Please conduct a synthesis. You must look up how to synthesize articles.
approx 500 words only
must use APA 7 format
Please conduct a synthesis. You must look up how to synthesize articles. approx 500 words only must use APA 7 format
Eller et al. Advances in Simulation (2023) 8:3 https://doi.org/10.1186/s41077-023-00243-6 ADVANCING SIMULATION PRACTICE © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Open Access Leading change in practice: how “longitudinal prebrieng” nurtures and sustains in situ simulation programs Susan Eller 1* , Jenny Rudolph 2 , Stephanie Barwick 3, Sarah Janssens 4 and Komal Bajaj 5 Abstract In situ simulation (ISS) programs deliver patient safety benets to healthcare systems, however, face many challenges in both implementation and sustainability. Prebrieng is conducted immediately prior to a simulation activity to enhance engagement with the learning activity, but is not sucient to embed and sustain an ISS program. Longer- term and broader change leadership is required to engage colleagues, secure time and resources, and sustain an in situ simulation program. No framework currently exists to describe this process for ISS programs. This manuscript presents a framework derived from the analysis of three successful ISS program implementations across dierent hospital systems. We describe eight change leadership steps adapted from Kotter’s change management theory, used to sustainably implement the ISS programs analyzed. These steps include the following: (1) identifying goals of key stakeholders, (2) engaging a multi-professional team, (3) creating a shared vision, (4) communicating the vision eec- tively, (5) energizing participants and enabling program participation, (6) identifying and celebrating early success, (7) closing the loop on early program successes, and (8) embedding simulation in organizational culture and operations. We describe this process as a “longitudinal prebrief,” a framework which provides a step-by-step guide to engage col- leagues and sustain successful implementation of ISS. Keywords In situ simulation, Prebrieng, Organizational change, Healthcare quality, Patient safety Background In situ simulation is conducted in the actual care envi – ronment  and serves as a vehicle of study or a test of change [2, 3]. Simulation practitioners deploy ISS in sev – eral ways: system probing for latent threats [4, 5], target training for specic crisis events , embedding new system processes , assessing safety of new environ – ments [7, 8], and team training [9, 10]. Learning from ISS can occur at the individual, team, unit, or organizational level, with measurable improvements often greatest at the organizational level [11, 12]. In situ simulation (ISS) is the nexus of rival priorities in healthcare systems. e competing demands of clini – cal performance, eciency, patient safety, and applied learning often clash when they intersect in frontline ISS. Despite more than 10 years of demonstrated benets to *Correspondence: Susan Eller [email protected] 1 Immersive Learning and Learning Spaces, Center for Immersive and Simulation-Based Learning, School of Medicine, Stanford University, 291 Campus Drive, Stanford, CA LK311B, USA 2 Surgery, Health Professions Education, Center for Medical Simulation, Harvard Medical School, Massachusetts General Hospital-Institute for Health Professions, Boston, MA, USA 3 Clinical Education, Mater Education, Mater Misericordiae, Brisbane, Australia 4 Obstetrics and Gynaecology, Clinical Simulation, Mater Health, Mater Misericordiae, Brisbane, Australia 5 Obstetrics & Gynecology and Women’s Health, Department of Quality & Safety, NYC H+H Simulation Center, NYC Health + Hospitals/Jacobi, Albert Einstein College of Medicine, Bronx, NY, USA Page 2 of 9 Eller et al. Advances in Simulation (2023) 8:3 healthcare systems [13–15], ISS leaders often struggle with how to balance the daily pressures of patient care, stang levels, and patient throughput with the known benets of applied practice. To manage this tension, ISS is often framed as a “nice to do,” an add-on, when time permits, in busy clinical units. Understandably, it may be seen as distracting or taking away precious time from overworked clinical professionals. is produces two challenges for simulation practitioners: 1) When they are not adequately tuned in to the com – peting priorities, they can be blind sided when their well-intentioned eorts to start and sustain ISS pro – grams are met with reluctance, fear, resentment, or outright refusal [16–18]. 2) Health system leaders who have committed space, simulation equipment, sta time and faculty develop – ment to improve quality, and safety or sta engage – ment via these programs may wonder about the return on investment. Simulation leaders must therefore design for impact across nested organizational levels, in which individu – als are nested in groups, nested in departments, nested in organizations which are part of health systems, and inuenced by the external environment. A case for simu – lation that is persuasive at the team or sub-unit level, to be successful, may need to demonstrate impacts at higher levels. And research on change leadership that includes simulation will benet from a multi-level lens . e simulation literature has focused intently on pre – brieng — information sharing for participants that play a role in psychological safety to build engagement for participants, primarily with a focus on during a session that typically immediately follows the prebrieng. Criti – cal actions suggested for prebrieng include the follow – ing: clarifying objectives, equipment functionality, roles of the participants and faculty, condentiality of the ses – sion, and expectations of participants during the simula – tion [11, 12, 14, 20, 21]. Prebrieng ISS teams may pose additional challenges including complexity of scheduling participants within a clinical environment and safety risks related to using real or simulated equipment in clinical areas [17, 18]. While usual guidance on prebrieng may have demonstrated impacts on proximate learning, they often do little to tap into health system “pain points,” or key goals and there – fore fail to build either the legitimacy or a compelling narrative that entices busy healthcare workers and lead – ers to “buy in” to the program. is puts well-designed ISS programs at risk for low enrollment, session cancel – lations, or even defunding — outcomes many simulation leaders have learned the hard way. Standard recommen – dations for prebriengs for incenter or ISS temporally proximate to the learning session are necessary, but not sucient to guide the long-term factors that inuence organizational adoption ISS. is paper therefore explores the question, “How did three disparate ISS programs address the challenge of linking in situ simulation to the concerns and goals of health system colleagues?” We present a retrospec – tive description of our evolving practice of managing and leading ISS programs and apply Kotter’s theory of change leadership  to categorize and illuminate the processes we noticed empirically. ese eorts yielded a change leadership framework  we call “longitudinal prebrieng.” Methods: learning from each other and practice e author group convened based on dialogue prompted by postings on an online journal club about in situ simu – lation (Simulcast, September 2019). Authors S. E., S. B., S. J., and K. B. described establishing programs at three locations, encountering comparable institutional and learner barriers, and using similar strategies to aid imple – mentation. ese anecdotal comparisons of successes inspired a more formal exploration of the processes to see if we could identify a framework to guide others in ISS implementation. We inductively analyzed emergent prac – tices that authors S. E., S. B., S. J., and K. B. developed and adapted as they rolled out ISS programs in three settings in North America and Australia. Program A, in a large health system in Queensland, Australia, employed ISS to evaluate and improve code team performance at an urban academic medical center on the east coast of the USA, utilized ISS to improve performance on obstetrical emer – gencies; program B, at an urban academic medical center on the east coast of the USA, utilized ISS to improve per – formance on obstetrical emergencies; and program C used ISS to improve adherence to national resuscitation guidelines in a neonatal intensive care unit at a Midwest – ern United States Medical Center. Analyzing programs from three unique contexts allowed the author team to consider knowledge gained from their own programs as insiders and also view the other programs as outsiders in alignment with comparative qualitative methodology . Reporting on ethical considerations pertaining to human subjects is an important consideration for dis – seminating academic knowledge; due to the de-identied nature of the narratives, we did not seek IRB approval for this work when we initiated our analysis. Change leadership as insiders Most research reported in biomedical and health pro – fessions education literature is “outsider” research Page 3 of 9 Eller et al. Advances in Simulation (2023) 8:3 conducted from an observer perspective . In this dominant paradigm, the legitimacy of ndings relies on the “objectivity” of the researcher standing outside of the phenomena under study [26, 27]. However, participa – tory action research traditions have nurtured an alterna – tive known as “insider” research . is is research by “actors immersed in local situations generating contextu – ally embedded knowledge that emerges from experience”  (p. 60). is allows for “pre-understanding” of con – text, relationships, and organizational processes. In our analysis, our team’s insider status was benecial in several ways. Firstly, our situated understanding enabled us to identify individual, unit, and organizational pain points to customize program priorities. Secondly, our insider status allowed us to analyze relationships and internal social networks to build a coalition to support the pro – gram and enroll participants. irdly, we were able to build on knowledge of other people’s roles and scope of practice to analyze how these interacted and inuenced program implementation at multiple levels. Following recommendations from the insider research literature , we analyzed our own ISS implementation journeys combining both insider experiential and outsider theo – retical knowledge to reframe and generalize our under – standing of the processes deployed in ISS programs we developed. Identication of common themes To better compare our ISS implementation narratives, each site wrote their respective approach without any specied form/structure other than removing all iden – tiable information. In reconstructing timelines and developing their narratives, the authors reviewed docu – mentation from their own institutions, such as emails, meeting minutes, instructor notes, yers for participants, and reports of successes shared within our institutions or at professional organizations/conferences. All narratives and subsequent analyses were written on Microsoft Word documents and shared between the authors in a secure online portal. ese narratives were then reviewed as a group and analyzed initially using thematic analysis [30, 31] combined with comparative analysis strategies . Data analysis followed the six-step thematic analysis process as outlined by Braun and Clarke . Authors SE, SB, SJ, and KB rst familiarized themselves with all of the narratives and writing memos to distill and sharpen key prebrieng processes . In the second phase, we selected key phrases to generate the initial codes for actions . e group next searched these codes for similarities to determine if there was any natural cluster – ing that represented themes . During this third phase, the authors found that similar activities had been labeled dierently depending upon the context. is discussion led to adopting insider comparative qualitative analysis methodology of alternating between analytical closeness and analytical distance . is strategy allows for those with in-depth knowledge to compare and contrast data between contexts in order to develop a collective under – standing of the processes  and shared terminology. In the fourth thematic analysis phase of reviewing themes , the authors mapped themes/steps on an ISS imple – mentation timeline. Comparing timelines across the vari – ous contexts revealed that although the actual length of time between steps varied, the order remained consist – ent. is shared understanding guided the next phase of dening and naming the themes  so they were rele – vant across contexts. ese themes described a process for implementing ISS within an organization: identifying motivation for program development; obtaining buy-in from organizational leaders and participants; establishing program goals, branding, and promoting the program; educating the organization on simulation/ISS; planning for successes; closing the loop on any issues found; and formally embedding ISS program into the organization. Reviewing these inductive, empirically generated themes, the group realized they paralleled Kotter’s prescriptions for organizational change leadership in many ways. ese themes were then compared against Kotter’s change leadership steps to adapt prescriptions for the simulation community based on the authors’ collective experiences. e nal phase of thematic analysis is pro – ducing the report , and the longitudinal prebrieng process we outline here describes our adaptation of Kot – ter’s theory of change leadership to categorize and illu – minate the processes we noticed empirically as we built our programs. Digital supplement 1 provides snapshots of the program narratives as well as examples of how each program executed the longitudinal prebrief. Digital supplement 2 provides additional details regarding the phases of thematic analysis. Trustworthiness Several techniques were employed to enhance the trust – worthiness of our data analysis . During thematic analysis, the initial author group maintained an audit trail in their secure online portal. e authors used docu – mentation from their ISS implementations to reconstruct their narratives to minimize hindsight bias. Author JR was invited to review the methodology, thematic codes, and the table for longitudinal prebrieng. By cross-walk – ing the nal themes back to the raw data, author J. R.’s review provided additional verication of the themes and actions described in the process table. Our author group reviewed the initial narratives after the manuscript, table, and gure were developed to ensure adequate descrip – tion of the process and prevent conrmation bias by Page 4 of 9 Eller et al. Advances in Simulation (2023) 8:3 leaving out or misconstruing concepts that cross-walked Kotter’s model to the processes we describe. We would like to note there might be some limitations to our conclusions drawn via these methods because of our insider status and commitment to change leader – ship. Our research team was highly