See attached Chp 1 manuscript and corrections that are needed - this is about the ABCDE bundle in reducing the length of hospital stay in a long-term acute care hospital. In the margin are track chan

Intensive Care Unit Liberation Bundle Impacts Length of Stay

Submitted by

Cathy Ann Jones

A Direct Practice Improvement Project Presented in Partial Fulfillment

of the Requirements for the Degree

Doctor of Nursing Practice

Grand Canyon University

Phoenix, Arizona

November 1, 2022

© by Cathy Ann Jones, 2023

All rights reserved.

GRAND CANYON UNIVERSITY

Intensive Care Unit Liberation Bundle Impacts Length of Stay

By

Cathy Ann Jones

has been approved

xxxxx xx, 2023

APPROVED:

Brandi Wilford, DNP, DPI Project Chairperson

Rosla Royal, DNP, ACNP,. Project Mentor/Content Expert

ACCEPTED AND SIGNED:

________________________________________

Lisa Smith, PhD, RN, CNE

Dean and Professor, College of Nursing and Health Care Professions

_________________________________________

Date

Abstract

Increased length of hospital stay (LOS) is a concern nationwide in all healthcare settings. Long-term acute care hospitals (LTACHs) are certified acute care hospitals equipped to provide long-term care for an average (LOS) of 25-28 days. The purpose of this quality improvement project is to determine if the translation of Hsieh et al. research implementing the ABCDE bundle would impact length of stay among adult patients in a long-term acute care hospital in a high observation unit. The project is to be piloted over an eight-week period in an urban Virginia long-term acute care hospital. The ABCDEF bundle is a set of six evidence-based interventions that, when implemented together, can significantly improve the quality of care for any patient in any healthcare setting and impact LOS. Virginia Henderson's Nursing Needs Theory and John Kotter's Eight Step Change Model was the scientific underpinnings for the DPI project.

Keywords: ABCDEF bundle, length of stay, long-term acute care hospital, John Kotter’s eight-step change model, Virginia Henderson Nursing Needs Theory, patient outcomes, quality improvement project

Dedication

I want to thank God Almighty for everything that he has done for me and dedicate my work to him as my creator, my solid pillar, and my true inspiration. Throughout the entirety of this journey, He remained the basis of my strength, and it is only on His wings that I have been able to soar. I would also like to dedicate this undertaking to my family, who have been there for me every step of the way to offer guidance and encouragement. It will also be illogical for me to ignore the vast number of patients who have suffered in one way or another due to the shortcomings of the suggested implementation. Thanks to them, I have had an easy time understanding their grievances thus making it easy to provide a comprehensive analysis on the topic.

Acknowledgments

I would want to convey my profound gratitude to my mentor, who was instrumental in contributing to this motivational experience by providing me with support, direction, and expert understanding of this topic. In addition, I’d love to express my earnest appreciation to all my patients, physician colleagues and nursing staff who took part in this quality improvement project. In conclusion, I would want to take this opportunity to thank my family for the support and encouragement they have provided me with during the process of completing this terminal degree.

Table of Contents

Chapter 1: Introduction to the Project 11

Background of the Project 13

SWOT Analysis 15

Threats 19

Problem Description 20

Definition of Terms 21

Summary  23

Chapter 2: Scientific Underpinnings 25

Literature Search Strategy 25

Synthesis of Literature 25

Evidence-Based Practice Question 26

Change Recommendation: Validation of [Enter Name of EBP Intervention] 26

Theoretical Framework 27

Nursing Theory 28

Synthesis of Nursing Theory 28

Evidence-Based Change Model 28

Synthesis of Change Model 29

Integration of the Christian Worldview 29

Summary 30

Chapter 3: Project Design and Methodology 31

Purpose 31

Project Planning and Procedures 32

Interprofessional Collaboration 32

Project Management Plan (list required resources—delete this parenthetical note) 33

