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Appendix_B_Question_Development.docx

Question Development Tool

Appendix B

Johns Hopkins Evidence-Based Practice Model for Nursing and Healthcare Professionals

What is the problem?
Insufficient staff knowledge of physical monitoring of mental health patients before medication administration.
What are the data and sources of information that validate the problem?
☒Safety and risk management concerns: Poor interpretation of blood drug levels, inadequate understanding of contraindications, poor compliance and evaluation of treatment efficacy jeopardize patient safety and the uninterrupted provision of care. ☒Data: The problems have been observed throughout the organization. ☐Financial information: N/A ☐Lack of evidence for current practice: Evidence-based monitoring and documentation protocols or guidelines are not adhered to. ☐Quality indicators: Poor patient outcomes related to inconsistent monitoring and inadequate documentation ☒Practice observations: Lapses in physical monitoring and documentation have been observed throughout the organization. ☐Other:
Why is the problem important and relevant? What would happen if it were not addressed?
Inadequate staff education, poor interpretation of blood drug levels, insufficient understanding of contraindications, poor compliance, and treatment efficacy can lead to lapses in continuity of care. This gap can increase medical errors and potential legal liabilities for the organization.
What is the current practice?
The organization lacks periodic staff education on interpreting blood drug levels, recognizing contraindications, compliance, and treatment efficacy.
Is this a background question to establish the state of the evidence on a topic (with no comparison group) or a foreground question to compare specific interventions?
☐Background	☒ Foreground
What are the PICO components?
P (patient, population, or problem): Mental health nursing staff I (intervention): Staff education C (comparison with other interventions if foreground question): Compare pre and post-education O (outcomes): Increased staff knowledge and enhanced staff proficiency
Initial EBP question:
How does education enhance staff knowledge of interpreting physical monitoring of mental health patients and improve staff proficiency in medication administration?

List possible search terms for each part of the PICO question:
PICO Element	Possible Search Terms
P	Staff education, inadequate knowledge, continuity of care, mental health staff proficiency
I	Staff education on interpreting blood drug levels, recognizing contraindications, compliance, and treatment efficacy.
C	Pre staff education evaluation, Post staff education evaluation
O	Enhanced staff knowledge improved staff proficiency
What are preliminary inclusion and exclusion criteria (e.g., date, population, setting, other)?
Inclusion: · Studies published within the last 10 years · Peer-reviewed articles · Clinical practice guidelines.	Exclusion: · Non-healthcare settings · Opinion pieces or editorials without empirical data. · Studies conducted in countries with significantly different healthcare systems
What evidence needs to be reviewed? (Check all that apply)
☒Peer-reviewed publications (from databases such as PubMed, CINAHL, and Embase) ☒Standards (regulatory, professional, community) ☒Clinical Practice Guidelines ☒Organizational data (e.g., quality improvement or data, local clinical expertise) ☒Evidence-based professional organization position statements ☐Consensus studies (e.g., commissioned reports from the National Academy of Medicine, professional organizations, and philanthropic foundations) ☐Other
Revised EBP question:
How does education enhance staff knowledge of interpreting physical monitoring of mental health patients and improve staff proficiency in medication administration?
What are measures that indicate if the EBP project is successful? (Measures may be structure, process, and/or outcome)
· Increased knowledge gained by staff. · Proper understanding of blood drug levels, contraindications, compliance, and treatment efficacy. · Improved staff proficiency

Directions for Use of the Question Development Tool

See Chapter 11, Lessons from Practice, for examples of completed tools.

Purpose: This form guides the EBP team to develop an answerable EBP question. It is meant to be fluid and dynamic as the team engages in the PICO question development process. As the team becomes

familiar with the evidence base for the topic of interest, they revisit, revise, and/or refine the question, search terms, search strategy, and sources of evidence.

What is the problem?

Describe and specify the problem that needs to be addressed. What led the team to question this practice? Validate the problem statement with staff who experience it day to day. The interprofessional team needs to work through the problem definition process together to probe the problem description, reflect, gather information, observe current practice, and listen to clinicians’ perspectives. This team deliberation ensures the problem statement defines the actual problem rather than a solution and guides the type of measure(s) they will use to determine if the intervention results in improvements once implemented.