motivated to iden – tify themes and patterns to clarify the ISS work we had done. While this served as an engine for the work, it subjected us to “motive-driven cognition,” i.e., we were at risk for arriving “at a particular conclusion, attempt to be rational, and to construct a justication of [our] desired conclusion that would persuade a dispassionate observer”  (p.272). To mitigate this sort of bias, we worked in good faith and with signicant rigor to analyze each other’s program data (not just our own) and to have a member of the team not involved in any of the pro – grams reanalyze in the thematic analysis. Applying Kotter’s model of change leadership to ISS In his seminal work “Why Transformation Eorts Fail” , Kotter describes eight steps to organizational trans – formation based on his study of over 100 companies of varying sizes and achievement. As each author shared their institution’s ISS implementation journey, it was clear that signicant engagement and culture change, the hallmarks of organization transformation, were required for success. Longitudinal prebrieng, which begins well before initiation of any simulations, helped to acceler – ate the necessary engagement and culture change. Fig – ure 1 summarizes our theory elaboration of Kotter’s eight transformational steps applied to ISS. Below we describe the Kotter’s eight steps in detail and describe the ele – ments highlighted in the thematic analysis of our ISS pro – grams that relate to each step. is is also summarized in Table 1 along with empirical examples from the program narratives. Establish a sense of urgency in ISS implementation mir – rors Kotter’s rst step since successful implementation of ISS programs requires impetus to overcome organiza – tional complacency. Simulation change agents often nd that “no urgency-no buy-in.” Potent drivers of change can include “pain points” such as poor performance on benchmarked quality indicators, nancial impacts, trends from morbidity and mortality reports, and poignant sto – ries of patient outcomes [22, 35]. Exploring our institu – tional stories identied these factors as successful drivers for ISS buy-in: unfavorable outcomes in maternal hem – orrhage, gaps in training for emergency response teams, and unfamiliarity with equipment and national resusci – tation standards. e nature of the problems addressed then drives selection of ISS program guiding coalition of stakeholders. Kotter’s second step, Form a powerful guiding coalition, emphasizes that sustainable change requires a strong, thoughtfully composed team . It is essential to enlist a diverse team of bottom-up and top-down multi-pro – fessional organizational champions [36, 37]. is coali – tion provides formal and informal leadership, credibility, clinical expertise, and power to remove barriers . An organization’s visible commitment to improving culture and supporting simulation activities can improve the psy – chological safety and engagement of participants . Our analysis yielded examples as follows: gaining support Fig. 1 Longitudinal prebrieng Page 5 of 9 Eller et al. Advances in Simulation (2023) 8:3 Table 1 Adaption of Kotter’s change leadership for longitudinal prebrieng Leadership step Change leadership for ISS Illustrations Establish a sense of urgency Identify “pain points” or precious goals of key stakeholders to inspire action and program development ○ Leverage patient stories, moral imperatives, regulatory requirements, or institutional threats ○ Multiple incident reports of adverse outcomes for babies due to communi- cation issues identied in neonatal resuscitations ○ National accreditation requirements identied for training in recognition and response to deteriorating patients Form a guiding coalition Engage top-down and bottom-up multi-professional partners to create buy- in. Do not work alone ○ Simulation facilitators as well as clinical stakeholders and healthcare leaders form a working party to clarify goals of ISS program (e.g., clinical readiness, quality, inclusion) ○ Gain representation on relevant hospital committees to garner support across dierent levels of governance Create a vision Co-create shared goals and vision to address individual, unit, and organisa- tional needs ○ Host regular meetings with program sponsors/supporters to gather input into program scope and establish a shared mental model on program goals and expectations ○ Utilize evidence-based examples in the literature to inform goals Communicate the vision Communicate shared goals, vision, and outcomes that accurately represent value and assist with positive reinforcement of participation ○ Brand program with a “catchy name” that communicates the function and vision of the program ○ Socialize program in a variety of settings, including existing forums such as grand rounds or safety huddles Empower others to act on the vision Energize (or re-energize) program participants by clarifying program logistics and providing approachable opportunities for familiarization with the program ○ Commence program with “fun” simulation-based activities within the clinical environments to introduce departments to the program and educate them about simulation ○ Provide early adopters who want to learn more about simulation/debrieng professional simulation development opportunities Plan for and create short-term wins Identify and celebrate early adopters and early successes to build momen- tum ○ Commence program in clinical units that are excited, engaged, and who have had previous positive experiences with ISS ○ Publicly advertise the date, time, and the scenario theme, in advance, for the initial program commencement period Consolidate improvements to pro – duce still more change Ensure program impacts are visible by closing the loop with multi-profes- sional partners ○ Communicate identied issues uncovered during the simulations with hospital leadership ○ Share improvements at sta huddles ○ Create infographics to communicate improvements Institutionalize new approaches Embed simulation in the organisational culture and regular operations ○ Include ISS programs in specic policy documents on workforce training/ development ○ Establish formal reporting process/agenda item at quality and safety or hospital governance meetings ○ Celebrate program successes through annual anniversaries of program commencement and dissemination of annual reports Page 6 of 9 Eller et al. Advances in Simulation (2023) 8:3 from nursing unit managers and educators, includ – ing members of hospital resuscitation committee, and recruiting local sim-friendly participants as early adop – ters of the ISS program. Coalition members co-create overall ISS program goals. After program goals and scenario objectives are estab – lished, the third step is Create a vision . is step establishes purpose and direction, motivates people to engage, and coordinates actions of team members; when healthcare team members perceive new programs as relevant to their daily work, they are more amenable to changing for improvements . All authors identi – ed a critical component as clarication of the program purpose, explicating what the ISS program was and was not intended to achieve. Interprofessional participants at all institutions expressed anxiety regarding participation, and declaring the lack of formal evaluation during ISS alleviated simulation reluctance. A shared mental model of ISS program goals and expectations facilitates psy – chological safety, mitigates the risks of simulation in the actual clinical environment , and expedites program progression. In Communicate the vision, Kotter advocates for key elements to conveying the message, including simplic – ity, repetition, and use of multiple forums . One aspect of longitudinal prebrieng was developing titles/ branding that communicated the function and vision of the programs, and each of the program described pithy titles during our comparative analysis. All three institu – tions reported presenting at various levels: grand rounds, leadership meetings, nursing orientation sessions, and unit-based educator forums. Another common feature to our communication strategies was visits to the local unit. After these initial information sessions, we all pro – gressed to further simulation activities with potential participants. Empower others to act on the vision often involves removing structural barriers and providing training as needed to accomplish change . Our shared experi – ences found the need to remove cultural barriers that included concerns about scheduling or resources and reluctance to participate in ISS. Including the unit lead – ers in the coalition ameliorates some of the schedul – ing and supplies, by having mutually agreed-upon go or no-go parameters for running ISS on the unit. Creating fun simulation-based activities for unit participants over – came resistance to participation. Examples of such activi – ties included pop-up simulations with nonthreatening CPR games, scavenger hunts, and Olympic-style games for infrequently used equipment. Providing familiariza – tion to the equipment and ground rules of simulation prior to ISS decreased both anxiety and prebrief time on the day of the event. Another empowerment activity that enhanced psychological safety was oering debrieng courses to educators or early adopters, to increase their comfort with this vital component of ISS. Plan for and create short-term wins is another essential step for successful ISS program implementation. Deliv – ering evidence that culture change eorts yield positive results rewards early adopters, encourages further par – ticipation, and motivates managers to support program continuation . Part of planning for short-term wins is identifying early adopters and targeting ISS implemen – tation to those units rst. Detecting system issues that could lead to safety errors promoted instant changes that improved care for all patients and not just the simulated event. Another signicant short-term win was reporting back to participants on changes to unit practice, or the ISS program, based on their feedback. e next adapted step in longitudinal prebrieng is Consolidate improvements to produce still more change. During this phase, the coalition uses momentum from short-term wins to address more challenging organi – zational issues . Gains from improving CPR quality of rate and depth led to deeper exploration of leader – ship issues during resuscitation and reluctance to speak against hierarchy when performance/practice gaps occur. Feedback on successes from ISS should be communi – cated at multiple levels of the organization. Our strategies included sharing at unit and educator meetings, setting up whiteboards to display successes to entire organiza – tion, and celebrating time and participation milestones. e nal step Institutionalize new approaches  involves having ISS formally embedded in organizational policy. Providing reports of safety improvements allowed formal acknowledgement of success and rationale for institutional change. Our groups reported having ISS as a formal standing agenda item at resuscitation committee meetings, obtaining organizational funding for continu – ing the ISS program, and adoption of ISS as mechanism for addressing other organizational quality issues. Invest – ing time in longitudinal prebrieng for ISS yielded successful simulation-based programs, quality improve – ments, and organizational changes. Impact of insider status: benets and limitations Our author group’s insider status impacted the under – standing of context, organizational processes, and rela – tionships to develop the Kotter simulation-specic adaptations presented. As an example of the importance of insider insights into context, the initiation of program A was catalyzed by the need to hardwire protocols to address obstetric emergencies, identied by a series of unfavorable clinical events. is “insider” perspective on the impetus behind program A’s development allowed for a nuanced understanding of the context under which Page 7 of 9 Eller et al. Advances in Simulation (2023) 8:3 external and internal organizational priorities created urgency, details that might otherwise be missed by an outsider trying to gain understanding of those priorities (and how they evolved) retrospectively. Program B is an example of how insiders’ understand – ing of organizational processes may provide an advantage over traditional “outsider” research. e authors involved with this program had deep familiarity with the organi – zation and its processes of cardiac arrest response, since they practiced within the organization. is aorded them a practical understanding of the various code team compositions and the clinical governance structures sur – rounding code team responses. is familiarity ensured simulations could be tailored to specic unit and code team requirements and facilitated rapid authorization of process improvements suggested following simulation activities. While reecting on the implementation of the cardiac arrest ISS program, this “insider” perspective on organi – zational processes allowed clear elucidation of what processes were no longer adequate, where “business-as- usual” needed change, and the steps required to hardwire that change. As “insiders,” the authors also have a unique under – standing of both healthcare team’s structures and rela – tionships. Preexisting relationships that simulationists had with nursing educators, residency coordinators, and hospital leadership accelerated the implementation of the program C. Nursing and physician educators expressed discomfort with conducting the simulations and agreed to take a simulation instructor course based on positive relationships with the simulation leads. ese courses increased the NICU educators’ familiarity with simula – tion and built trust to within the ISS coalition. Based on negative previous experiences or unfamiliarity with the equipment, some nurses and pediatric residents work – ing in the NICU expressed reluctance to participate in the simulations. e simulation leads leveraged the trust with the NICU nurse and residency educators to oer mini brieng sessions to familiarize participants with the equipment and dene expectations. is positive expo – sure to simulation decreased the reluctance to participate and built trust with the ISS program leads. e conclusions and recommendations presented here are based on both analyzing our own initiatives as insid – ers (S. B., S. J., K. B., S. E.) and analyzing each others’ ini – tiatives as outsiders (all the authors). We appreciate that there are threats to the trustworthiness of our conclu – sions. As seen through the lens of outsider research, S. B., S. J., S. E., and K. B.’s insider status, and particularly their personal investment in the success of their pro – grams, and lack of blinding to outcomes introduce cru – cial biases. While these threats to our interpretations of our practice-based data exist, rather than seeing them as defects, we argue that they are assets. e inside researchers’ investment in change and richly contextual – ized understanding where it