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DNP Practicum Practice Change Project Proposal

Student Name Miami Regional University

APPROVED:

Dr. Alex De Varona DNP, MSN, FNP-BC Professor of the DNP 7700

Co-Professor of the DNP7700 & Associate Dean Dr. Anny Dionne DNP, MSN-Ed., MBA-PM, RN

Implementation of an Evidence-Based Anti-Neuropathic Prescribing Protocol with a Structured Provider Education Program for Nurse Practitioners and Physicians in a Pain Management Clinic

Introduction

Lumbar radiculopathy is a very common cause of neuropathic pain seen in pain management practice and has been found to result in significant physical disability, reduced quality of life and increased health care utilization. Lumbar nerve root compression or inflammation often causes pain, numbness, weakness, and functional disability of the lower extremity, disrupting patients' daily functioning and work. The compression or inflammation of the lumbar nerve roots is often associated with radiating pain, numbness, weakness and functional disability of the lower extremity, negating patients' ability to function in their daily lives and work (Samant et al., 2024). While pharmacologic treatment is a mainstay, treatment with medication varies greatly between providers. Opioids are still used even though there is increasing evidence of the low long-term effectiveness and high dependency, side effect, overdose, and rehabilitation participation risk associated with opioid use (Nadeau et al., 2021). Antineuropathic drugs (such as pregabalin and gabapentin) are recently emerging as first-line pharmacologic treatments to relieve symptoms of lumbar radiculopathy without many of the adverse effects seen with opioid use, and their effectiveness in this role has been demonstrated (Giménez-Campos et al., 2022; Kwon et al., 2024).

The aim of this Doctor of Nursing Practice (DNP) practice change project is to implement an evidence-based antineuropathic prescribing protocol with a structured provider education program for nurse practitioners and physicians at Miami Wellness Pain Relief Center. The intervention recommended is to encourage the use of pregabalin or gabapentin as a first-line drug for adults with lumbar radiculopathy, rather than opioid drugs, to standardize the recommended treatment approach. The study will compare provider compliance with the prescribing guidelines, functional results, and the involvement in physical therapy during the 8 week implementation. The project's purpose is to enhance patient outcomes and facilitate safer, evidence-based pain management which aligns with organizational goals.

Problem Statement

Pharmacological treatment of neuropathic pain remains highly variable and is a challenge in the treatment of lumbar radiculopathy (LRP). Even with a growing body of evidence supporting the use of anti-neuropathic drugs as the first-line treatment, opioid use is still occurring widely in pain management practice (Nadeau et al., 2021). Ongoing opioid use puts people at risk for medication dependence, medication-related adverse effects, reduced participation in rehabilitation, and avoidable health care costs (Florence et al., 2020; Oster, 2023). Prescribing practices are variable, resulting in variable outcomes for patients and limiting the opportunity to offer patients standardized evidence-based care in clinical settings.

Inconsistent pharmacologic management of adults with lumbar radiculopathy among nurse practitioners and physicians is the practice problem in Miami Wellness Pain Relief Center. Lack of standardized evidence-based prescribing guidelines leads to inconsistencies in prescribing and may reduce optimal patient outcomes. The proposed DNP practice change project will focus on an evidence-based anti-neuropathic prescribing protocol along with provider education to optimize the consistency of prescribing and the clinical outcomes for patients. The focus PICOT question is: What is the effect of implementing an evidence-based antineuropathic prescribing protocol with a structured educational program vs. current opioid-based prescribing practices on: Patient pain functional results as measured by the Oswestry Disability Index (ODI), provider adherence to the prescribing guidelines, and patient self-reported participation in physical therapy for eight weeks, in nurse practitioners and physicians treating adult patients (≥18 years) with lumbar radiculopathy at Miami Wellness Pain Relief Center?

Objectives and Aims

The overall objective for this antineuropathic prescribing protocol and structured educational program DNP practice change project is to implement and evaluate an evidence-based protocol of the antineuropathic in the practice of nurse practitioners and physicians at Miami Wellness Pain Relief Center within adults with lumbar radiculopathy. The project aims to increase the use of evidence-based prescribing and ensure that patients are not over or under prescribing opioids and are achieving positive outcomes.

To achieve this goal the following goals have been identified:

· To adopt an evidence-based prescribing guideline for the first line of pharmacologic treatment of the adult patient with lumbar radiculopathy (LR) prescribing pregabalin or gabapentin.

· To offer education on the evidence behind the use of anti-neuropathic medications, safe prescribing, monitoring of medication use, dosage adjustments, and patient education to nurse practitioners and physicians.

· To increase provider adherence to standardized prescribing guidelines during the 8-week implementation period.

· To enhance patient functional outcome with Oswestry Disability Index (ODI).

· To enhance patient compliance with their prescribed physical therapy and rehabilitation activities utilizing better pain management.

· To reduce the use of opioid drugs for the treatment of lumbar radiculopathy, if clinically feasible.

· To encourage standardization of evidence based clinical practice that will assist in supporting organizational quality improvement efforts.

· To improve patient safety, with a focus on reducing risks of opioid prescribing, such as dependence and adverse drug events.

· To assess the impact of the intervention through measurable provider and patient outcomes that can be used to enhance sustainability across the organization.

Significance of the Practice Problem

Lumbar radiculopathy is a significant health burden globally as it impacts millions of adults and is a significant contributor to disability, chronic pain, impaired productivity and health care costs. Patients often suffer from persistent neuropathic pain with sensory dysfunction, muscle weakness, and reduced mobility, all of which have negative impact on physical function, emotional state, and quality of life (Samant et al., 2024). With the increasing aging of the population and the rise of degenerative spinal issues, healthcare providers are increasingly under pressure to deliver appropriate and safe-approach pain management solutions, with evidence-based treatments that have minimal long-term complications. Opioids have been commonly prescribed for chronic pain syndromes for a variety of reasons, including lumbar radiculopathy (Aparasu et al., 2026). But massive studies have shown that long-term opioid use is never typically associated with significant functional gains and carries significant risk of dependence, misuse, respiratory depression, cognitive impairment, falls, overdose, and death (Nadeau et al., 2021). The concerns have drawn national attention to safer pharmaceutical alternatives that can be used effectively to treat neuropathic pain and reduce the risks of opioid-related complications. Systematic reviews have shown that pregabalin and gabapentin are clinically meaningful analgesics for the pain reduction and improvement of functional recovery of patients with lumbar radiculopathy and are considered first-line pharmacologic treatment (Giménez-Campos et al., 2022; Kwon et al., 2024). However, there is significant variation in prescribing across healthcare organizations, and therefore standardization of the application of current evidence is limited.

The opioid crisis has had substantial economic impacts across the health care system. The economic costs are incurred in the ED, hospital admission, addiction treatment, loss of productivity, disability, criminal justice engagement and premature death. Opioid use disorder and fatal opioid overdose place a tremendous economic burden on the United States health care system and society, according to Florence et al. (2020). Over the past few years, the total economic cost of the opioid crisis has been estimated to be in the billions of dollars, even trillions, including lost productivity, health-care costs and societal costs (Oster, 2023). Opioid stewardship is becoming more of a patient safety measure and a key financial tool for value-based care. Also ethical, legal and professional implications associated with the practice problem exist; HCP's have an ethical responsibility to ensure effective pain management while reducing unintended suffering. Prescribing opioids when alternatives are effective could result in patient harm and/or diversion from best practices (Varkey, 2021). Expectations for responsible opioid use continue to increase from regulatory agencies for patient education, monitoring, documentation and prescribing. Healthcare organizations are consequently under greater pressure to define standardized clinical protocols to increase prescribing consistency, while remaining compliant to regulations and ensuring patient safety. In the nursing field, APRNs have a pivotal role in evidence based pain management that includes patient assessment, prescribing medications, educating patients, collaborating, and evaluating outcomes. Standardized prescribing protocols further enhance clinical decision making, limit unwarranted practice variation, foster communication between health professionals, and facilitate consistency in the adoption of current best evidence. Structured education interventions further build provider confidence and competency in the management of neuropathic pain and contribute to continual professional development.

The identified practice problem at Miami Wellness Pain Relief Center directly impacts patient care, providers, and/or organizational performance. It specializes in comprehensive, non-surgical pain relief and is provided by an interprofessional team of physicians, nurse practitioners and physical therapists who operate from multiple locations across Miami-Dade and Broward counties (Miami Wellness-Pain Relief Center, 2025). While personalized care is at the heart of its mission, some variation in prescribing patterns could mean that patients experience different outcomes, are exposed to unnecessary opioids, or have different rates of provider compliance with current, evidence-based prescribing guidelines. Often, patients who are under the care of Miami Wellness will come in and look for pain relief, the ability to function physically again and avoid surgery. The variability in drug treatment can delay rehabilitation, extend the duration of disability, decrease patient satisfaction and increase the number of clinical visits. Inadequate pain control can also reduce patient involvement in PT, which can hinder functional recovery and delay progress towards treatment objectives (Hirani et al., 2025). Standardizing first-line anti-neuropathic prescribing could lead to better reduction in pain with increased participation in rehab activities and better QOL.