Feasibility 34

Setting and Sample Population 34

Setting 34

Population and Sample 35

Data Collection Procedures 36

Instrumentation or Data Source 36

Variables 37

Data Integrity and Storage 37

Data Management 37

Potential Bias and Mitigation 38

Ethical Considerations 39

Summary 40

Chapter 4: Data Analysis and Results 41

Data Analysis Procedures 41

Descriptive Data of Sample Population 42

Results 44

Summary 46

Chapter 5: Implications in Practice and Conclusions 47

Summary of the Project 47

Major Findings 48

Interpretation of Findings 48

Strengths and Limitations 48

Implications 48

Theoretical Implications 49

Nursing Practice Implications 49

Recommendations 49

Recommendations for Future Projects and Researchers 49

Recommendations for Sustainability 50

Plan for Dissemination 50

Conclusion and Contributions to the Profession of Nursing Practice 51

References 52

Chen, T. J., Chung, Y. W., Chang, H. R., Chen, P. Y., Wu, C. R., Hsieh, S. H., & Chiu, H. Y. (2021). Diagnostic accuracy of the CAM-ICU and ICDSC in detecting intensive care unit delirium: A bivariate meta-analysis. International Journal of Nursing Studies, 113, 103782. https://doi.org/10.1016/j.ijnurstu.2020.103782 53

Appendix A 57

SWOT Analysis 57

Appendix B 58

Literature Evaluation Table 58

Appendix C 63

Project Timeline 63

Appendix D 64

Plan for Educational Offering 64

Appendix E 65

Grand Canyon University Institutional Review Board Outcome Letter 65

Appendix F 66

Project Budget 66

Appendix G 67

Data Collection Tool for Evaluation (Use the name of the tool here) 67

Appendix H 68

Place the Permission to Use the Tool Here 68

Appendix I 69

Other Data Collection Tool and/or Permissions 69

Appendix J 70

APA Writing Style for the Direct Practice Improvement Project 70

List of Tables

Table 1 A Sample Data Table Showing Correct Formatting 44

Table 2 t-Test for Equality of Emotional Intelligence Mean Scores by Gender 45

Table 3 Primary Quantitative Research – Intervention (5 Articles) 58

Table 4 Additional Primary and Secondary Quantitative Research (10 Articles) 60

Table 5 Clinical Practice Guidelines (If applicable to your project/practice) 63

List of Figures

Figure 1 SWOT Analysis for Quality Improvement Project 57

Patients transferred or directly admitted to a long-term acute care hospital (LTACH) to the high observation unit (HOU) may have suffer from Post Intensive Care Syndrome (PICS). PICS is a cognitive, physical, and psychological impairment that results from ICU admission (Nordness, 2021). PICS can result in deconditioning, muscle wasting, pressure ulcer formation, decreased mobility, prolonged mechanical ventilation weaning, delirium, and hospital-acquired infections (Nordness, 2021). Other causes of PICS include short-term acute care readmissions or limited or no discharge destination, further prolonging their hospitalization and decreasing patient and family satisfaction (Hsieh et al., 2019).

Currently, at this long-term acute care facility in Virginia, there is a gap in care delivery of patients admitted or transferred to the HOU, impacting length of stay (LOS) and clinical outcomes. As a result, the mean LOS stay of 30-60 days exceeds an LTACH average LOS of 25-28 days. While the increased length of stay is multifactorial, implementing an evidence-based protocol may improve the throughput efficiency by impacting the length of stay and improving patient outcomes.

In 2013, the Society of Critical Care Medicine initiated the Intensive Care Unit (ICU) Liberation campaign from the Prevention and Management of Pain, Agitation /Sedation, Delirium, Immobility, and Sleep Disruption (PADIS) Clinical Practice Guideline. The guideline was updated in 2018, now known as the ICU Liberation Assess, Prevent, and Manage Pain, Both Spontaneous Awakening Trials (SATs) and Spontaneous Breathing Trials (SBTs), Choice of Analgesic and Sedation, Delirium, Assess, Prevent and Manage, Early Mobility and Exercise, Family Engagement and Empowerment (ABCDEF) Bundle. The Direct Practice Improvement (DPI) Project aims to impact LOS in a long-term acute care hospital in adult patients in the high observation unit translating Hsieh et al. research implementing the ABCDEF bundle to impact the length of stay. 