succeeded and failed com – plements outsider research by highlighting the lived experience and dilemmas of taking action in real-life contexts. Application to other projects Historically, simulation centers and programs were built on the old adage of “build it and they will come,” but such advice can be detrimental for ISS programs. Our insider research clearly highlights that “how you build it” mat – ters, and time should be spent “playing the long game” in considering change leadership principles for successful ISS implementation. e longitudinal prebrief provides a road map for successful ISS organizational integration. e generalizability of the change leadership framework we propose here is limited by location of the initiatives: North America and Australia. It would be useful to explore how and if change leadership in simulation would be dierent in more hierarchical or collectivist cultures . Beyond application to the three programs described, the authors have since utilized “e Longitudinal Pre – brief ” to implement other ISS programs in dierent con – texts and locations. All authors have provided support for other teams initiating ISS programs and activities across geographically dispersed health facility locations by pro – viding guidelines and mentorship that included Kotter’s leadership steps adapted for ISS. Authors S. B. and S. J. utilized this model to coach an ISS program implemen – tation in a smaller regional facility. A key factor to this process was gaining organizational motivation by rst spending time understanding the specic clinical and workforce need and connecting the ISS program as a solution to the identied needs. Similarly, author J. R. utilizes the guiding principle “no urgency-no program” when consulting with groups that wish to utilize ISS. Author S. E. developed a policy of ensuring all clinical educators involved in ISS were part of the guiding coa – lition by having them assist with program design and complete simulation instructor training. Author K. B. strengthened institutional buy-in by co-developing “no- go considerations” for ISS activities that empowered unit leaders and published the framework to provide guidance for others . Components of “longitudinal prebrieng” have also been the subject of faculty development pro – grams at various international conferences, which have been of great interest to the simulation community of practice. While not specically naming Kotter’s change leader – ship principles, many ISS program descriptions report Page 8 of 9 Eller et al. Advances in Simulation (2023) 8:3 elements of the process we describe in successful imple – mentation of programs for interprofessional health teams. Wheeler et al. described the successful implemen – tation of an ISS program for the deteriorating patient in a pediatric hospital . Change leadership steps described include creating and sharing a clear vision for the program, the presence of a guiding coalition, plan – ning for early gains, and leveraging early success to con – solidate change . Riley et al. described using real adverse outcome data to establish a sense of importance for buy-in for an ISS program, as well as feeding back improvements to maintain momentum . Kumar et al. have noted the importance of change manage – ment in sustaining simulation programs, highlighting the importance of institutional “buy-in” . ese exam – ples highlight how successful ISS programs have instinc – tively utilized elements of change leadership to embed programs and ensure sustainability. However, to our knowledge, thus far, there has been no comprehensively described approach to ISS program implementation. Conclusion Failing to “play the long game” in simulation program initiation is the norm, rather than the exception. Focus – ing on short-term gains, putting out res, and focusing on the urgent at the expense of the important set simu – lation program leaders up frustration and even burnout. We therefore have dierentiated “prebrieng” that is designed primarily as a process temporally proximate to an upcoming simulation session and designed to estab – lish an engaging learning environment for current learn – ers, from a longitudinal brieng process that focuses on building program legitimacy via connections with the politics and priorities of the larger organization. To suc – ceed in the long game, a more comprehensive approach is required to engage colleagues at all levels and ensure that organizations can implement and sustain simula – tion programs . is longitudinal prebrief focuses on both unleashing colleague’s intrinsic motivation  and building the political and clinical credibility of the program. It provides a road map both for linking with the priorities of the larger organization as well as estab – lishing a safe and engaging learning environment for participants. We modied a well-known organizational change leadership framework to clarify the specics of organi – zational engagement needed for successful implementa – tion of ISS. We cataloged and thematically analyzed our program descriptions to adapt Kotter’s framework and provided recommendations for each step. While our approach is limited by the benets and biases of describ – ing our own experiences, we believe the framework could provide a structured approach for others implementing ISS programs. To test the soundness of this approach in other contexts, we hope that additional examples of activities relevant to each step (and their relevant success or failure) might be reported by other authors to build collective knowledge for best practice ISS implementa – tion. We encourage those who are developing new ISS programs or expanding current programs to experiment with a “longitudinal prebrieng” to their program plan – ning and implementation. Abbreviation ISS In situ simulation Supplementary Information The online version contains supplementary material available at https:// doi. org/ 10. 1186/ s41077- 023- 00243-6. Additional le 1. Supplement 1. Descriptions of 3 dierent in situ simu- lation programs and examples of longitudinal prebrieng related to each change leadership step. Additional le 1. Supplement 2. Phases of thematic analysis. Authors’ contributions Authors SE, SB, SJ, and KB collected data. JWR provided expertise related to insider research. All authors contributed equally to the design of the work, interpretation of data, and manuscript writing and revisions, author SJ designed Fig. 1 with input from all authors. The author(s) read and approved the nal manuscript. Funding There has been no funding for this work. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Declarations Ethics approval and consent to participate Not applicable Consent for publication Not applicable Competing interests The authors declare that they have no competing interests. Received: 4 May 2022 Accepted: 12 January 2023 References 1. Loice L, Downing D, Chan T, Robertson J, Anderson JM, Diaz DA, et al. Healthcare Simulation Dictionary. In: Healthcare SfSi. 2nd ed. Rockville: Agency for Healthcare Research and Quality; 2020. 2. Brazil V. Translational simulation: not ’where?’ but ’why?’ A functional view of in situ simulation. Adv Simulation. 2017;2:20. 3. Lamé G, Dixon-Woods M. Using clinical simulation to study how to improve quality and safety in healthcare. BMJ Simul Technol Enhanced Learn. 2020;6(2):87–94. Page 9 of 9 Eller et al. Advances in Simulation (2023) 8:3 4. Guise JM, Mladenovic J. In situ simulation: identication of systems issues. Sem Perinatol. 2013;37(3):161–5. 5. Patterson MD, Geis GL, Falcone RA, LeMaster T, Wears RL. In situ simula- tion: detection of safety threats and teamwork training in a high risk emergency department. BMJ Qual Safety. 2013;22(6):468–77. 6. Riley W, Begun JW, Meredith L, Miller KK, Connolly K, Price R, et al. Inte – grated approach to reduce perinatal adverse events: standardized pro – cesses, interdisciplinary teamwork training, and performance feedback. Health Serv Res. 2016;51(Suppl 3):2431–52. 7. Gardner AK, Ahmed RA, George RL, Frey JA. In situ simulation to assess workplace attitudes and eectiveness in a new facility. Simul Healthcare. 2013;8(6):351–8. 8. Geis GL, Pio B, Pendergrass TL, Moyer MR, Patterson MD. Simulation to assess the safety of new healthcare teams and new facilities. Simul Healthcare. 2011;6(3):125–33. 9. Petrosoniak A, Auerbach M, Wong AH, Hicks CM. In situ simulation in emergency medicine: moving beyond the simulation lab. Emerg Med Australas. 2017;29(1):83–8. 10. Wheeler DS, Geis G, Mack EH, LeMaster T, Patterson MD. High-reliability emergency response teams in the hospital: improving quality and safety using in situ simulation training. BMJ Qual Saf. 2013;22(6):507–14. 11. Kurup V, Matei V, Ray J. Role of in-situ simulation for training in healthcare: opportunities and challenges. Curr Opin Anaesthesiol. 2017;30(6):755–60. 12. Rosen MA, Hunt EA, Pronovost PJ, Federowicz MA, Weaver SJ. In situ simulation in continuing education for the health care professions: a systematic review. J Contin Educ Health Prof. 2012;32(4):243–54. 13. Andreatta P, Saxton E, Thompson M, Annich G. Simulation-based mock codes signicantly correlate with improved pediatric patient cardiopul- monary arrest survival rates. Pediatr Crit Care Med. 2011;12(1):33–8. 14. Brazil V, Purdy E, Alexander C, Matulich J. Improving the relational aspects of trauma care through translational simulation. Adv Simul. 2019;4:10. 15. Lipman SS, Carvalho B, Cohen SE, Druzin ML, Daniels K. Response times for emergency cesarean delivery: use of simulation drills to assess and improve obstetric team performance. J Perinatol. 2013;33(4):259–63. 16. Purdy E, Borchert L, El-Bitar A, Isaacson W, Bills L, Brazil V. Taking simulation out of its “safe container”—exploring the bidirectional impacts of psycho – logical safety and simulation in an emergency department. Adv Simul. 2022;7(1):5. 17. Sorensen JL, Ostergaard D, LeBlanc V, Ottesen B, Konge L, Dieckmann P, et al. Design of simulation-based medical education and advantages and disadvantages of in situ simulation versus o-site simulation. BMC Med Educ. 2017;17(1):20. 18. Tapia V, Waseem M. Setup and execution of in situ simulation. StatPearls. Treasure Island (FL): StatPearls Publishing StatPearls Publishing LLC.; 2020. 19. Hitt MA, Beamish PW, Jackson SE, Mathieu JE. Building theoretical and empirical bridges across levels: multilevel research in management. Acad Manage J. 2007;50(6):1385–99. 20. Chamberlain J. Prebrieng in nursing simulation: a concept analysis using rodger’s methodology. Clin Simul Nurs. 2015;11(7):318–22. 21. Rudolph JW, Raemer DB, Simon R. Establishing a safe container for learn- ing in simulation: the role of the presimulation brieng. Simul Healthcare. 2014;9(6):339–49. 22. Kotter JP. Leading change: why transformation eorts fail. Harvard Busi- ness Rev. 2007;85(1):96–103. 23. Kotter J. Change management vs. change leadership — what’s the dier – ence? Forbes.com2011 [Available from: https:// www. forbes. com/ sites/ johnk otter/ 2011/ 07/ 12/ change- manag ement- vs- change- leade rship- whats- the- die rence/? sh= 1f0b0 a054c c6. 24. Wendt M. Comparing ‘deep’ insider knowledge: developing analytical strategies for cross-national qualitative studies. Int J Soc Res Methodol. 2020;23(3):241–54. 25. Louis MR, Bartunek JM. Insider/outsider research teams: collaboration across diverse perspectives. J Manage Inquiry. 1992;1(2):101–10. 26. Kuhn T. Second thoughts on paradigms. In: Suppe F, editor. The structure of scientic theories. 2nd ed. Chicago: University of Ilinois Press; 1977. p. 459–517. 27. Varpio L, Paradis E, Uijtdehaage S, Young M. The distinctions between theory, theoretical framework, and conceptual framework. Acad Med. 2020;95(7):989–94. 28. Friedman VJ, Rogers T. Linking causal theory and meaning making in action research. In: Reason P, Bradbury H, editors. Handbook of action research: participative inquiry and practice. London: Sage Publications Inc.; 2008. p. 252–65. 29. Brannick T, Coghlan D. In defense of being “native”: the case for insider academic research. Organ Res Methods. 2007;10(1):59–74. 30. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. 31. Gormley G, Kearney G, Johnston J, Calhoun A, Nestel D. Analyzing data: approaches to thematic analysis. In: Nestel D, Hui J, Kunkler K, Scerbo MW, Calhoun A, editors. Healthcare Simulation Research: A Practical Guide. Switzerland: Springer; 2019. p. 135–43. 32. Miles MB, Huberman AM. Qualitative data analysis. 2nd ed. Thousand Oaks: Sage; 1994. 33. O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for report – ing qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245–51. 34. MacCoun RJ. Biases in the interpretation and use of research results. Ann Rev Psychol. 1998;49:259–87. 35. Parvizi N, Shahaney S, Martin G, Ahmad A, Moghul M. Instigating change: trainee doctors’ perspective. BMJ Qual Safety. 2012;21(9):801. 36. Bradley EH, Brewster AL, McNatt Z, Linnander EL, Cherlin E, Fosburgh H, et al. How guiding coalitions promote positive culture change in hospi- tals: a longitudinal mixed methods interventional study. BMJ Qual Safety. 2018;27(3):218–25. 37. Liberati EG, Tarrant C, Willars J, Draycott T, Winter C, Kuberska K, et al. Seven features of safety in maternity units: a framework based on multisite ethnography and stakeholder consultation. BMJ Qual Saf. 2021;30:444–56. 38. Greeneld D, Nugus P, Travaglia J, Braithwaite J. Factors that shape the development of interprofessional improvement initiatives in health organisations. BMJ Qual Saf. 2011;20(4):332–7. 39. Bajaj K, Minors A, Walker K, Meguerdichian M, Patterson M. “No- go considerations” for in situ simulation safety. Simul Healthcare. 2018;13(3):221–4. 40. Hofstede G. Culture’s consequences: comparing values, behaviors, institu- tions, and organizations across nations. Thousand Oaks: SAGE Publica- tions; 2001. 41. Riley W, Davis S, Miller KM, Hansen H, Sweet RM. Detecting breaches in defensive barriers using in situ simulation for obstetric emergencies. Qual Saf Health Care. 2010;19(Suppl 3):i53–i6. 42. Kumar A, Kent F, Wallace EM, McLelland G, Bentley D, Koutsoukos A, et al. Interprofessional education and practice guide no. 9: sustaining interpro – fessional simulation using change management principles. J Interprofess Care. 2018;32(6):771–8. 43. Krupp S, Schoemaker P. Winning the long game: how strategic leaders shape the future Hachette. UK: PublicAairs; 2014. 44. Hilton K, Anderson A. IHI Psychology of Change Framework to Advance and Sustain Improvement. Boston: Institute for Healthcare Improvement; 2018. 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Please conduct a synthesis. You must look up how to synthesize articles. approx 500 words only must use APA 7 format
