Now that you have considered the evidence and potential options to address the local site problem and project objectives, it is now time to describe the proposed design of your project, specific details on the intervention, and the implementation plan. Use the Hopkins Transition and Action Planning Tool to assist you in this phase of project design.
In this assignment, you will continue to develop the proposal and add the following to your working draft:
- Revisions and recommendations from your Faculty Project Advisor for previously submitted and reviewed sections of the proposal.
First Drafts of the Following Subsections of the Project Design, Intervention, and Implementation Plan
- o Project Design – description of the type of project: QI process improvement, EBP intervention, Program evaluation, health policy change, etc.o Setting – type of setting (e.g., ED, family practice, ICU), include site barriers and facilitators for project implementationo Population targeted for the intervention (e.g., staff, patients, administration, the public)o Intervention – detailed description of intervention (what will you do, with whom, and how), feasibility of intervention at siteo Budget and Resources required for the projecto Cost-Benefit Analysis
Upload the revised draft of the proposal into the assignment tab. Review comments provided by your Faculty Project Advisor, and integrate these into future drafts of the proposal.
Now that you have considered the evidence and potential options to address the local site problem and project objectives, it is now time to describe the proposed design of your project, specific detai
The final phase of the PET process is translation, the value-added ste p in evidence-based practice. Translation leads to a change in practice, processes, or systems and in the resulting outcomes. Through transla- tion, the EBP team assesses the best evidence recommendations iden- tified in the Evidence phase for transferability to a desired practice setting; followed by implementation, evaluation, and communication of practice changes. This chapter covers the Translation phase of the PET process and will: ■ Examine evidence criteria that determine recommendation(s) for implementation ■ Review organization-specific considerations essential to translation of best evidence ■ Specify the components of an action plan ■ Identify steps in implementing and evaluating a practice change 8 Translation8 Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ucf/detail.action?docID=6677828. Created from ucf on 2022-10-17 02:42:22. Copyright © 2021. Sigma Theta Tau International. All rights reserved. 190 Implementation of best evidence is the primary reason to conduct an evid ence review. Critically appraising, rating, and grading existing evidence and makin g practice recommendations requires one set of skills; translation require s another. The EBP process requires both critical thinking and clinical reasoning. Critical thinking, a key skill or process integral for clinical reasoning, is kno wledge- based and is not dependent on the specific patient, situation, or envi ronment (Victor-Chmil, 2013). While critical thinking is an essential component of the Evidence phase of the PET process, clinical reasoning is the essential c omponent of the Translation phase. Clinical reasoning, a set of cognitive processes, requ ires clinicians to identify the relevance of the evidence and knowledge to a particular patient, situation, or setting. Thus, the EBP team engages in clinical r easoning to evaluate the relevance of the best evidence recommendations to their practice setting (Kuiper & Pesut, 2004; Victor-Chmil, 2013). Before we describe the translation process, it is important to clarify s ome terminology used in translation. Study or project teams often use the te rms translation and implementation interchangeably, which is appropriate; however, we describe the significant difference between translation and impleme ntation science (see Box 8.1). Translation Models The use of a translation model or framework in this phase of the PET pro cess is imperative in ensuring a systematic and intentional approach to the c hange. First and foremost, the team selects a model or framework to ensure a fu lly realized translation. There are multiple frameworks or models to choose from; Tabak et al. (2012) reviewed sixty-one current translation models. Many focus on implementing evidence into practice, enhanced by a body of literature that describes implementation strategies (Waltz et al., 2015). Secondly, translation requires organizational support, human and material resources, and a com – mitment of individuals and interprofessional teams. Context, communicati on, Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ucf/detail.action?docID=6677828. Created from ucf on 2022-10-17 02:42:22. Copyright © 2021. Sigma Theta Tau International. All rights reserved. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professi onals, Fourth Edition 191 leadership, mentoring, and evidence affect the implementation and dissem ination of best evidence into practice. Finally, planning and active coordination by the team are critical to successful translation, as is adherence to prin ciples of change that guide this process and careful attention to the characterist ics of the organization involved (Newhouse et al., 2007; White et al., 2020). Box 8.1 Implementation Science Implementation science is “the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practi ces into routine practice, and, hence, to improve the quality and effectiveness o f health services and care” (Eccles & Mittman, 2006, p. 1). Implementation s cience tries to understand how, when, where, and why change processes work. By rigorously studying methods of systems improvements, they attempt to ans wer the question: What are the best methods to facilitate the uptake of evid ence into practice? Over the last 20 years, there has been concern that local success in tra nslating evidence into practice is often challenging to replicate, spread, and su stain. Factors that facilitate the change in practice may work in one setting b ut not in another. These local successes, performed in a single setting of convenience, are not generalizable because the translation does not consider other cr itical organizational contributing or confounding factors. In addition, simplis tic impact measures are often used, and spread and sustainability are rarely part of the translation strategy. Implementation science focuses on researching the efficacy and effectiveness of different translation strategies and the rigorous testing of improvement strategies. Well-designed and effective implementation strategies affect the sustainability of those efforts (White et al., 20 20). We describe The Model for Improvement: PDSA (Langley et al., 2009) to t rans – late evidence into practice because it is one of the most used and succe ssful trans – lation approaches in healthcare. In addition to the PDSA cycle, other mo dels (see Table 8.1) may be more appropriate given the complexity and scale of cha nge being implemented. Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ucf/detail.action?docID=6677828. Created from ucf on 2022-10-17 02:42:22. Copyright © 2021. Sigma Theta Tau International. All rights reserved. 8 Translation 192 Table 8.1 Models and Frameworks for Translation and Implementation of Evidence Model or Framework Description Best Used For AHRQ: Knowledge Transfer Accelerates the transfer of research findings to organizations that can benefit from it. Includes three phases: 1) knowledge creation and distillation, 2) diffusion and dissemination, and 3) end user adoption (Nieva et al., 2005). Developing tools and strategies to implement research findings, specifically for AHRQ grantees and healthcare providers engaged in direct patient care to improve care quality (Nieva et al., 2005). Knowledge-to- Action Integrates creation and application of knowledge. Knowledge creation includes knowledge inquiry, synthesis, and tools/products; knowledge becomes more refined as it moves through these three steps. Action includes identifying and appraising the problem and the known research; identifying barriers and successes; planning and executing; and finally monitoring, evaluating, and adjusting (Graham, 2006). Facilitating the use of research knowledge by several stakeholders, such as practitioners, policymakers, patients, and the public (Graham et al., 2006). PARIHS Examines the interactions between evidence, context, and facilitation to translate evidence into practice by placing equal importance on the setting and how the evidence is introduced into the setting as well as the quality of the evidence itself (Bergström et al., 2020). Organizing framework to specify determinants that act as barriers and enablers influencing implementation outcomes (Bergström et al., 2020). Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ucf/detail.action?docID=6677828. Created from ucf on 2022-10-17 02:42:22. Copyright © 2021. Sigma Theta Tau International. All rights reserved. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professi onals, Fourth Edition 193 QUERI Implementation Roadmap to Implement Evidence- Based Practices Drives the adoption of high-value research innovations by empowering frontline providers, researchers, administrators, and health system leaders by focusing on the development of practical products (e.g., implementation playbook) and a data-driven evaluation plan (Stetler et al., 2008). Based on quality improvement science, is distinctively suited for use in real-world settings to support further scale-up and spread of an effective practice (Stetler et al., 2008). RE-AIM Designed to enhance the quality, speed, and public health impact of efforts to translate research into practice in five steps: ■ Reach your intended target population ■ Efficacy (or effectiveness) ■ Adoption by target staff, settings, systems, or communities ■ Implementation consistency, costs, and adaptations made during delivery ■ Maintenance of intervention effects in individuals and settings over time (Glasgow et al., 1999) Determine public health impact, translate research into practice, help plan programs and improve their chances of working in “real-world” settings, and understand the relative strengths and weaknesses of different approaches to health promotion and chronic disease self- management—such as in-person counseling, group education classes, telephone counseling, and internet resources (Glasgow et al., 1999). Notes: QUERI – Quality Enhancement Research Initiative; PARIHS – Promoting Action on Research Implementation in Health Service s The Model for Improvement: PDSA The Plan-Do-Study-Act (PDSA) cycle is a four-stage quality improvement (QI) model. PDSA approaches are simple, rapid cycle quality improvement proce sses that provide a structured, data-driven learning approach that allows tea ms to assess whether a change leads to improvement in a particular setting and to make appropriate, timely adjustments. PDSA uses a “test of change” approach to quickly troubleshoot issues as well as increase the scale and complex ity of the translation to achieve the desired improvement. To properly implement and evaluate the cycles, the EBP team must form a translation team. This tra nslation Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ucf/detail.action?docID=6677828. Created from ucf on 2022-10-17 02:42:22. Copyright © 2021. Sigma Theta Tau International. All rights reserved. 8 Translation 194 team may be different from the original team that evaluated the evidence due to the need to include team members who can identify and address any proble ms in the specific local context where the evidence is implemented. The translation team sets measurable goals and integrates measurement in to dai – ly workflows. Goal setting includes drafting aims using the SMART goal format (Table 8.2) and establishing measures to assess change. Table 8.2 Definition of a SMART Goal Specific Goals should be straightforward and state what you want to happen. Be specific and define what you are going to do. Use action words such as direct, organize, coordinate, lead, develop, plan, etc. Measurable If you can’t measure it, you can’t manage it. Choose goals with me asurable progress, and establish concrete criteria for measuring the success of y our goal. Achievable Goals must be within your capacity to reach. If goals are set too far ou t of your reach, you cannot commit to accomplishing them. A goal should stretch you slightly so you feel you can do it, and it will need a real commitment from you. Success in reaching attainable goals keeps you motivated. Relevant Goals should be relevant. Make sure each goal is consistent with your other goals and aligned with the goals of the company, your manager, or your department. Time-bound Set a time frame for the goal: for next week, in three months, end of th e quarter. Putting an end point on your goal gives you a clear target to work toward. Without a time limit, there’s no urgency to start taking action now. Source: Johns Hopkins Performance Evaluation Resource For successful data collection of the identified measures, a simple da ta collec – tion form may be beneficial, as well as assigning data collection into daily tasks (preferably of one or two point people). The PDSA process requires the team to answer three fundamental questions, in any order (Figure 8.1): What ar e we try – ing to accomplish? How will we know that a change is an improvement? Wha t change can we make that will result in an improvement? Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ucf/detail.action?docID=6677828. Created from ucf on 2022-10-17 02:42:22. Copyright © 2021. Sigma Theta Tau International. All rights reserved. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professi onals, Fourth Edition 195 To answer these questions, the team engages in four stages that compose t he PDSA model (Table 8.3). Table 8.3 Plan-Do-Study-Act Model Stages and Definitions Stages Activity Definition I Plan Develop a plan to test the change that answers the questions: What data will the team collect? Who? What? When? Where? II Do Carry out the plan and document unexpected problems and observations. III Study Analyze and study the results, summarize, and reflect on learning(s). IV Act Define the change based on what was learned from the test, and determine what modifications should be made. ActPlan Study Do What are we trying to accomplish? Model for Improvement How will we know that a change is an improvement? What change can we make that will result in improvement? Figure 8.1 Model for Improvement. Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ucf/detail.action?docID=6677828. Created from ucf on 2022-10-17 02:42:22. Copyright © 2021. Sigma Theta Tau International. All rights reserved. 8 Translation 196 Components of the Translation Phase Component 1: Identify Practice Setting–Specific Recommendations The translation phase begins when the interprofessional practice team se lects a course of action to implement a change or pilot (Appendix I) and agr ees on the organization-specific recommendations. Critical to the translation are the relationships of this interprofessional team that capitalize on the know ledge and skills that each member brings, including an understanding of the specifi c practice setting. The team takes responsibility for translation of the best evide nce to the local context. Translation requires that the team assess the fit, feasibility, and acceptability of the recommendations within the organization’s context (White et al., 2020). Component 2: Determine Fit, Feasibility, and Acceptability of Recommenda tions to the Organization Practice recommendations made in the evidence phase, even if based on co mpelling evidence, might not be suitable to implement in all settings. The EBP te am is responsible for evaluating best evidence recommendations for implementat ion within the practice setting (see Appendix I). Stetler (2001, 2010) r ecommends using specific criteria such as fit, feasibility, and desirability. Assessment of the fit to the current practice environment involves consideration of the extent to which the change is suited to the end user’s workflow and if the change sufficiently improves a specific practice problem. The EBP te am accomplishes this by evaluating the current environment, the extent to which the chan ge aligns with organizational priorities, and the infrastructure in place, such as resources (equipment or products) and the presence of people who can foster chan ge or facilitate the adoption of the evidence (Greenhalgh et al., 2004). Determining the feasibility of implementing best evidence recommendations within an organizational setting involves assessing the extent to which the tea m evaluates and believes the change is doable, that barriers are realistic to overco me, and that risk is minimal. The team should assess the practice environment’s readiness for change, which includes the availability of human and material resources, support from decision-makers (individuals and groups), and budget implications ; and they evaluate and determine whether it is possible to develop strategies to o vercome Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ucf/detail.action?docID=6677828. Created from ucf on 2022-10-17 02:42:22. Copyright © 2021. Sigma Theta Tau International. All rights reserved. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professi onals, Fourth Edition 197 barriers to implementation. Strategies include seeking input and involve ment from the frontline staff, stakeholders, and other individuals affected by the change and cocreating communication, education, and implementation plans with those most affected by the change. The final area to assess for feasibility befor e implementing proposed recommendations is to evaluate the risk of making the change in the specific practice environment. This risk assessment focuses on ide ntifying, analyzing, and discussing safety vulnerabilities that the change may cre ate for the organization. A Heat Chart is a useful quality improvement tool that shows a visual or graphical picture of complex dimensions of problems, or in t his case, the risk consideration during the action planning steps for translation. Figure 8.2 provides a color-coded stop light representation of the interrelated role of risk and strength and consistency of evidence when the team is determining whethe r best evidence should be put into practice. (NOTE: The ebook versions of this book present the heat chart in color with reds, yellows, and greens, while th e print book presents the same information using black, gray, and white indicating “stop,” “use caution,” and “proceed,” respectively.) Interventions with higher risks require more strong, consistent, and compelling evidence than those with lower risks. It is also important to note, that although an intervention with little or confli cting evidence may be low risk, it should still be translated judiciously to ensure the team is not wasting time and resources on a change not supported by the literature. Figure 8.2 Heat chart for interconnected role of safety risk and strength and consistency of best evidence. Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ucf/detail.action?docID=6677828. Created from ucf on 2022-10-17 02:42:22. Copyright © 2021. Sigma Theta Tau International. All rights reserved. 8 Translation 198 The final area to consider is that of acceptability. Acceptability refers to the extent to which stakeholders and organizational leadership perceive the EBP cha nge to be agreeable and palatable, and trust that the change is reasonable. Lea dership is a critical element in the effective implementation of innovations and chan ge within an organization (Aarons et al., 2015). EBP teams should seek opportunitie s to inform key stakeholders and leaders within the organization about their progres s to obtain their input and feedback throughout the PET process. Key collaborators i nclude leaders in areas such as organizational risk management, quality improve ment, and patient safety. Keeping these leaders and leaders of the target change area(s) informed positions the team for organizational support during implementa tion of recommended changes and increases the likelihood of change adoption a nd sustainability. In summary, change initiatives such as translation are prone to failure and waste valuable time and resources on efforts that produce negligible benefit s when the assessment of safety risk; quality of the best evidence; availability of resources, including money, time, and staff; and other factors that could negatively impact the translation are not considered during this action planning phase. Component 3: Create an Action Plan for Translation Creating an action plan, informed by a translation model or framework, p rovides manageable steps to implement change and assigns responsibility for carr ying the project forward. The translation team develops specific strategies to introduce, promote, support, and evaluate the practice change. It can be helpful to formulate the plan in a template that includes a timeline with progress columns (see Appendix I). The action plan includes: ■ Development of the strategy for translation of the change (e.g., protoc ol, guideline, system, or process) ■ Specification of a detailed timeline, assignment of team members to hi gh- level task categories and subtasks, an evaluation process, and a plan fo r how results will be reported ■ Solicitation of feedback on the action plan from organizational leadersh ip, bedside clinicians, and other stakeholders Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ucf/detail.action?docID=6677828. Created from ucf on 2022-10-17 02:42:22. Copyright © 2021. Sigma Theta Tau International. All rights reserved. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professi onals, Fourth Edition 199 The action plan begins with validation of the determination of fit, fe asibility, and acceptability for translation to the specific practice setting and the readiness of the unit, department, or organization for change. Organizational infrast ructure is the cornerstone of successful translation. Infrastructure provides hu man and material resources that are fundamental in preparation for change (Gree nhalgh et al., 2004; Newhouse & White, 2011). Readiness for translation includes assessing the current state and strategically planning for building the capacity o f the organization before implementation begins. Additionally, fully realized translation requires organizational resources and commitment. Paying particular atte ntion to the planning and implementation of organization-specific recommendatio ns can improve the potential for successfully meeting the project’s goals. Beyond human and material readiness, teams need to consider organizational/department /unit culture. Organizational culture refers to group-learned attitudes, beliefs, and assumptions as the unit, department, or organization integrates and adapts to intern al and external forces. These attitudes, beliefs, and assumptions become attrib utes of the group and subsequently become the preferred way to “perceive, think, and feel in relation to problems” (Schein, 2004, p. 17). To change the culture, the team must challenge tradition, reinforce the need for evidence to inform deci sions, and change old patterns of behavior, which sometimes requires new skills. Additional detail and tools to assess organizational readiness and culture are avai lable elsewhere (Poe & White, 2010). Johns Hopkins Nursing uses one strategy extensively to effectively manag e and work through the human side of organizational change. Bridges and Bridge s (2017) model, Managing Transitions: Making the Most of Change , suggests the Four Ps—Purpose, Picture, Plan, Part (see Table 8.4)—to give those affected by the change time and opportunity to internalize the change and a forum to express their questions or concerns. Those who are outspoken about the change ar e often those who genuinely care about getting things right and can recognize th e pitfalls and make great suggestions to improve the planning activities. Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ucf/detail.action?docID=6677828. Created from ucf on 2022-10-17 02:42:22. Copyright © 2021. Sigma Theta Tau International. All rights reserved. 8 Translation 200 Table 8.4 Four Ps Tool to Communicate Change Purpose Why are we making this change? Share with others who are not involved in the planning why things are changing and what will happen if things stay the same. Picture What will it look like? Share what the desired outcome will look like; invite staff to co- create the picture with you. Paint a picture of how the outcome will look and feel. Plan What is the plan and path to the end point? Lay out, step by step, the plan and path to the new state; invite staff to critique, contribute to, and change the path; make an idea list and a worry list. Part What part will they have in creating the plan and end point? People own what they create, so let staff know what you need from them, what part they will have, and where they will have choices or input. Component 4: Secure Support and Resources to Implement Action Plan To ensure a successful translation (see Appendix A), first appoint a project leader and identify change champions who are supportive of the recommend ed practice change and who will be able to support the project leader durin g the translation phase of the project. Change champions are individuals within an organization who volunteer or are selected to facilitate the change. The change champion is an active member of the staff who will be involved during th e full implementation of the practice change. Once champions are on board, cons ider whether the translation activities will require any additional skills, k nowledge, or individuals who can assist with or will be essential to the success o f the work. These additional members, often referred to as opinion leaders , are usually well- known individuals to the practice group in the organization whose opinio n is held in high esteem and could influence the practice group’s perspective for or against the change. The opinion leader is often someone that the group m embers Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ucf/detail.action?docID=6677828. Created from ucf on 2022-10-17 02:42:22. Copyright © 2021. Sigma Theta Tau International. All rights reserved. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professi onals, Fourth Edition 201 turn to for advice or views on matters of importance, so it is critical to identify them in the process. Once this group is organized, its members identify barriers and facilita tors to the success of the proposed practice change, surfacing strengths to tap into and use those to overcome the barriers. They consider how the change affects cur rent policies and procedures, the workflow and throughput of the unit or de partment, and technological supports to the group’s usual work, such as the electronic health record (EHR) or another technology that the group depends on. Securing support from stakeholders and decision-makers is critical to th e imple – mentation phase. Availability of funds to cover expenses associated with the translation and the allocation of human, material, and technological res ources is dependent on the endorsement of stakeholders, such as organizational lea ders or committees and in collaboration with those individuals or groups affecte d by the recommendations. It may be necessary to bring in content or external exp erts to consult on the translation. One key milestone in formulating the action plan is an estimation of expenses and resources needed for translation and potentia l fund – ing sources. Decision-makers may support wide implementation of the chan ge, request a small test of the change to validate effectiveness, request re visions of the plan or recommendations, or reject the implementation plan. Preparin g for the presentation or meeting with decision-makers, involving stakeholders (see Appendix C), and creating a comprehensive action plan are the key steps in building organizational support. The action plan should include identifying critical high-level categorie s of activi – ties and associated tasks designed to meet the goals of the project to c omplete the translation. The plan should include SMART goals, a schedule of all neces – sary activities, and an assignment of who is responsible for each activi ty and the target time frame for completion. The action plan should also include ac tivities associated with collection and analysis of the pre- and post-measures ( see Appen – dix B) for evaluation of the practice change. Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ucf/detail.action?docID=6677828. Created from ucf on 2022-10-17 02:42:22. Copyright © 2021. Sigma Theta Tau International. All rights reserved. 8 Translation 202 Component 5: Implement the Action Plan After the EBP team creates the action plan and secures support, implemen tation begins. The first step is a small test of the change, or pilot . The team seeks input from stakeholders and staff affected by the change and communicate s the effective date of implementation and the pilot evaluation plan. This communication can take the form of an agenda item at a staff meeting, an in- service, a direct mailing, an email, a bulletin board, or a video, for e xample. Stakeholders and staff must know who the project leader is, where to acc ess needed information or supplies, and how to communicate to the project le ader issues as they arise. The team obtains staff input along the way to iden tify problems and address them as soon as possible. Component 6: Evaluate Outcomes After implementing the change, the EBP team uses the measures identifi ed in the PICO to evaluate the success of the change. Collaborating with the Q I experts can be important during the evaluation process for guidance on t ools and appropriate intervals to measure the change. Selecting and developin g measures includes defining the purpose of measurement, choosing the cl inical areas to evaluate, selecting and developing the metrics, and evaluating the results (Pronovost et al., 2001 [adapted from McGlynn, 1998]). The EBP team compares baseline data to post-implementation data to determine whether the change should be implemented on a wider scale. Measures may encompass fi ve types of outcomes (Poe & White, 2010, p. 157); see Table 8.5. Table 8.5 Five Types of Outcome Measures Outcomes Definition Clinical Patient- or disease-focused and therefore reflects certain aspects of an illness; they can be physiological (e.g., a lab value), or they can be adverse event-focused (e.g., falls). Functional Measures patient responses or their adaptation to health problems; examples include factors such as ability to perform activities of daily living, self-care, or quality of life. Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ucf/detail.action?docID=6677828. Created from ucf on 2022-10-17 02:42:22. Copyright © 2021. Sigma Theta Tau International. All rights reserved. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professi onals, Fourth Edition 203 Perceptual Applies to both the patient and the provider and their self-report of experiences with care or their work environment, for example, their satisfaction; perceptual experiences also include comprehension related to education and the demonstration or application of that knowledge. Process or Intervention Measures of the appropriateness of treatment or care, including process measures such as The Joint Commission core measure of blood culture collection prior to antibiotic administration for treatment of pneumonia ; other evidence-based process measures include falls prevention, turning to prevent pressure ulcers, and medication reconciliation to prevent medication errors. Organization, Departmental, Unit-Based Focuses on administrative factors that provide evidence of effectiveness , or management issues such as staff fatigue related to working greater than three consecutive 12-hour shifts. Final Steps of the Translation Phase The Translation Phase needs to include communication to all participants and stakeholders in the translation process. The communication plan should b e targeted to the specific audience and can use multiple venues. For exa mple, the transition team provides regular communication about the progress at the ir unit or department meetings. Additionally, other forms of messaging, such as bulletin boards, posters, or data dashboards, can provide updates. Chang e champions and opinion leaders are critical assets to getting the updates out to all involved. Finally, targeting the report of the translation results to all stakeholders will require careful planning and discussion by the team. A one- size-fits-all communication strategy will not be successful. The trans ition team should customize the messages to the specific stakeholders and audienc es. Communication and dissemination are discussed in Chapter 9. Summary Translation is the value proposition of evidence-based practice. While th e PET Phases are linear, the steps in the process may be iterative and generate new questions, recommendations, or actions. The organizational infrastructur e needed to support robust translation of best evidence into practice includes bu dgetary Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ucf/detail.action?docID=6677828. Created from ucf on 2022-10-17 02:42:22. Copyright © 2021. Sigma Theta Tau International. All rights reserved. 8 Translation 204 support; human and material resources; and the commitment of individuals , stakeholders, and interprofessional teams. Translation of recommendations requires organizational skills, project management, and leaders with a h igh level of influence and tenacity. References Aarons, G. A., Ehrhart, M. G., Farahnak, L. R., & Hurlburt, M. S. (2015 ). Leadership and organizational change for implementation (LOCI): A randomized mixed me thod pilot study of a leadership and organization development intervention for evidence-b ased practice implementation. Implementation Science , 10 (11), 1–12. https://doi.org/10.1186/s13012-014- 0192-y Bergström, A., Ehrenberg, A., Eldh, A. C., Graham, I. D., Gustafsson, K., Harvey, G., Hunter, S., Kitson, A., Rycroft-Malone, J., & Wallin, L. (2020). The use of the PARIHS framework in implementation research and practice—A citation analysis of the liter ature. Implementation Science , 15(1), 1–51. https://doi.org/10.1186/s13012-020-01003-0 Bridges, W., & Bridges, S. M. (2017). Managing transitions: Making the most of change (4th ed.). Da Capo Lifelong Books. Eccles, M. P., & Mittman, B. S. Welcome to Implementation Science. Implementation Sci1, 1 (2006). https://doi.org/10.1186/1748-5908-1-1 Eccles, M. P., Lavis, J. N., Hill, S. J., & Squires, J. E. (2012). Knowledge trans lation of research findings. Implementation Science , 7(50). https://doi.org/10.1186/1748-5908-7-50 Glasgow, R. E., Vogt, T. M., & Boles, S. M. (1999). Evaluating the public health impact of he alth promotion interventions: The RE-AIM framework. American Journal of Public Health , 89(9), 1322–1327. https://doi.org/10.2105/AJPH.89.9.1322 Graham, I. D., Logan, J., Harrison, M. B., Straus, S. E., Tetroe, J., Caswell, W., & Robinson, N. (2006). Lost in knowledge translation: Time for a map? Journal of Continuing Education in the Health Professions , 26(1), 13–24. https://doi.org/10.1002/chp.47 Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P., & Kyriakidou, O. (2004). Diffusion of innovations in service organizations: systematic review and recommendati ons. The Milbank Quarterly. 82. 581–629. https://doi.org/10.1111/j.0887-378X.2004.00325.x Kuiper, R. A., & Pesut, D. J. (2004). Promoting cognitive and metacognitive reflective reasoning skills in nursing practice: self-regulated learning theory. Journal of Advanced Nursing, 45 (4): 381–391. Langley, G. L., Moen, R., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approach to enhancing organizational perf ormance (2nd ed.). Jossey-Bass Publishers. McGlynn, E. A. (1998). Choosing and evaluating clinical performance me asures. Joint Commission Journal of Quality Improvement , 24(9), 470–479. https://doi.org/10.1016/ s1070-3241(16)30396-0 Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ucf/detail.action?docID=6677828. Created from ucf on 2022-10-17 02:42:22. Copyright © 2021. Sigma Theta Tau International. All rights reserved. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professi onals, Fourth Edition 205 Newhouse, R. P., Dearholt, S., Poe, S., Pugh, L. C., & White, K. M. (2007). Organiza tional change strategies for evidence-based practice. JONA: The Journal of Nursing Administration , 37 (12), 552–557. https://doi.org/10.1097/01.NNA.0000302384.91366.8f Newhouse, R. P., & White, K. M. (2011). Guiding implementation: Frameworks and resou rces for evidence translation. JONA: The Journal of Nursing Administration , 41 (12), 513–516. https:// doi.org/0.1097/NNA.0b013e3182378bb0 Nieva, V. F., Murphy, R., Ridley, N., Donaldson, N., Combes, J., Mitchell, P., Kovner, C., Hoy, E., & Carpenter, D. (2005). From science to service: A framework for the transfer of patient safety research into practice. Advances in Patient Safety: From Research to Implementation (Volume 2: Concepts and Methodology). Poe, S., & White, K. (Eds.). (2010). Johns Hopkins Nursing: Implementation and translation. Sigma Theta Tau. Pronovost, P. J., Miller, M. R., Dorman, T., Berenholtz, S. M., & Rubin, H. (2001). Developing and implementing measures of quality of care in the intensive care unit. Current Opinion in Critical Care , 7(4), 297–303. https://doi.org/10.1097/00075198-200108000-00014 Schein, E. H. (2004). Organizational culture and leadership (3rd ed.). Jossey-Bass. Stetler, C. B. (2001). Updating the Stetler Model of research utilization to facilitate evidence-based practice. Nursing Outlook , 49(6), 272–279. https://doi.org/10.1067/mno.2001.120517 Stetler, C. B. (2010). Stetler Model. In J. Rycroft-Malone & T. Bucknall (Eds.), Models and frameworks for implementing evidence-based practice: Linking evidence to action. Wiley- Blackwell. Stetler, C. B., Mittman, B. S., & Francis, J. (2008). Overview of the VA Quality Enhancement Research Initiative (QUERI) and QUERI theme articles: QUERI series. Implementation Science , 3(1), 8. https://doi.org/10.1186/1748-5908-3-8 Tabak, R. G., Khoong, E. C., Chambers, D. A., & Brownson, R. C. (2012). Bridging research and practice: Models for dissemination and implementation research. American Journal of Preventive Medicine , 43(3), 337–350. https://doi.org/10.1016/j.amepre.2012.05.024 Victor-Chmil, J. (2013). Critical thinking versus clinical reasoning versus clinical judgment: Differential diagnosis. Nurse Educator , 38(1), 34–36. https://doi.org/10.1097/ NNE.0b013e318276dfbe Waltz, T. J., Powell, B. J., Matthieu, M. M., Damschroder, L. J., Chinman, M. J., Smith, J. L., Proctor, E. K., & Kirchner, J. E. (2015). Use of concept mapping to characterize relationships among implementation strategies and assess their feasibility and importa nce: Results from the Expert Recommendations for Implementing Change (ERIC) study. Implementation Science , 10, 109. https://doi.org/10.1186/s13012-015-0295-0 White, K. M., Dudley-Brown, S., & Terhaar, M. (2020). Translation of evidence into nursing and health care practice (2nd ed.). Springer Publishing. Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ucf/detail.action?docID=6677828. Created from ucf on 2022-10-17 02:42:22. Copyright © 2021. Sigma Theta Tau International. All rights reserved. 8 Translation Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ucf/detail.action?docID=6677828. Created from ucf on 2022-10-17 02:42:22. Copyright © 2021. Sigma Theta Tau International. All rights reserved.