The ABCDEF bundle, a validated evidence-based protocol, was initially created to improve the outcomes of patients in the ICU. As the bundle became popular and widely adopted into clinical practice it was noted to reduce LOS (Pun et al., 2019; Heish et al., 2019; Frade-Mera et al., 2022). The interventions of the ABCDEF bundle consists of (A) identifying and assessing for pain using the Critical-Care Observation Tool (CPOT), (B) mechanical ventilation liberation- assisting with spontaneous awakening trials (SATs) to decrease the use of sedation, and spontaneous breathing trials (SBTs) to wean patients off mechanical ventilation faster, using the Wake up and Breathe Protocol. (C) identifying the appropriate choice of sedation, using the Richmond Agitation Sedation Scale (RASS), (D) to correctly identify and assess for delirium screening using the Confusion Assessment Method for the ICU (CAM-ICU), (E) early progressive mobility to decrease ICU–acquired muscle weakness (Collinsworth et al., 2021). The (F) for a family was added later, further redefining the bundle, identifying the importance of family presence and involvement, and embracing patient-family-centered care (Delvin et al., 2018; Heish et al., 2019). 

Individually these interventions have impacted patient comes, such as in decreasing LOS (Heish et al., 2019; Frade-Mera et al.2022). The ABCDEF bundle interventions have impacted clinical outcomes, patient and family satisfaction, resulted in shorter duration of mechanical ventilation, impacted ICU and hospital LOS , (Pun et al., 2019; Frade-Mera et al., 2022, Hsieh et al., 2019). There continues to be significant supportive evidence that the ABCDEF bundle is considered the gold standard of care, adopted in several healthcare settings across the globe. 

The increased length of hospital stay is a concern nationwide in all healthcare settings. LTACHs are certified acute care hospitals equipped to provide long-term (average LOS of 25-28 days) acute-level care to medically complex patients (Grevelding et al., 2022). At the clinical practice site, an LTACH in Virginia, there has been an increased length of stay beyond 25-28 days in 75% of the patient population over the past 60 days that have been associated with delirium, cognitive and physical impairments as well psychiatric symptoms know as post-intensive care syndrome (PICS). Patients diagnosed with PICS are often admitted to an LTACH for ongoing complex medical care needs. LTACH admissions consist of illnesses related to sepsis, strokes, encephalopathy, heart failure and acute respiratory failure resulting tracheostomies needing ongoing mechanical ventilation support. The syndrome of PICS including chronic pain, has a significant impact of quality of life and the ability of ICU survivors to return to work and other daily activities, even years after illness (Nordness et al. 2021).

Prolonged LOS is felt locally, nationally, and globally. Locally, surrounding hospitals struggle discharging to LTACHS due to limited bed availability, which puts an undue strain on the surrounding healthcare systems to admit or divert critically ill patients to other surrounding localities. Nationally, LOS affects cost, as it affects clinical and economic outcomes determining where federal funds are allocated, and overall impacts mortality rates impacting resources supplied by the government. Globally, as LOS is often viewed as a measurement of hospital care, LOS is a prime indicator of resources worldwide, such as post-acute care facilities such as skilled nursing facilities, and rehabilitation facilities (Lorenzoni & Marino, 2017). 

LOS can impact patient care. The ABCDEF bundle has been incorporated many hospitals and healthcare organizations into their operations and protocols to improve patient outcomes and cut costs. Most of the ABCDEF bundle elements are relatively well established and have been demonstrated to improve patient outcomes while reducing costs. A critical part of the ABCDEF bundle is its development and widespread use. The use of clinical pathways may help to standardize and improve the treatment of patients across various medical specialties and departments within hospitals. The development of standardized clinical practice guideline allows for consistent treatment protocols across the organization and gives patients a greater chance of receiving high-quality care (Marra et al., 2017 ). 