Direct Practice Improvement : Title Appears in Title Case and is Centered Submitted by Insert Your Full Legal Name (No Titles, Degrees, or Academic Credentials ) Equal Spacing ~2.0” – 2.5” A Direct Practice Improvement Project Presented in Partial Fulfillment of the Requirements for the Degree Doctor of Nursing Practice Equal Spacing ~2.0” – 2.5” Grand Canyon University Phoenix, Arizona July 29, 2022 © by Your Full Legal Name (No Titles, Degrees, or Academic Credentials), 2022 All rights reserved . GRAND CANYON UNIVERSITY The Direct Practice Improvement Project Title Appears in Title Case and is Centered By Your Full Legal Name (No Titles, Degrees, or Academic Credentials), has been approved July 29, 2022 APPROVED: Full Legal Name, Ed.D., DBA, or Ph.D., DPI Project Chairperson Full Legal Name, Ed.D., DBA, or Ph.D., Project Mentor Full Legal Name, Ed.D., DBA, or Ph.D., Content Expert ACCEPTED AND SIGNED: ________________________________________ Lisa Smith, PhD, RN, CNE Dean and Professor, College of Nursing and Health Care Professions _________________________________________ Date Abstract The abstract is an accurate, nonevaluative, concise summary or synopsis of the direct practice improvement (DPI) project. It is not an introduction and is usually the last thing written. The purpose of the abstract is to assist future investigators in accessing the evidence-based materials and other vital information contained in the practice improvement project. Although only a relatively few people typically read the full practice improvement project after publication, the abstract will be read by many scholars and investigators. Consequently, great care must be taken in writing this section of the practice improvement project. The abstract is a concise statement of the nature of the project and the content of the practice improvement project. The content of the abstract covers the problem statement, evidence-based question(s), methodology, design, data analysis procedures, location, sample, theoretical foundations, results, and implications. The abstract does not appear in the Table of Contents and has no page number. Abstracts must be one paragraph, double-spaced, and no longer than 1 page. The abstract should be left justified with no indentions and no citations. Refer to the current APA Publication Manual, for additional guidelines for the development of the practice improvement project abstract. Make sure to add the keywords at the bottom of the abstract to assist future investigators. Examples and recommendations for writing this Abstract are offered in the DC Network. Keywords : Abstract, assist future investigators, limited to one page in length, vital information, include theories used, include outcomes and quality improvement Dedication An optional dedication may be included here. While a practice improvement project is an objective, scientific document, this is the place to use the first person and to be subjective. The dedication page has no page numbers and does not appear in the Table of Contents. It is only completed in the final practice improvement project and this page is a placeholder. If this page is not to be included in the final project, delete the heading, the body text, and the section break below. If you cannot see the section break, click on the ¶Show/Hide button (go to the Home tab and then ¶ Show/Hide on the Paragraph toolbar). Acknowledgments An optional acknowledgments page can be included here. This is another place to use the first person. If it applies, acknowledge and identify grants and other means of financial support. Also, acknowledge supportive colleagues who rendered assistance. The acknowledgments page has no page numbers and does not appear in the Table of Contents. This page provides a formal opportunity to thank family, friends, and faculty members who have been helpful and supportive. The acknowledgments page is only completed in the final practice improvement project and is not part of the proposal. If this page is not to be included, delete the heading, the body text, and the page break below. If you cannot see the page break, click on the ¶Show/Hide button (go to the Home tab and then to the Paragraph toolbar). Table of Contents Chapter 1: Introduction to the Project 10 Background of the Project 12 Organizational Needs Assessment 13 SWOT Analysis 13 Strengths 13 Weaknesses 13 Opportunities 13 Threats 14 Problem Description 14 Definition of Terms 14 Summary 16 Chapter 2: Scientific Underpinnings 17 Literature Search Strategy 17 Synthesis of Literature 17 Evidence-Based Practice Question 18 Change Recommendation: Validation of [Enter Name of EBP Intervention] 18 Theoretical Framework 18 Nursing Theory 19 Synthesis of Nursing Theory 19 Evidence-Based Change Model 19 Synthesis of Change Model 20 Integration of the Christian Worldview 20 Summary 21 Chapter 3: Project Design and Methodology 22 Purpose 22 Project Planning and Procedures 23 Interprofessional Collaboration 23 Project Management Plan (list required resources—delete this parenthetical note) 24 Feasibility 24 Setting and Sample Population 25 Setting 25 Population and Sample 25 Data Collection Procedures 26 Instrumentation or Data Source 26 Variables 27 Data Integrity and Storage 27 Data Management 27 Potential Bias and Mitigation 27 Ethical Considerations 28 Summary 29 Chapter 4: Data Analysis and Results 30 Data Analysis Procedures 30 Descriptive Data of Sample Population 31 Results 32 Summary 34 Chapter 5: Implications in Practice and Conclusions 35 Summary of the Project 35 Major Findings 35 Interpretation of Findings 35 Strengths and Limitations 36 Implications 36 Theoretical Implications 36 Nursing Practice Implications 37 Recommendations 37 Recommendations for Future Projects and Researchers 37 Recommendations for Sustainability 37 Plan for Dissemination 38 Conclusion and Contributions to the Profession of Nursing Practice 38 References 39 Appendix A 39 SWOT Analysis 39 Appendix B 40 Literature Evaluation Table 40 Appendix C 45 Project Timeline 45 Appendix D 46 Plan for Educational Offering 46 Appendix E 47 Grand Canyon University Institutional Review Board Outcome Letter 47 Appendix F 48 Project Budget 48 Appendix G 49 Data Collection Tool for Evaluation (Use the name of the tool here) 49 Appendix H 50 Place the Permission to Use the Tool Here 50 Appendix I 51 Other Data Collection Tool and/or Permissions 51 Appendix J 52 APA Writing Style for the Direct Practice Improvement Project 52 List of Tables Table 1 A Sample Data Table Showing Correct Formatting 32 Table 2 t-Test for Equality of Emotional Intelligence Mean Scores by Gender 33 Table 3 Primary Quantitative Research – Intervention (5 Articles) 40 Table 4 Additional Primary and Secondary Quantitative Research (10 Articles) 42 Table 5 Clinical Practice Guidelines (If applicable to your project/practice) 45 List of Figures Figure 1 SWOT Analysis for Quality Improvement Project 39 Chapter 1: Introduction to the Project The introduction of Chapter 1 provides a brief overview of (a) the project focus or practice problem, (b) states why the project is worth conducting, and (c) describes how the project will be completed. The introduction develops the significance of the project by describing how the project translates existing knowledge into practice, is new or different from other works, and how it will benefit patients at your clinical site. This section should also briefly describe the basic nature of the project and provide an overview of the contents of Chapter 1. This section should be three or four paragraphs long. Do not use single-sentence paragraphs or paragraphs longer than one double-spaced page. Keep in mind that you will write Chapters 1 through 3 as your direct practice improvement (DPI) project proposal and Chapters 1 through 5 for your final project manuscript. As you progress, changes will need to be made to the initial three chapters to enrich the content or to improve the readability of the final DPI project manuscript. In particular, after data analysis is complete, the first three chapters will need revisions to reflect a more in-depth understanding of the topic, to change the tense to past tense where appropriate, and to ensure consistency. To ensure the quality of both your proposal and your final practice improvement project and reduce the time for Academic Quality Reviews (AQR), your writing needs to reflect standards of scholarly writing from your very first draft. Each section should be well-organized, uniform, and logically presented. Each paragraph should be short, clear, and focused. A paragraph should (a) be three to eight sentences in length and (b) focus on one point, topic, or argument. If you have difficulty writing, it is recommended that you outline your paragraphs prior to writing the first draft of each chapter. Outlines should include the topic of each paragraph, evidence you would use to support this topic, explanations that connect the evidence to the topic, and a link or transition to the next paragraph. Outlining your paragraphs saves time when you’re writing and ensures coherence in your writing. In the final drafts, there should be no grammatical, punctuation, sentence structure, or American Psychological Association (APA) formatting errors. Be sure to use the check document feature in the Microsoft Word Review Menu. This feature will check for spelling errors and grammatical issues. Taking the time to put quality into each draft will save you time in all the steps of the development and review phases of the practice improvement project process. It will pay to do it right the first time. Verb tense is an important consideration throughout the manuscript drafting process. For the proposal, the learner (project manager) uses present tense (e.g., “The purpose of this project is to…”), whereas in the practice improvement final project, the chapters are revised into past tense (e.g., “The purpose of this project was to…”). However, when considering tense, you’ll want to pay attention to the conventions of grammar and APA style. For instance, when you signal the structure of a chapter, it should be written in the present or the future tense. Similarly, current or general problems should be written in the present tense. However, APA conventions stipulate referring to research studies in the past tense (i.e., “the research showed” vs. “the research shows). As a doctoral scholar, it is your responsibility to ensure the clarity, quality, and correctness of your writing and APA formatting. The DC Network provides various resources to help you improve your writing. Neither your chairperson nor your committee members will edit your documents nor will the AQR reviewers edit your documents. If you do not have outstanding writing skills, you will need to identify a writing coach, editor, or other resources, such as GrammarlyTM or ThinkingstormTM (GCU service), to help you with your writing and to edit your documents. The most important outcome is a scholarly product. Prior to submitting a draft of your proposal or practice improvement project or a single chapter to your chairperson, it is recommended that you have met previously with your Chair. Background of the Project The background section explains both (a) the history of and (b) the present state of the problem at the project site. This section should be two or three paragraphs in length. In this section, you should include your baseline data (see “Chapter 4: Using Data” in Clinical Analytics and Data Management). How many occurrences or current percentage of the problem compared to the industry have occurred over the 60 days prior to project implementation? Articulate how this “problem” has impacted or affected patient outcomes and nursing care (a) at the site, (b) the local level, (c) the national level, and (d) the global level. The section should close with a paragraph that ties these four concepts together, starting with the facility level and then adding the significance of the local, national, and global levels. Organizational Needs Assessment This section is one paragraph in length and should define what an organizational assessment is, why it is done, and that you did so utilizing a strengths, weakness, opportunities, and threats (SWOT) analysis. Explain why the SWOT analysis was appropriate for your quality improvement project. Present how you noted the gap between the current practice and the desired practice change that would improve patient outcomes at the project site. Use a transitional statement that takes you from describing the organization into the SWOT analysis. SWOT Analysis Introduce this section in one paragraph by briefly outlining the objective of performing a strengths, weaknesses, opportunities, and threats (SWOT) analysis. The SWOT analysis was created in DNP-840A. Within the weaknesses and threat, you will have barriers that emerge, so you will need to address how you mitigate them. Your SWOT should focus on the organization and the unit on which the project will be implemented (see Appendix A; see Figure 1). Strengths Concisely synthesize three to four strengths of the project site and unit that impact the successful implementation and ability to sustain this practice change. Do not implicate the site by name, be very general. Please refer to your scholarly readings and textbooks for examples. Weaknesse s Concisely synthesize three to four weaknesses, or challenges, of the project site that could negatively impact the successful implementation and ability to sustain this practice change. Again, do not implicate the site by name, be very general. Please refer to your scholarly readings and textbooks for examples. In addition, discuss the identified barriers and how you will mitigate them. Opportunities Concisely synthesize three to four potential opportunities for the organization and unit especially those to be gained from the implementation of this project. Do not implicate the site by name, be very general. Please refer to your scholarly readings and textbooks for examples. Threats Concisely synthesize three to four potential internal and external threats to the organization and unit that could impact the project’s implementation and sustainability. For instance, the COVID-19 pandemic may decrease staffing on the unit or lead to uneven patient populations seen at the project site. There may also be threats related to geographic location (urban vs. rural), patient population, or other facilities. Discuss the identified barriers and how you will mitigate them. Please refer to your scholarly readings and textbooks for examples. Problem Description This section should be two or three paragraphs long. It clearly states the problem or project focus, the problem statement, the patient population affected by the problem, the significance of the practice problem, and how the project will contribute to solving the problem. You will explain why you and your committee (project mentor/content expert) chose this problem. This section should be supported with literature and multiple examples that support why this problem was chosen and why it is both significant to the site and to current nursing practice. This section of Chapter 1 should be comprehensive, yet simple, providing the context for the practice project. A well-written problem statement begins with the big picture of the issue (macro) and works to the narrower, more specific problem (micro). It clearly communicates the significance, magnitude, and