EBP Application Sample

Examples of Effective EBP Applications

Following are samples of well-written, effective applications for funding of an Evidence-Based Practice Project. They are here to provide you with examples of the kind of thinking and detail our reviewers are looking for as they consider your application.

We hope you find these helpful as you draft your own application.

Example 1: ENERGY IN MOTION

Purpose of Project (200 words): The purpose of this evidence-based practice project is to implement and evaluate an exercise program for adult ambulatory oncology patients to reduce fatigue as a side effect of cancer treatment. The exercise program will be designed as a patient friendly activity promotion program to support patient use, and thus improve the impact for patients and families. The program will be designed to be sustainable in a busy oncology clinic in a tertiary care academic medical center serving patients locally and regionally. Individual Energy through Motion kits will be created to promote physical activity in a pilot group of adult patients with GI cancers in the Holden Comprehensive Cancer Center (HCCC). Patients with colon, rectal, gastric, pancreatic, esophageal, biliary track, GE junction, cholangiocarcinoma, and ampullary carcinoma receiving cancer treatment in two oncologists’ clinics will be included in the project pilot. Based on strong evidence and preliminary work beginning in September 2009, a rapid rollout is planned following pilot evaluation. Funding will be used for individual Energy through Motion kits for use during the pilot and rollout.

Background (400 words): Cancer related fatigue (CRF) is distressing and interferes with usual functioning.[1] Fatigue is the most frequently reported side effect of cancer treatment among outpatients and colorectal cancer patients.[2-4] CRF in patients with colorectal cancer is reported to be moderate to severe, interfering with quality of life[2, 5] and changes over the course of treatment.[6] Many patients are seen in the Holden Comprehensive Cancer Center with GI cancers and are likely to experience fatigue. Two participating oncologists treated 124 patients over the last two years with chemotherapy and/or radiation. 

Research demonstrates that exercise can impact CRF during cancer treatment.[7, 8] Many professional organizations support exercise for prevention and treatment of CRF.[1, 9-13] Research shows that focused, home-based programs that include patient education and patient materials can be helpful with promoting exercise.[14-17] A staff nurse identified that fatigue is a need for adult oncology patients and families and that they could benefit from an exercise program. The team has experience leading evidence-based practice changes.[18-25] The staff nurse functions as the project director and developed a team for program planning and piloting. The Energy through Motion initiative was developed with nurses, physicians and physical therapists caring for people with GI malignancies. For the Energy through Motion initiative, an educational brochure and DVD were developed, other related printed materials were gathered and a local home care agency funded the Energy through Motion kits. The kits included a bag, pedometer, activity contract, resistance bands and instructions for use, exercise prescription, and printed materials for use during the pilot. 

The staff nurse-project director led preliminary work functioning as adjunct faculty for a local BSN program. Physicians or nurses recommended gastrointestinal cancer patients to be approached by nursing students to: 1) introduce the activity program during the patient’s second clinic visit, 2) teach how to use the Energy through Motion kit, and 3) provide follow-up on treatment days and with phone calls. Students also held a “Health Fair” on the benefits of activity in the clinic waiting room for patients, families and visitors. If patient participation in exercise was a concern or patients demonstrated a functional decline, a referral was made to physical therapy for an evaluation and individualized activity prescription. Twenty-two patients participated between September 2009 and May 2010 providing feedback leading to modifications in the kit’s contents and program design.

Describe proposed change (500 words): Energy through Motion began as an identified need of cancer patients seen in the Holden Comprehensive Cancer Center. The process follows the Iowa Model of Evidence-Based Practice.[26] The project will include two patient groups both experiencing colon, rectal, gastric, pancreatic, esophageal, biliary track, GE junction, cholangiocarcinoma, or ampullary carcinoma cared for in two gastrointestinal (GI) cancer physician’s clinics. An ‘activity group’ and a ‘standard care group’ will be identified for comparison of fatigue, quality of life (QOL), and patient feedback for project improvements. Patients will be identified by their oncologist or nurse coordinator as appropriate to participate in low to moderate exercise during their cancer treatment. The program will be introduced by the nurse coordinator or medical assistant (MA) at the patient’s first or second scheduled treatment appointment. Both groups will complete a pre-assessment questionnaire to rate level of fatigue, the impact of fatigue on their QOL and perception about staying active during cancer treatment (Attachment 1). This questionnaire will be repeated again in 3 months (Attachment 2). 

The standard care group will receive information addressing cancer and treatment related fatigue using the current question and answer format and resources. 