Now that you have considered the evidence and potential options to address the local site problem and project objectives, it is now time to describe the proposed design of your project, specific detai
28 Implementation of Type 2 Diabetes Self-Management Education in an Impoverished Community Leonne M. Reid NGR 7911 Dr. Valerie Martinez University of Central Florida September 26, 2022 Abstract (blank placeholder) Table of Contents Abstract 2 Table of Contents 3 Introduction 5 Background, Significance 5 Description of Organization 7 Mission 8 Organizational Structure 8 Organizational Needs Assessment 8 Organizational Data Indicating a Problem 8 Stakeholder Analysis 10 Patients 10 Professional Organizations 11 Interdisciplinary Colleagues 12 Project Management Tools 13 SWOT Analysis 13 Local Problem Statement 14 Literature Review 15 Description of Search Strategy 15 Inclusion Criteria 15 Search Strategy 16 Quality Appraisal 17 Synthesized Key Findings 17 Interventions Used to Improve the Problem and their Outcomes 17 Peer Support or Coaching or Peer Health Coaching 17 Patient Education 18 Lifestyle Modification Programs 19 Problem-solving or Problem-Solving Therapy 20 Facilitators and Barriers to Implementation of the Interventions Identified 21 Purpose and Project Goals 22 EBP Model 22 References 23 Appendices 29 Appendix A – Summary of Evidence Table 29 Appendix B – Project Management Tools 44 Appendix C – SWOT Analysis 45 Introduction Background, Significance Ethnic and racial minority groups in the US, particularly impoverished communities, bear a more significant load from the increasing incidence of Type 2 diabetes (T2D), making the disease a primary focus for disparities in healthcare research (Haw et al., 2021). T2D is a complicated, dire disease in which the weight of self-care is on the patient. In the United States, there are approximately 37.3 million people with diabetes (Centers for Disease Control and Prevention, 2022). Unfortunately, T2D is among the greatest difficult chronic health conditions to manage and control. The increased demand for disease management and the incorporation of complicated self-management routines in the day-to-day lives of diabetics has been proven to lead to increased stress, leaving individuals discouraged, frustrated, and overwhelmed. These demands could also cause depression, anxiety, and reduced well-being (Papelbaum et al., 2010). However, patient behaviors such as lifestyle modifications associated with exercise and diet, medication, record keeping, and daily blood glucose monitoring are crucial in effectively managing the disease (Shrivastava et al., 2013). These behaviors are often referred to as self-management. Self-management is participating in self-care actions to enhance a person’s well-being and behaviors . This considerable burden affects patients from impoverished communities that usually find it challenging to deal with self-management. This is mainly because of cultural, economic, and social barriers, inadequate access to diabetes self-care and self-management resources, and high survival demands among disadvantaged populations (Haw et al., 2021). Recent immigrants and refugees might also experience difficulties adhering to diabetes self-management practices due to various factors, including the absence of preventive care, leading to late treatment and diagnosis (Heerman & Wills, 2011). Cultural differences in how people perceive the origin and treatment of diabetes might also make it challenging to manage the disease among disadvantaged populations (Heerman & Willis, 2011). Nonetheless, self-management is the most effective way of managing diabetes among populations that lack access to quality healthcare. Most of these practices require considerably less financial resources than frequent healthcare visits. For instance, self-management practices require patients to control and monitor their diet, engage in more physical activity, and monitor their glucose levels, which is more affordable than other management options . However, social support systems might address the effects of environmental and economic challenges that affect effective T2D management by increasing access to social capital, thus promoting self-efficacy behaviors. Nam et al. (2011) state that social support is essential since it is related to the hindrance and facilitation of self-care among patients suffering from chronic diseases like diabetes. Families are the key foundation of social support since they help patients manage their condition successfully. Ideally, social support is multifaceted and correlates with several social networks (institutional, community-based, occupational, or familial) surrounding a patient (Nam et al. 2011). It has a high potential to exert either negative or positive influences on the person’s capability to control the condition independently. A patient’s capacity to use social capital to capitalize on established resources could play a significant responsibility in self-care. They could activate constructive social capital resources by seeking and getting help from substantial people in several social positions, such as family members that understand how to manage the disease, thus minimizing the challenges associated with their poverty status that limit them from addressing the condition effectively. In most cases, some attributes of the healthcare system affect effective disease self-care, especially among disadvantaged communities for whom the cost and access to healthcare might provide significant barriers to achieving effective self-management. Description of Organization The professional organization that is both a stakeholder and a sponsor of this project is the American Diabetes Association (ADA). This organization is committed to printing innovative and timely information and publishing research for professionals specializing in diabetes care, treatment, research, and education (ADA, 2022). It is a non-profit membership organization that promotes the efforts of healthcare professionals to cure and prevent diabetes by enhancing the well-being of people with diabetes (ADA, 2022). ADA offers research grant awards, patient information programs or materials, and professional education programs and helps spread public awareness of diabetes. The organization’s technology assessment activities are publishing review articles, creating position papers, and sponsoring and funding consensus conferences. ADA also sponsors conferences, research symposia, and annual postgraduate courses that intend to spread new diabetes information or discuss crucial topics related to the disease. Mission “To offer the public and healthcare professionals comprehensive and correct information on technologies (drugs, medical devices, surgical or medical procedures among others) that are relevant to diabetes” (ADA, 2022). Organizational Structure The board members, professional members, and officers of the American Diabetes Association (ADA) often request for research to be conducted. Formal written requests are then submitted to the senior staff or volunteer leadership, who then set the research topic priorities. Research is often performed by assessors or researchers that have expertise in areas related to diabetes, such as public health, law, nutrition, medicine, and exercise. The key methods used in the assessments include cost analyses, group judgment, expert opinion, and information synthesis (Council on Health Care Technology, 2008). Organizational Needs Assessment Organizational Data Indicating a Problem According to the National Diabetes Statistics Report, roughly 8.2% of the United States population (26.9 million individuals) were diagnosed with diabetes in 2018 (Center for Disease Control and Prevention, 2020). In 2016, around 12.6 % of US citizens in non-metropolitan regions were diagnosed with diabetes, a higher statistic than 9.9 % in metropolitan regions (Center for Disease Control and Prevention, 2020). In the ‘diabetes belt’, the incidence of diabetes was about 11.7 % of the entire US population. Over one-third of counties within the diabetic belt are located in the Appalachian Region. Many states within the belt are extremely rural compared to the United States average (Centers for Disease Control and Prevention, 2022). These statistics show that diabetes is a major concern within impoverished and rural communities because of limited access to healthcare services and a higher prevalence of risk factors (Misra et al., 2019). For instance, impoverished communities often comprise populations at a higher risk of T2D, such as ethnic and racial groups and older adults (Mendenhall et al., 2017). Additionally, several barriers affect patient education and quality healthcare access in impoverished communities. First, fewer transport options in rural areas make it challenging for T2D patients to travel to doctor appointments (Stotz et al., 2021). Secondly, there are higher rates of uninsured patients in rural communities. Limited access to medical covers makes it difficult for impoverished populations to access medical supplies, medications, and cover medical appointments. Also, there are fewer healthcare providers in poor communities, making it difficult to offer patient education, replace retiring healthcare professionals, and retain nutritionists and dietitians. Workforce shortages in impoverished societies also limit access to specialized healthcare professionals, including endocrinologists (North et al., 2022). These data indicate a major problem within impoverished communities since T2D patients would fail to access pharmacological interventions for managing the disease. However, with the introduction of self-management practices, individuals in rural communities could learn about some of the efficient lifestyle modifications they should make to control their weight and glycemic levels. Self-management is cheaper and less cumbersome because it only requires the efforts of a patient and their family to manage the disease . Stakeholder Analysis The main stakeholders relevant to this research include patients, their families, the family advisory committee, professional organizations such as the American Diabetes Association (ADA), and interdisciplinary colleagues such as respiratory therapists, nutritionists, physicians, or occupational therapists (OT)/PT. Patients Patients are the main stakeholders in this project because the project will have a significant impact on them. This project will help patients understand how self-care and self-management could help manage T2D. Their families will also benefit from the project because they will be able to recognize effective strategies to incorporate self-management into their management regimen. Another major thing that patients, family advisory committees, and relatives need to understand from the project is examples of self-management interventions that have been proven effective in managing T2D. Patients and their families are also a great asset to the project because they will contribute by taking part in the project and having outcomes measured like HbA1c and glycemic levels, weight, and quality of life . Also, families of patients with the disease can contribute to the project by providing crucial information on the efficacy of the self-management interventions they have used on their relatives. However, patients might impede the project by providing false information on self-management efficiency and failing to commit to self-management interventions. Families can also affect the project by failing to give their relatives with type II diabetes the correct self-management interventions during the study period. The engagement of patients and their families in this project requires that self-care and self-management education be offered. Professional Organizations Utilizing professional organizations such as the American Diabetes Association (ADA) will help inform the project and have them approve whether the identified strategies are safe and effective in managing T2D. These organizations would contribute to the project by offering the study’s respondents patient education . They could also fund the research since the American Diabetes Association (ADA) often funds studies to control, treat, and prevent diabetes (ADA, 2022). The main way that professional organizations could impede the project is by refusing to fund and contribute to the project . The best way to engage professional organizations is having them offer patient education on safe self-management practices for T2D. Interdisciplinary Colleagues In a healthcare setting, an interdisciplinary team consists of practitioners from different disciplines that work together to address a patient’s psychological and physical needs ( Indeed, 2021 ). For instance, for a patient with T2D, the interdisciplinary team comprises respiratory therapists, nutritionists, occupational therapists, and other physicians. These stakeholders are crucial to the project because they will help inform the project and approve the self-management practices recommended at the end of the project. The main thing that this group of stakeholders is concerned with is whether self-management interventions are effective in managing T2D. This project will help them understand which patient education they need to provide to these patients and the self-management practices they would recommend to patients other than pharmacological interventions. Interdisciplinary colleagues could also contribute significantly to the project. For instance, nutritionists are well-equipped with the correct information on healthy diets for patients suffering from different diseases. Therefore, in this project, they will help recommend healthy lifestyles and dietary changes which would help control HbA1c and glycemic levels and weight. Additionally, occupational therapists (OT) are healthcare professionals that help injured, disabled, or sick patients improve, recover, or develop by maintaining the life skills needed for healthy living (Burson, Fette, & Kannenberg, 2017). Therefore, they could help T2D patients maintain, recover, and develop meaningful occupations or activities for communities, groups, and individuals. The interdisciplinary team could affect or obstruct this project when they do not recommend and administer appropriate and efficient self-management interventions for the project participants . For instance, if a nutritionist recommends a diet that would not be effective in reducing glycemic levels in a patient with T2D, then the project findings will be a ffected . Similarly, suppose an occupational therapist does not help a patient to develop a healthy lifestyle to manage the disease adequately. Patient health outcomes will be affected in that case, impacting the project’s findings. Project Management Tools SWOT Analysis Several factors would impede the efficient implementation of this study in the given practice setting (See Appendix C for the SWOT Analysis diagram of these factors). Strengths i. There is access to respondents who would help provide information on which strategies they have adopted and utilized in the effective management of T2D other than pharmaceutical interventions since the given setting is impoverished communities . ii. There is the availability of experienced researchers and