In terms of the Miami Wellness's mission of delivering patient-focused, innovative, non-surgical pain relief using the most effective treatments available (Miami Wellness-Pain Relief Center, 2025), a standardized evidence-based prescribing protocol is of assistance. Better provider compliance with evidence-based guidelines can lead to fewer opioid-related adverse events, better regulatory compliance, better quality measures, higher patient satisfaction, and lower costs of avoiding unnecessary follow up and opioid-related complications. Implementation will be low cost, as the intervention is mainly provider education and standardized clinical protocols, and will create opportunities for sustainable quality improvement in several clinical sites. The practice problem is a meso-level systems problem, as its main focus is on organizational clinical practice and provider behavior in Miami Wellness Pain Relief Center. While the intervention will directly impact patient care, the focus will be on process improvements across the organization, such as the streamlining of prescribing processes, provider education, interprofessional collaboration, and quality improvement. Successful implementation could potentially be a model for wider organizational uptake and the dissemination of wider models in future in similar outpatient pain management organizations.

Synthesis of Literature: Verification of Chosen Option sections

This literature synthesis analyzed the current evidence on the clinical burden, clinical management of lumbar radiculopathy, limitations of opioid-based prescribing, effectiveness of antineuropathic medications, and the role of evidence-based prescribing protocols with provider education. Studies came in the form of systematic reviews, meta-analyses, clinical practice guidelines, randomized controlled trials (RCTs), observational studies, and Delphi consensus statements. Together, the evidence allowed a comprehensive overview of the current treatment recommendations and areas of agreement and controversy. The synthesis was used to identify the highest risk evidence-based intervention for practice improvement and the PICOT question.

Burden and Clinical Management of Lumbar Radiculopathy

The patients of lumbar radiculopathy suffer from high pain ratings, disability, poor physical performance, and use of healthcare resources. According to the findings of Wexler et al. (2025), the researchers stated that most of the patients with lumbosacral radiculopathy were suffering from symptoms and used various treatment methods such as medications, injections, exercises, and alternative medicine. The results of the study suggested that there is high variation not only in treatment options but also in the usage of medication. Similarly, according to the study conducted by Thoomes et al. (2022), every individual suffering from lumbar radiculopathy needs a personalized and progressive approach for treatment. Patient education, physical activity, exercise therapy, and functional rehabilitation as per the stage of the disorder emerged as the key principles in their Delphi study. These findings all suggest that multifaceted approaches are needed to manage lumbar radiculopathy patients, both symptomatically and functionally.

Supporting the findings, Bianchi et al. (2025) indicated that lumbar radiculopathy causes great harm to pain, mobility, muscle strength, and quality of life. The authors mentioned that patients experienced improvement in pain, sensory symptoms, disability, and quality of life during the whole treatment period, with over 25% improvement in ODI scores at 6 weeks. Similarly, Thoomes et al (2022) argued that the focus on improving physical function rather than simply treating pain was the factor that was also crucial for recovery. Nevertheless, Bianchi et al. (2025) noted that objective functional improvements, such as muscle strength and mobility, need more time in comparison with subjective improvements.

As supported by these results, Zhou et al. (2024) also observed that international clinical practice guidelines recommend an active and multi-modal approach towards treating LBP. Education, therapeutic exercise, patient empowerment, and physical activity were some of the modalities that received consistent recommendations from the reviewed guidelines. Similarly, according to Wexler et al. (2025), there is better agreement on the use of non-invasive treatments like education and physical activity, with medication being heterogeneous. These findings further support the move towards the rehabilitation approach, apart from pharmacological therapy. The research has also shown persistent issues related to drug treatment. According to Wexler et al (2025) and Zhou et al (2024), pharmacologic recommendations are somewhat different, especially when talking about opioids and other medications. According to Zhou et al (2024), opioid recommendations varied among guidelines, since limited benefit, side effects, and dependency were the factors considered. Wexler et al. (2025) also noted varying medication use for LRP patients as seen in their study, suggesting a variability in clinical decision-making.

Limitations and Risks of Opioid-Based Prescribing for Lumbar Radiculopathy

Exposures to opioids have been repeatedly linked to chronic opioid usage, a higher risk for dependence, and poor functional outcomes. Berardino et al. (2021) reported an association with patients who received opioids prior to spine surgery and post-surgical opioid use. Opioid side effects were also identified, such as dependence, adverse effects on breathing, risk of overdose, and difficulty recovering from opioid abuse. Likewise, Nadeau et al. (2021) found that long-term opioid therapy may confer inconsistent pain relief and limited results in function or in aspects related to quality of life. Users consuming higher doses of opioids had a greater risk of overdose and other harmful effects, highlighting the importance of careful dosing practices.

Supporting these results, Sardi et al. (2024) investigated opioid use in adult spinal deformity surgery patients and reported that those who were taking opioids preoperatively were more likely to continue taking opioids postoperatively and experienced less favorable pain outcomes. Around 34.2% reported using opioids prior to surgery; 30.7% reported continuing opioid use 2 years after surgery. Before surgery, opioid users reported higher levels of back pain than non-users, and higher pain levels in the back at follow-up than non-users. In addition, opioid use preoperatively was a significant predictor of continued opioid dependence at two years. Fay et al. (2026) found similar findings on prolonged opioid use among patients who were exposed to opioids before the surgery due to anterior cervical spine disorders. Opioid-exposed patients demonstrated much higher scores of opioid use at 6 months compared to opioid naïve patients. Patients who had prior exposure to opioids, even a short one, faced increased risks of opioid use after their surgeries. However, opioids did not contribute to improved levels of pain, disability, and quality of life, suggesting no clinical benefits from increased opioid use.

A few studies have shown the benefits of using opioid sparing and multimodal approaches compared to opioid-based techniques. Berardino et al. (2021) have found that the enhanced recovery program, including non-opioid therapy, neuropathic opioids, patient education, and early mobilization, reduced the use of opioids and improved outcomes. In addition, Nadeau et al. (2021) suggested that exercise, physical therapy, psychological, and multidisciplinary rehabilitation can help in managing chronic pain and reducing dependence on opioids. Speaking about the use of non-pharmacological treatment options, Trager et al. (2025) reported that adults diagnosed with sciatica and undergoing spinal manipulation by chiropractors had fewer adverse events associated with opioids than patients under usual medical treatment. The frequency of opioid-related adverse events was significantly lower among the former than among the latter. Patients receiving chiropractic treatment had fewer opioid prescriptions.

Effectiveness of Antineuropathic Medications for Lumbar Radiculopathy

The treatment of targeted neuropathic pain medications may positively affect outcomes in patients suffering from lumbar radiculopathy. Kwon et al. (2024) evaluated pregabalin and gabapentin in patients with lumbar radiculopathy and discovered that pregabalin provided superior short-term pain relief after six weeks. Pooled analysis demonstrated that VAS and NRS pain scores improved over longer follow-up periods (six to twelve weeks), in favor of pregabalin. However, no significant differences between the two drugs were seen at these extended time points. Likewise, Curone and Tullo (2023) reported a considerable pain-decreasing impact in those who took a blend of uridine monophosphate, acetyl-L-carnitine, and alpha-lipoic acid. For the observational group, the proportion of patients with a ≥3-point decrease in VAS score at 90 and 120 days was 93% and 98%, respectively. These findings collectively indicate that therapies that act on the mechanisms of neuropathic pain can help decrease symptom burden in people with radiculopathy.

Similarities were found across the studies when it comes to the key points of selecting medications based on evidence to treat lumbar radiculopathy. Both Kwon et al (2024) and Curone and Tullo (2023) confirmed that neuropathic pain-specific treatment resulted in better pain outcomes than less specific therapy. Likewise, Dadkhah et al. (2024) assessed the effectiveness of non-opioids for pain control with magnesium sulfate and caudal triamcinolone blocks, and observed substantial decreases in pain and disability scores following treatment. The interventions differed, but all studies stressed the need to choose therapies targeting pain pathways instead of treating the pain problem traditionally by using analgesics.