Organizational Needs Assessment

Organizational assessment is a process that can be used to assess an organization's strengths and weaknesses. The purpose of organizational assessment is to understand an organization's current and potential future comprehensively. The ultimate goal of the assessment process is to identify areas for improvement so an organization can move forward and grow. The SWOT analysis was appropriate for this quality improvement project because it identified the organization's strengths, weaknesses, opportunities, and threats. This learner identified that LTACH might present challenges to implementing the quality improvement project . There are several potential reasons. One is the need for more familiarity with the guideline among healthcare providers—two, limited resources available at the clinical site to implement all six interventions of the ABCDEF bundle. Resources needed to implement the ABCDEF bundle effectively include personnel (e.g., nurses, pharmacists, physical therapists), equipment (e.g., patient monitors), and funding for additional staff and equipment (AHRQ, 2017). Third, the need for a standardized protocol for implementing the ABCDEF bundle. Without standardized protocols, care may be inconsistent within a facility—lastly, the organization's culture. The culture of a healthcare facility is defined by its values and norms, and it can take time to change the culture. This DPI project aims to identify and assess challenges that may present. The assessment was conducted using a SWOT analysis. 

SWOT is a strategic tool that identifies opportunities and threats within a company's business environment. The SWOT analysis was helpful to this QI project because it identified areas within the process that could be improved or eliminated. Using SWOT to analyze the quality improvement project was instrumental in determining which elements of the process needed improvement and strategically addressing those potential barriers to the quality improvement implementation .

 (see Appendix A; see Figure 1).

Strengths

The ABCDEF bundle implementation provides a family-centered approach that boasts as one of its key pillars. By providing a holistic approach to health and health services, the ABCDEF health bundle helps to address the needs of the whole family rather than just individual members. This approach ensures that all the family members have a say and are supported in taking an active role in the decision-making progression. The ABCDEF package is essential in reducing the risk of developing delirium and facilitating the patient's recovery in the shortest amount of time and with the fewest disruptions from the outside world (Otusanya et al., 2021). The bundle is designed to address various health concerns, making it a comprehensive approach to improving patient care. Similarly, the bundle is flexible and can be customized to meet the needs of specific organizations considering its well-documented and includes several tools and resources to support organizations in their efforts. Finally, the ABCDEF bundle has been shown to be effective in improving patient outcomes.

Weaknesses

Despite the tremendous clinical effects that can be achieved with the ABCDEF bundle, it is not commonly adopted in practice. Several potential obstacles could prevent the ABCDEF package from being used. The first obstacle is healthcare practitioners' unfamiliarity with the ABCDEF bundle interventions and tools. Effective deployment of the ABCDEF bundle necessitates several resources, including people, machines, and money for more machines and people (Collinsworth, Priest & Masica, 2020). There is also the possibility that the ABCDEF bundle will only partially be implemented; only utilizing certain elements per unit needs to yield favorable results, which presents the third challenge. Inconsistent care may be delivered between different units in a hospital or other healthcare facility if there are no established protocols. Lastly, the ABCDEF bundle may encounter resistance from the healthcare institution's culture. A healthcare institution's culture is shaped by its traditions and values, which makes it challenging to bring about a shift in that culture.

There are several ways to overcome the barriers to implementing the ABCDEF bundle. The first way is to increase awareness of the guideline among healthcare providers. Many providers may need to be aware of the guideline or their recommendations. Educational programs can increase awareness of the guideline among healthcare providers. Second, provide resources (e.g., personnel, equipment, funding) to healthcare facilities to implement all six interventions of the ABCDEF bundle (Loberg et al., 2022). Resources needed to implement the ABCDEF bundle effectively include personnel (e.g., nurses, pharmacists, physical therapists), equipment (e.g., patient monitors), and additional staff and equipment funding. A third way is to develop standardized protocols for implementing the ABCDEF bundle (Loberg et al., 2022). With standardized protocols, care may be consistent across different units within a facility. Standardized protocols can help ensure that care is delivered consistently across different units within a facility. Last, the culture of a healthcare facility can be changed by introducing new values and norms that support the implementation of the ABCDEF bundle.