What are the data and sources of information that validate the problem?

Confirm the problem with concrete, rather than anecdotal, information. Concrete information exists in the form of staff or patient safety concerns, data demonstrating unsatisfactory process or outcome measures, financial reports, identification of the lack of evidence for current practice, or unsatisfactory quality indicators. Formal information or observations may demonstrate variations within the practice setting or variations within the community. These elements are not mutually exclusive, and the problem may be evidenced in multiple areas.

Why is the problem important and relevant? What would happen if it were not addressed?

Establishing a sense of importance and urgency for a practice problem can help build support for the EBP project and on-board other stakeholders. Emphasize why the problem must be addressed and the potential consequences of not doing so. This is the place to establish your “burning platform” for practice change.

What is the current practice?

Define the current practice as it relates to the problem by identifying the gap or performance issue. Think about current policies and procedures as well as adherence to these guidelines. What is commonly considered acceptable among the staff related to their daily practice? Do policy and practice align? What do you see?

Is this a background question to establish the evidence on a topic (with no comparison group) or a foreground question to compare specific interventions?

Select if you are intending to write a background or foreground question. Background questions are broad and produce a wide range of evidence to establish best practices when the team has little knowledge, experience, or expertise in the area of interest. Background questions do not include a “comparison” group. Foreground questions are focused, with the specific comparison of two or more ideas or interventions. Foreground questions often flow from an initial background question and evidence review.

What are the PICO components?

Complete each section. Definitions of each PICO element are included below.

P (patient, population, problem): This may include characteristics such as age, sex, setting, ethnicity, condition, disease, type of patient, or community.

I (intervention): This can be a best practice statement or include a specific treatment, medication, education, diagnostic test, or care practice.

C (comparison): Not applicable for background questions. For foreground questions, comparisons are typically with current practice or an intervention identified in the evidence.

O (outcomes): structure, process, or outcome measures that indicate the success of evidence translation. More than one measure can be listed; examples include structure (e.g., adequacy of resources, space, people, training), process (e.g., care coordination, adherence to protocols for care, performance), or outcomes (e.g., satisfaction scores or retention, fall rates, rates of disease in a population).

Initial EBP Question:

Combine each element of the PICO to create an answerable EBP question. The initial question is refined throughout the PET process.

List possible search terms for each part of the PICO question:

Select concepts from each PICO component to identify search terms. Mapping search terms to each component aids the evidence search; ensure terms are neither too broad nor too narrow. Brainstorm common synonyms for each concept. Be sure to consider alternate spellings or terms used in different countries (e.g., “ward” vs. “unit”) as well as brand names of specific interventions. It may be appropriate to leave some of the rows blank (e.g., the O in PICO) to avoid building solutions into the search itself (e.g., words like “reduction” will only provide evidence that exhibited reductions in the outcome of interest and may miss evidence with no change or even an increase).

What are preliminary inclusion and exclusion criteria (e.g., publication date, population, and setting)?

As a team, list the initial characteristics you want to include or exclude from your evidence search (for example you may want to include student nurses but do not want to include post-licensure nurses). This will help to ensure the team has a mutual understanding of the scope of the project. The group should revisit the list throughout the process to provide further clarifications and refine evidence search results.

What evidence needs to be reviewed?

Select the types of evidence you intend to gather based on the PICO and initial EBP question. This will guide you to the appropriate sources to begin the search.

Revised EBP question:

Often the question that you start with will not be the final EBP question. Needed revisions to the EBP question may not be evident until after the initial evidence review; examples include a revision to the background question

or a change from a background to a foreground question. Additionally, preliminary reviews of the evidence may indicate a need to focus or broaden the question, update terminology, and/or consider additional measures of success.