The relationship between pain improvement and functional recovery was also determined from the evidence. Dadkhah et al. (2024) specifically measured functional outcomes using the Oswestry Disability Index (ODI) and found reductions in disability scores after caudal block treatment. In the first month, ODI scores dropped around 50% in the triamcinolone group and 55% in the magnesium group. Likewise, Kwon et al. (2024) proposed that greater pain control provided by antineuropathic medications could facilitate more mobility and engagement in rehabilitation exercises, though there were no direct measures of functional outcomes. The results suggest patients may benefit from better pain management to become more active during physical therapy and more active in their lives.

However, differences and controversies exist within the current evidence. Price et al. (2024) studied the clinical practice guidelines, and their results showed no significant consensus on the pharmacological treatment of lumbosacral radiculopathy. Several classes of medications (anticonvulsants, antidepressants, corticosteroids, NSAIDs, and opioids) were described in the review, and many guidelines disagreed on recommendations for their use. Various recommendations were made regarding the use of anticonvulsants, with some suggesting their use and others against the use of anticonvulsants due to scarce supporting evidence. This variation demonstrates the importance of uniformity of prescribing techniques and training for providers to ensure clinical uniformity and consistency in the decision-making process. Safety while using medications was one more interesting point discussed in the literature review. According to Kwon et al. (2024), there was no significant difference between the effectiveness of medication in the treatment of dizziness and sedation. Dadkhah et al. (2024) stressed the necessity of being very cautious about the use of steroid-based methods due to potential side effects. Similarly, Curone and Tullo (2023) noted the need for further controlled trials before widespread adoption of supplement-based therapies.

Evidence-Based Prescribing Protocols and Provider Education

The research conducted by Khorami et al. (2021), Zaina et al. (2023), and Lee et al. (2025) shows that using evidence-based treatment protocols and educating providers is a key way of improving the treatment of patients with lumbar radiculopathy. The authors mentioned that following clinical practice guidelines allows for giving consistent and quality treatment, which is based on the best evidence. Moreover, research indicated that providing effective treatment includes not only giving drugs but also educating patients and promoting physical activity. Khorami et al. (2021) indicated that consensus existed among 23 International Clinical Practice Guidelines regarding patient education, physical activity, and conservative treatment. In a similar way, Zaina et al. (2023) noted the existence of four high-quality guidelines that suggested that education, self-management, exercise, and multimodal rehabilitation were part of their recommendations. Lee et al. (2025) also recommended conservative treatment as the most appropriate initial treatment strategy and rated exercise therapy highly due to its safety, low cost, and functional benefits. These discoveries show a general consensus for a structured, evidence-based management approach that should be used in clinical practice.

The consistent findings included the value of employing both pharmacological and nonpharmacological interventions together. Patient education and physical activity were both suggested in the two studies by Khorami et al. (2021) and Zaina et al. (2023) as key components of conservative treatment. Likewise, Lee et al. (2025) also heavily promoted the use of structured exercise and physical therapy as the first line of treatment before moving on to more invasive options. Rehabilitation was always regarded as a fundamental part of patient recovery in all the studies; however, never regarded as an adjunct to medication therapy.

Practice Recommendations

The quality of evidence is moderate to high level, including systematic review, meta-analysis of randomized controlled trials, and literature based on clinical practice guidelines. The number of available pieces of evidence is quite large, and the results are consistent among many healthcare settings. Patient education, physical activity, and conservative management are universally recommended in international guidelines for the treatment of patients with lumbar radiculopathy (Khorami et al., 2021). Although there are still discrepancies concerning medications, all the studies focus on an individualized approach and avoidance of opioid treatment.

The evidence also indicates the effectiveness of antineuropathic agents and other nonopioid treatments in patients who have lumbar radiculopathy. In the short-term, pregabalin was found to be more effective at reducing pain than gabapentin, while the results were less differentiated in longer follow-up periods (Kwon et al., 2024). Inclusion of targeted neuropathic pain management also led to significant decreases in pain intensity for patients experiencing radiculopathy (Curone & Tullo, 2023). Opioid-based treatment, on the other hand, was seen to contain a higher likelihood of extended use of such medications, dependency, and reduced benefits for functional gains. Opioid-sparing approaches, including education, nonopioid medications, and early rehabilitation, were shown to reduce opioid exposure while supporting recovery outcomes (Berardino et al., 2021).

According to the results, the recommended change in practice is the implementation of an evidence-based prescription protocol in treating patients with lumbar radiculopathy, along with the education of healthcare providers. The evidence suggests the practice as an intervention that increases the consistency of the procedure as well as maintains the prescribing within the literature and research available currently. Evidence-based guidelines increase the clinical decision-making process and help in implementing the use of exercise and conservative approaches in the management of the disease (Lee et al., 2025). The protocol should ensure the proper choice of the medicine used and prevent the use of opioids when unnecessary. This practice change may improve pain outcomes, support functional recovery, and enhance the quality and safety of lumbar radiculopathy management.

Evidence-Based Practice: Verification of Chosen Option

The chosen evidence-based practice intervention is the use of the evidence-based prescribing protocol for antineuropathic medication along with the educational intervention for nurse practitioners and physicians treating adult patients with lumbar radiculopathy. Clinical guidelines and education help improve adherence to evidence-based recommendations and ensure proper management strategies (Zaina et al., 2023). The chosen quality improvement intervention was chosen due to the existing literature proving the effectiveness of structured prescribing interventions that reduce opioid-related risks.

Theoretical Framework & Change Model

Evidence-based findings must be translated into a sustainable clinical practice using a structured approach that is based on theoretical and organizational frameworks that are established. For the Doctor of Nursing Practice (DNP) projects, using a nursing theory and validated change model is the key to how clinical practice can be transformed and patient outcomes can be improved. The Roy Adaptation Model (RAM) is a comprehensive nursing model which guides nursing interventions for achieving positive change in health outcomes for groups and individuals and provides a way to measure outcomes across all four domains of adaptation. This theoretical work is supported by the Change Model developed by Lewin which gives a practical and predictable model for the implementation of organizational change in the three stages of unfreezing, changing and refreezing (Ellis, 2023). The frameworks, together, will target individual patient adaptation and organization practice transformation systematically as a part of the implementation of an evidence-based antineuropathic prescribing protocol along with a structured educational program for adult patients with lumbar radiculopathy at Miami Wellness Pain Relief Center.

Theoretical Framework

Sister Callista Roy's Roy Adaptation Model (RAM) is the foundation for this DNP project. DNP education and integrative practice experiences are especially appropriate for the use of RAM as it offers direction for the creation of positive health outcomes for people and groups. The focus of adaptation as a key concept for nursing practice and working in interprofessional teams is the perfect fit for this project's objective of changing prescribing behaviors through evidence-based guidelines and patient structured education (Lee et al., 2025). Practice generalizability can be used to adapt in one setting, leading to more adaptable changes in the healthcare system as a whole. This theoretical basis provides the basis for addressing not only the physiological aspects of pain management, but also the psychosocial aspects of patients adapting to chronic pain conditions in this change in practice.

The four adaptive modes identified by the RAM form the main premises in the framework: the physiologic-physical mode, the self-concept-group identity mode, the role function mode and the interdependence mode. Physiologic – physiological mode focuses on the physiological needs and functioning of the body, which is directly related to the patient's pain and response to pharmacologic treatment in patients with lumbar radiculopathy. Mode is the mode of the interaction between individuals, as a physical organism, and the environment and is the expression of the physiological processes of cells, organs and systems. Clinical practice guidelines for lumbar disc herniation (LDH) with radiculopathy focus on all-inclusive guidelines that incorporate multiple international evidence-based guidelines and expert opinions from a multidisciplinary group to improve treatment outcomes (Lee et al., 2025). Self-concept-group identity mode refers to the mode of the individual in terms of psychological and spiritual components, such as the way a patient views his or her pain condition and what options are available for treatment, and includes the combination of beliefs and/or feelings that a person has about himself or herself at any specific time. The role function mode highlights ways in which people carry out their social roles that may be negatively affected by chronic pain and disability; whereas interdependence mode emphasizes relationships and support systems that affect health outcomes and adherence to treatment.