Opportunities

There exist multiple opportunities which can play a crucial role in improving the ABCDEF bundle implementation. To begin with, the need to educate health care professionals about the guideline considering that most physicians may need to learn about the guideline, thus limiting the program's efficiency (Balas et al., 2022). It is also recommended that adequate resources should be provided to healthcare organizations in order to perform all six ABCDEF interventions. Many hospitals cannot perform all six ABCDEF treatments. Personnel, technology, and finance are required to implement ABCDEF successfully. Lastly, standardizing ABCDEF implementation protocols can also be handy as it will ensure consistent care throughout a facility's units.

There are several potential threats to implementing the ABCDEF bundle in an LTACH. One of the most significant is that it could lead to an increase in the length of stay for patients. The bundle requires that patients be monitored more closely, which could lead to more frequent interventions and testing. The ABCDEF bundle could, in turn, lead to patients staying in the hospital for more extended periods (Hsieh et al., 2019). Another potential threat is that the ABCDEF bundle could strain hospital resources. The strain on hospital resources requires more staff time and attention, as well as more equipment and supplies subsequently, which could lead to increased costs for the hospital, which could eventually be passed on to patients and their families. Finally, there is always the potential for human error when implementing any new system or procedure. It is especially true with the ABCDEF bundle, as it requires high coordination and communication between staff members. If there are any lapses in this process, it could lead to severe consequences for patients.

Implementation of the ABCDEF bundle is the proposed solution to impact LOS of those admitted or transferred to the HOU. In order to ensure that the ABCDEF bundle is effective, it is essential to consult with experts during the implementation process (DE Mellow et al., 2020). Consulting with content experts will help to ensure that the bundle meets the needs of all stakeholders. The specialists in the high observation unit in long-term acute care will be consulted to ensure that the bundle meets the needs of patients in this setting. Furthermore, this consultation will help ensure that the bundle effectively reduces the length of stay.

Over the past three years, the data shows many patients admitted to the practice site have required transfer into the HOU or have been directly admitted to the HOU upon admission to the practice site for acute complex care and management of their critical illnesses. Many of these patients suffered respiratory, neurological, or cardiovascular events warranting the HOU monitoring. Care provided to this vulnerable population was disjointed ; lack of a standardized approach impacting LOS, increased skilled nursing facility (SNF) admissions, increased infection rates, caused or worsened delirium, increased pressure ulcer formation, and decreased patient and family satisfaction . As a result, disposition to inpatient rehabilitation facilities or home rates decreased.

Increased LOS threatens the validity of LTACHs. Reimbursement rates decrease when care related to hospital-acquired infections occurs. The longer a patient remains an inpatient, there poses a risk of delayed recovery to the prehospital state. Despite the ABCDEF bundle's clinical significance, there is limited data regarding its effectiveness outside of short-term acute hospitals. LTACHs lack a standardized, evidence-based protocol that impacts LOS, disposition, and clinical outcomes. The clinical question of this DPI "In adult patients in a high observation unit in a long-term acute care hospital in Virginia, will the translation of Hsieh et al. research implementing the ABCDEF bundle compared to current practice impact length of stay over eight weeks?

Throughout the quality improvement project, many repetitive terms were used to illuminate the project's key components. Below are a few of the most common terms used.

ABCDEF Bundle- a validated evidence-based protocol with six elements, now known as the ICU Liberation-ABCDEF bundle. (A) Assess, Protect, and Manage Pain; (B) Breathing-SAT (spontaneous awaking trial) and SBT (spontaneous breathing trial); (C) Choices of Analgesia and Sedatives; (D) Delirium Assess, Preclude, and Manage; (E) Early Movement and Exercise; (F) Family (Collinsworth et al., 2021).