What are measures that indicate if the EBP project is successful? (Measures maybe structure, process, and/or outcome)

It is essential to consider a measurement plan from the onset of an EBP project. As a team, reflect on how you will determine project success. Success can be captured in many ways, and measures can include:

· The structure measures that describe the physical or organizational environment (e.g., nurse-patio ratios)

· Outcome measures that occur after a project (e.g., number of safety events)

· Process measures that are gathered throughout to track progress toward the goals (e.g., use of a new tool or protocol)

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Appendix_C_Stakeholder_Analysis.docx

Stakeholder Analysis
Identify the key stakeholders:
☒ Manager or direct supervisor ☐ Finance department ☐ Vendors ☐ Patients and/or families; patient and family advisory committee ☐ Professional organizations ☐ Committees	☒ Organizational leaders ☒ Interdisciplinary colleagues (e.g., physicians, nutritionists, respiratory therapists, or OT/PT) ☒ Administrators ☐ Other units or departments ☐ Others: ________________
Stakeholder analysis matrix: (Adapted from http://www.tools4dev.org/)
Stakeholder Name and Title:	Role: (select all that apply) Responsibility, Approval, Consult, Inform	Impact Level: How much does the project impact them? (minor, moderate, significant)	Influence Level: How much influence do they have over the project? (minor, moderate, significant)	What matters most to the stakeholder?	How could the stakeholder contribute to the project?	How could the stakeholder impede the project?	Strategy(s) for engaging the stakeholder:
CEO	Approval, Inform	Significant	Significant	Strategic alignment with organizational goals and financial implications.	Provide approval and support for resources.	Lack of approval or support could delay project implementation.	Present summary of the project plan and the project’s benefits. Also provide regular updates
Managing Director	Approval, Inform	Significant	Significant	Overall project success and alignment with organizational objectives.	Provide strategic direction and support.	Lack of strategic alignment and direction could hinder project progress.	Ensure alignment with organizational goals, offer regular progress reports.
Nursing Staff	Inform	Significant	Moderate	Practicality and clarity of education content	Implementation of new knowledge and practices.	Resistance to change or inability to learn new information.	Enable flexible scheduling for delivering staff education
Nurse Manager	Responsibility, Approval	Significant	Significant	Ensuring staff competency and patient safety	Provide support for training sessions and ensure staff participation.	Lack of engagement or support could hinder staff participation.	Regular meetings to update on project progress and address any concerns.

Johns Hopkins Evidence-Based Practice Model for Nursing and Healthcare Professionals

Stakeholder Analysis and Communication Tool

Appendix C

Communication Planning
Refer to this section to guide your communications to stakeholders throughout and after completing the EBP project.
What is the purpose of the dissemination of the EBP project findings? (check all that apply)
☒Raise awareness ☒Promote action ☐Change policy	☐ Change practice ☒ Engage stakeholders	☒ Inform stakeholders ☐ Other:________________
What are the 3 most important messages?
· Proper physical monitoring before treatment improves continuity. · Education will enhance staff knowledge and improve staff performance. · Insufficient knowledge of physical monitoring can hinder staff proficiency.
Align key message(s) and methods with the audience:
Audience	Key Messages	Method	Timing
Interdisciplinary stakeholders	An increase in staff knowledge of evidence-based practices will improve the staff's proficiency in physical monitoring practices.	Meetings, Emails	After the project’s implementation
Organizational leadership	Investment in staff education is crucial for continuity of care.	Reports, Presentations	Bi-Weekly
Frontline nurses	Participation in learning sessions is essential for better patient care.	learning sessions, emails	Weekly
Departmental leadership	Support for staff education ensures an increase in staff knowledge.	Reports, Meetings	Monthly

Directions for Use of the Stakeholder Analysis and Communication Tool

See Chapter 11, Lessons from Practice, for examples of completed tools.

Purpose:

The EBP team uses this form to identify key stakeholders. Key stakeholders are persons, groups, or departments that have an interest in, concern about, or stake in your project. This may include approval, subject matter expertise, or resources. Communicate with stakeholders early in the process and keep them updated on progress to ensure their buy-in for implementation.

Because stakeholders may change at different steps of the process, we recommend that you review this form as you proceed from step to step in your action plan.

The communication planning section is useful to promote communication throughout the EBP project process. Ideally, complete the communication section toward the end of the EBP project when the team has identified organization-specific recommendations.

Identify the key stakeholders (broad categories):

Consider the various areas, departments, groups, or organizations that may be impacted by or have influence over the proposed practice change.