professionals (such as nutritionists and occupational therapists) to help recommend effective self-management interventions to the study ‘s respondents. Weaknesses i. Lack of funding because there are fewer financial resources in impoverished communities; hence project initiators must fund the project themselves or look for a professional organization willing to fund the research. ii. Limiting beliefs among individuals , such as using cultural interventions like traditional herbs and ayurvedic medications, is the most effective way of preventing and treating T2D (Ahmad, 2021). These beliefs might impede the effective implementation of self-management interventions. Opportunities i. Increased interest among professional organizations and leading scientific institutions to research effective disease management strategies. For example, the American Diabetes Association has emerged to help fund research on effective T2D management, provide education on self-management practices that would help manage the disease and recommend healthy diets for the patients (ADA, 2022). ii. The availability of professional organizations which help provide education to patients with T2D in impoverished communities. Threats i. Language and cultural barriers. Researcher s might find it difficult to communicate with T2D patients from impoverished communities. Local Problem Statement T2D patients in impoverished communities have limited access to healthcare services due to different factors, such as geographical and financial barriers; this accounts for the high rates of T2D within these communities since patients lack professionals to guide them through pharmacological interventions. These high statistics could be mitigated through dietary and lifestyle modifications. Because treatments such as insulin and drugs are expensive and impoverished communities have fewer resources, it is important to prioritize prevention and manage the disease using self-management practices. It is also essential to spread awareness and educate patients on how lifestyle changes could be as effective as using drugs to manage and prevent T2D. Literature Review Description of Search Strategy Inclusion Criteria I screened this topic independently and then selected articles for quality appraisal and inclusion criteria. Once the pieces were screened, I developed a quality appraisal and inclusion criteria. For the articles to be included in the official review, they were analyzed using the following inclusion criteria. The article must have the following: i. Provided quantitative and qualitative empirical (descriptive, cohort study, quasi-experimental, RCT, systematic review, or meta-analysis) evaluative support. ii. Identified an intervention. iii. Included an outcome variable of self-care and self-management. iv. Included adult respondents with type II diabetes. v. Operationalized as a psychosocial indicator (such as support, stage of change, depression, stress, or emotional adjustment), physiological indicator (such as cholesterol, HbA1c, weight, blood pressure, blood glucose level), self-management outcomes (such as SBGM pattern, medication, exercise, diet) and knowledge. Search Strategy An all-inclusive search was performed through Ebscohost utilizing the following databases: PsycInfo, PsycArtiCLES, MEDLINE, Health Source: Nursing/Academic Edition, CINAHL, and Academic Search Complete. The search was conducted to establish best practices in self-management interventions for T2D. The top search terms used include randomized controlled trials, self-management, patient education, self-care, type 2 diabetes, and diabetes mellitus. Only peer-reviewed articles written in English between January 2015 to 2022 were selected. Additionally, the Cochrane Library was looked up for self-management review. The first search yielded 62 peer-reviewed articles abstracted for self-management intervention topics. Forty -six articles were excluded since they failed to meet the inclusion criteria because they focused on T1D rather than T2D. Duplicates were removed from search results. The themes of the remaining sixteen articles selected for review included patient education, lifestyle modification programs, peer support, and lifestyle adaptation. The reference lists of the selected articles were then analyzed to locate other relevant articles in the search. At the end of the reviews and search, 14 articles were chosen for synthesis. All articles chosen for review were critically appraised using the Johns Hopkins Evidence-Based Practice Model Heirchy of Evidence guide. The quality of the articles selected for this review could be summarized as high-quality randomized clinical trials (n=1), good-quality systematic reviews (n=2), good-quality meta-analysis (n=1), low-quality integrative review (n=1), high-quality qualitative descriptive study (n=11), and good quality literature reviews (n=4). See Appendix H for evidence table. Synthesized Key Findings Interventions Used to Improve the Problem and their Outcomes Peer Support or Coaching or Peer Health Coaching Peer support, peer coaching, and health coaching utilize volunteers or health care providers, often referred to as peer supporters or coaches, to offer self-management care to individuals with the same healthcare condition as them or those they consider their peers (Thom et al., 2013; Ghorob et al., 2011). These peers and coaches could include healthcare professionals, family members, educators, community health workers, and patients. Ideally, peer health coaching is done to connect a patient to other patients that have the same health issues. Regardless of peer support or coaching, the objective is to motivate and engage T2D patients in self-care and self-management. Peer support and coaching interventions have been adequately researched in disease education. Tang et al. (2011) explain that in diabetes self-management, peers and coaches play multiple roles, such as group facilitator, mentor, case manager, educator, cultural translator, and advocate. Peer support and coaching are often delivered by trained professionals and primarily emphasize self-management interventions based on documented curricula and time-limited. Based on efficiency, support and peer health coaching have effectively helped lower HbA1c levels and improve self-management (Powers et al., 2015; Moskowitz et al., 2013). Due to such favorable results, peer support and health coaching have received significant interest as effective interventions for disease self-care (Aschbrenner et al., 2015). Patient Education Diabetes self-management education (DSME) has been the most common and effective strategy for managing diabetes (Pamungkas, Chamroonsawasdi, & Vatanasomboon, 2017). This intervention program has evolved over the decades to include biopsychosocial treatment models and affective and behavioral tactics to deal with the psychosocial and medical requirements of individuals with T2D (Carpenter, DiChiacchio, & Barker, 2019). Patient education could be administered in different modalities, to groups or individuals, professionals or peers, in extended or short-term sessions. DSME entails various crucial components that should be maintained to prevent complications related to diabetes- monitoring checks, physical activity, adherence to diet, and treatments (Carpenter, DiChiacchio, & Barker, 2019). Powers et al. (2015) found that implementing self-management education effectively improves the quality of life for T2D . Lifestyle Modification Programs Lifestyle modification programs are used to improve health outcomes through behavior and lifestyle changes. Lifestyle modification programs could comprise a variety of topics such as stress management, exercise, diet, and medications (Carpenter, DiChiacchio, & Barker, 2019). Lifestyle modification programs have had a long history in managing diabetes because it usually combines interventions targeting behavior modification, exercise, diet, and medication management. Lifestyle modification programs such as self-efficacy, healthy diets, and greater exercise have helped patients with T2D manage their weight and control their glycemic and HbA1c levels (Delahanty et al., 2013; Kerrison et al., 2017; Carpenter, DiChiacchio, & Barker, 2019). Problem-solving or Problem-Solving Therapy Problem-solving therapy (PST) is a strategy for behavioral modification used to determine what needs to be done to attain a goal that is not apparent (Carpenter, DiChiacchio, & Barker, 2019). Problem-solving therapy aims to minimize adverse emotional reactions, change behavior, and improve positive emotional responses (Zhang et al., 2018). Problem-solving therapy entails teaching individuals suffering from a chronic disease how to deal with life issues by breaking them down into two different sections: utilizing problem-solving skills and employing problem-solving orientations to life. Additionally, problem-solving therapy mainly focuses on teaching a patient skills such as recognizing the health issue, defining the problems, comprehending them, setting health objectives associated with the health issue, identifying alternative strategies to solve the health issue, analyzing and selecting the best methods, implementing these alternatives, and analyzing their effort in solving the problem (Nezu et al., 2012). Problem-solving therapy (PST) has had an extended history in counseling and clinical mindset to deal with substance abuse, coping skills and stress management, relational and family distress, and several mental health disorders. Additionally, problem-solving therapy has been constantly used within diabetes care and education and is recognized as a crucial skill, intervention, and process in diabetes self-management (Carpenter, DiChiacchio, & Barker, 2019). Facilitators and Barriers to Implementation of the Interventions Identified Barriers to T2D self-management include lack of support, shortage of resources, inadequate behavioral beliefs and knowledge, and suffering from health issues (Shi et al., 2020). When patients lack support from their families (such as lack of emotional support, taking medications, and eating healthy) and professionals, it interferes with the efficacy of self-management interventions. Some health issues, such as insomnia, physical discomfort, and hyperglycemia, could also interfere with self-care (Shi et al., 2020). These issues reduce patient motivation to engage in self-management interventions. Moreover, the shortage of resources, such as limited access to patient education, lack of finances to buy healthy foods, little blood glucose monitoring, and unavailability of hypoglycemic medications. Lastly, inadequate behavioral beliefs, knowledge, and confusion about taking diabetes medications interfere with the efficacy of diabetes self-management (Kulhawy-Wibe et al., 2018). Shi et al. (2020) found that many diabetic patients did not understand how to use hypoglycemic agents. Many were confused about the medications’ side effects, usage, and names, which prevented them from efficiently managing diabetes. Recognizing these barriers is essential in creating effective strategies, including promoting successful self-management, implementing patient-centered care, reinforcing social and medical support, and creating favorable environments. Also, understanding these barriers will help patients understand how they will deal with them and educate their families and peers on how they can help them manage the disease on their own. Purpose and Project Goals The project aims to answer the EBP question of whether self-management effectively manages T2D in impoverished communities . Self-management could be one of the best alternatives for managing T2D among communities with inadequate access to quality healthcare since fewer financial resources are required than pharmacological means (Whittemore et al. 2019). For example, because T2D is mainly developed from poor diet and lifestyle practices, modifications such as eating a cleaner diet, exercising more often, and tracking glucose levels could help manage the disease. However, factors such as limiting beliefs among rural residents and lack of support from family could impede the effective use of self-management to control T2D (Shi et al. 2020). Therefore, this research will examine how such barriers could be addressed to ensure that patients manage T2D effectively without experiencing dire health effects. It will also look at how patient education could be improved within impoverished communities so that people with diabetes could learn how to manage the disease independently without the intervention of healthcare professionals. EBP Model This project utilizes the Johns Hopkins Nursing Evidence-Based Practice Model (JHNEBP). This model is structured to satisfy EBP needs by employing a simple process known as Practice Question, Evidence, and Translation(PET; Christenberry , 2017). In the first step, the EBP question is created, followed by searching, appraising, describing, and rating the quality of evidence. In the last step, feasibility of the project is determined, an action plan for implementation is created, and evidence-based practice changes are implemented (Christenberry, 2017). Also, findings are presented to the larger nursing faculty and healthcare organizations. References Ahmad, A. (2021). Medication-taking behavior and treatment preferences of Indian migrants with type 2 diabetes in Australia (Doctoral dissertation). American Diabetes Association (2022). About Us. https://diabetes.org/about-us Aschbrenner, K. A., Naslund, J. A., Barre, L. K., Mueser, K. T., Kinney, A., & Bartels, S. J. (2015). Peer health coaching for overweight and obese individuals with serious mental illness: intervention development and initial feasibility study. Translational Behavioral Medicine, 5(3), 277-284. Burson, K., Fette, C., & Kannenberg, K. (2017). Mental health promotion, prevention, and intervention in occupational therapy practice. AJOT: American Journal of Occupational Therapy, 71(S2), 7112410035p1-7112410035p1. Carpenter, R., DiChiacchio, T., & Barker, K. (2019). Interventions for self-management of type 2 diabetes: an integrative review. International Journal of Nursing Sciences, 6(1), 70-91. Center for Disease Control and Prevention (2022). 