in response
Early initiation of CPR (Bircher, Chan, & Xu, 2019).
1/8/2021
B.Holland.DNP960.Oral_Defense
For IHCA, provider-dependent determinants of survival are early defibrillation for shockable rhythms and high-quality cardiopulmonary resuscitation (CPR) (Bhanji, Donoghue, et al., 2015). Nurses are most likely first responders to witness an IHCA and provide treatment (McHugh et al., 2016). Furthermore, when rescuers respond slowly, survival is lower; early initiation of CPR links with improved outcomes for both out-of-hospital and IHCA (Bircher, Chan, & Xu, 2019). Therefore, CPR training for all hospital personnel has been mandatory in hospital systems for decades, facilitating the rapid identification and management of cardiac arrest before the arrival of the cardiac arrest team.
4
Background (cont.)
Acquisition and retention of resuscitation skills
Rapid response systems and teams
Evidence Based Practice (Maglangit, 2015)
IHI 100,00 Lives Campaign (IHI, 2008)
Activating RRT
Delays associated with high mortality
Early intervention, improves patient outcomes (Readron, Fernando, Maruphy, Rosenberg, & Kyeremantegn, 2018).
1/8/2021
B.Holland.DNP960.Oral_Defense
Rapid response systems are considered a powerful tool in patient safety (Jung et al., 2016). A rapid response team (RRT) is an evidence-based practice (EBP) that most hospitals in the country are utilizing (Maglangit, 2015). The RRT is one of the six initiatives that the IHI 100,000 Lives Campaign identified in 2004 (Mate, 2017). Delays in activating RRT calls are associated with high mortality, while early intervention during clinical deterioration can improve patient outcomes (Reardon, Fernando, Murphy, Rosenberg, & Kyeremanteng, 2018). Early RRT calls are associated with decreased mortality, while late calls are associated with increased patient morbidity and mortality (Jones, Moran, Winters, & Welch, 2013). Early requests for assistance allow identification of patients at risk of deterioration and target interventions to improve patient care (Maharaj, Raffaele, & Wendon, 2015). Recognition of altered physiological observations to complex process involves knowledge and experience (Guinane, Bucknall, Currey, & Jones, 2013).
Issues of delayed response and failure to notify the RRT are related to the inability to recognize patients’ deterioration and be associated with environmental factors. According to Jenkins, Astroth, and Woith (2015), recognition and addressing barriers can improve rapid response’ system safety culture and can have a positive impact on cardiac or respiratory arrests and mortality outside the intensive care unit (ICU). These barriers are related to perceptions that one has the necessary skills and abilities to perform or face issues or challenges related to navigation of the intra-professional and inter-professional hierarchies that lead to delays in activating the team when the patient condition deteriorates (Jenkins et al., 2015). Other possible system failures identified are multiple factors including delays in diagnosis and misdiagnosis (on physician’s side), inadequate interpretation of clinical symptoms, incomplete treatment, inexperienced staff, and patient management in appropriate clinical areas (Bagshaw et al., 2010 as cited in Jenkins et al., 2015).
5
Background (cont.)
Clinical nursing staff often provides suboptimal CPR during IHCA
Due to inadequate skills retention (Maiken, Castren, Nurmi, & Niemi-Murola, 2016; McHugh et al., 2016; Saramma, Raj, Dash, & Sarma, 2016)
Delay in recognition of clinical deterioration (Andersen et al., 2019)
Survival is lower; early initiation of CPR links with improved outcomes for both out-of-hospital and IHCA (Bircher, Chan, & Xu, 2019).
