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Part 2 book “Clinical research for the doctor of nursing practice” has contents: A community– academic collaboration to have an impact on childhood obesity, the impact of evidence-based design, the lived experience of chronic pain in nurse educators,… and other contents.
UNIT IV Examples of Studies and Projects CHAPTER 14 Reducing 30-Day Hospital Readmission of the Patient with Heart Failure: An Evidence-Based Quality Improvement Project 185 CHAPTER 15 A Community–Academic Collaboration to Have an Impact on Childhood Obesity������227 CHAPTER 16 The Impact of Evidence-Based Design������247 CHAPTER 17 The Lived Experience of Chronic Pain in Nurse Educators����������������������������������������291 © Sunny/DigitalVision/Getty 183 CHAPTER 14 Reducing 30-Day Hospital Readmission of the Patient with Heart Failure: An Evidence-Based Quality Improvement Project Julie C Freeman OBJECTIVES Upon completion of this chapter, the reader should be prepared to: Prepare a gap analysis for a capstone project Prepare a SWOT analysis (strengths, weaknesses, opportunities, threats) for a capstone project The Institute of Medicine (IOM) report Crossing the Quality Chasm: A New Health System for the 21st Century (2001) called for redesign in the methods utilized to provide care to Americans The first recommendation states that healthcare systems must restructure to develop systems that reduce the impact of challenging healthcare issues on the patient, family, and systems The second recommendation states that the healthcare systems must strive to ensure that the care provided across America meets 185 186 Chapter 14 An Evidence-Based Quality Improvement Project the following six aims: that health care should be safe, effective, patient centered, timely, efficient, and equitable The third recommendation states that there must be a method in place to observe and record healthcare processes to determine the attainment of the six aims (IOM, 2001) Even after the implementation of the six aims and the establishment of the Centers for Medicare and Medicaid Services (CMS) core measures, the United States of America ranks highest among eight industrialized nations, with an 18% readmission rate for patients with heart failure (HF) within 30 days of discharge (Westert, Lagoe, Keskimaki, Leyland, & Murphy, 2002) Therefore, it is imperative for systems to develop interventions to better prepare patients for discharge from the acute care setting The patient population selected for the quality improvement project is the patient with HF The quality improvement intervention selected to address the readmission of HF patients within 30 days is a standardized discharge notebook As the CMS does not reimburse costs associated with readmission of patients with HF within 30 days beginning in 2012, healthcare facilities must evaluate the discharge processes currently in place for the provision of efficient, cost-effective, patient-centered, and effective care (Foster & Harkness, 2010) As patient stays grow shorter and emphasis is placed on better self-management, the discharge process will take on greater significance as a viable option to improve self-management The cost for providing care for patients with HF is approaching $37 billion annually (Heidenreich, 2009) A major component of the cost is associated with readmission within 30 days of discharge (Ross et al., 2009) The individual cost associated with the initial admission is approximately $6,000 depending on the region of the nation Readmission of patients with HF within 30 days results in an additional cost of $2,500 to $4,000 in the Southeast region (Joynt & Jha, 2011; Ross et al., 2009) Mortality rates for patients with HF readmitted within 30 days are higher than for patients readmitted at 60 days or 90 days (Ross et al., 2009) As the United States faces increasing costs associated with readmission within 30 days of discharge, many organizations are evaluating interventions to determine the most effective opportunities for system change The Institute for Healthcare Improvement (IHI), the American Heart Association (AHA), the CMS, and other healthcare agencies have recommended guidelines, developed programs, or initiated campaigns to address directly better self-management of patients with