importance of the problem that will transition into the “Purpose of the Project.” The problem should be written as a declarative statement, such as “It is not known if the implementation of __________________ (specific evidence-based practice or intervention) would impact ______________ _______________ (patient outcome) among ___________ (population).” Definition of Terms The “Definition of Terms” section provides an understanding of the project constructs and a common understanding of the technical terms, jargon, variables, concepts, and other terminology used within the scope of the project. Terms should be defined in lay terms and discussed according to the context that they are used within the project. Each definition may be a few sentences to a paragraph in length. This section includes any words that may be unknown to a lay-person and taken from the evidence or literature. This section is also a good place to operationally define unique phrases specific to the project. Definitions must be supported with citations from scholarly sources. Do not use Wikipedia or general dictionaries (i.e., Merriam-Webster, Dictionary.com) to define terms. All definitions should be written in complete sentences. A lead-in paragraph is needed to introduce this section and should end with something like: “The following terms were used operationally in this project.” Project Manager Please refer do not refer yourself at all in the manuscript. It should be written in 3rd person. This term is for your reference only. Please remove this term from the Definition of Terms when writing up the project. Term Write the definition of the word. Make sure the definition is properly cited (Author, 2010). Terms often use abbreviations. According to APA (2019), abbreviations are best used only when they allow for clear communication with the audience. Standard abbreviations, such as units of measurement and names of states, do not need to be written out. Only certain units of time should be abbreviated. Abbreviate hr (hour), min (minute), ms (millisecond), ns (nanosecond), or s (second). However, do not abbreviate day, week, month, and year (APA, 2019). To form the plural of abbreviations, add “s” alone without apostrophe or italicization (e.g., vols., IQs, Eds.). The exception to this rule is not to add “s” to pluralize units of measurement (12 m not 12 ms) (APA, 2019). Besides abbreviations, the terms which may need to be defined include the outcome, the type of intervention, the sampling of data, special terminology, instruments, tool, and sources of data. Summary This section summarizes the key points of Chapter 1 and provides supporting citations for those key points. It then provides a transition discussion Chapter 2 followed by a description of the remaining chapters. This section should be two to three paragraphs. Chapter 2: Scientific Underpinnings Introduce the chapter by providing a general overview of the problem (one to two sentences). Explain the goal of the review of literature is to present an in-depth, current state of knowledge about your topic and approach to solving the problem. Literature Search Strategy This section should be one paragraph in length and should describe the search strategy used to find the applicable research articles. Include the databases that were used to search for research articles (e.g., CINAHL, Pubmed, Ovid, Google Scholar, etc.). Include the search terms or keywords that were used. Include the inclusion and exclusion criteria for relevant search strategies (e.g., last seven years, peer-reviewed, primary research, etc.) Synthesis of Literature The synthesis of literature should be no more than ten pages long and can pull from your assignment in DNP-820A. It should synthesize 15 original research studies, such as randomized control trials, synthesis of the literature with a meta-analysis, or quantitative studies. Book reviews and literature reviews should not be included. However, they should be reviewed to find sources for your literature review (i.e., hand search reference pages for applicable articles). All 15 sources should be no older than seven years. This section should reference the Literature Evaluation Table in Appendix B created in DNP-820A. This section focuses on the scientific evidence rather than the researcher(s)’s opinion of the evidence. The studies you cite in this section must relate directly to your project. Everything should be connected in a way that is evident to the reader. In your synthesis, you should address the similarities, differences, and controversies in the body of evidence. Additionally, there should be a minimum of one original research article that discusses the specific instrument, tool, or intervention that you will be implementing in your project. Another two to three articles that support the use of this intervention at other sites should also be discussed. View the following videos to assist you with writing your project: “What does it mean to synthesize in scholarly writing?” https://www.youtube.com/watch?v=CDvfwmatxjA&t=457s [links to an external site] “Writing a Literature Review” https://www.youtube.com/watch?v=jp8JKaz5VWI [links to an external site] Evidence-Based Practice Question This section should be two or three paragraphs long. It clearly states (a) the project focus, (b) the population affected, and (c) how the project will contribute to solving the problem. This section should be comprehensive, yet simple, providing context for the practice project. The evidence-based practice question is written using the template: To what degree will the implementation of _______________(intervention) impact______________(what) among _____________(population) patients in a______ (setting) in _______ (state)? Change Recommendation: Validation of [Enter Name of EBP Intervention] This section should be two paragraphs long . In this section, summarize the strength of the body of evidence (quality, quantity, and consistency), make a summary statement, and based on your conclusions drawn from the review, give a recommendation for practice change based on the scientific evidence. This section should include a brief statement about the evidence-based practice (EBP) and include the specific practice intervention, presentation, and toolkit that you will implement. Theoretical Framework This section identifies the nursing theories and EBP change models that provided the foundation for the DPI project. Describe how a theory-based evaluation is essential to address the problem. First, you should describe the main tenets (i.e., foundational concepts) of the theory. Then, you should describe how these tenets will be used to guide both the practice change (change model) and the nursing theory. Your discussions should clearly connect your theoretical foundations to the practice change you are implementing by explaining how the theories justify what is being measured as well as how those variables are related. This section also must include a discussion of how the clinical question aligns with the chosen nursing theory and illustrates how the project fits within other evidence based on the theories or models. The seminal source for each nursing theory and evidence-based change model should be identified and described. Overall, the presentation should reflect that you understand the theory or model and fully explain its relevance to the project. The discussion should also reflect knowledge and familiarity with the historical development of the theories or models. Please note models and theories are not capitalized in APA style (i.e., Lewin’s change model is correct whereas Lewin’s Change Model is incorrect). Nursing Theory This section discusses how the evidence-based question aligns with the respective nursing theory. This section should be at least three to four paragraphs long. When referring to your nursing theory, only reference the seminal sources (i.e., the original sources of the theory written by the theorist). Do not use secondary sources (i.e., criticism on the theory) or textbooks. In the first paragraph, state what the nursing theory is and how it was developed. In the second paragraph, state the main tenets of the theory. Explain what these tenets are and how they apply to nursing practice for your readers. In the third paragraph, address how one of the tenets will be used in your project. Explain the specific steps/factors that will be used to connect the nursing theory tenet to the implementation of your project. Explain how underpinning your intervention with this tenet will improve the (a) patient outcomes and (b) implementation of your project. Continue to explain all applicable nursing tenets and how they will be applied to the project. Synthesis of Nursing Theory This section synthesizes how the nursing theory has been applied in at least three other evidence-based articles, research studies, or peer-reviewed projects. These sources should be related to your particularly project topic. This section should end with a paragraph that synthesizes the literature to demonstrate the theory’s applicability to your project. This section should be two to four paragraphs long. Evidence-Based Change Model This section identifies and describes the chosen change model and the steps/factors that are included in the model. It connects those steps/factors and describe how they are being used, implemented, and/or supported in the project. Additionally, this section discusses how the evidence-based question aligns with the change model. This section should be at least four to five paragraphs long. When referring to your change model, only reference the seminal sources (i.e., the original sources of the theory written by the theorist). Do not use secondary sources (i.e., criticism on the theory) or textbooks. In the first paragraph, state what the change model is and how it was developed. In the second paragraph, state the steps of the model. Define these steps are and how they can be used to drive practice change. In the third paragraph, address how the first tenets will be used to drive the practice change. Explain the specific steps from the model that will be taken to implement the practice change. Describe (a) what you think this will look like at the proposal stage and (b) what this actually looked after the project is completed. Continue to explain all of the model steps and how they will be used to implement the project. Synthesis of Change Model This section synthesizes how the change model has been applied in at least three other evidence-based articles, research, or peer-reviewed projects on a topic similar to your project. End with a paragraph that synthesizes why the use of the model in the literature makes it applicable to your project. This section should be two to four paragraphs long. Integration of the Christian Worldview The lack of access to quality health care is a common problem in the U.S. despite various solutions offered through legislative and socioeconomic works: universal healthcare models, insurance models, and other business models. U.S. health care would be best transformed by returning to the implementation of a traditional system founded on the Christian principles of human dignity, solidarity, subsidiarity, and working for the common good. Consider diversity, equity, and inclusion and how these concepts should be considered in the project and sample population. This section should be no more than three paragraphs long. The linked article provides a good understanding of how to articulate a Christian worldview and what is relevant to Christian principles: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5375650/ Summary This section summarizes the key points of Chapter 2 and provides supporting citations for those key points. It then provides a transition discussion to Chapter 3 followed by a description of the remaining chapters. Chapter 3: Project Design and Methodology Introduce this chapter by describing how the project outcome will improve the quality of health care for the patient population. This section should report how the project is rooted in quality improvement from the outset of the improvement initiative. Then, in no less than three substantive paragraphs, discuss the differences between research, evidence-based practice, and quality improvement. Include what makes them each unique and how one leads the other. Please support your discussion with scholarly citations. Purpose The “Purpose” section of Chapter 3 should be two or three paragraphs long. It should (a) reflect on the problem statement, (b) identify how the project will be accomplished, and (c) explain how the project will contribute to the field. The section begins with a declarative statement, “The purpose of this project is….” which is based on your problem statement from Chapter 1. Included in this statement are also the project design, population, variables to be investigated, and the geographic location. Further, the section clearly defines the dependent and independent variables, relationship of variables, or comparison of groups (comparison versus intervention) for quantitative analyses. Keep in mind that the exact purpose statement (i.e., copy paste what is here) in this chapter is restated in the abstract and Chapter 5. This purpose statement aligns to the PICOT components from previous courses. Use the following template for structuring your purpose statement: The purpose of this quality improvement project is to determine if the implementation of _________________ (whose research are you translating or what clinical practice guidelines) would impact ______________(what) _______________________ among ___________(population). The project was piloted over an eight-week period in a (rural, urban, or directional (eastern, western, …)________ (state) ________ (setting i.e., primary care clinic, ER, OR). Project Planning and Procedures Introduce this section with three to five sentences. Include why project planning was initiated and how it helped the team to think systematically. This section addresses the overall concept of the project planning procedure. Interprofessional Collaboration This section should be three or four paragraphs long. The first paragraph should outline why organizational support is imperative when improving patient outcomes. Include what organizational support will be required for your quality improvement project. Ensure to use a transitional statement between this section and the next. The second paragraph will summarize the organizational support you are receiving from the stakeholders at the project site. In this paragraph, identify both the internal and external stakeholders from within the organization. What are their roles and how will this ensure sustainability of the project in the future? The third and fourth paragraphs should include the characteristics of the team that conducted the intervention (for instance, type and level of training, degree of experience, and administrative and/or academic position of the personnel leading workshops) and/or the personnel to whom the intervention was applied should