The patients in the activity group will receive additional instruction on the value of staying active during their cancer treatment by the nurse coordinator and will receive a signed exercise prescription from their oncologist to participate in low to moderate exercise (Attachment 3). These booklets will be provided: Energy through Motion; Exercise calorie chart; Step up to better health: start walking; Eat Smart, Food Safety, and resistance band instruction sheets (Attachment 4). Tools to facilitate low to moderate exercise activities will also be provided to the patient at time of instruction. Tools include a pedometer, resistance band(s) and a weekly exercise contract (Attachment 5) which will be placed inside a tote bag or Energy Through Motion kit for the patient to keep. ‘Activity conversations’ including the benefits of exercise and standardized questions about their activity since their last appointment (Attachment 6), will be completed by the patient’s oncologist, nurse and/or MA. 

All patients will be asked questions about their levels of fatigue and its impact on QOL on each scheduled visit throughout the 3 month period (Attachment 6). Funding will be used for patient kits for the activity promotion group and rapid rollout to other cancer populations in the clinic.

EBP Process model: Iowa

Outcomes (400 words): Preliminary data suggest patients found student contact in the clinic, the activity kits and phone calls to be helpful. The outcomes of this project will be measured through feedback from patients during their regularly scheduled clinic visits on their levels of fatigue and the impact it has on their QOL. Patients will also be asked for feedback on the implementation process. These evaluations will be made through a patient questionnaire (Attachments 1 & 2). The first section of the patient questionnaire will evaluate the intensity of fatigue using a single item based on a validated assessment[27-29] and the impact of fatigue using relevant items from the Brief Fatigue Inventory which has been validated and is widely used.[27, 30, 31] The second section will request patient’s feedback on the implementation process and if patients feel revisions are needed. Twenty-five patients from each of the activity and standard care groups will be asked for feedback. Because cancer fatigue is variable over the course of cancer treatment, fatigue and QOL scores will be compared within and between groups using basic descriptive statistics as part of the EBP evaluation. 

Frequency of clinician “activity conversations” with the patient will be identified (Attachment 6) and clinician feedback about the implementation process will also be evaluated through questionnaires (Attachment 7). This questionnaire is based on a well developed process evaluation[32] that has been used in a number of evidence-based practice project evaluations.[33-35] Clinician feedback will be used to evaluate and adapt the implementation process as needed, to improve sustainability of the project within the busy ambulatory clinic setting. 

At the completion of three months, pre and post assessment surveys will be compared within and between the groups. Based upon these findings, recommendations can be provided to the institution’s cancer clinic director regarding the merits of offering the Energy through Motion program to other people undergoing cancer treatment. Project evaluation results will be reported in quality improvement and throughout the department and HCCC (e.g., at committee meetings).

How clinicians will be involved: A project team that includes a staff nurse opinion leader, an APN with advanced oncology certification, and change champions will be formed. The opinion leader and APN will provide education on the evidence to support the practice change. Teamwork will be enhanced by clinician input to enrich the project. Additional members of the team will include the clinic nurse manager, survivorship ARNPs, and Nurse scientist with extensive EBP knowledge and expertise. The team will focus on how to identify who to include in the project, who will do the assessments, what materials to include in the ETM kits, and how to keep track of who and when to follow-up with these patients. This group will also determine the tools to use to capture both process and outcome measures. Nursing student support will be enlisted to help provide patient education and encouragement.

Example 2:

Purpose of Project (200 words): The purpose of this project is to support the acquisition of various fall risk products and to develop an educational program to assist the staff, patients and families to participate in this evidence-based intervention. Evaluation of the success of this EBP initiative will include comparison of fall rates, falls with injuries and the use of restraints per 1000 patients and cost of using constant observers pre- and post-intervention. Additionally nurses and family satisfaction with the toolkit of interventions will be assessed.

While the entire hospital population will be studied, the highest risk group and the care areas with the most constant observers are our oncology units. We will conduct a subset analysis of the effectiveness of this EBP intervention for this group of patients. This targeted evaluation meets the goals of the J. Patrick Barnes research and EBP program and will enable us to enhance care for this very high risk group of patients.

Background (400 words): Delirium may occur in as many as 56% of hospitalized older adults according to a literature review by Inouye and colleagues.1 Delirium is an independent risk factor for hospital associated injuries including falls and dislodging tubing and lines. Falls in oncology patients, who may be at increased risk for bleeding, may have devastating consequences. One method to ensure the safety of patients with delirium is to use a constant observer or sitter. The CO, who is usually a hospital or nursing aid She or he watched over and supervised the patient to prevent such behaviors as unsafe ambulation and tube or line removal. COs provided an alternative to using restraints, which have been associated with the development of delirium1 and can also result in the loss of muscle strength, pressure ulcers, incontinence, and even strangulation.2 Nurses in all inpatient areas could request a CO from the staffing office and one would be sent from an internal resource pool or an external staffing agency. The use of COs increased steadily over the years and reached an annual cost of more than $1.5 million in 2004. In addition to their high cost, it was found that COs did not consistently decrease the incidence of unsafe patient behaviors. If she or he were not close enough to the patient, for example, the CO could not always react quickly enough to prevent the patient from injury. Therefore, we are seeking to implement and evaluate evidence-based alternatives to ensure patient safety in a cost effective manner.