HF An area of particular review and concern is the discharge or transition in care processes in place for the HF population Approximately million individuals are living with HF, and almost 300,000 individuals with HF expired in 2008 (Roger et al., 2011) Poorly managed HF has resulted in a diminished quality of life, difficulty performing activities of daily living (ADLs), frequent hospital admissions, and early mortality for Americans (Neilsen et al., 2008; Roger, 2011) The case for the pursuit of better discharge processes is related to the lack of primary care providers (PCPs) within the community The Montgomery County, Alabama, area and the surrounding counties are considered underserved by PCPs (Health Resources and Services Administration, 2011) Therefore, this patient population often does not have a PCP to return to upon discharge In addition, many individuals in the Montgomery area have not completed high school and have low literacy levels affecting the ability to understand the care required, recognize signs and symptoms requiring intervention, and how to go about seeking the care required The National Center for Education Statistics (2003) estimated the low literacy level for Montgomery County to be 14% As a result of the lack of PCPs, the emergency department (ED) is often utilized by the patient with HF, and many admissions and Needs Assessment 187 readmissions occur through the ED Improving the patient’s ability to self-manage care through a well-constructed, literacy-appropriate discharge notebook has been acknowledged as a positive intervention regarding self-management (AHA, 2009; Boutwell, Griffin, Hwu, & Shannon, 2009; CMS, 2006; IHI, 2010; Neilsen et al., 2008) In addition, reducing readmission through improving the discharge process with a discharge notebook can result in savings of $2,000 to $6,000 per patient to both the facility and the healthcare system (Joynt & Jha, 2011) The overall purpose of the project is to decrease readmission rates for patients with HF through the development and implementation of a standardized discharge notebook Components of the discharge notebook include education material regarding HF, ADLs education, exercise education, proper technique for daily weights, low-sodium diet, education on signs and symptoms to report, and the follow-up plan after discharge Patients will receive a follow-up phone call within 72 hours utilizing a telephone survey developed and based on the AHA’s (2013) Get With the Guidelines Heart Failure Campaign and the IHI’s (2010) Transforming Care at the Bedside How-to Guide: Creating an Ideal Transition Home for Patients With Heart Failure recommendations to determine level of understanding regarding self-management after receiving the discharge notebook In addition, each patient receiving a discharge notebook will be tracked for readmission within 30 days ▸▸ Institute of Medicine Six Aims As a component of implementing a quality improvement project, it is necessary to reflect on the IOM six aims The six aims provide a worthy goal for the project ▸▸ Safe—Avoiding injuries to patients and improving outcomes by providing standardized written and verbal discharge instructions via a discharge notebook to patients with HF Effective—Provision of an evidence-based discharge education plan for all HF patients in an effort to reduce readmission within 30 days Patient-centered—Provision of an evidence-based discharge notebook that is culturally sensitive, is literacy appropriate, and is inclusive of the patient and the family in the self-management process, and will help reduce readmission within 30 days Timely—The quality improvement project will begin upon admission for patients with HF and will follow the patient through to the discharge to reduce readmission within 30 days Efficient—Developing a project that will improve self-management and reduce readmission within 30 days Equitable—Provision of care to all patients without consideration of gender, race, social standing, economic status, or geographic area in an effort to reduce readmission within 30 days for all patients with HF Needs Assessment The collaborating facility is not meeting the national benchmarks regarding readmission of patients with HF within 30 days of discharge As of this writing, the national average for readmission