RAM for this DNP project must be translated to the context of implementing antineuropathic prescribing protocols. The project in the physiologic-physical mode is based upon the premise that when treating radicular pain, the neuropathic component requires evidence-based treatment protocols with gabapentin. The currently available analgesics are just able to control the nociceptive part of pain, while a more holistic approach would simultaneously include the use of neurotropic analgesics targeting the neuropathic part, to achieve better pain relief and reduce the use of potent opioids. Preserving conservative care options such as individualized advice and information for self-care, as well as a physical and psychological package are recommended as well as pharmacological management in clinical practice guidelines. The physiologic adaptation is assessed with a modification of pain score and functional outcome based on the Oswestry Disability Index (ODI) (Powers et al., 2026). The self-concept-group identity mode is implemented by the structured educational program component, which allows patients to learn about their disease and treatment options and thus gain in their sense of control and self-efficacy. Role function mode operationalization deals with the question of how lumbar radiculopathy and current opioid use impacts patients' role function in the domains of occupation, family, and social roles. The educational component emphasizes patient empowerment in their opioid treatment program as a component of a comprehensive care plan, and stresses the importance of physical therapy participation. Interdependence is enacted by collaborative working relationships among nurse practitioners and physicians at Miami Wellness Pain Relief Center and by the patient-provider relationship and shared decision-making. The middle range theory template helps the practice-experienced scholar identify the stimuli and coping processes and the adaptive modes that describe the problem, activity, and outcome in adaptive terms, which can aid in evidence-based practice initiatives.

Change Model

The evidence-based practice change is going to be implemented at Miami Wellness Pain Relief center using Lewin's Change Model as the framework for change. The three-stage model – unfreeze, change, refreeze – has been found to work well in the implementation of nursing and was chosen because it has been effective in the implementation of practice changes that involve the skills, behaviors, culture and service delivery elements of a change. Lewin's model provides structure and predictability in complex change and aids a leader in predicting the challenges, involving employees and maintaining improvements over time (Raza, 2024). The model has been successfully adapted to be used in healthcare organizations to change patient outcomes through changes in the care model and offers a means to practically frame local and system-based nursing initiatives. The patterns are especially relevant for this organizational change, as the model extends beyond individual clinician behavior to patterns of system-level practices, which is important when making a transformation to evidence-based treatment approaches for antineuropathic pain rather than using opioids (Dowell et al., 2022). Lewin's theory states that the equilibrium of an organization can be upset by driving and restraining forces, and it may be easier to make changes by trying to eliminate the restraining forces and/or to reduce the strength of the restraining forces.

Unfreezing involves preparing the organization for change by increasing its readiness and urgency. This phase starts with an in-depth review of existing prescription information and statistics at Miami Wellness Pain Relief Center such as opioid prescription rates, patient functional outcomes based on ODI scores, physical therapy referral and participation. Education sessions will be provided to educate nurse practitioners and physicians about the rationale behind best practice bundles and the importance of decreasing opioid use when treating lumbar radiculopathy (Dowell et al., 2022). Important activities are the identification of key players, especially informal leaders and staff members who are actively involved who will be effective change agents and champions. Charge nurses and clinical champions are recognized early as key to everyday operations and coached specifically in change management, and emotional intelligence prior to the implementation. Highly engaged staff, members of shared governance, are identified as informal leaders to help spread the idea of the change, provide initial feedback and build a collective sense of urgency to improve. The preparation time also sets up data baselines and plans regular communication, both weekly and daily, about the current situation and upcoming changes, thereby exciting the teams about the change. To ensure there is always someone available to support change champions, all staff members are included, not just during the day, but also on evenings and weekends.

During the changing phase, the evidence-based prescribing protocol and structured educational program are implemented, and the implementation team coordinates intensive and ongoing at-the-elbow peer coaching and guidance. The practice change involves transitioning away from current opioid-based prescribing to an antineuropathic prescribing protocol with gabapentin along with NSAIDs to treat the inflammatory aspect of radicular pain (Dowell et al., 2022). The clinical practice guidelines suggest that Epidural Steroid Injection or surgery should be considered only in cases where radicular symptoms persist following 3 months of best conservative treatment. During this stage, the structured educational program for patients is initiated to improve the understanding of the mechanisms of lumbar radiculopathy, medication adherence and physical therapy engagement. Daily accountability mechanisms are put in place in team huddles to check implementation progress, and to address and celebrate early successes and implementation setbacks. Purposeful rounding by local leadership to collect first hand feedback from patients on the new prescribing approach and the educational interventions (Raza, 2024). Consistent communications with system leaders help to ensure support is in place and local accountability for practice bundle adoption is upheld. Rewards and weekly/ monthly awards are popular and publicized throughout the organization to build momentum and encourage good behavior. Change process also involves immediate targeted coaching on deviations from new processes, creating culture of accountability and continuous improvement.

The refreeze stage involves embedding the new prescribing practice and educational program into the norm of the daily operations at Miami Wellness Pain Relief Center. The phase is ongoing with existing accountability measures in place such as daily and weekly team meetings to discuss adherence to the prescribing guidelines, missed opportunities for care and patient results. Calls provide opportunities for immediate solutions to barriers and continued assistance in implementation (Crawshaw & McCleary, 2025). The project will monitor several indicators such as provider compliance with prescribing guidelines, patient functional outcomes (measured by ODI) and patient involvement in physical therapy. Data transparency is crucial for sustaining; regular progress reporting towards goals, and celebrating victories to encourage positive behavior. The refreezing phase includes strategies for cultural integration, to make the change in behavior part of the organizational culture. This involves integrating the protocol into provider orientation, updating clinical policies and procedures and continuing education for current providers. During the unfreezing stage, clinical champions are identified and will act as a resource for colleagues, mentoring and supporting them as the practice change is established (Prosci, 2024). Spot checks and data monitoring are implemented on a regular basis to reinforce the change as the new way of doing things within the department, and change managers are encouraged to recognize the progress made with staff, and advertise the success through the department communication board or at meetings. This sustainable pathway provides patients with lumbar radiculopathy with the best evidence-based, optimal and non-opioid focused care.

Organizational Need, Operational Framework, and Implementation Strategy for the DNP Practicum

The main organizational issue that will be targeted in this Doctoral Practicum project is optimization of prescribing practices and clinical management strategies for the adult population with a diagnosis of lumbar radiculopathy in an outpatient pain clinic environment. Despite recommendations from the literature and baseline clinical audit and retrospective organizational data, there was a troubling pattern of opioid analgesics being used as a first-line or primary choice of intervention, with inconsistent documentation of alternative evidence-based treatments, and delayed or infrequent referral to physical therapy for patients with a primary complaint of pain. Lumbar radiculopathy is one of the most significant causes of chronic musculoskeletal disability and functional decline, but the clinical workflow often does not align with the current recommendations from the federal and professional groups that have developed recommendations for the treatment of this disorder (Newton et al., 2026). In the absence of a standard decision making process, clinicians become cognitively overloaded, suffer from workflow inefficiencies and continue to prescribe opioids at high rates, which puts patients at increased risk for adverse effects, dependence, and decreased functional recovery. This is where an interactive, point-of-care printed evidence-based prescribing protocol and structured provider education come into play to address the gap. This evidence-based project aims to reduce opioid prescribing without increasing the risk of overdoses and improve the accuracy of the opioid prescription, patient education, engagement in physical therapy and patient functional outcomes at 8 weeks as measured by the Oswestry Disability Index (ODI) directly by addressing the gap between current clinical practices and standard guidelines.

Organizational Support

Support from leadership and provision of resources are essential to the successful implementation of this practice change. Clinic leadership, the medical director, clinical preceptor, and nursing leadership will support the printed protocol and provider training. Resources will focus on provider education, printed materials, routine clinical-record review, and project data collection; no IT resources or EHR integration are required.

Project Stakeholders

The multi-level nature of stakeholders is crucial in the success of this quality improvement initiative. Multi-level stakeholders involvement in the microsystem, mesosystem and macrosystem is crucial. The primary stakeholders at the microsystem level are the nurse practitioners, physicians, medical assistants and patients presenting at the pain clinic with lumbar radiculopathy and the site preceptor (the clinical champion). At the mesosystem level, stakeholders include managers of the clinic departments, the IT and clinical informatics staff managing the EHR, and regional quality improvement committees that monitor measures of prescribing (Newton et al., 2026). The macrosystem level of stakeholders includes the executive board of the broader health care organization, regional health policy makers and public health agencies focused on mitigating the national opioid crisis. By involving these various populations, the clinical objectives are aligned, regulations are met, and everyone is onboard.

SWOT Analysis

Strengths

The outpatient pain clinic has an interprofessional team of nurse practitioners and physicians who are engaged in quality improvement and evidence-informed clinical practice. The project will use a standardized printed prescribing protocol and paper-based quick-reference materials; it will not require EHR integration, software development, or electronic clinical decision-support alerts.

Weaknesses

Although the organization is prepared, documentation practices vary across providers, making retrospective review and consistent tracking of non-pharmacological interventions challenging. Providers also have limited time during patient visits. Clinical inertia toward early opioid use may delay consideration of appropriate alternatives. The printed protocol, concise provider education, and standardized paper-based data collection forms are intended to address these constraints without adding electronic alerts or changing the EHR.