Perceived low level of confidence in ability to perform CPR
Infrequent opportunities to perform CPR
Lower proficiency, leading to hesitancy (Makinen et al., 2016)
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The incidence of IHCA in the medical-surgical setting poses distinct challenges for acute care nurses. Considering that early interventions could save lives, issues concerning delays in calling the RRT do exist. The recognition of physiological observations and response to complex processes involves knowledge and experience, and early intervention and escalation of care are essential (Guinane et al., 2014). The clinical staff is often providing suboptimal CPR due to inadequate skills retention (Makinen et al., 2016; McHugh et al., 2016; Saramma et al., 2016), recognition of clinical deterioration leading to delay initiating CPR (Andersen et al., 2019), and hesitation to start CPR, which is associated with perceived low level of confidence in their ability to perform (Adcock et al., 2020; Makinen et al., 2016).
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Background (cont.)
Nurses’ self-efficacy with a timely response to IHCA is a critical link to the delivery of American Heart Association (AHA) basic life support (BLS) recommendations with the outcome of survival of cardiac arrest (Makinen et al., 2016).
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Background (cont.)
History at project site:
Rolling 12-month data for IHCA indicates that 44.6% of cardiac arrests occurred outside of the ICU
59.60% occurred in the medical-surgical division (i.e., outside of ICU and Progressive Care Unit (PCU)) equating to 5.16 per 1,000 discharges.
For the month of May 2020, the incidence rate per discharges of IHCA in the medical surgical areas/units was 6.08 per 1,000 discharges.
Survival to discharge rate of 29%, better than the national average of 24.8%; however, only 38% of non-ICU codes had a rapid response within the previous 24 hours.
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Background (cont.)
Contributing factors:
Code Blue committee:
Appropriate patient placement outside of ICU
Patients are sicker than their level of care placement
Delay in recognition of patient deterioration resulting in the delayed activation of the rapid response team (RRT)
Failure to rescue in medical-surgical patient population
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The project site Code Blue committee notes appropriate patient placement as a factor outside of ICU IHCA; patients are sicker than their level of care placement. Whenever the RRT is activated, patients are treated then transferred to a higher level of care. However, as noted in previous slide, only 38% of codes occurring outside of the ICU had a rapid response within the previous 24 hours. Clinical staff outside of the critical care areas may not have the exact knowledge, skills and experience in treating critically ill patients, however, they are instrumental in implementing a timely and appropriate intervention to prevent deterioration and reduce mortality and morbidity because timely deployment most often depends on staff nurses (Massey et al., 2017). Currently, there exists a nursing practice issue of failure to rescue in the medical-surgical patient population (i.e., a delay in recognition of patient deterioration resulting in the delayed activation of the RRT).
The rationale for many of these strategies on implementing a timely and appropriate intervention is to prevent patients from deteriorating through providing education, informing staff of data, and providing them with the necessary skills (Massey et al., 2017). Due to their proximity to patients and familiarity with their clinical conditions, bedside nurses are ideally positioned to alert the RRT for anticipatory response and intervention (Connell et al., 2016). They are the first caregivers to identify the subtle changes in the patient’s condition, indicating clinical deterioration. They must be educated and trained to activate preemptively and proactively the rapid response system (RRS) (Jenkins, Astroth, & Woith, 2015).
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Background (cont.)
Code blue nurse champion
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The literature is sparse on code blue nurse champion roles; however, Banks and Trull (2012) employed a process improvement strategy implementing code blue nurse champions. The strategy educates code blue champions by using simulations and a communication framework. Educators collaborated with experienced code leaders to develop a framework for the tasks, roles, and priorities of code management. Each person was responsible for a specific task to provide a focused approach to a potentially chaotic situation (Banks & Trull, 2012). Team training included the application to simulated realistic patient situations allowing individuals to practice as a team. The champions then use their education to improve practice in their departments (Banks & Trull, 2012). The authors note findings demonstrated that nurses’ report increased confidence and competence in managing a code blue situation, and patient outcomes reflect the improvement in skills. The results of code blue champions on each unit reported a 74% survival rate compared to the national average of 44% (Banks & Trull, 2012).
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Problem statement
The purpose of the project is to compare the impact of the implementation of the code blue nurse champion role in a select nursing medical-surgical division patient care department on nurses’ self-efficacy to initiate cardiac resuscitation and survival of IHCA.