within 30 days is 23.8%, and the facility readmission within 30 days was 188 Chapter 14 An Evidence-Based Quality Improvement Project 24.8% for the period 2007 to 2010 (CMS, 2010) The facility was also inconsistent in meeting the core measure for HF discharge instructions ranging from 89% to 100% from June 2010 through August 2011 (Agency for Healthcare Research and Quality [AHRQ], 2010) In June 2010, discharge instructions were provided to patients with HF 89% of the time; they were provided 94.5% of the time in September 2010; 92.9% of the time in October 2010; 94% of the time in April 2011; 90% of the time in June 2011; and 91.7% of the time in July 2011 Although the readmission rate is not extremely off the mark, the facility cares for many uninsured and underinsured patients, and the upcoming loss of reimbursement from the CMS for readmitted patients will add a further burden to the system In addition, as discharge education has been identified as a key component in the reduction of readmissions, the inconsistent degree of discharge education must be addressed The facility is a 155-bed hospital offering medical, surgical, emergency, obstetric, and pediatric services The facility is one of three affiliated hospitals within the region All three facilities are a part of the same healthcare system In 2010, the facility admitted approximately 7,500 patients with a wide range of health problems The facility is committed to serving the community, and its mission statement includes a goal of meeting the diverse needs of the community served, striving to provide programs and services that promote health and well-being across the community, collaborate with other entities to promote health and well-being, and be the first choice among the community for provision of healthcare services at a high level of quality at a reasonable cost The facility would like to improve its discharge processes in an effort to better align with its mission statement A strengths, weaknesses, opportunities, and threats (SWOT) analysis was completed and is seen in Appendix 14A A gap analysis revealed the current resources and discharge processes available, as well as the changes necessary to move the facility toward the goal of reduced HF readmissions in 30 days The GAP analysis is presented in Appendix 14B Approximately 90% of patients with HF are admitted through the ED (Nurse manager, personal communication, August 17, 2011) The DNP student attended a meeting regarding the introduction of an express admission unit (EAU) for the ED in an effort to move admitted patients from the main ED and improve throughput During the meeting, the nurse manager of the ED stated the ED must a better job of capturing the data unique to patients experiencing HF upon their admission and indicated a goal for initiating the education necessary to improve the discharge process (Nurse manager, personal communication, August 17, 2011) The current protocol for patients with HF at the facility is The Joint Commission Heart Failure Core Measure Set (Joint Commission, 2009) The current protocol and the amended protocol are seen in Appendix 14C The quality improvement project will improve the process of discharge for the patient with HF The IHI (2010) states a well-executed discharge begins upon admission The stakeholders include the chief nursing officer, the nurse manager from the ED, and the nurse manager from the cardiac step-down unit that admits patients with HF, the coordinator for the EAU, the community case management director and staff nurses, the quality improvement and risk assessment (QI) cncentives for participation, 44, 123, 144, 146 independent variable, 24 Index Medicus (MEDLINE), 40 indexicality in ethnomethodology, 95 inductive codes, 159 inductive reasoning, 28 inductive research, 88 inferential statistics, 157–158 informed consent, 94 autonomy and, 48 beneficence and, 48 data collection procedures for, 135 in e-mail interviews, 135 IRBs’ role in, 51–52, 125 in literature review, 45 participant rights and, 49 in survey data collection, 147 videotaping, 136 Institute for Healthcare Improvement (IHI), 182, 183 Institute of Medicine (IOM), 181, 224 six aims of, 183 institutional review boards (IRBs), 50, 52–56, 188, 313 applications, 54 conditions for approval, 52 exempt reviews, 53 expedited