An interdisciplinary team (Psychiatric Clinical Nurse Specialist, Oncology Clinical Nurse Specialist, Physical Therapy, Occupational Therapy, Pharmacy, Social Work, and Medicine) has been created to review of the literature to identify possible alternatives. We have identified the following strategies: fall risk prevention products (bed/chair exit alarms), self-releasing belts, non-skid slippers along with strategies to decrease the development or severity of delirium.

Describe proposed change (500 words): The purpose of this proposal is to support the acquisition of various fall risk products and to develop an educational program to assist the staff, patients and families to participate in this evidence-based intervention. Examples of the strategies/evidence-based interventions that will be used:

TEAMWORK: (1) Institute teamwork among nursing staff; for example, check on each other’s patients. (2) Implement frequent scheduled checks by both nurses and hospital or nursing assistants. (3) Involve family and friends in patient care. (4) Encourage teamwork across disciplines; for example, all staff respond to bed alarms. (5) • Improve the nurse-to-patient ratio to increase nurse’s availability to confused patients. ENVIRONMENT: (1) Move the patient to a room with high visibility for nursing staff. (2) Perform charting in the patient’s room. INTERVENTIONS: (1) Use fall risk prevention products, such as bed and chair exit alarms, bed and chair self-releasing belts, chair wedge foam cushions, floor mats, nonskid slippers. (Note – our medical facility is purchasing these fall-risk prevention products) (2) Use a gait belt for patient transfers and ambulation. (3) Place a No Fall Zone poster in the patient’s room with the patient’s safety plan noted including universal fall precautions and patient-specific needs such as assistive devices (walker, cane) and the assistance required for transfers. (4) Provide the patient and family with education on the fall risk prevention plan (a pamphlet will be created based on literature and designed in collaboration with the Patient/Family Advisory Panel and the Patient/Family Education Center at our hospital). (5) Implement scheduled or frequent toileting. (6) Review medications and discontinue or minimize the use of medications that cause delirium. (7) Evaluate the need for as-needed medications for delirium such as antipsychotic medications. (8) Use physical restraints as a last resort only. Other interventions will be added based on a review of the literature and input from multidisciplinary team and the Patient Family Advisory Council.

Outcomes (400 words): The following outcomes will be used to evaluate the effectiveness of our EBP intervention.

(1) Fall rate, falls with injuries and the use of restraints per 1000 patients with full-time COs (historical data) versus fall rates, falls with injuries and use of restraints per 1000 patients receiving new interventions.

(2) Cost of COs for 6 months pre/post implementation of the intervention.

(3) Nurse satisfaction with the interventions. The survey will be developed to reflect specific interventions. Face validity of the survey will be obtained before use.

(4) Family satisfaction with the interventions, including their perception of their role in ensuring patient safety. A review of the literature failed to find any instruments specific to the aims of this study. A family satisfaction survey will be developed based on a review of the literature for similar types of projects. Input will also be sought from the Patient/Family advisory council and the survey will be pilot tested and face validity established before use. Survey instruments for nurses and families will be developed and validated as a part of this project.

Family members of the Patient/Family Advisory Council will be invited to participate in the role-out of this project and the creation and validation of the evaluation instrument and the results will be presented to the Patient/Family Advisory Council.

Analysis of the outcomes data will be performed by the nurse researcher at our medical center in collaboration with the team and our Center for Clinical Excellence. No identifiable data will be analyzed – only performance improvement data in aggregate and cost estimates related to constant observers.

Timeline

Budget: Funds are available for direct expenses only. Institutional overhead may not be included. Provide budget using the following chart, and describe/provide justification for how you will use the grant funding to support your project (e.g., cost for reproduction of booklets - 500 booklets @ $2/booklet = $1000). If the funding level offered by The DAISY Foundation is not adequate for your project, please email bonniebarnes@DAISYFoundation.org to discuss.

(Note – this example was based on a QI project conducted at the University of Washington Medical Center – Sweeny SJ, Bridges EJ, Sayre C, Wild L. Care of the patient with delirium. Am J Nurs, 2008, 108(5), 72CC-72GG).

Equipment/Supplies:

Reusable “No Fall Zone” signs will be created – these will be placed on the doorway of any patient identified as high risk for falling ($300).

A Family Information pamphlet will be created based on the specifics of the program and developed in collaboration with our Patient/Family Advisory Council and our Patient/Family Education Center. The pamphlet will explain the program and provide suggestions of what family members can do to keep a family member safe and to aid in the resolution of their confusional state ($300).

References