be specified. Often the influence of the people involved in the project is as great as the project components themselves. Explain the role of a project manager of this quality improvement project and how a project manager influences and facilitates the team and the project. Include your responsibilities and duties using third person without referring to yourself. Next, describe the role and responsibilities of the team members in your project. Project Management Plan (list required resources—delete this parenthetical note) This section should be two to three paragraphs long. This section details the step-by-step plan for the project’s implementation. Include that the project starts with IRB approval and ends at data analysis. Every change that could have contributed to the observed outcome should be noted. Each element should be briefly described. Refer to the project timeline completed in DNP-840A (see Appendix C). The plan should include a complete procedure and outline of the education that will provide to the staff. Explain where the education was derived from (typically the instrument/tool/evidence-based intervention) and discuss how it will be deployed. Refer to the Educational Plan in Appendix D. Describe how or why you are qualified to teach this information to the staff. Include if you required additional outside resources to implement the education. Describe your procedure in such a way that your reader could follow the same steps and get the same results. The project was initiated after receiving approval for Grand Canyon University’s Institutional Review Board. (see Appendix E) This Appendix will become Appendix A once your project has been evaluated by the Grand Canyon University institutional review board and an outcome letter issued. Feasibility This section should be one or two paragraphs. What is required to make your project successful? Do you have adequate staff and time to educate the healthcare providers (nurses, doctors, mid-levels, tech, medics, etc.) on the evidence-based intervention? Do you need supplies or technology for support? As the project manager can you do the education or is there a cost to bring someone in (is this addressed in your budget)? Refer to the budget completed in DNP-840A as an appendix (see Appendix F). Remember having a balanced budget is imperative in today’s healthcare so as you show expenses, there should be some reference to anticipated improved revenue. Is the project designed in a way to ensure realistic implementation of the project? Support your discussion with scholarly citations. Setting and Sample Population This section discusses the total population, project population, and project sample based on the geographical setting of the project site. A description of the sample is essential for other clinicians to apply your findings to their settings. Setting In one paragraph, introduce this section by providing a broad description of the project site. Describing the organization in which in intervention took place in detail is necessary to assist readers in understanding whether the intervention is likely to “work” in the local environment (consider what the organization’s public description is on their website). This includes the description of the community, its makeup, and current services. Include additional information as needed, such as information about the location, practice type, teaching status, system affiliation, patient population (i.e., number of patients in a given time frame), size of the organization, staffing, and relevant processes in place. Follow the broad overview of the organization with a more focused overview of the specific area of practice (i.e., ER, OR, or ICU). Population and Sample The discussion of the sample includes the proper terminology specific to the type of sampling method used for the project. This section should be three to four paragraphs long and include the following components: The characteristics of the total population and the project population from which the project sample (project participants) is drawn. Describe the characteristics of the project population and the project sample. Clear definitions and differentiation of the sample versus the population for the project. Describe the project population size and project sample size and justify the project sample size (e.g., power analysis) based on the selected design. Details on the sampling procedures, including the specific steps taken to identify, contact, and recruit potential project sample participants from the project population. If subjects withdrew or were excluded from the project, you must provide an explanation of why. The informed consent process, confidentiality measures, project participation requirements, and geographic specifics. How the intervention answers the evidence-based question(s). Data Collection Procedures This section should be three or four paragraphs in length. This section details the entirety of the process used to collect the project data and describes the sources from which the data will be obtained. Describe the step-by-step procedures used to carry out all the major steps for data collection for the project in a way that would allow another investigator to replicate the project. Data should include descriptive or demographic data of the project sample and outcome data. Describe who/and from where data are obtained. Instrumentation or Data Source The first paragraph should include a description of data sources including any instrumentation. This paragraph should address the procedures for data collection, including how each instrument or data source was used, how and where data were collected (including demographic data), and how data were recorded. If survey/instruments are used, then their validity and reliability must be explained, including the psychometric data, using relevant scholarly citations. Refer to the instrument in Appendix G. Include permission to use the tool in Appendix H. If an instrument was not used for data collection, then explain the reliability and validity of the data source (e.g., reliability and validity of the EHR). If other instruments or sources of data are needed, provide evidence in the appendices. (see Appendix I). Variables The second paragraph should include an explanation of the independent and dependent variables (if applicable), and how the resulting change in those variables is measured (if applicable). It should also include a description of the procedures for project sample selection and how the data for the participants were grouped (e.g., comparison versus implementation). Data Integrity and Storage The third paragraph should include how the data integrity will be managed throughout project implementation. Include the description of how the final analysis data collection set and data dictionary were created and if any data manipulation was required. It should also provide a description of the type of data to be analyzed, identifying the descriptive, inferential, or nonstatistical analysis used. Data Management The fourth paragraph should provide a detailed description of the relevant data collected for each project question. It should also detail how the raw data were organized and prepared for analysis. Include any methods for data cleansing. There should also be a description of the procedures adopted to maintain data security, including the length of time data will be retained, where the data will be retained, and how the data will be destroyed following the project site’s policy. What data management errors were anticipated during the data collection period? Include how errors in data collection and entry will be discovered early and remedied. Support your discussion with scholarly references. Potential Bias and Mitigation In this section, you will describe the potential biases that may impact your project (proposal stage) and biases that did impact your project (finished manuscript). In addition, you will explain how these biases were mitigated to ensure the validity of the project. This section should be at least four paragraphs long. You should explain at least five potential biases that are related to (a) the project methodology, (b) the project design, (c) the sampling procedures, (d) data collection, and (e) data interpretation. For each bias, you need to (a) clearly define what the bias is/was, (b) clearly explain how the bias may have been present in your project, and (c) explain how you mitigated this bias. Your discussion should be supported with scholarly citations. Please note, you will need to personalize the possible biases based on the project you conducted. For example: If my project employs an internet survey and there are people who meet the criteria but do not have access to the internet to take the survey, I will miss all those people who met the criteria for participation! Or When conducting a quality improvement project, it is not possible or not practical to choose a random sample. In those cases, a convenience sample might be used. Sometimes it is plausible that a convenience sample could be considered as a random sample, but often a convenience sample is biased. If a convenience sample is used, inferences are not as trustworthy as if a random sample is used. Ethical Considerations This section should be one paragraph and summarize the ethical aspects of implementing an intervention and analyzing the data. This section should include a description of the procedures for protecting the rights and well-being of the project sample as well as the staff completing the intervention. The key ethical issues that must be addressed in this section include: How any potential ethical issues will be addressed. Ethical issues are related to the project and the sample population of interest, institution, or data collection process. Anonymity, confidentiality, privacy, lack of coercion, and potential conflict of interest. The key principles of the Belmont Report (respect, justice, and beneficence) in the project design, sampling procedures, and within the theoretical framework, practice or patient problem, and clinical questions. Include a statement that the project has undergone a formal ethics review by the GCU IRB. Select the following statement that best aligns with your IRB determination and embed it in your paragraph (see Appendix E): Quality Improvement: This project was reviewed by the Institutional Review Board at Grand Canyon University, and was determined not to be human subjects research. As such, this project did not require IRB review. Exempt/Expedited: This project was reviewed by the Institutional Review Board at Grand Canyon University, and was determined to be exempt/expedited. As such, this project was approved. Summary This section summarizes the key points of Chapter 3 and provides supporting citations for those key points. It then provides a transition discussion to Chapter 4 followed by a description of the remaining chapters. This section should be two paragraphs long. Chapter 4: Data Analysis and Results This chapter provides a summary of the collected data, describes how the data were analyzed, and then presents the results. Chapter 4 includes a brief restatement of the problem statement and the evidence-based practice question. The organization of the chapter is briefly outlined in this section. Make sure this chapter is written in past tense and reflects how the project was actually conducted. This chapter contains the analyzed data presented in both text and tabular or figure format. The structure of the chapter is imperative. You should aim to ensure both the readability and clarity of the findings. Sufficient narrative should be provided to highlight the findings on the measurable patient outcome. Ask the following general questions before starting this chapter: Are there sufficient data to answer the evidence-based practice question asked in the project? Are there sufficient data to support the conclusions you will make in Chapter 5? Are the data clearly explained using a table, graph, chart, or text? Data Analysis Procedures This section provides a step-by-step description of the procedures to be used to conduct the data analysis. This section should be two paragraphs. The first paragraph should provide a step-by-step description of the procedures used to conduct the data analysis. In this paragraph, describe all statistical and nonstatistical analyses employed. State the specific tests you plan to use to analyze your outcome data. Rationale should be provided for each of the data analysis procedures (statistical and nonstatistical) and supported by relevant scholarly citations. The second paragraph should explain how and why the data analysis techniques selected align with the DPI project design and question. The level of the statistical significance used for the quantitative analyses is identified a priori (p < .05). Please note that the independent variables in quasi-experimental projects are a nominal or categorical level variables that are used to identify the sample or group associated with the intervention. It is the dependent variable (i.e., the project outcome measure) that directs the type of statistical analysis selected, e.g., parametric versus non-parametric. If the dependent variable is a ratio or interval, a parametric test, such as an independent t-test, should be used. If the dependent variable is an ordinal or nominal level, a non-parametric test, such as a Chi-square or Mann Whitney U, should be used. Descriptive Data of Sample Population This section provides a narrative summary of the project sample’s characteristics and demographics. Descriptive data should be collected based on the sample (there will always be data for the patient sample but include nursing staff data if applicable). It establishes the total sample size, gender, age, education level, organization, or setting and other appropriate sample characteristics. Graphic organizers, such as tables, charts, histograms, and graphs should be used to provide further clarification, organize the data, and promote readability. Ensure these data cannot lead to the identification of participants or the project setting in any analysis or narrative. All tables, graphs, and figures must always be introduced and discussed within the text prior to their presentation. Data in the tables should match data in the text exactly. When writing numbers, equations, and statistics, spell out any number that begins a sentence, title, or heading, or reword the sentence to place the number later in the narrative. In general, use Arabic numerals (11, 12, 13) when referring to whole numbers 11 and above, and spell out whole numbers below 11. There are some exceptions to this rule: If small numbers are grouped with large numbers in a comparison, use numerals (e.g., 7, 8, 10, and 13 trials); but do not do this when numbers are used for different purposes (e.g., ten items on each of four surveys). Numbers in a measurement with units (e.g., 6 cm, 5 mg dose, 2%). Numbers that represent time, dates, ages, sample or population size, scores, or exact sums of money. Numbers