The focused education for the code blue nurse champion role includes IHI rapid response education (IHI, 2008) and participation in cardiac arrest in situ simulation scenario (Liaw, Rethans, Scherpbier, & Piyanee, 2011).
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Importance of project
Survival depends on early recognition (Chang et al., 2018).
Literature indicates that adequate training and evaluation are essential to ensure that CPR skills are correctly acquired, translating into clinical practice (Brennan et al., 2016; Gonzalez et al., 2016).
Interventions designed to improve the recognition and management of patient deterioration can improve learner outcomes when they incorporate medium to high-fidelity simulation (Connell et al., 2016).
When a nurse has self-confidence, recognizing, and responding appropriately to an emergency is increased (Horowitz, 2018).
Adequate training and evaluation are essential to ensure that CPR skills are correctly acquired, translating into clinical practice (Brennan et al., 2016; Gonzalez et al., 2016).
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Patient safety is a hospital priority. Survival of cardiac arrest event depends on early recognition of the event and immediate response including activation of a “code blue” team and initiation of high-quality CPR (Chang et al., 2018). An integrative review of the literature revealed that CPR skills retention and poor-quality CPR remain a major challenge in the clinical setting. The findings have consistently demonstrated that the quality of CPR is directly related to survival outcomes. Literature indicates that adequate training and evaluation are essential to ensure that CPR skills are correctly acquired, translating into clinical practice (Brennan et al., 2016; Gonzalez et al., 2016). CPR training helps individuals learn and apply cognitive, behavioral, and psychomotor skills then develop the self-efficacy to provide CPR when necessary (Bhanji, Finn et al.,2015; Horowitz, 2018). Nurses are often the first to activate the chain of survival when a cardiorespiratory arrest happens. It is crucial that nurses keep their knowledge and skills up to date, as well as attitudes to resuscitation are very important (Tiscar-Gonzalex, Blanco-Blanco, Gea-Sanchez, Molinuevo, & Moreno-Casbas, 2019). Many times, nurses lack the confidence to identify a deteriorating patient. When a nurse has self-confidence, recognizing, and responding appropriately to an emergency is increased (Horowitz, 2018). Adequate training and evaluation are essential to ensure that CPR skills are correctly acquired, translating into clinical practice (Brennan et al., 2016; Gonzalez et al., 2016).
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Theoretical foundations
Bandura self-efficacy (BSE) theory
Bandura (1982) defined confidence as “the perception that one is competent and capable of fulfilling particular expectations’” whereas self-efficacy is the personal judgment of “how well one can execute courses of action required dealing with prospective situations” (p. 122).
Confidence is important as it may influence the degree of self-efficacy experienced
Individuals are more likely to engage in behaviors if they have confidence in their ability to perform the task (Bandura, 1995).
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Applying this theory, Participants that have received the training will potentially respond to patient deterioration with more confidence.
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Theoretical foundations
The Transtheoretical Model (TTM)
Health behavior change involves progress through six stages of change: pre-contemplation, contemplation, preparation, action, maintenance, and termination
Focus on the individual’s decision making
Model of intentional change
Key assumption: people do not change behaviors quickly and decisively; instead, change in behavior, especially habitual behavior, occurs continuously through a cyclical process (Boston University School of Public Health [BUPH], 2019).
Based on the processes of change in TTM, behavioral change in the attitude stage facilitated by raising awareness, discussing relevant events and cases, and providing effective models, media campaigns, and group discussion opportunities (Keshmiri et al., 2017).
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For nurses to move from the pre-contemplation to the termination stage, education needs to be effective, focusing on the harmful effects of “failure to rescue” [current state] and identify with the positive benefits of timely initiation of cardiac resuscitation.
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Clinical questions
Does the implementation of a code-blue nurse champion role, as a cardiac arrest first responder, improve nursing self-efficacy to initiate cardiac resuscitation and survival of IHCA patients when compared to current practice among adult medical surgical patients in an acute care hospital in California over four-weeks?
