Posted: November 5th, 2022
Evidence-Based Practice Proposal Final Paper.
Throughout this course, you have developed a formal, evidence-based practice proposal.
The proposal is the plan for an evidence-based practice project designed to address a problem, issue, or concern in the professional work setting. Although several types of evidence can be used to support a proposed solution, a sufficient and compelling base of support from valid research studies is required as the major component of that evidence. Proposals must be submitted in a format suitable for obtaining formal approval in the work setting. Proposals will vary in length depending upon the problem or issue addressed (3,500 and 5,000 words). The cover sheet, abstract, references pages, and appendices are not included in the word count. Evidence-Based Practice Proposal Final Paper.
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Section headings for each section component are required. Evaluation of the proposal in all sections will be based upon the extent to which the depth of content reflects graduate-level critical thinking skills.
This project contains seven formal sections:
1.Section A: Organizational Culture and Readiness Assessment
2.Section B: Proposal/Problem Statement and Literature Review
3.Section C: Solution Description
4.Section D: Change Model
5.Section E: Implementation Plan
6.Section F: Evaluation of Process
Each section (A-F) will be submitted as a separate assignment in Topics 1-6 so your instructor can provide feedback (refer to applicable topics for complete descriptions of each section).
The final paper submission in Topic 7 will consist of the completed project (with revisions to all sections), title page, abstract, compiled references list, and appendices. Appendices will include a conceptual model for the project, handouts, data and evaluation collection tools, a budget, a timeline, resource lists, and approval forms, as previously assigned in individual section assignments.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is required.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to LopesWrite. Please refer to the directions in the Student Success Center.
Final Research Proposal for Evidence-Based Practice Change in the Management of Hypertension in the Organization by Incorporating Isotonic Aerobic Exercise and Resistance Exercise in the Pharmacologic Treatment of the Condition
The practice of nursing and medicine in general is now guided primarily by the use of evidence-based interventions and therapies backed up by research. For this reason, many practices that are currently being practiced but not rooted firmly in science are frowned upon. In organizations with these challenges, change is needed. In one such organization, the need to change its management of hypertension necessitated a change in the organization culture. This is a process that requires a solid theoretical framework with stages that lead to the final adoption and translation of evidence into practice. This evidence is the benefit of exercise in the treatment of hypertension. Evidence-Based Practice Proposal Final Paper.
Key words: change, hypertension, theoretical framework
The practice of medicine and nursing has increasingly veered towards using only those treatment and management modalities that have been scientifically proven to be efficient. This is what has become known as evidence-based practice or EBP. However, it also goes without saying that old habits are difficult to drop. For this reason, it is not uncommon to still find practices that have no solid scientific backing still flourishing in healthcare organizations. To change this, there needs to be a systematic approach targeting the organization culture that encourages this. Innovators or those who come up with change ideas have therefore to study the culture of the organisation, come up with a plan for change, identify barriers and facilitators, and sensitize and educate on the need for change. To this end, the application of change theories such as Roger’s diffusion innovation theory or DOI has come in handy. This project proposal attempts to do exactly that by proposing a practice change in the management of hypertension by incorporating the element of exercise which has hitherto been ignored by prescribers in the organisation. Evidence-Based Practice Proposal Final Paper.
1. To identify the hypertension treatment practice gaps that allow for foreseeable complications like stroke and coronary artery disease or CAD
2. To conduct a search for evidence on the effectiveness of this missing practice in the management of hypertension
3. To investigate the organization’s readiness for change in view of evidence-based practice
4. To come up with a plan of action to facilitate change and incorporate the identified evidence-based practice in hypertension management into the organization’s culture
5. To implement the plan by marshalling both material and human resources, creating awareness, and evaluating its success
6. To make appropriate changes and modifications to the evidence-based practice implementation plan, during the translation into organizational culture phase.
Section A: Organizational Culture and readiness Assessment
The journey for this proposal commenced with an assessment of the organizational culture of my organisation with a view to gauging its readiness for change. This was achieved by using a Likert scale questionnaire as a data collection tool from the employees of the organization. The areas assessed included communication within the organization (both among the staff and between staff and the management), the management style within the organization, employee motivation status, and employee views of the organization as a whole, amongst others (Sample Organizational Culture Survey, n. d.). Evidence-Based Practice Proposal Final Paper.
