NUR 682 Module 7 Milestone Three Example

Milestone Three: Implementation and Evaluation Plan for Nurse-Led Urinary Catheter Removal

[Student Name]

Southern New Hampshire University

NUR 682: Generalist Nursing Capstone

Module Seven Milestone Three

[Instructor Name]

[Date]

Milestone Three: Implementation and Evaluation Plan for Nurse-Led Urinary Catheter Removal

Earlier milestones established that Harbor Point's 30-bed medical floor has a high rate of catheter infections, that catheters stay in because removal waits for an order and that nurse-led removal is supported by moderate, consistent evidence. This milestone explains how the protocol will be introduced and how its effects will be judged. It describes the setting and team, the sequence of small tests of change, the measures and data sources, the approach to analysis, the implementation outcomes that will show whether nurses actually use the protocol, a timeline and the resources required.

Setting, Team and Protocol

The project runs on the 30-bed adult medical floor, which averages about 23 patients a day. The team includes the student as project lead, a hospitalist co-lead, two night-shift nurse champions, an infection preventionist and the nurse manager. The protocol, approved by the medical executive committee, authorizes a registered nurse to remove an indwelling catheter after the daily review finds none of the CDC indications documented, then to perform a bladder scan six hours after removal or sooner if the patient has not voided, and to follow a retention algorithm before any reinsertion. The nurse notifies the physician through the electronic record, not by page, so removal is not delayed.

Testing the Change in Small Cycles

Taylor et al. (2014) reviewed published projects that claimed to use plan-do-study-act cycles and found that few followed the method as intended. Most described a single large change rather than a series of small tests, and many did not collect data repeatedly over time. The authors argued that the value of the method lies in learning quickly from small, low-risk tests and adjusting before spreading a change.

This project uses four cycles. In the first, one champion uses the checklist on her own patients for three night shifts, and the team studies whether the criteria are clear and how long the review takes. In the second, all nurses on one hall use it for two weeks, and the team looks at completion rates, removals and any reinsertions. In the third, the whole unit uses it on day shifts for two weeks. In the fourth, it runs on all shifts. Each cycle has a written prediction, for example that at least 80% of reviews will be completed on the pilot hall, and the next cycle begins only after the team compares results with the prediction and revises the checklist or training.

Table 1. Planned PDSA Cycles

Note. Predictions are set before each cycle and compared with results afterward.

Measures and Data Sources

The outcome measure is catheter infections per 1,000 catheter days, taken from infection prevention surveillance each month. The intermediate outcome is catheter days per 1,000 patient days, calculated weekly from the daily device census. Process measures are the percentage of catheter patients with a completed daily review, how many catheters carry a written guideline reason and the median hours from the first review showing no indication to removal, all drawn from the electronic record. Balancing measures are reinsertions within 48 hours, bladder scans with volumes above the retention threshold and incontinence-associated skin damage, since earlier removal could shift problems elsewhere.

Weekly process and use measures give enough points for learning during the twelve weeks. Infection counts are small, so they will be followed each month for half a year past the full rollout.

Analysis with Run Charts

Perla et al. (2011) explain how a run chart, a simple plot of a measure over time with its median, can separate a real change from ordinary variation. Their rules, based on probability, call six consecutive readings that all land higher than the median, or all lower, a shift, a run of five or more climbing or falling values as a trend, an unusually low or high number of crossings of the median as a signal and one value far from all others as an outlier worth investigating. Because the rules do not depend on assumptions about the data's distribution, they suit small unit samples.

Each chart will open with a year of pre-protocol catheter days per 1,000 patient days, then weekly values after the protocol, and will annotate each chart with the start of each cycle. A shift below the baseline median that begins with cycle two or three would be evidence that the protocol, and not a background trend, is responsible.

Implementation Outcomes

A protocol can fail because it does not work or because nobody uses it. Proctor et al. (2011) distinguished a set of implementation outcomes from clinical ones, such as whether staff judge a practice agreeable and suitable, how many take it up, whether it is carried out as designed, its expense, its spread across eligible patients and its staying power. Four of them are tracked here: acceptability, with a five-item staff survey after cycle two; adoption, as the share of nurses who complete at least one review in each two-week period; fidelity, as the share of removals in which the bladder scan and notification steps were documented; and sustainability, as review completion three and six months after the student's role ends.

Timeline and Resources

Weeks one and two cover education, with fifteen-minute sessions at huddles on all shifts and a short video. Weeks three through nine cover cycles one to three, and weeks ten through twelve begin cycle four and hand the process to the unit. Resources are modest: about 20 hours of champion time, one hour of each nurse's time for education, a few hours of analyst time to build the report and existing bladder scanners. No new equipment is required. The main cost is attention, which the nurse manager has agreed to protect.

Conclusion

This plan introduces the protocol in small tested steps, measures its effects on outcomes, processes and balancing concerns, reads the results with run chart rules and checks whether the change is actually used and sustained. The final project will bring the problem, evidence, stakeholder work and this plan together in one capstone paper.

References

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

Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., Griffey, R., & Hensley, M. (2011). Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health and Mental Health Services Research, 38(2), 65-76. https://doi.org/10.1007/s10488-010-0319-7

Taylor, M. J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D., & Reed, J. E. (2014). Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Quality & Safety, 23(4), 290-298. https://doi.org/10.1136/bmjqs-2013-001862