Opportunities

Opportunities to improve practice include strengthening interprofessional collaboration, standardizing the use of a printed clinical protocol, and coordinating with physical therapy services. The Oswestry Disability Index (ODI) can provide a standardized measure of functional status. Findings may inform future quality-improvement work, but no EHR-integrated decision-support tool or electronic workflow build is proposed.

Threats

Potential external threats include staff turnover, competing clinical priorities, and patient-level barriers such as expectations for rapid pain relief or insurance limitations on physical therapy. These threats will be addressed through standardized orientation materials, brief provider education, printed protocol copies, stakeholder communication, and patient education. Software maintenance and IT outages are not anticipated to affect the intervention because the protocol is printed and is not integrated into the EHR.

Barriers and Facilitators

Potential barriers include provider resistance to changing established prescribing patterns, competing clinical priorities, and patient difficulty adhering to physical therapy recommendations. Facilitators include leadership support, concise provider education, the printed protocol, regular interprofessional communication, and feedback on prescribing patterns and ODI outcomes.

Project Schedule

The practice change will be implemented over eight weeks. Week 1 will include baseline data review, finalization and distribution of the printed protocol, and provider education. Weeks 2–7 will be the active implementation phase, during which nurse practitioners and physicians will consult the printed protocol during eligible encounters and record relevant care decisions in the usual clinical record and project forms. Week 8 will include post-implementation data collection, comparison of pre- and post-implementation outcomes, and a stakeholder debriefing.

Resources Needed

The project requires human and material resources rather than new technology. Resources include the DNP student project manager, site preceptor, participating nurse practitioners and physicians, printed copies of the prescribing protocol, the provider-education PowerPoint presentation, quick-reference guides, case examples, data-abstraction forms, and authorized copies of the Oswestry Disability Index (ODI). Existing clinical records may be reviewed through approved access for baseline and outcome data; no IT development or EHR integration is required.

Project Manager Role

The Doctor of Nursing Practice (DNP) student will become the project manager of this evidence-based practice project, using the principles of transformational leadership to create change in an organization and promote interprofessional commitment. Transformational leadership is a style well suited to improving healthcare quality, with a focus on inspiring a vision, stimulating team members' thinking, and personalized care for team members. The project manager will actively involve nurse practitioners, physicians, clinical preceptors, and informatics specialists in the implementation of the printed evidence-based prescribing protocol for the management of lumbar radiculopathy (Ibrahim et al., 2024). The project manager will help alleviate clinical inertia by clearly communicating the clinical rationale, reduce unnecessary opioid use and increase access to evidence-based antineuropathic and non-pharmacological treatment, and minimize resistance to workflow change. Empathetic leadership, feedback systems that are open, and a clear commitment to the needs of providers will help to make the clinical team feel supported, valued and empowered in the practice transition.

The DNP student project manager will coordinate the eight-week schedule, communication, provider education, and data collection. The manager will distribute the printed protocol, confirm completion of the PowerPoint-supported education session, monitor use of the protocol through the project fidelity form, review clinical-record data, and address implementation barriers with clinic personnel. No electronic workflow prompts will be built or launched.

Plans for Sustainability

Sustainability measures will include retaining the printed protocol in the clinic’s approved clinical reference location, incorporating the protocol and PowerPoint-supported education into provider orientation, and conducting periodic audits of prescribing and physical therapy referral patterns. The protocol will not be embedded in clinical order sets or EHR templates.

Project Vision, Mission, and Objectives

The DNP project aims to enhance evidence-based management of adults with lumbar radiculopathy through a printed evidence-based prescribing protocol and structured provider education in a pain management clinic.

The goal of this project is to build a culture of evidence-based clinical decision making that will always support safe, effective and patient-centered care for people living with lumbar radiculopathy. The long-term vision is to foster ongoing changes in practice beyond the implementation period that help to decrease the unnecessary use of opioids and promote interdisciplinary collaboration, while improving the quality of life for patients by incorporating comprehensive pain management strategies (Amin et al., 2026). The project aims to develop a protocol that can be easily incorporated into clinical practice and possibly be implemented in other pain management applications.

The project promotes evidence-based prescribing by distributing and implementing a printed protocol and providing structured provider education. Providers will consider antineuropathic medications when clinically appropriate, reinforce patient education, consider physical therapy referral, and review functional status using the ODI.

The project is very similar in scope to the mission and vision of the practicum organization's organization, which focuses on providing high-quality, patient-centered, safe and evidence-based pain management services. Most modern clinics now aim to maximize the positive outcomes of their treatment for patients, whilst reducing the risks associated with treatment by working in a multi-disciplinary team and through continuous quality improvement and compliance with the national clinical guidelines (Amin et al., 2026). The proposed DNP project directly addresses the organizational priorities by advancing evidence-based prescribing practices, fostering interdisciplinary communication among providers and physical therapists, optimize patient education, and initiate quality improvement projects that will decrease overdose exposure to opioid medications.

Short-term objectives during the eight-week implementation period include educating participating providers using the uploaded PowerPoint presentation, distributing and implementing the printed protocol, improving documentation of evidence-based prescribing decisions, increasing appropriate physical therapy referrals and patient education, and collecting ODI scores when applicable.

Long-term goals include maintaining provider adherence to evidence-based guidance, enhancing functional outcomes, mitigating avoidable opioid-related risks, fostering interdisciplinary collaboration, and sustaining use of the printed protocol through clinic policy, provider orientation, and periodic review.

PICOT Question

The following PICOT question will serve as the basis for the proposed DNP project:

In nurse practitioners and physicians treating adult patients with lumbar radiculopathy at a pain clinic (P), will implementation of a printed evidence-based anti-neuropathic prescribing protocol with structured provider education (I), compared with current prescribing practices (C), improve adherence to evidence-based prescribing guidance by reducing avoidable opioid prescriptions, increasing appropriate antineuropathic medication prescribing, enhancing patient education, increasing physical therapy referrals and adherence, and improving patient functional outcomes measured by the Oswestry Disability Index (ODI) (O) over an eight-week period (T)?

Population.

The target population is nurse practitioners and physicians who treat adults with lumbar radiculopathy in an outpatient pain management clinic. Approximately 6–10 providers are expected to participate. Providers regularly assess symptoms, prescribe treatment, educate patients, and coordinate referrals for conservative management. The intervention is a printed protocol supported by structured provider education; it is not an EHR-integrated tool.

Outcome data will be based on patient records. There will be an expectation of 40-60 adult patient encounters in the implementation period. Patients will not be recruited directly, but rather, via routine clinical visits, since this project is not human subjects research, but rather an evidence based quality improvement project. Approval will be sought from the institution as per the policy. There is no individual informed consent unless there are experimental treatments in the course of patient care, which will be based on and follow published evidence-based recommendations.

Adults (age 18 years or older) who are diagnosed with lumbar radiculopathy and treated during the implementation period by participating providers are included in the study. Patients should have a history of documented lumbar radiculopathy and be referred for pharmacologic treatment and physical therapy. Exclusion criteria are those who are under the age of 18 years, those with malignancy in the spine, those with an infected spine, those who had a recent spine trauma that needed emergency surgery, pregnant women, and those who are going to be undergoing immediate surgical treatment.

Intervention.

The intervention involves adoption of a printed evidence-based anti-neuropathic prescribing protocol with structured provider education. The protocol will guide clinicians through assessment, red-flag screening, individualized treatment options, patient education, physical therapy consideration, and functional assessment with the ODI. It will be informed by the VA/DoD Clinical Practice Guideline for the Diagnosis and Treatment of Low Back Pain and relevant supporting evidence. The protocol supports, but does not replace, provider judgment; medication selection remains individualized and clinically appropriate.

Provider education will use the uploaded PowerPoint presentation and will cover the purpose of the project, the VA/DoD Clinical Practice Guideline for the Diagnosis and Treatment of Low Back Pain as the guiding clinical practice guideline, conservative management of lumbar radiculopathy, opioid stewardship, appropriate medication alternatives, physical therapy referral, patient education, ODI administration, and documentation expectations. Printed copies of the protocol, a workflow diagram, quick-reference guide, case examples, and written instructions will reinforce the education.

The printed protocol will prompt providers to assess symptoms and red flags, consider evidence-based treatment options, document patient education and clinical reasoning in the usual clinical record, consider physical therapy referral, and measure functional status with the ODI when appropriate. The protocol is a paper-based aid to clinical decision-making and does not require EHR integration, electronic alerts, or software changes. Providers retain responsibility for individualized clinical decisions.