Among the notable findings was that communication between employees and between the different departments is superb. However, top-down communication is not as impressive as it should be. This is especially true with mid to low rank management like supervisors. It was especially noted that departmental heads and supervisors were averse to change and took quite negatively any practice criticism directed at them. They also clearly showed some sort of favoritism towards particular employees, a fact that is bound to breed resentment and de-motivation in the organization. As such, for the organization to be considered ready for change these blemishes have to be done away with. What is encouraging though is the unanimity of the employees on the need for change in the organization in the manner in which things are done, including treatment. Evidence-Based Practice Proposal Final Paper.
Organizational Readiness, Barriers, Facilitators, and Clinical Inquiry Integration
The assessment of the organizational culture revealed important information in so far as readiness of the organization for change is concerned. As stated earlier, different facets of the organization were examined by carefully structuring 38 Likert-type questions posed at employees working in the organization. The questionnaire focussed on staff-to-staff relations, management-to-staff relations, communication (both top-down and bottom-up), and employee motivation amongst others. What emerged from this exercise was an identified need for the organizational mindset or culture to change in order to herald the readiness for acceptance of this change project on hypertension treatment (Fritzel, 2019). This is not to say that the organization is any different from similar organizations. In fact, no organization would claim to be perfect, and in any organization there will be some resistance to change brought about by the comfort afforded by long-held traditions that may not have a scientific basis. As such, just like it would be with any other organization, inherent barriers and enhancers were identified during the evaluation of the organization for change readiness.
Analysis of the data obtained from the questionnaire responses by employees of the organization revealed barriers which included poor bottom-down communication, especially from the mid to low-level management. This included departmental heads and section supervisors. Another clear barrier identified was the lack of tolerance to constructive criticism of traditional practices by the same mid to low-level management. It was then immediately clear that this was the weakest link in the quest to introduce new evidence-based practices in line with current standards of care. But because policies are usually formulated at the apex of all organizations, it was deemed easy to find a solution to these identified barriers. Evidence-Based Practice Proposal Final Paper.All that it required was an impassioned presentation to the chief executive officer and his board of directors on the need for a change in practice. This would be done with all the gathered evidence clearly elucidated to the top management. From there, with the apex management convinced of the need and importance of having this practice change, all the other lower management cadres would fall in line as it would then be a policy directive. On the same findings, the positive enhancers or facilitators that were identified were the good inter-employee and inter-departmental communication, and the overwhelming employee willingness to bring about change in practice for better patient care. As mentioned, the solution to the mid to lower management barrier is the inclusion of top management who then lead by example and demand lower level management accountability for the success or failure of this change project (Folz, 2016). Evidence-Based Practice Proposal Final Paper.
Section B: Proposal/ Problem Statement and Literature Review
In looking at the organization the most striking problem identified by the nurse innovator as per her area of interest was in the management of hypertension. From this topic of hypertension, this area of interest was then narrowed down to prevention of complications arising from long-standing high blood pressure. As with any other systematic scientific investigation, the aim was to come up with a problem statement that could then be scientifically solved by looking for the available evidence in support of the hypothesis. To arrive at this, the best way was to formulate or structure the problem in a PICO statement (problem, intervention, comparison, and outcome). In the organization in question, both physicians and advanced practice registered nurses or APRNs who are the prescribers were noted to be using only pharmacologic modalities of treatment to manage the condition of hypertension. This seemed outdated and did not quite embrace the often acclaimed benefits of non-pharmacologic modes of therapy. Specifically, the role of exercise was striking in its absence in the management of hypertension in this organization. Put in PICO format, therefore, this statement reads like this: Evidence-Based Practice Proposal Final Paper.
“For hypertensive patients (P), does regular exercise (I) lower the likelihood of getting a stroke (O) compared to lack of physical activity (C)?”
In this format, this statement would aid and facilitate the search for evidence by clinical inquiry into evidence-based solutions to the identified problem. But to clearly understand the problem to be solved, there is need to put it into its context in the organizational setting. To effectively do this, a proposal statement is paramount. To this end, the hypertension management problem identified put into the proper context as a proposal statement reads as follows:
“Well-managed hypertension is not life-threatening and the patient may live long without having any of the known complications like stroke and coronary heart disease. This is however not always the case as most hypertensive patients usually end up suffering complications sooner rather than later. This research aims at finding the role that exercise can play in preventing the early onset of these complications.” Evidence-Based Practice Proposal Final Paper.