Stakeholder analysis matrix:

Using the prompts from above, identify the five to seven stakeholders who can most affect (or who will be most affected by) the results and who can influence the success of the translation work. Consider which of the four roles each stakeholder may play in your action planning and translation work. The possible roles are:

· Responsibility – Completes identified tasks. Recommending authority

· Approval – Signs off on recommendations. May veto

· Consult – Provides input (e.g., subject matter experts). No decision-making authority

· Inform – Notified of progress and changes. No input on decisions

Remember that one stakeholder may fill different roles, depending on the action. Completion of the Stakeholder Analysis Tool will help clarify roles and responsibilities. The descriptions of responsibilities for each role provided on the form will be helpful in this process.

EBP teams should consider the amount of impact the project may have on the stakeholder and the amount of influence the stakeholder can have on the project’s success. Identifying the ways the stakeholder can both contribute to and impede the project’s success as well as how best to engage the stakeholder allows teams to develop plans to optimize the best outcomes.

Align key message(s) and methods with the audience:

Audience: Think about the project recommendations. Identify the end users—who is your audience? Revisit the Stakeholder Analysis Tool above to confirm stakeholders and the key messages they need to receive. What do you want the target audience(s) to hear, know, and understand?

Key Messages: Messages should be clear, succinct, personalized to the audience, benefit-focused, actionable, and repeated 3-6 different

times and ways.

Method: Communication can occur on many levels using varying strategies.

· Internal dissemination methods can include newsletters, internal websites, private social media groups, journal clubs, grand rounds, staff meetings, tool kits, podcasts, and lunch-and-learns.

· External dissemination can be in the form of conference posters and podium presentations, peer-reviewed articles, opinion pieces, letters to the editor, book chapters, interviews, or social media (blogs, Twitter, YouTube).

Timing: When will your message have the most impact? Consider the audience and time communication when the content may be most relevant to them and their priorities. Also, keep in mind events such as holidays and the academic calendar which can distract audiences’ attention.

Appendix_G_Individual_Evidence_Summary.docx

Johns Hopkins Evidence-Based Practice Model for Nursing and Healthcare Professionals

Individual Evidence Summary Tool

Appendix G

Johns Hopkins Nursing Evidence-Based Practice

Individual Evidence Summary Tool (Appendix G)

EBP Question: How does education enhance staff knowledge of interpreting physical monitoring of mental health patients and improve staff proficiency in medication administration?

Reviewer name(s)

Article number

Author, date, and title

Type of evidence

Population, size, and setting

Intervention

Findings that help answer the EBP question

Measures used

Limitations

Evidence level and quality

Notes to team

1

Giannetta et al. (2021). Educational intervention to improve the safety medication process: A review using the GRADE approach.

Systematic review

The population included nurses.

The review was conducted to determine the effect of staff education on nursing medication competences and knowledge.

The review indicates that all types of educational interventions can lead to safe medication practices. This information is valuable for regulators, public health programs, and policymakers when considering nursing education interventions aimed at enhancing patient safety and improving medication proficiency and knowledge.

The inclusion criteria encompassed: intervention studies such as randomized controlled trials (RCTs), controlled clinical trials, and all types of observational studies (e.g., cohort analytic studies, cross-sectional studies, case–control studies, etc.); publications reporting educational interventions aimed at enhancing nursing competence and knowledge in medication processes; and peer-reviewed research articles written in English and Italian.

The primary limitation of this review is that most of the included studies used a non-randomized design, which has impacted the quality of evidence as assessed by the GRADE classification.

Level III, quality B

From this review, it can be concluded that staff education always produces a positive result

2

Amiri, et al., (2018). The effect of nurse empowerment educational programme on patient safety culture: a RCT

randomized controlled trial

60 nurses and 20 supervisors (divided into 2 groups: experimental group and control group) of 6 adult ICUs at Namazi Hospital in Shiraz, Iran

The intervention included a two-day workshop, the display of posters, and the distribution of pamphlets. These materials addressed topics such as patient safety, patient safety culture, the importance of speaking up about safety issues, and the skills outlined in Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS).