Delirium- Delirium is a disturbance in attention and awareness that develops over a short period, represents an acute change from baseline attention and awareness, and fluctuates in severity during the day (American Psychiatric Association, 2013)

Direct Project Improvement (DPI) – a translation of existing knowledge or new clinical guidelines into clinical practice that will have a direct and measurable patient outcome. (GCU). 

Intensive Care Unit (ICU) -a multidisciplinary specialty unit committed to the comprehensive management of patients having or at risk of developing life-threatening organ dysfunction by use of technology that supports failing organ systems to prevent further physiologic deterioration (Marshall et al., 2017).

Lengths of stay (LOS)- The timeframe that a patient spends in the hospital care unit is the metric that constitutes this measurement (Pun et al., 2019).

LTACH- long-term acute care hospitals- are certified acute care hospitals equipped to provide long-term (average LOS of 25-28 days) acute-level care to medically complex patients (Grevelding et al., 2022).

PICS - Post Intensive Care Syndrome- associated with delirium, cognitive and physical impairments, and psychiatric symptoms (Hsieh et al., 2019).

In 2013 the Society of Critical Care Medicine initiated the ICU Liberation campaign from the PAD Clinical Practice Guideline. The guideline was updated in 2018, now known as the ICU Liberation-ABCDEF bundle. The ABCDE (Awakening and Breathing Coordination, Delirium Monitoring and Management, and Early Exercise and Mobility) bundle, a validated evidence-based protocol, was initially created to improve the outcomes of patients in the intensive care unit (ICU). Since the ABCDEF Bundle has been widely utilized across different healthcare settings locally, nationally, and globally serving the purpose of mechanical ventilation liberation, reducing the incidence of delirium to reducing healthcare costs and length of stay (Heish et al., 2019; Frade-Mera et al., 2022).

Reducing unnecessary healthcare costs is everyone's responsibility. The ABCDEF bundle is a cost-effective, scalable intervention. The ABCDEF bundle may ameliorate the effects of PICS, reduce HAI, facilitate mechanical ventilator liberation quicker, and impact LOS; all are equally important for improving care delivery and outcomes in critically ill patients in any healthcare setting. Implementing the ABCDEF bundle is a significant milestone for any institution. The ABCDEF bundle consists of six elements of interventions proven to reduce the length of stay and improve patient outcomes. The ABCDEF bundle gives medical practitioners access to a wider variety of treatment alternatives that can be tailored to meet the requirements of –patients and their families while improving clinical outcomes and impacting hospital length of stay. According to Pun et al. (2019), studies exist examining the effectiveness of the ABCDE bundle. These studies have shown significant reductions in delirium prevalence, ventilator days, coma days, readmission, and in-hospital mortality, and a significant increase in the number of patients who were mobilized out of bed during their ICU stay, decreased length of stay (Pun et al., 2019).

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.

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.)

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]

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)?

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.

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).

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.

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.

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.

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.

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/

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.

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.

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).

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.

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.

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.

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.

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.

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).

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:

1. 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.

2. 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.

3. 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.

4. The informed consent process, confidentiality measures, project participation requirements, and geographic specifics.

5. How the intervention answers the evidence-based question(s).

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.

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).

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).

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.

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.

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.

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.

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:

1. Are there sufficient data to answer the evidence-based practice question asked in the project?

2. Are there sufficient data to support the conclusions you will make in Chapter 5?

3. Are the data clearly explained using a table, graph, chart, or text?

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.

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:

1. 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).

2. Numbers in a measurement with units (e.g., 6 cm, 5 mg dose, 2%).

3. Numbers that represent time, dates, ages, sample or population size, scores, or exact sums of money.

4. 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 1
A Sample Data Table Showing Correct Formatting

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 .

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:

1. The amount and quality of the data or information is sufficient to answer the evidence-based question(s) is well presented.