With the PICO statement and the proposal statement, it was thereafter easy to proceed to the search for available evidence into the possible solutions to the problem. This involved a meticulous review of literature on the possible benefits of exercise as adjuvant therapy for those suffering from chronic hypertension. What was found as a result was that sufficient evidence exists for exercise to be included as an additional treatment option to the usual drug treatment of hypertension. Carefully structured randomized controlled trials (RCTs) have proven that both aerobic (isotonic) exercise and resistance exercise are beneficial in the treatment and management of chronic hypertension (Byrd, 2014; Kaplan, 2016; MacDonald & Pescatello, 2018). For instance, 20% of the study subjects in one of the research studies reported not remembering receiving any prescription for exercise as part of their hypertension treatment (Byrd, 2014). This is the same situation that pertains in the current organization under review. Prescribers in the organization – who include physicians and nurse practitioners – are currently not prescribing exercise for hypertension management. This is partly due to complacency and partly due to the organization’s resistance to change. It is therefore this complacency and resistance to change that this practice change proposal seeks to alter. Evidence-Based Practice Proposal Final Paper.
Section C: Solution Description
As is already familiar, the identified problem in the organization is the non-prescription of exercise as an addition to the treatment measures of hypertension. This is despite there being overwhelming evidence to support the practice. By addressing the inherent organizational factors acting as barriers to implementation of new evidence-based practices, this situation is bound to change. But this will only be possible with the support of the top level management who are the policy makers and providers of resources. With the support of the top management and access to the needed resources, the solution to this problem is the integration of exercise as part of hypertension treatment into the organizational culture and gold standard of care. It has been stated earlier that there is overwhelming evidence in support of exercise as a viable treatment for hypertension. For instance, in a randomized controlled trial of 84 subjects with hypertension, Sushma et al. (2011) examined the role of walking (isotonic exercise) and found it greatly beneficial to hypertensive patients by significantly improving quality of life and preventing complications. As opposed to the control group, isotonic exercise (just walking) as an intervention lowered complicating risk factors such as high blood sugar and the body mass index (BMI) apart from the blood pressure itself. As such, the researchers put forward a compelling argument for the inclusion of aerobic isotonic exercise in the management of hypertension and its complications. There was also later work by other researchers who sought to build on this finding by Sushma et al (2011). These were studies by Byrd (2014), Kaplan (2016), and MacDonald and Pescatello (2018). These studies went on to confirm the finding that isotonic and resistance exercise are both beneficial in the treatment and management of chronic hypertension. Evidence-Based Practice Proposal Final Paper.
With this scientific evidence in hand, it was therefore just a matter of acceptance by the top management and education/ sensitization of the organization’s medical community for the change to be effected by its prescribers. Of note is the pleasant fact that the implementation of this practice change is not overly resource-intensive. The most work that is required is the education geared towards a change in mindset and disentanglement from the shackles of tradition clothed as organizational culture. Evidence-Based Practice Proposal Final Paper.
Alignment with Organization Culture and Objectives
In the evaluation of the organizational culture at the beginning what emerged was a great communication relationship between individual employees and between departments. The resistance that was noted and which forms the heart of the barriers was with the lack of willingness to accept change by the mid to low-level management and supervisors. It has been noted that involvement of the top management would be the best solution to solving this barrier. This is because the resistant section of management in the organization is answerable to the top level management. With the goodwill and the support of the top echelons of management in this organization, this change proposal will be successful.
Some of the goals of this change proposal include the observable reduction in the disease burden and mortality, and a more improved quality of life for the organization’s hypertension patients. The indicators that will be used to assess these outcomes will be assessed both objectively and subjectively. They will be both physical measurements and laboratory tests. Finally, recorded patient testimony data will also be collected by way of a Likert-style questionnaire. Therefore, frequent and regular blood pressure measurements will be taken during each scheduled visit, low-density lipoprotein cholesterol (LDL-C) levels will be checked, together with random blood sugar measurement. Lastly, the patient will be required to answer the few questionnaire questions as well on each of these scheduled visits. Evidence-Based Practice Proposal Final Paper.