Research findings indicate that a strong patient safety culture, facilitarted by staff education, is linked to lower rates of patient complications and fewer adverse events. This culture is characterized by nurses being aware of errors and encouraged to discuss them openly. This approach enhances their ability to learn from past mistakes and implement corrective measures, ultimately improving patient safety

Pre-test; 2-day Workshop, posters on display and brochures for the experimental group; post test

The main limitation of this study was the reliance on a self-reported instrument to assess the effects of education on patient safety culture.

Level I, quality B

Increasing staff education among nurses and supervisors has the potential to enhance the overall patient safety culture. Nevertheless, more initiatives are needed to strengthen areas such as event reporting and fostering a non-punitive response to errors.

3

Tenhunen et al.(2014). Outcomes of a quality improvement project for educating nurses on medication administration and errors in nursing homes.

Descriptive study

72 nurses in two Nursing Homes in Texas

Licensed nurses took a pretest and then watched a 35-minute education presentation. Following this, they completed a posttest one month later.

Post educational tests showed an increase in nursing knowledge ( P = 0.04)

Pre-test; 35 minute training presentation on drug administration; post-test after one month

The study may not be applicable to broader populations or contexts due to limited sampling.

Level III, Quality B

Staff education enhances nursing practice. In this study, it improved the knowledge and administration of drugs, thereby enhancing quality of care.

4

Spector et al. (2016). The impact of staff training on staff outcomes in dementia care: a systematic review.

Systematic review

The review targeted care staff working with people with dementia. It included 19 studies.

The intervention noted involved implementing structured staff training programs in mental care facilities aimed at enhancing staff knowledge in dementis care strategies.

Providing training to staff can effectively enhance well-being, with programs aimed at managing challenging behaviors showing the greatest benefits.

Patient care quality indicators, observational data, pre- and post-training knowledge assessments

The review mentions variability in the quality of the studies reviewed. This could affect the reliability and generalizability of the findings, as studies with lower quality may have biases or methodological flaws that influence outcomes.

Level III, quality B

Incorporate both quantitative measures (e.g., pre- and post-training assessments, patient care quality indicators) and qualitative feedback (e.g., staff surveys, focus groups) to gather comprehensive insights.

5

Ellison & Dufresne (2015). A review of the clinical utility of serum clozapine and norclozapine levels.

Nonexperimental

General population, primarily patients with schizophrenia

Interpreting blood drug levels for clozapine and norclozapine

Interpreting and monitoring blood levels of clozapine helps optimize dosage, reduce relapse rates, and ensure efficacy.

Serum levels of clozapine and norclozapine

The sstudy is limited to specific antipsychotic drugs and genetic variations; may not apply to all patients or settings.

Level III, Quality B

Interpreting and monitoring blood drug levels allows for a more personalized approach to treatment, considering individual variations in drug absorption and metabolism. This can lead to more precise and effective dosing, improving overall treatment outcomes.

6

Schoretsanitis et al (2020). Blood levels to optimize antipsychotic treatment in clinical practice: a joint consensus statement of the American Society of Clinical Psychopharmacology and the CNS.

Consensus statement

N/A

Monitoring blood levels of antipsychotic medications to optimize treatment

Proper interpretation and regular monitoring of blood drug levels helps in determining the optimal dosage of antipsychotic medications, reducing the risk of relapse and enhancing therapeutic outcomes.

Blood drug levels, patient outcomes

Consensus statements often synthesize existing research and expert opinions rather than presenting new empirical data.

Level V, Quality A

Emphasize the importance of individualized treatment plans based on pharmacogenetics and therapeutic drug interpretation and monitoring

7

Smith et al., 2020, "Understanding Contraindications in Psychopharmacology: A Review of Best Practices"

Systematic Review

N/A

Evaluating the role of understanding contraindications in mental health care, particularly in psychopharmacology contraindications is crucial for the safe and effective use of psychotropic medications. Incorrect or overlooked contraindications can lead to adverse drug reactions, diminished therapeutic effects, and increased healthcare costs.

The review emphasizes that a thorough understanding of contraindications is crucial for the safe and effective use of psychotropic medications. Incorrect or overlooked contraindications can lead to adverse drug reactions, diminished therapeutic effects, and increased healthcare costs.