2. The results of each statistical test are presented in appropriate statistical format with tables, graphs, and charts.

3. The p-value ( p=) and test statistics are reported.

4. Outliers, if found, are reported.

5. 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 2
t-Test for Equality of Emotional Intelligence Mean Scores by Gender

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]

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.

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.

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.

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.

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.

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.

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 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.

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.

Provide a brief transition (three to five sentences) that describes this section of the manuscript.

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.

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.

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.

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.

Agency for Healthcare Research and Quality. [AHRQ]. (2017). Evidence behind Pain, Agitation, and Delirium: Assessments and Sedation Management: Slide Presentation: Overview. https://www.ahrq.gov/hai/tools/mvp/modules/technical/pain-mgmt-slides.html

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.

Balas, M. C., Tan, A., Pun, B. T., Ely, E. W., Carson, S. S., Mion, L., Barnes-Daly, M. A., & Vasilevskis, E. E. (2022). Effects of a national quality improvement collaborative on ABCDEF bundle implementation. American Journal of Critical Care, 31(1), 54–64. https://doi-org.lopes.idm.oclc.org/10.4037/ajcc2022768

Barnes-Daly, M. A., Phillips, G., & Ely, E. W. (2017). Improving hospital survival and reducing brain dysfunction at seven California community hospitals: Implementing PAD guidelines via the ABCDEF bundle in 6,064 patients. Critical Care Medicine, 45(2), 171–178. https://doi-org.lopes.idm.oclc.org/10.1097/CCM.0000000000002149

Collinsworth, A. W., Brown, R., Cole, L., Jungeblut, C., Kouznetsova, M., Qiu, T., Richter, K. M., Smith, S., & Masica, A. L. (2021). Implementation and routinization of the ABCDE bundle: A mixed methods evaluation. Dimensions of Critical Care Nursing: DCCN, 40(6), 333–344. https://doi-org.lopes.idm.oclc.org/10.1097/DCC.0000000000000495

Collinsworth, A., Priest, E., & Masica, A. (2020). Evaluating the cost-effectiveness of the ABCDE Bundle: Impact of bundle adherence on inpatient and 1-year mortality and costs of care. Critical Care Medicine, 48(12), 1752-1759. https://doi.org/10.1097/ccm.0000000000004609

DeMellow, J. M., Kim, T. Y., Romano, P. S., Drake, C., & Balas, M. C. (2020). Factors associated with ABCDE bundle adherence in critically ill adults requiring mechanical ventilation: An observational design. Intensive & Critical Care Nursing, 60. https://doi-org.lopes.idm.oclc.org/10.1016/j.iccn.2020.102873

Frade-Mera, M. J., Arias-Rivera, S., Zaragoza-García, I., Martí, J. D., Gallart, E., San José-Arribas, A., Velasco-Sanz, T. R., Blazquez-Martínez, E., & Raurell-Torredà, M. (2022). The impact of ABCDE bundle implementation on patient outcomes: A nationwide cohort study. Nursing in Critical Care. https://doi-org.lopes.idm.oclc.org/10.1111/nicc.12740.

Hsieh, S. J., Otusanya, O., Gershengorn, H. B., Hope, A. A., Dayton, C., Levi, D., Garcia, M., Prince, D., Mills, M., Fein, D., Colman, S., & Gong, M. N. (2019). Staged implementation of awakening and breathing, coordination, delirium monitoring and management, and early mobilization bundle improves patient outcomes and reduces hospital costs. Critical Care Medicine, 47(7), 885–893. https://doi-org.lopes.idm.oclc.org/10.1097/CCM.0000000000003765

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Figure 1
SWOT Analysis for Quality Improvement Project

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 3
Primary Quantitative Research – Intervention (5 Articles)

Table 4
Additional Primary and Secondary Quantitative Research (10 Articles)

Table 3: Theoretical Framework Aligning to DPI Project

Table 5
Clinical Practice Guidelines (If applicable to your project/practice)

Legend:

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