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The Journal of the American Board of Family Medicine, 31(1), 139-150. Appendices Appendix A – Summary of Evidence Table EBP Question: For type II diabetics in impoverished communities, is the implementation of self-management effective? Author and Date Title of Article Population, size (n) Setting Type of Evidence Description of Intervention Outcome Measures Findings that Help Answer the EBP Question Limitations Evidence Level and Quality Implications for Proposed Project Authors: Margaret A. Powers, Joan Bardsley, Marjorie Cypress, Paulina Duker, Martha M. Funnell, Amy Hess Fischl, Melinda D. Maryniuk, Linda Siminerio, & Eva Vivian Publication Date: 5 June 2015 Diabetes Self-management Education and Support in Type 2 Diabetes: A Joint Position Statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics N/A N/A Literature Review This is a study of a given phenomenon through a thorough survey of peer-reviewed articles. Quality of life. Type II diabetes is a burdensome and complex disease that demands individuals to make rational health decisions to maintain a healthy lifestyle. The implementation of self-management is therefore effective for diabetics in rural communities where they would have difficulty accessing healthcare resources. This literature review did not incorporate a section highlighting the limitation. Nonetheless, there are minor differences between the findings of these articles. The findings of this article are consistent and hence adequate to be used in the project. This article will help build on the research concerning the importance of introducing self-management care for diabetes type II in impoverished communities. Authors: Morgan Griesemer Lepard, Alessandra L. Joseph, April A. Agne & Andrea L. Cherrington Publication Date: 7 May 2015 Diabetes Self-Management Interventions for Adults with Type 2 Diabetes Living in Rural Areas: A Systematic Literature Review N/A N/A Literature Review This is a study of a given phenomenon through a thorough survey of peer-reviewed articles. Rates of type II diabetes The authors found that in impoverished communities, there are higher rates of type II diabetes due to limited access to diabetes education, health services, and community resources. However, interventions such as collaborative goal-setting and motivational support are likely to enhance the metabolic control of a diabetic. Possible publication bias. Difficulty comparing data from several articles. The interventions analyzed were of different lengths and designed for several cultural groups hence making it difficult to compare the studies. The evidence provided by this article is sufficient, however, the inconsistencies in the results in different articles interfere with the validity of the results. The findings from this article will be used to build on the research since the results indicate that there is a positive impact of self-management care for diabetics in rural communities. Authors: Roger Carpenter, Toni DiChiacchio & Kendra Barkera Publication Date: 10 Jan 2019 Interventions for self-management of type 2 diabetes: An integrative review N/A N/A Integrative review It is a methodology that summarizes past theoretical and empirical literature to offer a comprehensive comprehension of a phenomenon. HbA1c level. A significant amount of literature showed that self-management has a short-term improvement in distress reduction and glycemic control. Due to the exhaustive nature of the existing evidence on this phenomenon, it is difficult to be informed about the entire body of literature on this topic. The evidence offered by this article is inadequate because different articles reveal different results on the efficacy of self-management in diabetes care. Implications remain inconclusive. Authors: Fadli, F. Publication Date: 2022 The Impact of Self-Management-Based Care Interventions on Quality of Life in Type 2 Diabetes Mellitus Patients: A Philosophical Perspective N/A N/A Literature Review This is a study of a given phenomenon through a thorough survey of peer-reviewed articles. The quality of life of type 2 diabetes mellitus patients. Most articles indicated an increase in the quality of life and self-care behaviors among type 2 diabetes patients after being subjected to self-management interventions. Some articles did not indicate a major difference in the quality of life among diabetics utilizing self-management in impoverished communities. The article provides valid evidence because most of the articles reviewed provided similar results. Since this article indicates a positive relationship between self-management and diabetics in impoverished societies, it will be used to build research on the topic. Authors: Burd, C., Gruss, S., Albright, A., Schumacher, P. & Alley, D. Publication Date: 28 Jan 2022 Translating knowledge into action to prevent type 2 diabetes: Medicare expansion of the National Diabetes Prevention Program lifestyle intervention. Over 3,000 adults RCT groups Literature Review This is a study of a given phenomenon through a thorough survey of peer-reviewed articles. Rate of Diabetes Type II among groups using medicine and self-management. The self-management group indicated a 71% rate of reducing the effects of diabetes type II while the group using metformin indicated a 31% likelihood of managing the disease. Racial inequality because a majority of the respondents were not at a high risk of developing diabetes type 2. High-quality evidence because there are expert opinions from Medicaid Innovation Center. Results will help answer the EBP question and build on the research. Authors: Yamaoka, K., Nemoto, A., & Tango, T. Publication Date: 19 June 2019 Comparison of the Effectiveness of Lifestyle Modification with Other Treatments on the Incidence of Type 2 Diabetes in People at High Risk: A Network Meta-Analysis n=113 Online research PUBMED database Meta- analysis An epidemiological, formal, and quantitative study design is utilized to systematically analyze the findings of past research on a given topic. Quality of life of diabetics. Findings indicate that self-management through lifestyle modifications help prevent the progression of type 2 diabetes. The type of education training utilized was ununiform among different studies. The study only used PUBMED in the review. Good quality of evidence because the sample used was adequate. However, some articles provide inconsistent results. The findings will be used to supplement the findings of other articles on the same topic. Authors: Kerrison, G., Gillis, R. B., Jiwani, S. I., Alzahrani, Q., Kok, S., Harding, S. E., Shaw, I. & Adams, G. G. Publication Date: 16 Apr 2017 The Effectiveness of Lifestyle Adaptation for the Prevention of Prediabetes in Adults: A Systematic Review Population: 1,780 studies n:9 studies Electronic Databases such as CENTRAL, Cochrane, PsycINFO, EMBASE, MEDLINE, CINAHL Systematic Review Summary of literature that use reproducible and explicit methods to synthesize, critically appraise, and search a particular issue. Glycemic control, weight changes, BMI, and physical exercise capacity. Self-management such as changing lifestyle behaviors helps minimize the incidence of diabetes type 2. Minor differences in the findings of the studies. High-quality evidence These results will help formulate the final project’s report on the efficacy of self-management in individuals with diabetes type II. Authors: Walker, R. J., Strom Williams, J., & Egede, L. E. Publication Date: April 2016 Influence of Race, Ethnicity, and Social Determinants of Health on Diabetes Outcomes N/A N/A Systematic Review Summary of literature that use reproducible and explicit methods to synthesize, critically appraise, and search a particular issue. Quality of life Even though the findings of this article do not address the evidence-based question directly, it helps highlight factors that might affect certain groups from receiving treatment such as economic classes. Limited evidence on how ethnicity and race affect the quality of health outcomes of diabetics in impoverished communities. The evidence provided is of moderate quality. The findings of this article could be used to explain some of the factors that prevent diabetics in impoverished communities from accessing medical care services. This will help indicate a need for the implementation of self-management. Authors: Delahanty, L. M., Peyrot, M., Shrader, P. J., Williamson, D. A., Meigs, J. B., Nathan, D. M., & DPP Research Group. Publication Date: 2013 Pretreatment, Psychological, and Behavioral Predictors of Weight Outcomes Among Lifestyle Intervention Participants in the Diabetes Prevention Program (DPP) n: 274 DPP community centers Randomized clinical trial Assigning respondents to different groups (control group and treatment group) that receive different treatments. Weight loss. Self-efficacy, healthy diets, and greater exercise helped 40.5% of the participants in the Diabetes Prevention Program (DPP) achieve their weight loss goal. The participants in this study did not fully represent all diabetics trying to lose weight. The evidence provided is high quality. These findings show that self-management could help diabetes manage the disease. Authors: Whittemore, R., Vilar-Compte, M., De La Cerda, S., Marron, D., Conover, R., Delvy, R., & Pérez-Escamilla, R. Publication Date: 23 August 2019 Challenges to diabetes self-management for adults with type 2 diabetes in low-resource settings in Mexico City: a qualitative descriptive study n: 20 adults 3 Seguro Popular primary care clinics in Mexico City Qualitative descriptive study This approach systematically describes a phenomenon. Glycemic targets. Factors that interfere with the efficacy of self-management in diabetics include lack of resources, mental health issues, cultural beliefs, and lack of family support. The sample was in a single geographical location hence it does not mirror the situation in other impoverished regions. High-quality evidence. The findings could be used in the project to show how self-management helps patients in impoverished societies manage the disease. Appendix B – Project Management Tools Figure 1: Driver Diagram Appendix C – SWOT Analysis Strengths Access to respondents who would help provide information on which strategies they have adopted and utilized in the effective management of T2D. Availability of experienced researchers and professionals. Weaknesses Lack of funding. Limiting beliefs. Opportunities Increased interest among professional organizations and leading scientific institutions to research effective disease management strategies. Availability of professional organizations which help provide education to patients with T2D in impoverished communities. Threats Language barriers. Cultural barriers. Table 2: SWOT Analysis
Now that you have considered the evidence and potential options to address the local site problem and project objectives, it is now time to describe the proposed design of your project, specific detai
Implementing an Asthma Education Program for Elementary School Staff Student Department of Nursing, University of Central Florida NGR 7911C: Doctoral Project I Dr. Valerie Martinez Abstract Table of Contents Introduction 5 Background and Significance 5 Organizational Needs Assessment 7 Description of the Sponsoring Organization 7 Stakeholder Analysis 9 Project Management Tools 9 Local Problem Statement 11 Literature Review and Synthesis 11 Purpose and Project Goals 14 Conceptual/Theoretical Framework 15 Methods 17 Project Design 17 Setting 17 Population 17 Intervention 17 Budget and Resources 17 Cost-Benefit Analysis 17 Outcome Measures 17 Data Collection 17 Data Analysis Plan 17 Ethical Considerations 17 Timeline for project completion 17 References 17 Appendices 20 Appendix C: Individual Evidence Summary Tool 20 Appendix B: Project Management Tools – Stakeholder Analysis and Communication Tool 23 Appendix B: Project Management Tools – Driver Diagram 24 Appendix B- SWOT Analysis 25 Data Collection Sheet/Instrument 27 Education Plan 27 Coded Data Management Sheet 27 Timeline Figure 27 Organization Letter of Support 27 Introduction Background and Significance Asthma is a leading illness among children and adolescents in the United States (Centers for Disease Control and Prevention [CDC], 2022). Asthma is a chronic disease characterized by inflammation and swelling of the airways (Asthma and Allergy Foundation of America [AAFA], 2022). Inflammation can be triggered by several factors such as smoke, allergens, cold air, viruses, dust, and a variety of chemicals. Asthma symptoms include shortness of breath, difficulty talking, coughing, wheezing, and chest tightness. There is no cure for asthma but with proper management asthma symptoms could be controlled and quality of life improved (AAFA, 2022). Asthma affects approximately 10% of the pediatric population and is often debilitating (AAFA, 2022). As a result, more than half of missed school days are due to asthma in the United States (Ruvacalba et al., 2019). In the year 2013 alone, it accounted for more than 13.8 million missed school days (AAFA, 2022). School absenteeism affects most asthmatic school-aged children (59%) and is associated with lower academic performance (Hsu et al., 2016). It has a disproportionately higher prevalence in low-income populations, minority backgrounds, and African Americans, with a prevalence of 15.8% among these populations, while other racial and ethnic backgrounds report a prevalence rate of 7.8% (Rubacalva et al., 2019). A huge burden is placed on both the family and the economic system due to asthma- related management and complications (Carpenter et al., 2016). Each year approximately 50% of children experienced at least one asthma attack (Getch et al., 2019). The average emergency room visit rate among the pediatric population was 88.1 per 10,000 population from the years 2010 to 2018 (CDC, 2021). The total economic impact of asthma among school-aged children is approximately $791 per child each calendar year and includes medical costs, loss of work productivity among parents, school absenteeism, and premature death (Carpenter et al., 2014). Although children spend approximately half of their day in school and asthma is prevalent, relevant knowledge and resources among school personnel are limited (Lucas et al., 2012). Evidence points to limited education in asthma symptom recognition and management among unlicensed school staff (Anderson et al., 2005; Kawafha & Talbeth 2015; Reznik et al., 2020). A study done among schoolteachers in Illinois revealed that only 25% of teachers received any asthma training at their workplace (Lucas et al., 2012). Thus, recognition of asthma triggers and symptoms of an asthma attack are subpar (Al Aloola et al., 2017; Anderson et al., 2005). Furthermore, a lack of confidence in managing asthma exacerbations and increased anxiety in medication administration are common themes among school personnel (Al Aloola et al., 2017; Anderson et al., 2005; Reznik & Halterman, 2016). There is substantial evidence to argue that increased asthma knowledge can lead to increased confidence and reduced anxiety among school staff, which is needed to calmly respond in emergencies and to be more proactive in asthma management (Reznik et al., 2020). “Asthma-Friendly Schools” is a CDC initiative that focuses on producing a safe environment conducive to learning for students with asthma and has been shown to improve asthma management (CDC, 2022). This is accomplished through providing asthma awareness programs for students and school staff, supporting evaluation of the programs and utilization of appropriate outcome measures, and providing school health services for students with asthma. In addition, using a collaborative approach in identifying students most in need of intervention contributes to ensuring a safe environment for students with asthma (CDC, 2022). The goal of this project is to create a safe environment for all asthmatic students through the implementation of an asthma education program for school personnel and the establishment of a referral program for the identification of possible asthmatic students. Through increased knowledge, staff will be more confident and comfortable in asthma identification and management and be proactive facilitators in identifying possible