reviews, 53 explanatory research designs and, 107 informed consent responsibilities, 125 interview guides and, 94 in methods section appraisal, 44 mixed method data collection, 139–140 pitfalls, 54–55 privacy reviews and, 50–51 protected health information and, 51 qualitative research and, 90 reading level for, 55 research proposal evaluations, 52–53 review criteria, 47 risk/benefit ratio assessment, 54, 56 success with, 56 institutional review committee (IRC), 186 instructions to authors, 168 instrument development for data collection, 130 model, 108 instrumentation, 80, 144 integration of practice change, 17 integration stage, 186 interaction of selection and experimental treatment, 82 intercoder reliability, 139, 159 interdisciplinary healthcare providers, constant barrage of, 266 interim analysis, 159 internal validity, 75 threats, 80–82 International Association for the Study of Pain (IASP), 290 chronic pain definition of, 339 Internet data authorization and, 51–52 e-mail interviews, 134–135 journal prominence in search engines, 168 questionnaires and surveys on, 77 representative responses from, 134 Web-based surveys, 144, 152 interpretive pedagogies, 352 interpretive phenomenology, 92, 295 interpretive research approach, 296–297 interrater reliability, 132 interrupted time series with multiple replications, 81 with nonequivalent no-treatment comparison group, 81 with switching replications, 82 interruptions, EBD, 243, 259–260 interval level of variable, 157–158 interval statistical measurement, 157 interview guides, 94 interviews, 134–136 intracoder reliability, 159 intrarater reliability, 132 Index introduction sections critical appraisal of, 42–43 in manuscript writing, 169 IOM See Institute of Medicine IRBs See institutional review boards IRC See institutional review committee irrelevant replicability of treatments, 82 irrelevant responsiveness of measures, 82 J job market for DNPs, Joint Commission, 301 The Joint Commission Heart Failure Core Measure Set, 184 The Joint Commission standards, 266 justice, 48 K key contacts, 124, 125 knowing patterns, 14 knowledge application, 13 knowledge in ethnomethodology, 95 Kolmogorov-Smirnov test, 158 L legal capacity, 48 life history grid, 94 life history research design, 94 Lifeworld, 291 limitations, childhood obesity, 232–233 literature reviews, 37–46 abstract sections, 41–42 bracketing and, 92 critical appraisal, 18, 39–40, 41–45 data collection, 130 data source collection, 40–45 discussion/conclusion sections, 45 introduction sections, 42–43 in manuscript writing, 170 methods sections, 43–44 purpose, 38 references sections, 45 results sections, 44–45 structure, 38–39 lived experience, definitions of, 312 logs (record-keeping), 133 377 longitudinal designs, 151 longitudinal studies using cohorts, 74, 78 M MADOS See medication administration dispensing observation sheet mail surveys, 135 maintenance of practice change, 17 Mann-Whitney U test for independent groups, 158 manuscript writing format, 170–171 submission for publication, 168–169 maturation, 80, 81 maximum variation sampling, 123 mean, statistical, 156 median, statistical, 156 medical/nursing databases, 40 medication administration dispensing observation sheet (MADOS), 255–257, 259 medication errors, 244, 250, 260 medication therapy, side effects of, 301 medicine, 244 MEDLINE, 40 member checking, 317–318 memoing, 159 meta-analysis, 62 eight stages of characteristics, 63 meta-analysis literature reviews, 39 methodology, selection of, 61–70 curriculum, development of, 67 gap analysis, 65–66 health policy development, 63–65 models, comparison of, 69–70 quality improvement project, designing, 68–69 secondary data analysis, 61–62 systematic reviews, 62–63 methods sections critical appraisal of, 43–44 of manuscript, 170–171 microrange theory, 28 midrange theories, 28 mixed method capstone research projects, 101–112 across-stage mixed model designs, 104 advantages and limitations, 102–103 approaches, 103–104 data analysis, 109 data collection, 139–140 378 Index mixed method capstone research projects (continued) decision to utilize, 103 design type selection, 108–109 design types, 104–108, 105t embedded designs, 106 explanatory designs, 106–107 exploratory designs, 107–108 mixing, 108 process stages, 109–110 timing, 108–109 triangulation designs, 104–106 