Q1: Does educational training consisting of IHI rapid response education, and cardiac arrest in situ simulation for code blue nurse champion nurses’ increase self-efficacy in responding to cardiac arrest?
Q2: Does the implementation of a code blue nurse champion role increase survival of IHCA?
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This project is based on the following overall question—
Sub questions include…
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methodology
Quantitative methodology
Statistical analysis to analyze data
Objective measurements; used to test or confirm theories and assumptions (Fain, 2017).
Cause and effect relationship; convey numerically what is seen in research; arrive at specific, observable conclusions (Klazema, 2014).
One Group quasi-experimental design
Assess the effectiveness of implementation of the code blue nurse champion role to improve IHCA survival
Identify if the additional training makes a difference in nurses’ timely recognition of patient deterioration and if appropriate action impacts the survival of IHCA
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In other words, Discover through statistical analysis quantifiable, objective data related to the implementation of code blue nurse champion role on nurses’ self-efficacy to respond cardiac arrest and survival of IHCA.
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Specifics on Methodology: PICOT
P=Acute Care Registered Nurses’; Hospitalized patients experiencing IHCA
I=Code blue nurse champion role
C=Current practice
O=Improved nurse knowledge, self-efficacy [attitude] towards CPR; improved IHCA survival
T=Over six weeks timeframe
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Specifics on methodology: Variables
Characteristics of Variables
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Specifics on methodology: Population and Sample
Voluntary convenience sample of RNs (at least 16) from medical-surgical department, 4S
Equal representation from night shift (1900 to 0730) and day shift (0700 to 1930)
To achieve the effect size of 0.80 and an alpha level of significance of 0.05, twenty-five subjects are required
IHCA patients during project timeline
Hispanic ethnicity represents a high proportion of the population
Cardiovascular disease (CVD) is a leading cause of death among Hispanic adults (Balfour et al, 2016).
Hispanic population, compared to the non-Hispanic population, less than 10 percent of affected Hispanic patients are effectively managing their disease (e.g., use of anti-hypertensive medications) (Carlson et al., 2019) leading to higher US health care costs and hospitalization.
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Specifics on methodology : Instrument
Nursing Knowledge and Attitude in Cardiorespiratory Arrest (CAEPCR) questionnaire (Tiscar-Gonzalez et al., 2019)
Three distinct sections
Demographic data
Knowledge of CPR
Attitude / Self-efficacy
Validity:
Three Delphi rounds
Reliability
Piloted on a test-retest basis with a convenience sample of 30 RNs (Tiscar-Gonzalez et al., 2019); psychometric characteristic evaluated by 347 nurses
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The Knowledge and Attitude of Nurses in the Event of a Cardiorespiratory
Arrest (CAEPCR) questionnaire comprised three sections: sociodemographic
information, theoretical and practical understanding, and attitudes of ethical issues.
The questionnaire was designed using the Delphi technique (three rounds). The
questionnaire was adjusted and it was piloted on a test-retest basis with a convenience
sample of 30 registered nurses. Psychometric characteristics were evaluated using
a sample of 347 nurses using Cronbach’s alpha. Descriptive analysis was performed
to describe the sociodemographic variables and Spearman’s correlation coefficient
to assess the relationship between two scale variables. Pearson’s chi-squared test used to study the relationship between two categorical variables. Wilcoxon Mann
Whitney test and the KruskalWallis test were performed to establish relationships
between the demographic/work related characteristics and the level of understanding.
Cronbach’s alpha for the internal consistency of the attitudes questionnaire was 0.621.
The knowledge that nurses self-reported with regard to cardiopulmonary arrest directly
affected their attitudes. Their responses raised a number of bioethical issues.
Conclusions. CAEPCR questionnaire is the first one which successfully linked knowledge
of cardiopulmonary resuscitation to the attitudes towards ethical issues Health
policies should ensure that CPR training is mandatory for nurses and all healthcare
workers, and this training should include the ethical aspects.