undiagnosed students. Organizational Needs Assessment Description of the Sponsoring Organization Imagine Schools at Town Center is a non-profit, public charter school founded in 2004 in Palm Coast, Florida. Its mission is to equip students for lives of leadership, success, and excellent character by offering high-quality education. The vision of the school is for every child to reach their full potential and find the path to lifelong success (Imagine Schools, 2022). For the past ten years, Imagine Schools at Town Center has employed a full-time certified nursing assistant (CNA) to run the nursing clinic. The purpose of the clinic is to improve the health of all people on campus and provide feedback to parents (S. Swanson, personal communication, September 16, 2022). The school employs approximately 50 teachers and has 900 students from K-8th grade (S. Swanson, personal communication, September 16, 2022). There are currently only 14 students (2% of the student population) with diagnosed asthma which is considerably below the national average of 10% (AAFA, 2021) and indicates there are likely many undiagnosed students with asthma at this school. At the beginning of each school year, parents are required to indicate medical comorbidities and medication usage on admission forms. The CNA will then follow-up with each parent of an asthmatic student to develop an Asthma Action Plan and an Emergency Health Care Plan that are updated yearly. The completed Asthma Action Plans are kept in the clinic and with each teacher that has a student with asthma (S. Swanson, personal communication, September 16, 2022). However, for the past ten years, there have been no training for most of the school staff to address asthma identification and management, review current school policies, or use of Asthma Action Plans. Furthermore, there is no referral program set up for school staff to report asthma symptoms and collaborate with the school CNA to identify possible asthmatic students that have been missed (S. Swanson, personal communication, September 16, 2022). Stakeholder Analysis The proposed project will incorporate different key stakeholders including the school principal, CNA, schoolteachers and staff, and parents, as identified in Appendix A. Each stakeholder carries a specific role in the implementation and can either contribute or impede the project through their influence. To engage key stakeholders, the benefits of asthma education and a referral program must be clearly presented and collaboration between each entity established. The school principal is responsible for approving the project. The CNA is responsible for collaborating with the project coordinator, school staff, and parents of each student referred to the asthma program. Staff’s responsibilities include attending an educational session and identifying and referring possible asthmatic students. Ease and usefulness of the program, in addition to convenient scheduling of the educational session, are critical factors in ensuring staff engagement. Lastly, parents are responsible for following up with their child’s provider for asthma screening and possible diagnosis. To ensure their participation, the referral process and the importance of following up with their child’s provider for asthma screening must be clearly explained to each parent. Project Management Tools Several project management tools were utilized to gain a clear picture of the project aim and to make project plans strategically. The driver diagram, as detailed in Appendix B, illustrates change ideas that will be implemented through this project, primary and secondary drivers, and the project aim. The project aim is to increase the staff’s confidence in identifying and managing pediatric asthma by at least 30% and have at least three students referred to the school clinic for further follow-up. The primary drivers include increasing staff confidence in asthma management and identifying possible asthmatic students. Secondary drivers include the staff’s lack of knowledge and confidence in identifying asthma triggers, asthma symptoms, and correct treatment. Other secondary drivers include the staff’s uncertainty about their school policy and the lack of a referral program. Change factors to facilitate project success include asthma identification and management training for the school staff, arranged collaboration between the school staff and the CNA, and establishment of a referral program. The strength, weakness, opportunities, and threats (SWOT) analysis is also detailed in Appendix B. Strengths of the proposed project include the following: 1) Support from the school administration and CNA, 2) Cost-effectiveness of the program, 3) Assurance of staff participation, and 4) Obvious need for the educational session. Weaknesses address the fact that the referral program will be based on the willingness of the school staff and CNA and the training will require their already limited time. Opportunities focus on improving students’ safety and health through asthma education and identification of undiagnosed asthma students through the referral program. However, an obvious threat exists to successful implementation as most of the school staff is not used to health education sessions and might not be open to an in-service. Local Problem Statement Imagine School at Town Center for the past ten years has not offered an asthma educational session for most of its school staff. Thus, the school staff might lack the necessary knowledge and confidence to successfully prevent, identify, and manage asthma emergencies. Because the school’s asthma prevalence is much lower than the national and state average and there is no established referral program to identify possible asthmatic students, the health of many asthma students might be jeopardized as they remain undiagnosed and unmanaged. Literature Review and Synthesis Search Strategy To address the need for school staff asthma education, a literature search was conducted to answer the following PICO question: “In school personnel, how does an asthma education program compared to no education program affect identification of possible asthmatic students and staff’s confidence in pediatric asthma identification and management?” The literature search was conducted through the EBSCOhost research platform using Medline, CINAHL Plus with Full Text, and APA PsycInfo databases. Search terms used included [“asthma educat*” OR “asthma program” OR “asthma intervention” OR “asthma referral*”] AND [“school personnel” OR teacher OR “school staff”]. An initial search yielded 146 articles from which 37 were excluded due to duplication. All peer-reviewed articles in the English language were then reviewed and included if they mentioned an asthma intervention or education program geared towards school staff. Hence, all asthma programs or educational sessions geared towards students, parents, or only school nurses were excluded. A total of eight articles were included in this synthesis as documented by Appendix C. Synthesized Key Findings The Need for an Educational Program An emerging theme throughout the literature is the need for asthma identification and management education geared toward school personnel (Anderson et al., 2005; Carpenter et al., 2014; Reznik & Halterman, 2016). Most school personnel reported no asthma education classes or sessions offered in their school and thus decreased knowledge in identifying and managing asthma (Anderson et al., 2005; Kawafha & Tawalbeth, 2015; Reznik & Halterman, 2016; Ruvalcaba et al., 2019). Common misconceptions surrounded around recognition of asthma attack symptoms, steps to take during an emergency, current school policies, and medication use (Anderson et al., 2005; Reznik & Halterman, 2016; Neuharth-Pritchett & Getch, 2016). School personnel also demonstrated low confidence scores in identifying and managing asthma attacks (Al Aloola et al., 2017; Neuhartg-Pritchett & Getch, 2016; Reznik et al., 2020; Reznik & Halterman, 2016). Sixty-six percent of teachers felt uncomfortable helping students to manage an asthma attack and 44% worried about a potential asthma attack during their school day (Reznik & Halterman, 2016). High anxiety levels were present among many elementary school teachers as they worried about asthma attacks and medication administration (Reznik & Halterman, 2016). Benefits and Content of the Educational Program A standardized asthma education program has been shown to improve school personnel’s knowledge and confidence in asthma identification and management (Kawafha & Tawalbeth, 2015; Neuharth-Pritchett & Getch, 2016; Reznik et al., 2016; Ruvalcaba et al., 2019). Significant recognition of asthma symptoms and comfort assessing for an asthma attack were seen post- asthma-education interventions (Al Aloola et al., 2017; Kawafha & Tawalbeth, 2015; Reznik et al., 2020). Symptom recognition and identification, emergency management, and medication use were all vital components of an effective educational session (Al Aloola et al., 2017; Anderson et al., 2005; Reznik et al., 2020; Reznik & Halterman, 2016; Ruvalcaba et la., 2019). A successful educational session that was conducive to learning was interactive and often included visual aids, PowerPoint presentation, inhaler demonstration, case studies, question/answer session, and/or supplemental printed materials (Al Aloola et al., 2017; Neuharth-Pritchett & Getch, 2016; Reznik et al., 2020; Ruvalcaba et al., 2019). Another vital component of an asthma educational program that has been shown to improve staff’s knowledge and students’ asthma symptoms is reviewing current school policies regarding asthma emergencies and the role of the teacher (Carpenter et al., 2014 Reznik et al., 2020; Ruvalcaba et al., 2019). Sustainability of the Educational Program and Practice changes Lastly, a sustainable education program includes asthma practice or policy changes that are written, reviewed with the school personnel, and in collaboration with the school staff (Carpenter et al., 2014; Reznik & Halterman, 2016; Ruvalcaba et al., 2019). Any changes or additions to the current practice are based on the school’s individual need and discussed with the school staff (Carpenter et al., 2014). Evidence shows that practice changes focused on the assessment of students with asthma symptoms, in addition to educating the school staff, have been shown to improve asthma management (Carpenter et al., 2014). However, the practices of teachers are not always consistent with practice guidelines due to insufficient knowledge of existing policies and their processes, lack of written policies, and absence of collaboration between school personnel (Anderson et al., 2005 & Carpenter et al., 2014). Thus, successful implementation of a practice change should be clearly explained, easily accessible, and in collaboration with the school nurse (Carpenter et al., 2014). Purpose and Project Goals The purpose of this project is to improve the confidence of the school staff in pediatric asthma identification and management. This will be accomplished through an educational session focused on asthma prevention, identification, and management within the school setting. The second aim of the project is to improve the safety and well-being of students by establishing a referral program for identifying possible undiagnosed asthmatic students. Conceptual/Theoretical Framework Bandura’s Theory of Self-Efficacy is the theoretical framework guiding this project. The concept of self-efficacy is defined as an individual’s belief in their capabilities which determines how one will carry out actions to produce a certain desired outcome. The term self-efficacy and its impact on confidence, motivation, and empowerment was first described by Albert Bandura in 1986 (Bourne, 2021). Self-efficacy influences one’s efforts and subsequently their results (Bourne, 2021). People with higher self-efficacy aim for more ambitious goals, initiate action, and are more persistent in their efforts, even if actual capabilities do not match their beliefs at that time (Warner et al., 2020). Current literature describes the need for self-efficacy in carrying out any role successfully (Bourne, 2021; Khan et al., 2021). Teacher self-efficacy is associated with motivation, initiative, and resilience, and thus, knowledge application, skill acquisition, and positive engagement of students (Bourne, 2021; Romjin, 2020). Khan et al., (2021) defines caregiver self-efficacy as being confident in their ability to support and take care of a loved one while maintaining emotional well-being and seeking support. Patient self-efficacy has been associated with better asthma disease control and outcomes (Reznik et al., 2020). One of the goals of this project is to increase the staff’s confidence in preventing, identifying, and managing asthma attacks. Higher self-efficacy is associated with reduced anxiety and improved comfort, thus school staff will be more proactive in creating a safe environment for asthmatic students and managing emergencies (Reznik et al., 2020). Furthermore, they will feel more competent and empowered to make a difference in the lives of their students. As a result, the safety and health of asthmatic students will be improved within the school setting. Methods Project Design Setting Population Intervention Budget and Resources Cost-Benefit Analysis Outcome Measures Data Collection Data Analysis Plan Ethical Considerations Timeline for project completion References Al Aloola, N. A., Saba, M., Nissen, L., Alewairdhi, H. A., Alaloola, A., & Saini, B. (2017). Development and evaluation of a school-based asthma educational program. The Journal of Asthma: Official Journal of the Association for the Care of Asthma, 54(4), 419–429. https://doi.org/10.1080/02770903.2016.1218015 Anderson E.W., Valerio M, Liu M, Benet DJ, Joseph C, Brown R, & Clark NM. (2005). Schools’ capacity to help low-income, minority children to manage asthma. Journal of School Nursing, 21(4), 236–242. https://doi.org/10.1177/10598405050210040901 Asthma and Allergy Foundation of America (AAFA). (2022). Asthma Facts and Figures. https://www.aafa.org/asthma-facts/ Bourne. (2021). Clinical teacher self-efficacy: A concept analysis. Nurse Education in Practice., 52, 103029. https://doi.org/10.1016/j.nepr.2021.103029 Carpenter, L. M., Lachance, L., Wilkin, M., & Clark, N. M. (2013). Sustaining school-based asthma interventions through policy and practice change. Journal of School Health, 83(12), 859–866. https://doi.org/10.1111/josh.12104 Centers for Disease Control and Prevention (CDC). (2021, April 9). Asthma emergency department (ED) visits 2010–2018. https://www.cdc.gov/asthma/asthma_stats/asthma-ed-visits_2010-2018.html Centers for Disease Control and Prevention (CDC). (2022, August 18). Asthma. https://www.cdc.gov/healthyschools/asthma/index.htm Imagine Schools. (2022). Vision & Mission. http://imagineschooltowncenter.org/home/ Getch, Y. Q., Neuharth-Pritchett, S., & Schilling, E. J. (2019). Asthma and the public-school teacher: A two state study. Pediatric Allergy, Immunology, and Pulmonology, 32(3), 109–116. https://doi.org/10.1089/ped.2019.1041 Hsu, J., Qin, X., Beavers, S. F., & Mirabelli, M. C. (2016). Asthma-related school absenteeism, morbidity, and modifiable factors. American