Methodology of Goal Achievement
There will be need to first create awareness of the existence of the problem in the organization. This will be achieved by in-house continuous medical education (CME) by external expert speakers in conjunction with organizational educators on the proven role of exercise in hypertension management. The aim is to have the prescribers in the organization include exercise as part of the prescribed treatment for hypertension, alongside the usual pharmacologic treatment options. What will then follow after successful introduction will be the assimilation of isotonic exercise and resistance exercise into the standard operating treatment procedures of the organization. This will alter the standard of care offered in the organization for the better. In all this, the main assumption is that the patients to whom this exercise will be prescribed will actually engage in it as prescribed to give the desired results. If that be the case, then; the impact of the achievement of this intended goal will be a marked improvement in the standard of care for hypertension by the organization.
Section D: Change Model
To achieve the above goal of bringing about change in the treatment of hypertension, there is need to employ one of the several theoretical models used to drive change in organizations. One of those theoretical frameworks is the Roger’s Diffusion of Innovation Theory or DOI. The DOI theory describes the way an idea or innovation is accepted and spreads or diffuses within a given population, from the time the innovator puts it forward to the time that it is successfully translated into practice (LaMorte, 2018). Evidence-Based Practice Proposal Final Paper. The main goal of the diffusion of innovation theory is that the new idea is accepted and incorporated into the organization’s new way of doing things or practice. Once successful, change will therefore have occurred. However, for the new idea or innovation to be successfully accepted by the targeted population, the implementers within the organization must first find the new idea interesting and useful to their patients (LaMorte, 2018). It should be noted, however, that the acceptance of new innovations is not by itself without challenges. These are the barriers that were identified when an evaluation of the organizational culture was carried out at the beginning. And as alluded to before, every organization has its own inherent barriers and facilitators or enhancers which must first be identified if successful implementation is to be achieved.
Individuals within the organization fall into different categories according to the diffusion of innovation theory. There are those that are the originators of the new ideas. These are the innovators. Then there are the early adopters of the new idea and inevitably the late adopters. The late adopters are referred to as the late majority, and before them are the early majority after the early adopters. The late majority are followed lastly by the laggards, who are the most resistant to change. The laggards are the last to embrace the change when it becomes apparent that everybody else is actually going with the new idea. These different classes of employees have been labelled as “degrees of innovativeness” (LaMorte, 2018; Dearing & Cox, 2018). The relevance, therefore, of the diffusion of innovation theory to the implementation of this hypertension treatment project cannot be gainsaid.
The Diffusion of Innovation Theory Stages
The DOI theory has got distinct stages through which the idea has to go before it becomes part of the organizational culture. These are:
i. Knowledge dissemination/ creation of awareness
ii. Persuasion and the decision to adopt the idea or reject it
iii. Early trials of the new idea
iv. Acceptance, integration, and continuation of the new evidence-based practice as culture (Pashaeypoor et al., 2016; LaMorte, 2018).
Application of DOI Theory in this Project
The dissemination of knowledge will involve several hours of continuous medical education or CME; persuasion will involve the departmental heads persuading their staff to adopt the idea by motivating them; early trials will require using tools like positive reinforcement; and acceptance, integration, and continuation will involve translating the new practice into the organization’s standard operating procedures or SOPs. Evidence-Based Practice Proposal Final Paper.
Section E: Implementation Plan
The project implementation and adoption of this particular project of integrating evidence-based intervention/ innovation to normal practice (prescription of exercise for hypertension) adopts the Iowa model of implementation of evidence-based practice (White et al., 2016). However, it also borrows a little from the Johns Hopkins Nursing evidence-based practice or JHNEBP model (Jones & Bartlett Learning LLC, n.d.). Evidence-Based Practice Proposal Final Paper.Because it borrows from the Iowa model, it therefore means that implementation will first start with a phase of small-scale piloting of the innovation. For this, a total of ten patients with hypertension and on similar treatment will be selected. Five of these will be from the outpatient and the other five from the inpatient clinicians and physicians. They will be matched for age and other factors, after which five will be subjected to controlled exercise (the in-patients) and the other five will act as a control group (with no exercise) for the entire duration of the pilot. Therefore, the setting for the in-patients will be the usual hospital physician rounds, during which they will suggest exercise as an additional measure of treatment. The physiotherapist will then assist the patient with this. As for the outpatients, the setting will be the nurse practitioner’s and physician’s consultation rooms where they are usually seen. Because they are the control group, they will be left to continue with their usual pharmacologic treatment only the entire duration of the piloting phase. For both of these groups, there will be no need for consent, since they are patients that are already under the care of their respective nurse practitioners and physicians.