The results of the studies that support the use of clinical decision-support tools are very consistent, showing benefits for provider adherence to clinical guidelines, prescribing accuracy, patient safety, and quality of care. Evidence-based educational interventions enhance clinician knowledge, adherence to best practices, and promote sustainable practice change (Horsom et al., 2026). The current national clinical guidelines suggest a conservative approach for the treatment of lumbar radiculopathy, with a focus on non-opioid pharmacologic treatments, physical therapy, patient education, and continued functional evaluation prior to recommending opioid and/or invasive therapies.

Comparison.

The comparison condition is current clinic practice before implementation of the printed protocol. Providers currently do not have a standardized paper-based decision-support tool specifically developed for managing lumbar radiculopathy and rely on individual clinical judgment. Variation may occur in medication selection, documentation of patient education, referral patterns, and functional outcome monitoring.

Current practice shows inconsistent documentation of adherence to guidelines, variability in the prescribing of opioids, inconsistent initiation of antineuropathic medications, minimal standardized patient education and inconsistent utilization of physical therapy referral. The incidence of routine use of the standardized instrument (ODI) to measure functional outcomes isn't reported, which makes it challenging to objectively assess patient progress over time. Baseline data will be collected in a retrospective manner prior to the intervention implementation and will be used for comparison. The baseline information will help to compare provider adherence and patient outcomes before and after implementation of the printed protocol.

Outcome.

Multiple outcomes will be assessed to determine the effectiveness of the intervention. Primary outcomes involve decreases in opioid prescription, more use of prescribed evidence-based antineuropathic medications, more adherence to provider prescribing guidelines, more documentation of patient education, more referrals and adherence to physical therapy, and better functional outcomes for patients.

The Oswestry Disability Index (ODI) is a standardized questionnaire used to measure functional status. The project will use an authorized copy of the ODI, subject to applicable institutional and instrument-use requirements. The completed instrument will be scored according to its instructions, and the project will retain only the minimum information needed for outcome analysis.

Patient education and the provider’s treatment rationale will be documented in the usual clinical record and, where applicable, on the paper-based project form. Medication prescribing and physical therapy referrals will be abstracted from approved clinical records for the baseline and implementation periods. The ODI will be administered at the first eligible encounter and at follow-up when clinically appropriate. Demographic and clinical data will be limited to variables needed to describe the sample and assess outcomes.

Time Frame

The implementation phase of the proposed evidence-based practice project will be eight weeks long to allow for provider education, implementation of the printed evidence-based prescribing protocol, data collection, appropriate monitoring of intervention fidelity, evaluation of outcomes, and analysis of project results.

Feasibility

Given the eight-week timeline, the project is feasible because it requires no new organizational structure, software, or EHR integration. Providers will receive a brief education session supported by the PowerPoint presentation and use the printed protocol during routine care. Retrospective baseline data and implementation-period data will be abstracted from approved existing clinical records and project forms. Outcomes include prescribing patterns, documentation of patient education, physical therapy referrals, and ODI scores.

Factors that may create a barrier consist of provider resistance to process changes, provider variability in adherence with the printed protocol, provider competing clinical priorities, and patient variability in compliance with physical therapy recommendations. A range of barriers will be tackled by engaging early with stakeholders, securing leadership support, educating providers, providing regular performance feedback and maintaining communication during the implementation period (Alodhialah, 2025). Simple workflow tools, reminder materials, and ongoing monitoring will enhance fidelity of intervention and ensure the consistent use of the printed protocol. Project Stakeholder meetings will ensure that implementation issues are quickly identified and addressed. The intervention is based on evidence-based recommendations and does not require much extra resources, making it possible to be completed within 8 weeks and sustainable practice change.

Sample and Setting

The proposed DNP project will be carried out in an outpatient pain management clinic, which specializes in the diagnosis and treatment of acute and chronic musculoskeletal pain syndromes, including lumbar radiculopathy. The multi-disciplinary team of nurse practitioners, physicians, nurses, medical assistants, rehabilitation specialists and administrative staff are all working together to ensure the best possible patient outcomes in the management of pain. The outpatient setting is an ideal context for the implementation of evidence-based clinical decision support, as providers are continually assessing patients that need medication management, patient education and referrals for conservative treatment.

The average patient that visits the clinic is an adult patient with a chronic or subacute lumbar radiculopathy from a chronic degenerative spine condition, herniated intervertebral discs, spinal stenosis or associated musculoskeletal conditions. Patients often have chronic back pain with associated symptoms in the lower extremities such as pain, numbness, weakness, or decreased functional ability for activities of daily living. Many patients suffer from several chronic conditions and require a complex pain management approach, focusing on non-pharmacologic as well as pharmacologic therapies.

The mission of the clinic is to provide timely, evidence-based, patient-centered and compassionate care, and to enhance pain management outcomes and patient safety. It has a vision of becoming a regional innovator, quality improver and leader in comprehensive multidisciplinary pain management, through excellence in clinical care (Alodhialah, 2025). Opportunities for implementing evidence-based interventions to reduce unnecessary opioid prescribing and enhance patient function and quality of life are strongly supported by organizational priorities.

The organization has physician leadership, advanced practice registered nurses, nursing staff, rehabilitation staff, administrative leadership, and quality-improvement staff. Its culture emphasizes evidence-based practice, professional development, interdisciplinary communication, patient participation, and quality improvement. This environment can support implementation and sustainability of the printed prescribing protocol.

Implementation Plan/Procedures

The proposed DNP project will evaluate implementation of a printed evidence-based anti-neuropathic prescribing protocol and structured provider education to improve evidence-based care for adults with lumbar radiculopathy in an outpatient pain management clinic. The project will use an eight-week implementation period and a pre/post quality-improvement design, subject to the institution’s review and determination. The goal is to reduce unwarranted variation in prescribing, encourage appropriate pharmacologic and nonpharmacologic care, strengthen patient education and physical therapy referral, and assess functional outcomes using the ODI. Approximately 6–10 nurse practitioners and physicians and an estimated 40–60 eligible patient encounters may be included. Activities will include preparation, retrospective baseline assessment, provider education, distribution and use of the printed protocol, monitoring, and evaluation. The project manager will secure required organizational approvals and work with the clinic medical director, providers, nursing and rehabilitation staff, and other relevant stakeholders. The project does not include an EHR-integrated tool or software build.

An eight-week retrospective baseline period will be reviewed before implementation. Approved existing clinical records will be examined for opioid prescriptions, appropriate antineuropathic medication prescriptions, documentation of evidence-based prescribing considerations, patient education, physical therapy referrals and adherence when available, and ODI scores when available. A standardized paper-based data-abstraction form will be used. Before implementation, providers will receive structured education using the uploaded PowerPoint presentation. Education will identify the VA/DoD Clinical Practice Guideline for the Diagnosis and Treatment of Low Back Pain as the guiding guideline and cover conservative management, opioid stewardship, appropriate medication alternatives, physical therapy referral, patient education, ODI administration, and documentation expectations. The intervention materials will include the printed protocol, PowerPoint presentation, workflow diagram, quick-reference guide, case examples, and written instructions.

After provider education, the printed protocol will be made available for use during eligible clinical encounters. It will guide providers in evaluating symptoms and red flags, considering individualized treatment options, documenting patient education and clinical reasoning, considering physical therapy, and assessing functional status with the ODI when appropriate. Providers will continue to document care in the usual clinical record. The printed protocol will assist, not replace, clinical judgment. No electronic decision-support tool, EHR integration, electronic prompt, or IT build will be used.

The DNP project manager will conduct fidelity checks during weeks 1–8. Reminders and feedback will support proper use of the printed protocol. Weekly monitoring will assess provider participation, completion of education, documented use of the protocol, and completion of required project forms. The project manager will maintain a paper-based or institutionally approved electronic fidelity log and communicate barriers to the project mentor and organizational stakeholders.

Data Collection Procedures

Retrospective baseline data and implementation-period data will be collected from approved existing clinical records and paper-based project forms. Baseline data will cover the eight weeks before implementation; implementation data will cover the eight-week intervention period. The same eligibility criteria, operational definitions, and data-collection procedures will be used in both periods. Data will relate to eligible adult encounters for lumbar radiculopathy managed by participating providers.

The main data source will be approved existing clinical records, supplemented by the paper-based project data-abstraction form and ODI where applicable. Names and medical record numbers will not be included in the analytic dataset; a unique project identification number will be used. Variables may include age, sex, diagnosis, provider type, encounter date or period, opioid prescription, antineuropathic medication prescription, documentation of evidence-based alternatives, patient education, physical therapy referral and documented adherence, baseline and follow-up ODI scores, and eligibility variables. Access will follow institutional authorization and privacy procedures.