that represent a specific item in a numbered series (e.g., Table 1). A sample table in APA style is presented in Table 1 and more examples can be found at “Sample Tables” on the APA Style Website. Be mindful that all tables fit within the required margins, and are clean, easy to read, and formatted properly using the guidelines found in Chapter 5 (Displaying Results) of the APA Publication Manual 7th Edition. As noted, all tables and figures should be introduced in a paragraph above them. Here is an example: There were N = X patients sampled, n = x in the comparative group and n = x in the intervention group. The mean age of the comparative sample was X (SD = x), and the mean age of the intervention group was X (SD = x) (see Table 1). Table 1A Sample Data Table Showing Correct Formatting Column A M ( SD ) Column B M (SD) Column C M (SD) Row 1 10.1 (1.11) 20.2 (2.22) 30.3 (3.33) Row 2 20.2 (2.22) 30.3 ( 3.33) 20.2 (2.22) Row 3 30.3 (3.33) 10.1 (1.11) 10.1 (1.11) Note. Adapted from “Sampling and Recruitment in Studies of Doctoral Students,” by I.M. Investigator, 2010, Journal of Perspicuity, 25, p 100. Reprinted with permission . Results This section, which is the primary section of this chapter, presents a summary and analysis of the data in a non-evaluative, unbiased, and organized manner that relates to the evidence-based practice question. The section should also include appropriate graphic organizers, such as tables, charts, graphs, and figures. Please ensure that: The amount and quality of the data or information is sufficient to answer the evidence-based question(s) is well presented. The results of each statistical test are presented in appropriate statistical format with tables, graphs, and charts. The p-value ( p=) and test statistics are reported. Outliers, if found, are reported. The results must be presented without implication, speculation, assessment, evaluation, or interpretation. Discussion of results and conclusions are left for Chapter 5. Both descriptive and inferential statistics are required to be reported in this section. Descriptive statistics describe or summarize data sets using frequency distributions (e.g., to describe the distribution for the IQ scores in your class of 30 pupils) or graphic displays such as bar graphs (e.g., to display increases in a school district’s budget each year for the past five years), as well as histograms (e.g., to show spending per child in school and display mean, median, modes, and frequencies), line graphs (e.g., to display peak scores for the classroom group), and scatter plots (e.g., to display the relationship between two variables). Descriptive statistics also include numerical indexes such as averages, percentile ranks, measures of central tendency, correlations, measures of variability and standard deviation, and measures of relative standing. Inferential statistics describe the numerical characteristics of data, and then go beyond the data to make inferences about the population based on the sample data. Inferential statistics also estimate the characteristics of populations about population parameters using sampling distributions, or estimation. Table 2 presents example results of an independent t-test comparing Emotional Intelligence (EI) mean scores by gender. Table 2t-Test for Equality of Emotional Intelligence Mean Scores by Gender t Df p EI 1.908 34 .065 Chapter 4 can be challenging with regard to mathematical equations and statistical symbols or variables. When including an equation in the narrative, space the equation as you would words in a sentence: x + 5 = a. Punctuate equations that are in the paragraph as you would a sentence. Remember to italicize statistical and mathematical variables, except Greek letters, and if the equation is long or complicated, set it off on its own line. Refer to your APA manual for specific details on representation of statistical information. Basic guidelines include: Statistical symbols are italicized (t, F, N, n) Greek letters, abbreviations that are not variables and subscripts that function as identifiers use standard typeface, no bolding or italicization Use parentheses to enclose statistical values (p = .026) and degrees of freedom t(36) = 3.85 or F(2, 52) = 3.85 Use brackets to enclose limits of confidence intervals 95% CIs [- 5.25, 4.95] Summary This section provides a concise summary of the project results. It briefly restates essential data and data analysis presented in the chapter, and it helps the reader see and understand the relevance of the data and analysis to the evidence-based question(s). It should summarize the statistical data and results of statistical tests in relation to the evidence-based question(s). Finally, it provides a lead or transition into Chapter 5 where the implications of the data and data analysis relative to the evidence-based question(s) will be discussed. This section should be two to three paragraphs long. Chapter 5: Implications in Practice and Conclusions Introduce Chapter 5 by providing (a) a general reminder of the problem, (b) the purpose of the project, and (c) overviewing the information that will be presented in this chapter. This section should be one to two paragraphs long. Chapter 5 is perhaps the most important chapter in the practice improvement project manuscript because it presents the project investigator’s contribution to the body of knowledge. For many who read evidence-based literature, this may be the only chapter they will read. No new data or citations should be introduced in Chapter 5; however, references should be made to findings or citations presented in earlier chapters. You should articulate new frameworks and new insights. All discussions in this chapter should be presented in the simplest possible form, making sure to preserve the conditional nature of the insights. Summary of the Project This section provides a comprehensive summary of the project by describing previous chapters in the simplest possible terms. It should recap the essential points of Chapters 1 to 3. It reminds the reader of the evidence-based question(s), the main issues being evaluated, and provides a transition, and reminds the reader of how the project was conducted. This section should be no more than two paragraphs. Major Findings Summarize the major findings (results) of your DPI project. Explain the statistical significance of your project findings. Explain the clinical significance of your project findings. This section should be no more than two paragraphs. Interpretation of Findings Describe how the findings of your DPI project align with other original research studies and/or quality improvement projects by comparing and contrasting the significance of the results. Provide possible explanations as to why your project findings confirmed or opposed previous published scholarly works. If your results did not achieve statistical significance, provide possible explanations why. This section should be no more than three to four paragraphs long. Strengths and Limitations In this section, describe the strengths of your project. In this discussion, you should consider the project design or methodology, the intervention, and the unit culture. Strengths should be presented in two paragraphs. Then, summarize the limitations of your DPI project. Limitations could be related to the project timeline, threats discussed in your SWOT, etc. Discuss the efforts that were made to minimize the limitations. Limitations should be addressed in two paragraphs. Implications In this section, you should present the “so what” (i.e., why was this important) of your project based on the project results. This section should describe the types of implications that could happen as a result of this project. It also tells the reader what the DPI project results imply both theoretically and for future nursing practice. Separate sections with corresponding headings provide proper organization. Provide a transition of three to five sentences for this new section. Theoretical Implications Theoretical implications involve the interpretation of the DPI project findings in terms of the evidence-based question(s) that guided the project. It is appropriate to evaluate the strengths and weaknesses of the project critically and include the degree to which the conclusions are credible given the method and data. It should also include a critical, retrospective examination of the framework presented in the Chapter 2 “Scientific Underpinnings” considering the practice improvement project’s new findings. In addition, you should describe whether the results of your project or the implementation process demonstrate the need to develop new or re-think current nursing theories. This section should be no more than two paragraphs. Nursing Practice Implications In this section, explore two to three ways the DPI project findings are important for nursing practice. Will it change practice? How? This section should be no more than two paragraphs. Recommendations Provide a brief transition (three to five sentences) that describes this section of the manuscript. Recommendations for Future Projects and Researchers This section should contain a minimum of four to five recommendations for future DPI projects. Project recommendations should include the areas of project that need further examination, address project or research gaps, new patient populations, or system needs. Each recommendation should be fully explained in one paragraph and should include (a) why the future project should be conducted, (b) how the project should be conducted (methodology and design), (c) what data would be collected, and (d) how the project would advance healthcare or patient outcomes. Recommendations for Sustainability This section should describe two to three recommendations for how the DPI project can be sustained. For example, does the new practice change require a policy in order for it to be sustained? Each recommendation should be fully explained in one paragraph that includes (a) what the sustainability plan is, (b) why the sustainability plan is needed, and (c) how the sustainability plan would work at the unit, organization, state, and national levels. Include any organizations or stakeholders who should be included in the sustainability discussions and what their role or involvement should be. Plan for Dissemination This section should contain a detailed plan regarding how the DPI project results will be disseminated to others in the nursing profession and other disciplines. Provide three to four specific examples of what your plan is for dissemination for your site, the community, the local nursing community, and when applicable, nationally. Describe the appropriate audience(s) for dissemination of the DPI project results. The audience(s) should be broad and should extend beyond the academic setting. Discuss informal and formal venues for electronic dissemination. Select the most appropriate peer-reviewed journal(s) in which you could publish your DPI project findings. Discuss oral dissemination opportunities (i.e., a podium or poster presentation or abstract submission). Consider presentation opportunities at regional, state, national, or international meetings. This section should be no more than three paragraphs. Conclusion and Contributions to the Profession of Nursing Practice This final section should briefly wrap up the project. Concisely describe the contributions your DPI project has made to the nursing profession. This section should be no more than two paragraphs. References American Psychological Association. (2021). Publication Manual, 7th edition student paper checklist. https://apastyle.apa.org/instructional-aids/ publication-manual-formatting-checklist.pdf American Psychological Association. (2020). Publication manual of the American Psychological Association 2020: The official guide to APA style (7th ed.). American Psychological Association. Sylvia, M. L., & Terhaar, M. F. (2018). Clinical analytics and data management for the DNP. New York, NY : Springer Publishing Company, LLC Appendix A SWOT Analysis Figure 1SWOT Analysis for Quality Improvement Project Appendix B Literature Evaluation Table Learner Name: Instructions: Use this table to evaluate and record the literature gathered for your DPI Project. Refer to the assignment instructions for guidance on completing the various sections. Empirical research articles must be published within 5 years of your anticipated graduation date. Add or delete rows as needed. PICOT-D Question: Table 3Primary Quantitative Research – Intervention (5 Articles) APA Reference (Include the GCU permalink or working link used to access the article.) Research Questions/ Hypothesis, and Purpose/Aim of Study Type of Primary Research Design Research Methodology Setting/Sample (Type, country, number of participants in study) Methods (instruments used; state if instruments can be used in the DPI project) How were the data collected? Interpretation of Data (State p-value: acceptable range is p= 0.000 to p= 0.05) Outcomes/Key Findings (Succinctly states all study results applicable to the DPI Project.) Limitations of Study and Biases Recommendations for Future Research Explanation of How the Article Supports Your Proposed Intervention Table 4Additional Primary and Secondary Quantitative Research (10 Articles) APA Reference (Include the GCU permalink or working link used to access the article.) Research Questions/ Hypothesis, and Purpose/Aim of Study Type of Primary or Secondary Research Design Research Methodology Setting/Sample (Type, country, number of participants in study) Methods (instruments used; state if instruments can be used in the DPI project) How were the data collected? Interpretation of Data (State p-value: acceptable range is p= 0.000 to p= 0.05) Outcomes/Key Findings (Succinctly states all study results applicable to the DPI Project.) Limitations of Study and Biases Recommendations for Future Research Explanation of How the Article Supports Your Proposed DPI Project Table 3: Theoretical Framework Aligning to DPI Project Nursing Theory Selected APA Reference – Seminal Research References (Include the GCU permalink or working link used to access each article.) Explanation for the Nursing Theory Guides the Practice Aspect of the DPI Project Change Theory Selected APA Reference – Seminal Research References (Include the GCU permalink or working link used to access each article.) Explanation for How the Change Theory Outlines the Strategies for Implementing the Proposed Intervention Table 5Clinical Practice Guidelines (If applicable to your project/practice) APA Reference – Clinical Guideline (Include the GCU permalink or working link used to access the article.) APA Reference – Original Research (All) (Include the GCU permalink or working link used to access the article.) Explanation for How Clinical Practice Guidelines Align to DPI Project Place the primary quantitative research used in the clinical practice guidelines in Table 1. This is part of the primary quantitative research used to support your intervention. Legend: Appendix C Project Timeline Appendix