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Specifics on methodology: Instrument (cont.)
Electronic Medical Record (EMR)
Source of data for cardiac arrest events
Queried based on an internal report from hospital operator for activation of code blues
Code blue documentation record embedded in the EMR as a scanned document
Process is determined to be sound based on random audits of actual code blue events and cross validation with internal operator report
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Specifics on methodology: Intervention
Code Blue Nurse Champion role education:
Rapid response education (IHI, 2008)
Includes rapid response team (RRT) composition, role, and purpose, patient physiological changes and early warning signs of deteriorating status, when to call RRT, how to call RRT, and the SBAR (Situation, Background, Assessment, and Recommendation(s)) communication that should be used during calls.
In situ simulation—cardiac arrest scenario
Focused on responding to a deteriorating patient, specifically on cardiac arrest
team roles, prioritizing actions, and effective communication, inclusive of the role of RRT.
Scenario is based upon AHA BLS and ACLS standards for frontline responders (Liew et al., 2011).
The staff must identify the unresponsive, apneic adult patient, call the code, assess the carotid pulse, and provide high quality CPR. Additional responders arrive with the crash cart and automated external defibrillator (AED), turn on AED and apply pads, analyze rhythm, and safely defibrillate if the AED indicates a shockable rhythm. Responders set up oxygen and suction, appropriately communicate with the code team (e.g., through SBAR format), and prepare to assist physician provider with endotracheal intubation.
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Specifics on Methodology: data collection (cont.)
Day of class:
Each participant receives CAEPCR questionnaire. Instructed to be anonymous
Seal and place their completed pre and post survey tools in a marked separate envelopes (pre-survey and post-survey) after completion.
Each envelop is labeled by the project lead with a numerical value (e.g., one to 16, depending on the number of participants); identical numbers for pre and post envelops will correlate to associate with same participant.
Completed survey tools will only be accepted when they are placed in an envelope and are sealed by the participants.
The surveys will be placed in a locked cabinet in the project lead’s office on hospital property and will only be opened by the project lead during data coding and analysis.
The data will be entered into a password protected computer for analysis.
Survey results will not be shared with any personnel not directly associated with the development and implementation of the project. After the study is completed, survey results will be shredded and disposed of in a protected hospital bin.
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Specifics on methodology: Data collection (cont.)
IHCA data:
Provided by Quality Management Specialist; internal reports on documented code blue activations, initiated by the hospital operator.
Data extracted from the electronic health record (EMR) including scanned code blue documentation records.
Data is compiled in an excel spread sheet.
Data points include inpatient location, date and time of cardiac arrest, and outcome of arrest (i.e., survival or expired). Only cardiac events occurring within the project site’s nursing department on a single medical-surgical unit will be included.
Quality Management Specialist to provide project lead raw data; no PHI included.
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Specifics on methodology: data analysis
CAEPCR tool
Descriptive statistics for categorical variables (gender, age, years of experience as RN, last completed CPR course, frequency of performing CPR, recommended frequency of renewal, able to attend a real CPR event).
Knowledge section
Scores range from zero to 11—reflective of correct answers
Paired one tail t test to analyze data—difference between paired scores and ranking difference
Attitude (self-efficacy) section
Likert scale one (strongly disagree) to five (strongly agree)
Total scores maximum of 60
Paired one tail t test to analyze data–difference between paired scores and ranking difference
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Specifics on methodology: data analysis (cont.)
IHCA
Data extracted by Quality Management Specialist
Percentage rate
Numerator survival of IHCA
Denominator total IHCA during project timeline
Data analysis using one tail paired t test for dependent means
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Specifics on methodology: data analysis (cont.)
Dependent variables
Nurses knowledge of CPR
Nurses attitude (self-efficacy)
Survival of IHCA
One-way multivariate analysis of variance (MANOVA) will be used to determine whether there are any differences between the dependent groups
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