NUR 550 Module 6 Milestone Two Example

Milestone Two: Using i-PARIHS to Plan the Implementation of a Delirium Prevention Bundle on a Medical Unit

[Student Name]

Southern New Hampshire University

NUR 550: Evidence-Based Practice and Scholarly Inquiry

Milestone Two

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Milestone Two: Using i-PARIHS to Plan the Implementation of a Delirium Prevention Bundle on a Medical Unit

Knowing that an intervention works is not the same as knowing how to make it work on a particular unit. The evidence synthesis for this project concluded that a multicomponent bundle reduces delirium in older medical inpatients, and it identified the main risk: most successful programs used trained volunteers, while this 30-bed medical unit has none. This milestone applies i-PARIHS, the integrated revision of a long-standing research implementation framework, to plan how the bundle will be put into practice. It argues that the bundle can succeed with nursing staff alone only if facilitation is treated as the central ingredient, with an experienced facilitator, night-shift champions and a deliberately narrowed innovation that fits the unit's real workload.

Why i-PARIHS

In i-PARIHS, implementation succeeds when facilitation works on three targets at once: the innovation, the recipients who must adopt it and the context in which they work (Harvey & Kitson, 2016). Two features make it a good fit. First, it treats context, from the unit's culture to hospital priorities and outside pressures, as a force that shapes success, which matters when the main risk is staffing. Second, it places facilitation at the center and describes facilitator roles at different levels of experience, which gives the project a way to plan the support it needs rather than assuming staff will adopt the bundle after a training session. Other models, such as the Iowa Model, describe the steps of an evidence-based practice project well, but i-PARIHS says more about why implementation succeeds or fails once those steps are reached.

The Innovation

In i-PARIHS, the innovation is judged by how it is perceived as well as by the strength of its evidence: its relative advantage, its fit with existing practice and how easily it can be tried and adapted. The evidence is strong, and program evaluations show that sites commonly adapt the Hospital Elder Life Program while keeping its core (Hshieh et al., 2018). To fit a unit without volunteers, the bundle was narrowed to five nursing actions already partly done: orientation and conversation at each contact, walking three times a day, a non-drug sleep routine, fluids offered hourly while awake and making sure glasses and hearing aids are in use. Therapeutic activities and feeding assistance, which depend heavily on volunteers in the original program, were set aside for a later phase. A shorter bundle that nurses can deliver consistently is more valuable than a complete one they cannot.

The Recipients

The recipients are everyone whose work changes: registered nurses and nursing assistants, who deliver most components; physical therapists, who support mobility; pharmacists and hospitalists, whose sleep medicine orders affect delirium; and families, who can help with orientation and glasses. A brief survey and two staff meetings on the unit found that nurses recognized delirium as a problem and wanted fewer night-time emergencies, a strong motivation. They also reported two barriers: they did not see walking patients as their job when therapy was involved, and night staff felt excluded from decisions made on day shift. Hospitalists were supportive but routinely ordered sleep medicines on admission. Each of these findings shapes facilitation.

The Context

Context in i-PARIHS runs from the local unit to the organization and beyond (Harvey & Kitson, 2016). Locally, the unit has a respected manager and a history of a successful falls project, but staffing is tight and night shifts carry the heaviest delirium burden. At the organizational level, the hospital has joined an age-friendly health system initiative, whose framework names mentation, including delirium prevention, among four priorities for older adults (Fulmer et al., 2018), which gives the project leadership attention and a reporting channel. Beyond the hospital, publicly reported falls measures add incentive. The main contextual weakness is the absence of any volunteer program and a hiring freeze that rules out new positions this year.

Assessment and Facilitation Responses

Table 1 summarizes the assessment of each element and the facilitation response it calls for.

Table 1

i-PARIHS Assessment and Facilitation Responses

The Facilitation Plan

i-PARIHS describes facilitators at different levels, from novices learning the role to experienced facilitators who guide local teams (Harvey & Kitson, 2016). The unit's clinical nurse specialist, who led the falls project, will serve as the experienced facilitator: coaching champions, running short plan-do-study-act cycles and presenting data. Four unit champions, two from days and two from nights, will act as novice facilitators, modeling the bundle, answering questions at the bedside and bringing barriers back to the team. The facilitator will meet champions weekly for the first eight weeks, then every two weeks. Facilitation will include audit and feedback: a weekly display of bundle completion and 4AT screening rates by shift, so each shift sees its own progress.

Risks to Watch

Three risks remain. The narrowed bundle may still be too much on the busiest nights, so completion by shift will be tracked from the first week. Champions may burn out without protected time, which the manager has agreed to provide. And a hospital initiative can lose attention when leadership priorities shift, so the project will report through the age-friendly channel monthly to keep delirium visible. If completion stays low after two cycles, the bundle will be narrowed again rather than abandoned, consistent with the evidence that adapted programs can still work (Burton et al., 2021; Hshieh et al., 2018).

Conclusion

Applied to this unit, i-PARIHS shows why the delirium bundle could fail and how to prevent that. The innovation is narrowed to fit a unit without volunteers; the recipients' motivations and barriers are addressed one by one; the context's strengths, a successful falls project and an age-friendly initiative, are used; and facilitation by an experienced nurse specialist and night-shift champions carries the change. The next module turns this framework into a detailed implementation plan.

References

Burton, J. K., Craig, L. E., Yong, S. Q., Siddiqi, N., Teale, E. A., Woodhouse, R., Barugh, A. J., Shepherd, A. M., Brunton, A., Freeman, S. C., Sutton, A. J., & Quinn, T. J. (2021). Non-pharmacological interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database of Systematic Reviews, 2021(7), Article CD013307. https://doi.org/10.1002/14651858.CD013307.pub2

Fulmer, T., Mate, K. S., & Berman, A. (2018). The Age-Friendly Health System imperative. Journal of the American Geriatrics Society, 66(1), 22-24. https://doi.org/10.1111/jgs.15076

Harvey, G., & Kitson, A. (2016). PARIHS revisited: From heuristic to integrated framework for the successful implementation of knowledge into practice. Implementation Science, 11, Article 33. https://doi.org/10.1186/s13012-016-0398-2

Hshieh, T. T., Yang, T., Gartaganis, S. L., Yue, J., & Inouye, S. K. (2018). Hospital Elder Life Program: Systematic review and meta-analysis of effectiveness. The American Journal of Geriatric Psychiatry, 26(10), 1015-1033. https://doi.org/10.1016/j.jagp.2018.06.007