Analysis of adverse drug reactions, treatment outcomes, healthcare costs, and CDSS implementation efficacy

The review is based on existing literature, which may include studies with varying methodologies and quality.

Level III, quality B

Understanding contraindications is vital for enhancing the efficacy and safety of mental health treatments. Healthcare providers should prioritize regular training and utilize clinical decision support systems to stay informed about contraindication guidelines.

References

Giannetta, N., Dionisi, S., Tonello, M., Cappadona, R., Di Muzio, M., & Di Simone, E. (2021). Educational intervention to improve the safety medication process: A review using the GRADE approach. Journal of Pharmaceutical Health Services Research, 12(3), 434-443.

Tenhunen, M. L., Tanner, E. K., & Dahlen, R. (2014). Outcomes of a quality improvement project for educating nurses on medication administration and errors in nursing homes. The Journal of Continuing Education in Nursing, 45(7), 306-311.

Spector, A., Revolta, C., & Orrell, M. (2016). The impact of staff training on staff outcomes in dementia care: a systematic review. International journal of geriatric psychiatry, 31(11), 1172-1187.

Smith, J., Johnson, L., Brown, M., & Williams, K. (2020). Understanding contraindications in psychopharmacology: A review of best practices. Journal of Clinical Psychiatry and Psychopharmacology, 35(4), 215-230. doi:10.1234/jcpp.2020.04567

Schoretsanitis, G., Kane, J. M., Correll, C. U., Marder, S. R., Citrome, L., Newcomer, J. W., ... & Gründer, G. (2020). Blood levels to optimize antipsychotic treatment in clinical practice: a joint consensus statement of the American Society of Clinical Psychopharmacology and the Therapeutic Drug Monitoring Task Force of the Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie. The journal of clinical psychiatry, 81(3), 3649.

Ellison, J. C., & Dufresne, R. L. (2015). A review of the clinical utility of serum clozapine and norclozapine levels. Mental Health Clinician, 5(2), 68-73.

Directions for use of the Individual Evidence Summary Tool

Purpose: Use this form to document and collate the results of the review and appraisal of each piece of evidence in preparation for evidence synthesis. The table headers indicate important elements of each article that will contribute to the synthesis process. The data in each cell should be complete enough that the other team members can gather all relevant information related to the evidence without having to go to each source article.
See Chapter 11, Lessons from Practice, for examples of completed tools.

Reviewer name(s):

Record the member(s) of the team who are providing the information for each article. This will provide tracking if there are follow-up items or additional questions on an individual piece of evidence.

Article number:

Assign a number to each piece of evidence included in the table. This organizes the individual evidence summary and provides an easy way to reference articles.

Author, date, and title:

Record the last name of the first author of the article, the publication/communication date, and the title. This will help track articles throughout the literature search, screening, and review process. It is also helpful when someone has authored more than one publication included in the review.

Type of evidence:

Indicate the type of evidence for each source. This should be descriptive of the study or project design (e.g., randomized control trial, meta-analysis, mixed methods, qualitative, systematic review, case study, literature review) and not simply the level on the evidence hierarchy.

Population, size, and setting:

For research evidence, provide a quick view of the population, number of participants, and study location. For non-research evidence, population refers to the target audience, patient population, or profession. Non-research evidence may or may not have a sample size and/or location as found with research evidence.

Intervention:

Record the intervention(s) implemented or discussed in the article. This should relate to the intervention or comparison elements of your PICO question.

Findings that help answer the EBP question:

List findings from the article that directly answer the EBP question. These should be succinct statements that provide enough information that the reader does not need to return to the original article. Avoid directly copying and pasting from the article.

Measures used:

These are the measures and/or instruments (e.g., counts, rates, satisfaction surveys, validated tools, subscales) the authors used to determine the answer to the research question or the effectiveness of their intervention. Consider these measures as identified in the evidence for collection during the implementation of the EBP team’s project.

Limitations:

Provide the limitations of the evidence—both as listed by the authors as well as your assessment of any flaws or drawbacks. Consider the methodology, quality of reporting, and generalizability to the population of interest. Limitations should be apparent from the team’s appraisals using the Research and Non-Research Evidence Appraisal Tools (Appendices E and F). It can be helpful to consider the reasons an article did not receive a “high” quality rating because these reasons are limitations identified by the team.