weighting, 108–109 mixed model research, 103–104 mixed purposeful sampling, 124 mode, statistical, 156 monitoring by IRBs, 52 in survey development, 145 mortality, 80, 81 motivational interviewing, 96–97 motivations for research participation, 158 multidisciplinary discharge process, 187 multiple healthcare providers, constant barrage of, 266 multiple-treatment interference, 82 N narrative analysis, 160 National Center for Education Statistics, 182 National League for Nursing Accrediting Commission (NLNAC), 348 needs assessment, 183–184 negative emotion, 344, 347 negative-case sampling, 110, 124 nominal statistical measurement, 157 nondirectional hypothesis, 26 nonequivalent control group designs, 77, 80–81 nonexperimental designs, 77–79 nonrandom sampling types, 119–120, 150 nonrandomized clinical trials, 77 nonstructural environmental design, 244 null curriculum, 351 null hypothesis, 26 Nuremberg Code, 48 nurse educators, 6, 266 nurse faculty, definitions of, 311 nurse interruptions, characteristics of, 250 nursing, 243 implications for, 351–353 reality of clinical practice in, 291 Nursing Academic Search Premier, 291 nursing intervention/patient care outcomes link, 17 nursing pain curriculum education and, 305–310 ineffectiveness of current, 306–310 nursing/medical databases, 40 Nvivo 10 software, 315 O obese, 224 objectivity, 92, 133 observational methods, 132–134 observational studies, 74 one-group posttest-only designs, 80 one-stage cluster sampling, 119 open-ended items in surveys, 136 operational curriculum, 351 operationalization, 130, 139 opportunistic sampling, 124 ordinal statistical measurement, 157 organizational data, 252–253 organizing themes, 160 outcomes of quality improvement intervention, 189 vs process, 87 overweight, 227 P pain See also chronic pain, lived experience of nurse educators assessment, 300 curriculum, education and nursing, 305–310 evolution of concept of, 299–300 knowledge deficits and attitudinal barriers to, 309 measurement and management, 301–302 subjectivity of, 291 pain numeric scale (PNS), 302 pain-related fear, 343 panel studies, 151 paradigm emphasis, 104 participants See also informed consent; populations for research studies characteristics, 43 observation of, 132–134 rights, 49 selection model, 107 Index passive participation, 133 patient care, 244 patient care outcomes/nursing intervention link, 17 patient education materials, 187–188 patterns in narrative analysis, 160 PCPs See primary care providers PDSA quality improvement model See plan, do, study, act quality improvement model Pearson correlation coefficient, 158 pedagogic discourse, need for, 319t, 333–336, 344–346 peer reviews, 10, 42, 161, 165, 170 percentiles, 227 performance measures, identification of, 189–190 periodicity, 118 personal knowing, 15 personnel resources for research project, 131 phases of project, 187–188 phenomenologic approach, 310 phenomenologic research, 298 phenomenology, 88, 92–93, 294 physician/provider trust, 319t, 326–328, 341–342 physiological measurements, 131–132 PICOT, 22, 247 pilot reliability, 139 pilot tests, 17, 130, 147 plan, do, study, act (PDSA) quality improvement model, 185 planning in survey development, 144 population health, populations, 118 populations for research studies in cluster sampling, 150 confidence intervals and, 123 in convenience sampling, 119, 150 definition of, 43 description in manuscript, 170 in disproportional stratified sampling, 119 external validity and, 82, 110 generalization of, 103, 110, 118 homogeneity considerations, 122 inferential statistics and, 157–158 in mixed research designs, 107 motivation for participation, 158 participant observation and, 132–134 in proportional stratified sampling, 119 in purposive sampling, 120, 150 in quota sampling, 120 random sampling/random assignment, 122 representative sample, 118 379 response rate, 78, 150 in simple random sampling, 118, 147 size, 43, 122–123, 150 in snowball sampling, 120, 150 in stratified random sampling, 150 survey data collection and, 150 in systematic sampling, 118, 147 positive emotion, 344, 347 positivism, 74, 88 potential risks/alternative strategies, 187 pragmatism, 102 preeducation assessment, 262 pretest sensitization, 76, 82 pretesting, in survey development, 145 pretest-posttest designs, 76–77, 81 primary care providers (PCPs), 182 primary sources, 42 privacy, 50, 56 Privacy Rule, 50–51 problem words in questionnaires, 136 process outcomes vs., 87 products vs., 87 processing in survey administration, 145 programmatic research, 131 proportional stratified sampling, 119 proposal evaluations, 52–53 proposed project evidence levels for, 248–250, 249f purpose of, 245–246 target population and location, 245 ProQuest, 291 protected health information, 51, 137 Provision of Care, Treatment and Service (PC), 301 publication (of research paper), 168–169 See also research report, writing PubMed, 186, 291 purposive sample method, 312 purposive sampling, 120, 123, 146, 150 pursuit of knowledge, 297 Q qualitative capstone research projects, 87–98 advantages and limitations, 89–91 data analysis, 158–161 ethnography, 91–92 ethnomethodology, 95–96 grounded theory, 93 life history, 94 motivational interviewing, 96–97 380 Index qualitative capstone research projects (continued) phenomenology, 92–93 qualitative sampling strategy, 124–126 qualitative/quantitative research differences, 88 research designs, 91–97 sampling designs, 123–124 sampling strategies, 124–126 selection, 97–98 sensitive topic issues, 90–91 types, 87–89 qualitative data, 189 analysis, 190 qualitative design, 310 qualitative research project, qualitative study sample sizes, 311 quality improvement, 185–186 and DNP graduates, intervention, 182 and methodology, 68–69 quality improvement project, 185–186, 190, 224–226, 231–233 implementation of, 188 quantitative capstone research projects, 73–84 advantages and limitations, 74–75 case control studies, 74, 78–79 cross-sectional surveys, 74, 77–78 data analysis, 156–158 differences, 88 experimental designs, 75–77 external validity, 82 longitudinal studies using cohorts, 74, 78 nonequivalent control group designs, 80–81 nonexperimental designs, 77–79 one-group posttest-only designs, 80 pretest-posttest designs, 74, 76–77 quasi-experimental designs, 79–83 randomized controlled trials, 74, 75–76 research types, 75 sampling designs, 118–120 subgroups of clinical trials, 77 time series, 81–82 quantitative data, analysis of, 305 quasi-experimental designs, 77, 79–83 external validity, 82 nonequivalent control group designs, 80–81 one-group posttest-only designs, 80 time series, 81–82 quasi-experimental studies, 13 questionnaires, 103, 134–136 quota sampling, 120 R race, definition of, 304 random sampling types, 118–119, 147, 150 randomization clinical trials, 43, 77 controlled trials, 75–76 random number generator, 118 selection vs random assignment, 122 rating scales, 135 ratio statistical measurement, 157 reactive effects of experimental arrangements, 82 reading level for IRB application, 54 records/existing data, 137–138 red carpet, 254 red zone, 253 education on, 256–257 plan for measuring, 259t project, data from proposed, 264 references sections critical appraisal of, 45 in manuscript writing, 170 reflexivity, 95, 110 regularly as problem word, 136 reliability, 131 assessment of literature reviews, 43 in data analysis, 159 in data collection, 131, 135 in healthcare practice and outcomes, 13 pilot reliability, 139 in qualitative studies, 90 types, 159 reporting, of content analysis results, 139 representative samples, 80, 118 representativeness, 78 research designs confidentiality and, 50 hypotheses and, 45 IRBs and, 56 in literature review, 44 in manuscript format, 170 mixed method research, 101–112 qualitative research, 87, 88, 91–97 quantitative research, 75–77 quasi-experimental research, 79–82 research hypothesis, 26 research problem, 21–22 selection of, 21–23 research proposal, writing, 167–168 research question, 22 appropriate use of, 23–24 development of, 21–23 ... quasi-experimental research, 79– 82 research hypothesis, 26 research problem, 21 22 selection of, 21 23 research proposal, writing, 167–168 research question, 22 appropriate use of, 23 24 development of, 21 23 ... HF 89% of the time; they were provided 94.5% of the time in September 20 10; 92. 9% of the time in October 20 10; 94% of the time in April 20 11; 90% of the time in June 20 11; and 91.7% of the time... determine the attainment of the six aims (IOM, 20 01) Even after the implementation of the six aims and the establishment of the Centers for Medicare and Medicaid Services (CMS) core measures, the United