D Plan for Educational Offering Appendix E Grand Canyon University Institutional Review Board Outcome Letter Appendix F Project Budget Appendix G Data Collection Tool for Evaluation (Use the name of the tool here) Appendix H Place the Permission to Use the Tool Here Appendix I Other Data Collection Tool and/or Permissions Appendix J APA Writing Style for the Direct Practice Improvement Project Information and resources are also available on the APA Style website. If you have questions about specific assignment guidelines or what to include in your APA Style paper, please check with your assigning instructor or chair. The DNP manuscript should be written based on the 7th edition American Psychological Association’s APA Style (7th edition). This document is based on the American Psychological Association’s Publication Manual, 7th Edition – Student Paper Checklist located at https://apastyle.apa.org/instructional-aids/publication-manual-formatting-checklist.pdf Use this checklist while writing your paper to make sure it is consistent with seventh edition APA Style. Page Header: The page header does not contain a page number until Chapter 1. The fore pages are not numbered. All pages which are numbered are included in the Table of Contents. Font and Font Size: Times New Roman 12-point Font. Use the same font and font size throughout your paper (exception: figure images require a sans serif font and can use various font sizes). Line Spacing: Double Spacing. Double-space the entire paper. Do not add extra lines before or after headings or between paragraphs. Margins: Left Margin is 1 ½ inch. Margins are 1 in. on all other sides (top, bottom, and right). Paragraph Alignment and Indentation: Left-align the text (do not use full justification). Indent the first line of each paragraph 0.5 in. (one tab key). Paper Organization Chapters: Center and bold the Chapter title. Use the Level 1 heading style. Start the first line of the text one double-spaced line after the title. Headings: Use Level 2, Level 3, and Level 4 style headings for subsections. Start each new section with a heading. Write all headings in title case and bold. Also italicize Level 3. Indent Level 4 headings ½ inch and format on the same line as the text but do not include in the Table of Contents using Styles. Section Labels: Bold and center labels, including Abstract, References and Appendices. Writing Style Continuity: Check for continuity in words, concepts, and thematic development across the paper. Explain relationships between ideas clearly. Present ideas in a logical order. Use clear transitions to smoothly connect sentences, paragraphs, and ideas. Conciseness: Choose words and phrases carefully and deliberately. Eliminate wordiness, redundancy, evasiveness, circumlocution, overuse of the passive voice, and clumsy prose. Do not use jargon, contractions, or colloquialisms. Avoid overusing both short, simple sentences and long, involved sentences; instead, use varied sentence lengths. Avoid both single-sentence paragraphs and paragraphs longer than one double-spaced page. Clarity: Use clear and precise language. Use a professional tone and professional language. Do not use jargon, contractions, colloquialisms, or creative literary devices. Check for anthropomorphistic language (i.e., attributing human actions to inanimate objects or nonhuman animals). Make logical comparisons using clear word choice and sentence structure. Grammar: Verb Tense: Use verb tenses consistently in the same and adjacent paragraphs. Use appropriate verb tenses for specific paper sections, e.g., future tense for proposal and past tense for final manuscript. Subject Verb Agreement: Use verbs that agree in number (i.e., singular or plural) with their subjects. Pronouns: Use first person pronouns to describe your work and your personal reactions (e.g., “I examined,” “I agreed with”), including your work with coauthors (e.g., “We conducted”). Use the singular “they” when referring to a person who uses it as their self-identified pronoun or to a person whose gender is unknown or irrelevant. Use other pronouns correctly. Otherwise, deliver the project in third person as if narrating or presenting it. Bias-free language: Eliminate biased language from your writing. Use bias-free language to describe all people and their personal characteristics with inclusivity and respect, including age, disability, gender, participation in research , racial and ethnic identity, sexual orientation, socioeconomic status, and intersectionality. Mechanics of APA Style: Use punctuation marks correctly (periods, commas, semicolons, colons, dashes, parentheses, brackets, slashes), including in reference list entries. Use varied punctuation marks in your paper. Avoid having multiple punctuation marks in the same sentence; instead, split the sentence into multiple shorter sentences. Use one space after a period or other punctuation mark at the end of a sentence. Use a serial comma before the final element in lists of three or more items. Use parentheses to set off intext citations. Quotation Marks: Use quotation marks correctly. Place commas and periods inside closing quotation marks; place other punctuation marks (e.g., colons, semicolons, ellipses) outside closing quotation marks. Use quotation marks around direct quotations. Do not use quotation marks in the reference list. Italics: Use italics correctly to draw attention to text. Use italics for the first use of key terms or phrases accompanied by a definition. Capitalization: Use Title Case and sentence case capitalization correctly. Capitalize proper nouns, including names of racial and ethnic groups. Do not capitalize names of diseases, disorders, therapies, treatments, theories, concepts, hypotheses, principles, models, and statistical procedures, unless personal names appear within these terms. Abbreviations: Use abbreviations sparingly and usually when they are familiar to readers, save considerable space, and appear at least three times in the paper. Define abbreviations, including abbreviations for group authors, on first use. Do not use periods in abbreviations. Use Latin abbreviations only in parentheses, and use the full Latin term in the text. Do not define abbreviations listed as terms in the dictionary (e.g., AIDS, IQ) and abbreviations for units of measurement, time, Latin terms, and common statistical terms and symbols. Numbers: Use words to express numbers zero through nine in the text. Use numerals to express numbers 10 and above in the text. In all cases, use numerals in statistical or mathematical functions, with units of measurement, and for fractions, decimals, ratios, percentages and percentiles, times, dates, ages, scores and points on a scale, sums of money, and numbers in a series (e.g., Year 1, Grade 11, Chapter 2, Level 13, Table 4). Statistics: Include enough information to allow readers to fully understand any analyses conducted. Space mathematical copy the same as words, with spaces between signs. Use statistical terms in narrative text: “the means were,“ not “the Ms were.” Use statistical symbols or abbreviations with mathematical operators: “(M = 6.62),” not “(mean = 6.62).” Lists: Ensure items in lists are parallel. Use commas to separate items in simple lists. Use semicolons to separate items when any items in the list already contain commas. Tables and Figures General Guidelines: Include tables and/or figures in your manuscript. When possible, use a standard, or canonical, form for a table or figure. Do not use shading or other decorative flourishes. In the text, refer to each table or figure by its number. Explain what to look for in that table or figure by calling out the table or figure in the text (e.g., “Table 1 lists…” “As shown in Figure 1…”). Embed each table or figure in the text after it is first mentioned. Place the table or figure at either the top or the bottom of the page with an extra double-spaced line between the table or the figure and any text. Tables: Use the tables feature of your word-processing program to create tables. Number tables in the order they are mentioned in the text. Include borders only at the top and the bottom of the table, beneath column headings, and above column spanners. Do not use vertical borders or borders around every cell in the table. All tables include four basic components: number, title, column headings, and body. Write the table number above the table title and body and in bold. Write the table title one double-spaced line below the table number and in italic title case. Label all columns. Center column headings and capitalize them in sentence case. Include notes beneath the table if needed to describe the contents. Start each type of note (general, specific, and probability) on its own line, and double-space it. See sample tables on the APA Style website. Figures: Use a program appropriate for creating figures (e.g., Word, Excel, Photoshop, Inkscape, SPSS). Number figures in the order they are mentioned in the text. Within figures, check that images are clear, lines are smooth and sharp, and font is legible and simple. Provide units of measurement. Clearly label or explain axes and other figure elements. All figures include three basic components: number, title, and image. Write the figure number above the figure title and image and in bold. Write the figure title one double-spaced line below the figure number and in italic title case. Write text in the figure image in a sans serif font between 8 and 14 points. Include a figure legend if needed to explain any symbols in the image. Position the legend within the borders of the figure and capitalize it in title case. Include notes beneath the figure if needed to describe the contents. Start each type of note (general, specific, and probability) on its own line, and double-space it. See sample figures on the APA Style website. In-Text Citations: Cite only works you read and ideas you incorporated into your paper. Include all sources cited in the text in the reference list (exception: personal communications are cited in the text only). Make sure the spelling of author names and the publication dates in the in-text citations match those of the corresponding reference list entries. Paraphrase sources in your own words whenever possible. Cite appropriately to avoid plagiarism, but do not repeat the same citation in every sentence when the source and topic do not change. For guidance on appropriate citation, see the Appropriate Level of Citation page. Write author–date citations according to seventh edition guidelines: Include the author (or title if no author) and year. For paraphrases, it is optional to include a specific page number(s), paragraph number(s), or other location (e.g., section name) if the source work is long or complex. One author: Use the author surname in all intext citations. Two authors: Use both author surnames in all in-text citations. Three or more authors: Use only the first author surname and then “et al.” in all in-text citations. Use either the narrative or the parenthetical citation format for in-text citations. Parenthetical citation: Place the author name and publication year in parentheses. Narrative citation: Incorporate the author name into the text as part of the sentence and then follow with the year in parentheses. For works with two authors, ° use an ampersand (&) in parenthetical in-text citations: (Guirrez & Castillo, 2020) ° use the word “and” in narrative in-text citations: Guirrez and Castillo (2020) When citing multiple works in parentheses, place the citations in alphabetical order. When multiple parenthetical citations have the same author(s), order the years chronologically and separate them with commas (e.g., Coutlee, 2019, 2020). When the authors are different, separate the parenthetical citations with semicolons (e.g., Coutlee, 2019, 2020; Ngwane, 2020; Oishi, 2019). Quotations: Limit the use of direct quotations. Include the author (or title if no author), year, and specific part of the work (page number(s), paragraph number(s), section name) in the citation. Short quotation (less than 40 words): Use double quotation marks around the quotation. Block quotation (40 words or more): Use the block format: Indent the entire quotation 0.5 in. from the left margin and double-space it. References Start the reference list on a new page after the text. Center and bold the section label “References” at the top of the page. Double-space the entire reference list, both within and between entries. Use a hanging indent for each reference entry: First line of the reference is flush left, and subsequent lines are indented by 0.5 in. Apply the hanging indent using the paragraph formatting function of your word-processing program. All reference entries should have a corresponding in-text citation. The beginning of the reference entry (usually the first author’s surname) and year should match the corresponding in-text citation. List references in alphabetical order according to seventh edition guidelines. Do not create reference entries for personal communications and secondary sources. For a list of works to include and exclude from a reference list, see the APAstyle.org website. Each reference entry includes four elements: author, date, title, and source. List authors in the same order as the original source. Use initials for authors’ first and middle names. Put a comma after the surname and a period and a space after each initial (e.g., Lewis, C. S.). Put a comma after each author (even two authors). Use an ampersand before the last author. List up to 20 authors in the reference list. If more than 20, use ellipsis between the last author and 19th author. Capitalize titles in sentence case: Capitalize only the first word of the title, the subtitle, and any proper nouns. Format titles according to the type of work. ° Works that stand alone: Italicize the title (e.g., authored books, reports, data sets, dissertations and theses, films, TV series, albums, podcasts, social media, websites). ° Works that are part of a greater whole: Do not italicize or use quotation marks around the title (e.g., periodical articles, edited book chapters, TV and podcast episodes, songs). Write the title of the greater whole (e.g., journal or edited book) in italics in the source element. Do not include database information for works retrieved from academic research databases. Do include database information for works retrieved from databases with original, proprietary content or works of limited circulation (e.g., UpToDate). Include a DOI for any work that has one. If there is no DOI, include a URL if the work is retrieved online (but not from a database). Present DOIs and URLs as hyperlinks (beginning with “http:” or “https:”). Copy and paste DOIs and URLs directly from your web browser. Do not write “Retrieved from” or “Accessed from” before a DOI or URL. Do not add a period after a DOI or URL. Source: American Psychological Association. (2021). Publication Manual, 7th edition student paper checklist. https://apastyle.apa.org/instructional-aids/ publication-manual-formatting-checklist.pdf