NUR 675 Module 7 Milestone Three Example

Milestone Three: A Practicum Project Plan Built for PDSA Cycles and SQUIRE 2.0 Reporting

[Student Name]

Southern New Hampshire University

NUR 675: MSN Seminar: Preparation for Practicum

Module Seven Milestone Three

[Instructor Name]

[Date]

Milestone Three: A Practicum Project Plan Built for PDSA Cycles and SQUIRE 2.0 Reporting

Many practicum projects falter not because the idea is poor but because the plan is vague: no clear aim, no measures chosen in advance, a single large rollout that cannot be adjusted and a final report pieced together from memory. The student in this paper will test a change to reduce night-shift falls on a medical-surgical unit at a composite hospital, where most falls involve patients getting up alone to use the bathroom, often after sedating medications. The evidence review favored toileting schedules and medication review over bed alarms. This milestone presents the project plan. It argues that framing the project with the Model for Improvement, testing in small cycles, measuring process and outcome from the start and documenting according to a reporting standard will make the project achievable and its results credible.

The Model for Improvement

Langley et al. (2009) set out an improvement approach built on three guiding questions, about the aim, the evidence that will show progress and the change worth trying, combined with rapid small-scale testing. Each test runs through a Plan-Do-Study-Act loop: the team writes down what it expects, tries the change on a handful of patients, compares the results with its expectation and then keeps, modifies or drops the change. The strength of the approach for a practicum is that small tests produce learning quickly and cheaply and let the team adjust before a larger rollout.

For this project, the aim is to reduce night-shift falls on the unit from a baseline of 4.1 per 1,000 night patient days to 2.5 by the end of the twelve-week practicum. The change is a program in which nurses offer toileting to every high-fall-risk patient at 10 p.m., midnight, 2 a.m. and 4 a.m. and in which the evening charge nurse, pharmacist and admitting provider review sedating medications on admission and each evening.

Testing in Cycles

The first cycle will run for one week on four rooms with high-risk patients. The prediction is that nurses will complete at least 80% of scheduled toileting rounds and that no patient in those rooms will fall. The student will observe two nights, collect round completion sheets and interview the nurses at the end of the week. If completion is low, the cycle will study why, for example whether rounds collide with medication passes, and adapt the schedule. The second cycle will expand to the whole unit for three weeks with the adapted process, and the medication review will be added. A third cycle, if time allows, will test ways to sustain the process, such as adding the round schedule to the electronic task list. Each cycle's prediction, results and decision will be recorded on a one-page form.

Staff will be involved from the start. Before the first cycle, the student will meet with the night nurses on the four test rooms to explain the change, ask what might get in the way and adjust the round times if they clash with other work. Their suggestions, and the reasons behind any changes, will be recorded in the project log.

Measures

Table 1 lists the measures. The outcome measures reflect the aim, the process measures show whether the change is actually happening and the balancing measures check that the change is not causing harm elsewhere, such as interrupting sleep, which can itself increase delirium and falls.

Table 1. Project Measures and Operational Definitions

Note. Balancing measures watch for unintended effects, such as disturbed sleep, that could undermine the change.

Displaying and Interpreting Data

Because the unit has relatively few falls each week, weekly fall rates will vary a great deal by chance. Perla et al. (2011) describe run charts, which plot data over time around a median, and give a handful of simple rules, based on runs of points above or below the median and on steady climbs or drops, for telling a real signal from noise. The project will plot twelve months of baseline data and then weekly data during the practicum on run charts for each measure. Process measures, which change quickly, will be interpreted first; the outcome measure will be interpreted cautiously, since a twelve-week window gives a rare event little room to show a dependable shift.

Data collection has been kept light so that it does not become a burden that staff resent. Round completion sheets take seconds to mark, the morning sleep question is asked by the day nurse during routine rounds and the chart audit is done by the student.

Documenting for SQUIRE 2.0

Ogrinc et al. (2016) produced SQUIRE 2.0, a consensus standard for writing up improvement projects. In plain terms, a SQUIRE report explains why the problem mattered and what was already known, why the team expected its change to help, what the local setting was like, what was actually done and how it shifted along the way, how the effects were studied and measured, what the numbers showed, including anything unexpected, and what the team concluded, with limits and ethical points. Knowing these elements from the start changes what the student records. She will keep a project log noting context, such as staffing changes and other initiatives on the unit, each PDSA decision and its reasons and any unexpected effects. At the end, the final practicum report will follow the SQUIRE headings, drawing directly on the log, run charts and cycle forms.

Conclusion

The project has a clear aim, a change grounded in evidence, small tests that allow adjustment, measures defined in advance with balancing checks, run charts to read the data honestly and documentation organized for a recognized reporting standard. With these in place, the practicum can produce both a useful test of change for the unit and a credible account of what was learned.

References

Langley, G. J., Moen, R. D., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). Jossey-Bass.

Ogrinc, G., Davies, L., Goodman, D., Batalden, P., Davidoff, F., & Stevens, D. (2016). SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised publication guidelines from a detailed consensus process. BMJ Quality & Safety, 25(12), 986-992. https://doi.org/10.1136/bmjqs-2015-004411

Perla, R. J., Provost, L. P., & Murray, S. K. (2011). The run chart: A simple analytical tool for learning from variation in healthcare processes. BMJ Quality & Safety, 20(1), 46-51. https://doi.org/10.1136/bmjqs.2009.037895