The outcome variables will be various forms of measurement. The age of patients will be a continuous variable. Sex and provider type will be nominal categorical variables. Opioid prescribing, antineuropathic medication prescribing, documented patient education and physical therapy referral will be dichotomous nominal variables at the encounter level, with ‘yes' or ‘no' codes. The counts of prescriptions and referrals can also be summarized. Documentation (such as whether the physical therapy was attended or not) will be treated as a dichotomous variable and the number of therapy visits as a count variable for physical therapy adherence. ODI scores will be considered as continuous percentage values ranging from 0% to 100%, with the higher the score the more disability. The original project proposal outlines the ODI as being 10 sections with each section being scored from 0 to 5 and the disability score then calculated as a percentage.

The guideline adherence will be implemented by applying a pre-established guideline documentation criterion. An encounter will count as guideline-adherent if the provider records considering or using evidence-based alternatives to opioids when clinically appropriate, before prescribing opioids. The denominator will be all eligible encounters that involve medication-management decision making. The numerator will consist of time spent in encounters where the pre-defined elements of evidence-based decision making are recorded. A percentage for adherence to the guideline will then be calculated as:

Guideline adherence (%) = encounters that meet guideline requirements / total number of eligible encounters x 100.

Opioid prescribing will also be reported as a rate instead of only raw counts as the number of encounters can vary between the baseline period and intervention period. Opioid prescribing rate will be defined as the proportion of eligible encounters for which opioid was prescribed to the number of eligible medication-management encounters. The denominator for the rate of antineuropathic medications will be the same. The proportions of eligible encounters for patient education and physical therapy referral will also be reported.

Potential confounding will be addressed by applying the same inclusion and exclusion criteria, clinic setting, provider group, outcome definitions, and eight-week comparison periods. The project will document provider participation and whether required education was completed. Patient characteristics will be summarized for both periods. Changes in staffing, prescribing policy, physical therapy availability, or use of the printed protocol will also be documented.

Standardized definitions, a data dictionary, duplicate review of a sample of data and missing or inconsistent entries will be incorporated into a data quality procedure. Before full data collection the data abstraction form will be reviewed by the DNP project manager. When patient does not complete, missing ODI scores will not be imputed. Rather than that, the extent and distribution of the missing ODI data will be reported. Documented nonadherence will be differentiated from nonadherence with physical therapy. Formative assessment will happen during the implementation. The documented use of the printed protocol at the weekly level, completion of provider education, and documentation compliance and workflow barriers will be assessed. Summative evaluation will be conducted at week 8 and will make comparisons between baseline and implementation outcomes. This separation will allow the project team to assess the effectiveness of the intervention, and whether the intervention was delivered in a way that can reasonably be considered to have led to the desired outcomes.

Recruitment and Selection

Approximately 6–10 nurse practitioners and physicians who treat adults with lumbar radiculopathy will participate. Provider eligibility will be based on responsibility for assessment, prescribing, education, and treatment coordination at the clinic. Providers must complete the project education and be involved in care for eligible patients. Patient outcomes will be abstracted from routine clinical records and project forms; patients will not be directly recruited solely for data collection.

Patient-level data will be identified from typical clinical visits, not from direct research recruitment. Adults (age 18 or older) with a documented diagnosis of lumbar radiculopathy, receiving care from a participating provider during the baseline or intervention period will be included. Patients should have a diagnosis of lumbar radiculopathy documented in their medical chart and be undergoing or planning pharmacologic treatment and/or conservative care including physical therapy. Exclusion criteria will be as follows: patients less than 18 years of age, patients with spinal malignancy, spinal infection, recent spinal trauma requiring emergency surgery, pregnancy, patients to be treated with immediate surgery. These are the same criteria that were set forth in the project's Week 6 proposal.

The project examines a change in practice within an established clinical context where random assignment of a practice change is not required or feasible, thus a quasi-experimental preimplementation/postimplementation design is appropriate. The 8 week baseline and the 8 week implementation time will be compared to each outcome. If the weekly data are available, weekly outcome rates will also be analyzed for trends. While interrupted time-series methodology is known to be a helpful way to assess quality-improvement interventions in healthcare systems, the limited 8-week period may not allow for sufficient time points to conduct a thorough interrupted time-series analysis. As such, the main analysis will be conducted through pre/post comparisons, and descriptive/exploratory analysis will be performed when deemed appropriate, particularly for the weekly trend data.

Data Analysis Plan

Data Preparation

During the eight-week intervention period, the analysis will assess the impact of the printed protocol and provider education on adherence to evidence-based prescribing practices and patient outcomes. Analysis will occur after data collection and quality checks. Descriptive and, where appropriate, inferential statistics will be selected according to the measurement level and sample size. Interpretation will consider effect sizes, confidence intervals, and clinical significance in addition to p values.

The initial step will be data cleansing. The data set is expected to be checked for duplicate encounters, missing data, implausible data, inconsistencies in coding and eligibility classification. Each variable will be defined in a data dictionary along with its coding, measurement level, numerator, denominator and possible values. The categorical variables will be coded uniformly and continuous variables like age and ODI score will be checked for range and distribution. No missing data will be automatically completed, but will be quantified instead. The number of completed baseline and follow-up instruments will be reported separately for the ODI.

The baseline and implementation groups will then have descriptive statistics calculated. Categorical variables (sex, opioid prescribing, antineuropathic medication prescribing, patient education, physical therapy referral, and physical therapy adherence) will be summarized by frequencies and percentages. Approximately normally distributed continuous variables like age and ODI scores will be presented as means and standard deviations. Where continuous variables are significantly skewed, medians and interquartile ranges will be used.

Primary Outcome: Guideline Adherence

The main process outcome will be adherence to evidence-based prescribing guidelines by the provider. Compliance with guidelines will be expressed as the percent of eligible encounters that meet the documentation and treatment requirements of the project. The preimplementation percentage compared to the implementation percentage will be compared. The guideline adherence is categorical type of outcome measure; therefore, a Chi-Square Test of Independence will be used if there are sufficient expected cell counts. Fisher's exact test will be used in the case of small cell counts. Absolute percentage points change and relative percentage points change will also be mentioned. If, for instance, compliance goes from 40% to 70% over the course of the project, the project will report 30 percentage point increase as well as the relative increase.

The primary interpretation will not be based exclusively on the statistical significance. If a small QI sample shows a result that is not statistically significant, this does not imply that the intervention is not of practical value. Thus, wherever possible, the report will be based on direction and size of change and 95% confidence intervals. The project aims at improving the practice and therefore clinical and operational significance will be taken into consideration as well as statistical significance.

Opioid Prescribing

Opioid prescribing is a primary outcome as it is the most common and effective method for managing pain and the project aims to reduce unnecessary opioid exposure and promote evidence-based, effective management. The opioid outcome will be calculated as the percentage of all medication-management encounters that lead to a prescription for an opioid. Prescription counts will also be reported with no adjustments for refills.

A chi-square test or Fisher's exact test will be used to compare the baseline proportion of opioid prescriptions with the proportion of opioid prescriptions in the intervention period. The number of opioid prescriptions will be determined by absolute reduction in percentage of opioid prescriptions. If the baseline rate is greater than zero, then a relative reduction will also be reported. Due to the possibility of differences in patient case mix between periods, age, sex and other clinical characteristics available will be explored descriptively. Provider level variation will also be looked at. The limited number of providers participating in the study may limit the power of provider-level inferential analyses and provider-specific rates will be used primarily to evaluate fidelity of implementation and variation that may need to be addressed with feedback.

Antineuropathic Medication Prescribing

Prescribing of appropriate antineuropathic drugs will be measured as dichotomous encounter-level outcome. The numerator will be the number of encounters eligible for the exam where an evidence-based antineuropathic medication was prescribed when clinically indicated, and the denominator will be all medication management encounters in the same time period for the same type of patient. Chi square or Fisher's exact test will be used to compare the proportions before and after implementation. The percentage point change will be reported. The analysis won't presume a patient should be on an antineuropathic drug. Rather, the project definition will focus on the appropriate and documented use of prescription, where appropriate. This distinction should be made because the intervention is designed to encourage treatment based on the individual's evidence, not to prescribe a particular class of medication, e.g. substituting one type of medication for another automatically.

Patient Education

Patient education will be tracked through documentation in the usual clinical record and on the structured paper-based project form, where applicable. The numerator will include eligible encounters documenting education about treatment options, medication risks and benefits, conservative management, physical therapy, or other evidence-based strategies. The denominator will be the total number of eligible encounters.