Journal of Preventive Medicine, 51(1), 23–32. https://doi.org/10.1016/j.amepre.2015.12.012 Kawafha, M. M., & Tawalbeh, L. I. (2015). The effect of asthma education program on knowledge of schoolteachers: A randomized controlled trial. Western Journal of Nursing Research, 37(4), 425–440. https://doi.org/10.1177/0193945914528070 Khan, T. S., Hirschman, K. B., McHugh, M. D., & Naylor, M. D. (2021). Self‐efficacy of family caregivers of older adults with cognitive impairment: A concept analysis. Nursing Forum., 56(1), 112–126. https://doi.org/10.1111/nuf.12499 Neuharth-Pritchett, S., & Getch, Y. Q. (2016). The effectiveness of a brief asthma education intervention for childcare providers and primary school teachers. Early Childhood Education Journal, 44(6), 555–561. https://doi.org/10.1007/s10643-015-0751-0 Reznik, M., Greenberg, E., Cain, A., Halterman, J. S., & Ivanna Avalos, M. (2020). Improving teacher comfort and self-efficacy in asthma management. Journal of Asthma, 57(11), 1237–1243. https://doi.org/10.1080/02770903.2019.1640732 Reznik, M., & Halterman, J. S. (2016). School asthma policies and teachers’ confidence and attitudes about their role in asthma management. Annals of Allergy, Asthma & Immunology, 116(5), 473–475. https://doi.org/10.1016/j.anai.2016.03.005 Romijn. (2020). Teachers’ self-efficacy and intercultural classroom practices in diverse classroom contexts: A cross-national comparison. International Journal of Intercultural Relations, 79, 58–70. https://doi.org/10.1016/j.ijintrel.2020.08.001 Ruvalcaba, E., Chung, S. E., Rand, C., Riekert, K. A., & Eakin, M. (2019). Evaluating the implementation of a multicomponent asthma education program for Head Start staff. The Journal of Asthma: Official Journal of the Association for the Care of Asthma, 56(2), 218–226. Warner, Stadler, G., Lüscher, J., Knoll, N., Ochsner, S., Hornung, R., & Scholz, U. (2018). Day‐to‐day mastery and self‐efficacy changes during a smoking quit attempt: Two studies. British Journal of Health Psychology, 23(2), 371–386. https://doi.org/10.1111/bjhp.12293 Appendices Appendix C: Individual Evidence Summary Tool EBP Question: In school personnel, how does an asthma interventional program compared to no interventional program affect identification of possible asthmatic students and staff’s confidence in pediatric asthma identification and management? Author and Date Title of Article Journal Population, Size (n) Setting Type of Evidence Description of Intervention Outcome measures Findings that help answer the EBP question Limitations Evidence level and quality Implications for Proposed Project Al Aloola et al., 2017 Development and evaluation of a school-based asthma educational program Journal of Asthma 47 teachers Girls’ primary schools in Riyadh, Saudi Arabia Quasi-Experimental Study A 3hr school-based asthma educational program Asthma awareness, attitudes, and competence in in providing asthma-related first aid interventions 84% of teachers reported increased confidence in providing care to children with asthma after the program Competence scores increased by 7x post education It’s a pilot program so results should be interpreted cautiously regarding generalizability. Even though instruments to measure asthma awareness and attitude have been found to be reliable, they have not been formally validated. Level II High Quality-B Schedule session at a time convenient for school staff Can use a Likert Scale to evaluate pre and post confidence scores Implement an interactive session to include case studies, discussions, and demonstrations (see content and format of education session) Anderson et al., 2005 Schools’ capacity to help low-income, minority children to manage asthma Journal of School Nursing 14 schools Detroit public schools Descriptive Study School staff’s /parents’ surveys Emerging concerns and current knowledge 35% of teachers listed incorrect asthma attack symptoms such as dizziness, fever, eyes rolled back, etc. Only 36% recognized trouble breathing as a sign of asthma attack and 9% a cough Practices of teachers not consistent with asthma guidelines Survey of a specific population group of teachers in Detroit Most schools had no nurse on site so results may be different slightly Level III Good Quality-B Results show the need for asthma education especially in symptom recognition and identification and what to do next… Teach proper medication use and school policy as 15% of parents that reported school asthma problems -of those 37% stated school personnel was reluctant to give medication when needed… Carpenter et al., 2014 Sustaining school-based asthma interventions through policy and practice change Journal of School Health 14 Missouri Programs Missouri community settings to include schools Mixed method Policy and practice changes brought about through the Childhood Asthma Linkages in Missouri (CALM) program Childhood asthma symptoms Policy changes regarding assessment and monitoring Practice changes to include regular asthma education programs for school personnel Improvement in childhood asthma symptoms have been shown through practice changes focused on assessment of asthmatic students and educational sessions for school personnel No long-term evaluation of the CALM program Level III Good Quality-B Reviewing Asthma Action Plans is beneficial Policy changes tailored for individual schools’ need, such as the referral program, can be beneficial in improving overall asthma management Kawafha & Tawalbeh 2015 The effect of asthma education program on knowledge of schoolteachers: A randomized controlled trial Western Journal of Nursing Research Experimental group (n=36) Control group (n=38) Teachers at all public primary schools in Jordan, north region. RCT 3 asthma education sessions, each lasting 1 hr Teacher’s knowledge in pediatric asthma using the Asthma General Knowledge Questionnaire for Adults (AGKQA). Experimental group had significantly higher rates of asthma knowledge compared to the control group and at the retention phase (1 week and 3 months post-implementation) Sample only included female teachers and was geographically and culturally different than USA Level I High Quality- A At end of program, provide pamphlets summarizing key components Powerpoint presentation may be helpful Improved knowledge correlates to improved confidence in asthma recognition of symptoms and management of emergencies Neuharth-Pritchett & Getch, 2016 The effectiveness of a brief asthma education intervention for childcare providers and primary school teachers Early Childhood Educational Journal 65 participants total. 25 child care providers and 40 primary school teachers State of Georgia Quasi-Experimental Study Two 3-hr workshops of education on asthma identification and management Teacher’s knowledge and comfort in assisting during asthma attacks Significant increase in recognition and symptom management by 2x. Significant increase in comfort levels of staff helping students with asthma and medication administration. Convenience sampling Brief intervention-participants not followed to examine results more longitudinally Level II Good quality B Include in the educational session identification and minimization of asthma triggers in the classroom, medication administration, and physical activity factors. Include case studies. Reznik et al., 2020 Improving teacher comfort and self-efficacy in asthma management Journal of Asthma 65 teachers Four Bronx elementary schools Quasi-Experimental Study 45-minute workshop for teachers Perceived teacher comfort and self-efficacy in asthma management Mores teachers felt comfortable assessing and handling the situation during a child’s asthma attack Self-efficacy scores measuring confidence increased post-intervention Population very specific (Bronx) and has one of the highest asthma prevalence in the country Level II High Quality-A Sample inhaler and spacer to be used to demonstrate proper medication technique. Supplemental printed materials may be beneficial Implement “National Heart, Lung, and Blood Institute (NHLBI) guidelines on asthma management in schools” during the session Include possible PowerPoint and interactive question/answer session and current asthma policies (and the need for improved identification and referral system) Reznik & Halterman, 2016 School asthma policies and teachers’ confidence and attitudes about their role in asthma management Annals of Allergy, Asthma & Immunology 65 teachers 4 Bronx schools Cross-sectional Study Survey of teachers Awareness of written asthma policy and its influence on teacher confidence 69% of teachers felt uncomfortable assessing and 66% felt uncomfortable managing an asthma attack 43% of teachers were anxious when a student was having an asthma attack Teachers in schools with written asthma policy in place felt more confident during a student’s asthma attack (89.5% vs. 53.5%), assisting with asthma medication (68.4% vs. 29.5%), and confident in reducing triggers (52.6% vs. 20.5%). Cross-sectional study Only surveyed a specific group of teachers (2nd to 5th grade in Bronx schools) Level III Good Quality For teachers to feel more confident in referring students to the nurse for possible asthma symptoms and further evaluation, a written policy must be in place. Proposed written policy (referral program) must also be reviewed with the teachers. Study shows the need for intervention geared to reducing anxiety and improving confidence in asthma assessment and management Ruvalcaba et al., 2019 Evaluating the implementation of a multicomponent asthma education program for Head Start staff Journal of Asthma 13 Head Start programs and included 16 asthma-specific staff training sessions with a total of 159 staff members for the full duration the program Baltimore City Head Start Programs Quasi-Experimental Study 5-year multicomponent staff asthma education session (2 hrs.) that is offered annually Also included health fairs, parent workshops, health advisory committee education opportunities Asthma knowledge and skills Asthma medication management Year 5 HS staff reported higher self-assessed asthma knowledge and skills compared to pre-intervention by 13% No controls No matching of surveys so hard to evaluate individual improvement rates Level II Good quality -B Education sessions were interactive and included images, videos, demonstration of inhaler, and review of Asthma Action Plans At least 1/3 of training time was focused on symptom recognition Appendix B: Project Management Tools – Stakeholder Analysis and Communication Tool Identify the key stakeholders: School principal, CNA, schoolteachers and staff, and parents of students ☒ Manager or direct supervisor (principal) ☐ Finance department ☐ Vendors ☒ Parents of students ☐ Professional organizations ☒ Committees ☐ Organizational leaders ☒ Interdisciplinary colleagues (School CNA) ☐ Administrators ☐ Other units or departments ☒ Others: School teachers/staff Stakeholder analysis matrix: Stakeholder Name and Title: Role: (select all that apply) Impact Level: How much does the project impact them? Influence Level: How much influence do they have over the project? What matters most to the stakeholder? How could the stakeholder contribute to the project? How could the stakeholder impede the project? Strategy(s) for engaging the stakeholder: School principal Approval Minor Significant No interruptions in workflow Outcomes Approve the project Refuse the project Provide evidence of asthma interventional project School CNA Approval Responsibility Consult Significant Significant Ease and usefulness of program Approve the project Collaborate with project coordinator and school staff Refuse to implement the project Fail to follow-up within the referral process Provide evidence of asthma interventional project Collaboration Be open to suggestions School staff Responsibility Significant Significant Ease and usefulness of program Convenient scheduling Identify asthmatic students and refer Not participate in implementation Fail to refer possible asthmatic students Provide evidence of asthma interventional project Schedule session at convenient time within allotted timeframe Parents Inform Moderate Minor Succinct and clear presentation of a child’s possible diagnosis and next steps Convenient time of phone calls Follow-up with a provider for asthma screening Failure to be reached through telephone use Failure to follow-up with a provider Explain the referral process, possible signs of asthma attack noticed in their child, and importance of following up with a provider for asthma screening Appendix B: Project Management Tools – Stakeholder Analysis and Communication Tool – Communication Planning Refer to this section to guide your communications to stakeholders throughout and after completing the EBP project. What is the purpose of the dissemination of the EBP project findings? (check all that apply) ☒ Raise awareness ☒ Promote action ☐ Change policy ☒ Change practice ☒ Engage stakeholders ☒ Inform stakeholders What are the 3 most important messages? Asthma educational session improves school staff’s knowledge and confidence in identifying, preventing, and managing asthma attacks. It is highly likely that a significant number of students have undiagnosed asthma based on USA statistics. The referral program will aid in identifying undiagnosed asthmatic students to improve their health and safety. Align key message(s) and methods with audience: Audience Key Messages Method Timing School principal Inform how asthma interventional program aids in student safety Meeting 2 months School CNA Educate of benefits of asthma interventional program: collaboration of school staff to improve student safety Meeting 2 months School teachers/Staff Educate on benefits and use of asthma interventional program Encourage use of asthma referral program when appropriate Meeting 6 months Parents Importance of prompt provider follow-up for child asthma screening Phone call 6-7 months Appendix B: Project Management Tools – Driver Diagram Aim Primary Drivers Secondary Drivers Change Ideas Appendix B- SWOT Analysis Strength Weaknesses Need for the program is obvious: No asthma educational session for most of the teachers has been utilized in the past ten years Support from administration and school CNA No extra costs for the school to implement the program A one-time educational session for the teachers instead of multiple sessions Educational session will be made mandatory for one schoolteacher from each grade-level Educational session will require school staff’s time (either during or after school hours) Referral program will be based on willingness of school staffs’ and CNA’s participation and collaboration Opportunities Threats Identify possible undiagnosed asthmatic students since number of students with asthma falls below the state-average Research points that most school staff report no education on pediatric asthma and feeling of inadequacy and fear in asthma identification and management Improve students’ safety and health Most school staff are not used to health educational sessions and might not be open to an in-service Data Collection Sheet/Instrument Pre and post-test confidence questionnaire Demographics questionnaire Asthma referral form Education Plan Coded Data Management Sheet Timeline Figure Organization Letter of Support