Time Needed for Completion
The total amount of time that will be needed to complete this project will be twelve calendar months. Time planning through a common time frame helps team members move forward together with the implementation whilst facilitating feedback. This project implementation will adopt the Gantt chart timeline for its time planning (Jones & Bartlett Learning LLC, n.d.). Evidence-Based Practice Proposal Final Paper.
For this project the resources needed will be material or physical, human, and fiscal. These resources may also be looked at as being either internal or external (Kueny et al., 2015; Mick, 2017; Jones & Bartlett Learning LLC, n.d.). First will be human resources. These will include the speakers at the continuous medical education functions (in-service training), staff physicians and advanced practice registered nurses (who are the prescribers or implementers), ward nurses and other departmental nurses, the librarian, educators, research advanced practice nurses or APNs, catering staff, and the ICT (information communication technologies) departmental staff. Second will be the material resources. These will include a medical library, printing paper and printing facilities, laptop, projector, writing board, and writing material. And lastly will be the money required to facilitate all this (Kueny et al., 2015; Jones & Bartlett Learning LLC, n.d.).
According to the JHNEBP model, the implementation phase of this project is occurring at the translation stage (Dearholt &Dang, 2018). The method that will be used to evaluate the progress and success or failure of the intervention will flow from the objectives set out when the PICO (problem, intervention, comparison, and outcome) problem was being formulated. The method to be used in this case will involve data collection by using indicators that will be both objective and subjective. The data will then be analysed using descriptive statistical measures such as means and frequencies to derive meaning (Dearholt &Dang, 2018). Subjective data will be collected from the patients using a questionnaire instrument utilizing a Likert scale and assessing their well-being. Objective data will include blood pressure measurement and laboratory serum cholesterol values. Evidence-Based Practice Proposal Final Paper.
Delivery Process of Evidence-Based Treatment
Training will be done for a month and this will be basically four sessions of in-house presentations, one per week for four weeks. After this, during the piloting the APRNs and physicians whose patients have been chosen for the pilot will go ahead and prescribe exercise to the intervention in-patient group. The control outpatient group will just be monitored and both the objective and subjective evaluation data collected as above. After the piloting phase, all physicians and APRNs will routinely prescribe exercise as part of treatment for hypertension; this being an organizational policy.
Feasibility encompasses areas like money, human resources, and time available (Jones & Bartlett Learning LLC, n.d.). In order to capture this, a budget estimate is necessary. The cost of personnel in this case will be in getting the external speakers who will complement the in-house educators. This will be once a week for four weeks and is estimated to cost USD 600. Then there will be the lunch and refreshments once each week for the four weeks, at an estimated cost of USD 1,500. This is followed by the printing of learning materials at an estimated cost of USD 750. Lastly, miscellaneous costs (library access for latest journals and journal articles not available in the organization, writing pads for participants, pens, and so on) will be about USD 600.
Maintenance/ Revision Plan
The piloting will take 3 months then organization-wide implementation for six months. After this the practice will become organizational policy, barring failure.
Section F: Evaluation of Process
Evaluation involves taking baseline measures before beginning and later comparing the values with those taken after implementation (Mick, 2017). As such the outcome measures assess the level to which the project goals have been achieved by revealing a considerably lower blood pressure reading and low-density lipoprotein cholesterol (LDL-C) levels. All this will be in a patient who will be feeling well, fit, and with a general feeling of well-being. Evidence-Based Practice Proposal Final Paper.
Measuring Outcomes Based on Evidence
Evaluation of the outcomes or goals based on evidence will be done by analyzing the data trends from the formative and summative evaluation of practice (Mick, 2017). Reliability – that is replicability of the results – is assured by the use of triangulation in all respects (Friesen-Storms et al., 2014). For instance, three indicators are used – blood pressure, serum cholesterol, and well-being. Also, data analysis is done by multiple researchers. On the other hand, validity (the level at which the indicators and tools actually measure what is intended) is secured by carrying out a pilot trial of the practice (Dearholt, & Dang, 2018). All this leads to the question of applicability. Once the implementation passes the piloting phase, applicability is assured and dissemination follows.
Implications for practice are a paradigm shift in the management of hypertension. Future research will be needed to enumerate the extent of the benefit of exercise. Evidence-Based Practice Proposal Final Paper.
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