Chi square or Fisher's exact test will be used to compare the baseline and implementation education-documentation rates. The analysis will also calculate the percentage point gains in documented education. The project will not consider this as evidence of delivery or of learning, but as evidence of discussion about learning. This distinction will help avoid the risk of misinterpretation of EHR documentation.

Physical Therapy Referrals and Adherence

The physical therapist's referral will be analyzed as dichotomous variable. The numerator will include encounters in which a physical therapy referral was recorded and the denominator will include encounters when physical therapy was clinically indicated. Before and during implementation the proportion of referrals will be compared; using a chi-square or Fisher's exact test. Physical therapy adherence will be assessed on its own as it is not necessarily attended upon referral. If adequate documentation is provided, attendance will be considered the recommended therapy and/or completion of at least the documented initial therapy visit. Clinics will adhere to a more specific definition of adherence if it has one, and will use it consistently. Referral and adherence should not be used as a single metric as they are two distinct phases in the process of care.

Oswestry Disability Index

The principal patient reported functional outcome will be obtained from the ODI. The scores range between 0% and 100% (the higher the score, the more disabling the problem). The project proposed that is uploaded, shows that the ODI is the standardized assessment of functional status, and suggests that the instrument can be completed generally in about 5–10 minutes. The primary analysis will be based on the difference between the baseline and follow-up ODI measurements for patients who have both measurements available:

Change in ODI = follow up ODI score – baseline ODI score.

A negative change will indicate an improvement in function (disability reduced). If the distribution of ODI change scores is normally-distributed, a paired-samples t test will be used. In cases where the normality assumption is not satisfied, Wilcoxon signed-rank test will be performed. Mean change and/or 95% CIs (where appropriate) and effect size will be reported. The independent-samples t test will be employed with approximately normally distributed scores and the Mann–Whitney U test will be used with non-normally distributed scores (when baseline and follow-up scores have been obtained from different patient groups, rather than from the same patients). The analysis will thus depend on the structure of the data that is collected and not assume that all baseline patients are the same as all implementation patients.

Missing Data and Outliers

Frequency and pattern of missing data will be evaluated. The project will report the amount of missing observations for a variable and will perform the planned analysis with the available observations if less than 5% of the observations are missing for the variable. If the missingness is more, the project manager will discuss with mentor or statistician from the DNP for the possibility of using sensitivity analysis. No ODI scores will be falsified or substituted with assumed scores. Graphical and descriptive methods will be used to examine Outliers. An extremely high ODI score will not be automatically removed as it could be a good clinical case. Data will only be removed when there is evidence of an entry or extraction error. There will be a record of any data cleaning decisions made for audit trails.

Statistical Significance and Clinical Significance

The conventional alpha level of .05 will be used for inferential testing. As several secondary outcomes are assessed, p values will be interpreted with care and not considered evidence of intervention effectiveness, if statistically significant. The project will focus on effect sizes and confidence intervals (because of the relatively small sample size).

Absolute percentage-point change will be reported for categorical outcomes; relative risk or odds ratio will be reported when meaningful. Mean / median changes and an appropriate standardized effect-size will be reported for continuous ODI outcomes. Outcomes will be evaluated as met, partially met or not met, according to the project aims established at the start of the project. This will enable the evaluation to capture improvements in practice even if there is not a large sample size.

Control of Confounding

The project is not randomized, so there may be differences between baseline and intervention populations which may affect outcomes. The same inclusion/exclusion criteria, clinic setting, provider group, outcome definitions and the same 8-week comparison periods will be utilized to minimize potential confounding. The demographic properties of patients will be compared descriptively across time periods.

Changes in provider staffing, large scale changes in provider policy, availability of physical therapy, and other concurrent interventions will be noted. Large differences will be recognized as possible causes of changes in outcomes observed. The project will not make causal statements that are more than could reasonably be concluded from a single-site pre/post QI design.

Intervention Fidelity Analysis

Intervention fidelity will be measured by provider education completion, availability/use of the printed protocol, and completion of required documentation elements. The number of eligible implementation encounters in which use of the printed protocol is documented on the project fidelity form will be divided by the total number of eligible implementation encounters.

Clinical outcomes will be interpreted in light of intervention fidelity. If use of the printed protocol is low and outcomes do not improve, implementation limitations may explain the result. If protocol use is consistently documented and adherence to evidence-based guidance improves, the findings will better support continued use of the printed protocol in routine practice.

Data Presentation

The final results will be summarized in tabular form, and, as appropriate, in simple figures. Patient characteristics and primary outcomes will be presented on a baseline versus implementation table. A second table will provide a summary of prescribing, education, and physical therapy and outcomes of the ODI. Information on the progress of implementation may be presented graphically by weekly percentages. The final report will separate descriptive from inferential results. There will be no manipulation of data to get a desired result. Results will be reviewed both in support and partial support of the expected change in practice and when this does not happen.

Instrumentation

Two main data collection instruments will be used: a researcher-developed Clinical Record Data Abstraction and Guideline-Adherence Form and the Oswestry Disability Index (ODI). The abstraction form will capture variables relevant to the PICOT outcomes, including patient age, sex, diagnosis, provider type, opioid prescription, appropriate antineuropathic medication use, documentation of evidence-based treatment consideration, patient education, physical therapy referral and adherence, opioid dosage/duration when available, baseline and follow-up ODI scores, and relevant eligibility criteria. Binary variables will generally be coded 1 = yes and 0 = no, with missing/not applicable options. The form will be paper-based and aligned with the PICOT outcomes and printed protocol.

The ODI is a standardized patient-reported questionnaire for disability associated with low back problems. The authorized ODI version selected for the project will be administered at the first eligible clinical encounter and at follow-up when clinically appropriate, following its instructions and applicable institutional requirements. Scores will be entered into the project dataset using the unique project identification number. The appendices should include the completed project data-abstraction form, data dictionary, printed protocol documentation checklist, and an authorized copy of the ODI. An authorized copy of the selected ODI version must be included in the appendices after this paragraph and before the heading “Instrument Reliability and Validity.”

Instrument Reliability and Validity

The ODI is a well-established patient-reported outcome measure, which has been proven to be reliable and valid in patients with lumbar spine disorders. A study of 1,515 patients receiving lumbar spinal surgery in 2024 reported good internal consistency with a Cronbach's alpha of .87, and confirmed that the instrument was unidimensional. These results justify the use of the ODI as a valid instrument for functional disability for the project of lumbar radiculopathy. The instrument is also practically short enough to be completed in the outpatient clinic setting, though the time of approximately 5-10 minutes is estimated in the project proposal.

The researcher-developed Clinical Record Data Abstraction and Guideline-Adherence Form will not undergo psychometric reliability testing because it is being developed for this specific quality-improvement project. Each field will map to a PICOT outcome, project objective, printed protocol step, or evidence-based practice criterion. The project manager and mentor will review the form for clarity, completeness, and content alignment. Inter-rater agreement will be assessed on a small sample of records; discrepancies will be resolved and operational definitions finalized before full abstraction.

Ethics and Human Subjects Protection

Safety, confidentiality, patient privacy, and protection of patients’ rights are central to the project. The intervention is a printed protocol and provider education, not an experimental drug or procedure. The project will undergo the appropriate institutional review to determine whether it is quality improvement, evidence-based practice, or requires IRB review; the DNP student will not make that determination independently. Only the minimum data needed will be collected. Direct patient identifiers will not be included in the analytic dataset, and each eligible encounter will receive a project identification number. Any linking document will be stored separately with access restricted to authorized personnel. Clinical records will be accessed only through approved institutional systems. Project files will be stored on a password-protected, institutionally approved laptop or system with access controls; paper forms will be kept in a locked cabinet in a restricted-access area. DocuSign forms, if used for project approvals or acknowledgments, will be stored electronically in the institution-approved DocuSign account and retained on a password-protected, institutionally approved secured laptop or repository with access restricted to authorized personnel. They will not be stored on a personal device. If a physical copy is specifically required by institutional policy, it will be kept in a locked cabinet in a restricted-access area.

Individual treatment decisions, including medication selection, physical therapy, diagnostic evaluation, and referral, will remain the responsibility of the treating provider. The printed protocol will support consideration of evidence-based options but will not mandate a specific treatment when clinical circumstances indicate otherwise. Patients who meet exclusion criteria will receive appropriate clinical care outside the project analysis. Project data will be retained and destroyed according to institutional policy and applicable regulations; the retention period will be confirmed with the institution rather than assumed. Electronic files will be securely deleted and physical files securely destroyed at the end of the approved retention period. No identifiable patient information will be included in academic papers, posters, or dissemination materials. Results will be reported honestly, including missing data, implementation challenges, unexpected findings, and possible confounders.

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