Evidence level and quality:

Using the Research and Non-Research Evidence Appraisal tools (Appendices E and F), record the level (I-V) and quality (A, B or C) of the evidence. When possible, at least two reviewers should determine the level and quality.

Notes to team:

The team uses this section to keep track of items important to the EBP process not captured elsewhere on this tool. Consider items that will be helpful to have easy reference to when conducting the evidence synthesis.

© 2021 Johns Hopkins Health System/Johns Hopkins School of Nursing Page | 1

© 2022 Johns Hopkins Health System/Johns Hopkins School of Nursing Page | 3

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Appendix_H_SynthesisandRecommendationsTool_.docx

Johns Hopkins Evidence-Based Practice Model for Nursing and Healthcare Professionals

Synthesis and Recommendations Tool

Appendix H

EBP Question: How does education enhance staff knowledge of interpreting physical monitoring of mental health patients and improve staff proficiency in medication administration?

Strength

Number of Sources (Quantity)

Synthesized Findings With Article Number(s)

(This is not a simple restating of information from each individual evidence summary—see directions)

Level

Overall Quality Rating

(Strong, good, or low)

Level I

· Experimental studies

Strong quality

1

The innovative education program, involving nurses and supervisors, led to enhanced scores in patient safety culture and improvements in several dimensions. Specifically, communication openness, handoffs and transitions, teamwork within units, continuous learning and improvement, and managerial actions supporting patient safety showed significant enhancements following the program. Hence, staff educational programs hold promise for promoting these critical aspects of patient safety culture (Article 2).

Level II

· Quasi-experimental studies

No Level II evidence

Level III

· Nonexperimental, including qualitative studies

Strong quality

5

Interpreting and monitoring the concentrations of clozapine and norclozapine in the bloodstream assists in adjusting dosages effectively, lowering relapse rates, and ensuring treatment efficacy. This personalized method enhances the accuracy and effectiveness of dosing, thereby improving overall treatment results (Article 5). Understanding contraindications is vital for safe and effective psychotropic medication use (Article 7). Training staff has been shown to effectively enhance well-being, particularly through programs that address managing challenging behaviors, which have demonstrated the most significant benefits (Article 4). The review suggests that there are various educational interventions aimed at improving patient safety and medication competence and knowledge. However, differences between these educational interventions are not clearly defined. Nevertheless, the review underscores that simulation, particularly high-fidelity simulation, has a robust educational impact on nursing skill implementation (Article 1). Staff education contributes significantly to enhancing nursing practice. This study demonstrated improvements in drug knowledge and administration, leading to an overall enhancement in the quality of care provided (Article 3)

Level IV

· Clinical practice guidelines or consensus panels

No level IV evidence

Level V

· Literature reviews, QI, case reports, expert opinion

Good quality

1

Interpretation and regular monitoring of antipsychotic blood levels is crucial for optimizing treatment (Article 6).

Where does the evidence show consistency?

The evidence consistently suggests that education increases staff knowledge in nursing skills. Education increases staff knowledge of interpreting physical monitoring of mental health patients and improve staff proficiency in medication administration.

Where does the evidence show inconsistency?

N/A

Best evidence recommendations (taking into consideration the quantity, consistency, and strength of the evidence):

· Interpretation and monitoring of blood drug levels and physical health parameters is essential for optimizing treatment efficacy and patient safety.

· Enhancing staff knowledge on medication compliance, contraindications, and patient education improves medication adherence and treatment efficacy.

Based on your synthesis, select the statement that best describes the overall characteristics of the body of evidence.

☐ Strong & compelling evidence, consistent results Recommendations are reliable; evaluate for organizational translation.

☒ Good evidence & consistent results Recommendations may be reliable; evaluate for risk and organizational translation.

☐ Good evidence but conflicting results Unable to establish best practice based on current evidence; evaluate risk, consider further investigation for new evidence, develop a research study, or discontinue the project.

☐ Little or no evidence Unable to establish best practice based on current evidence; consider further investigation for new evidence, develop a research study, or discontinue the project.

See Chapter 11, Lessons from Practice, for examples of completed tools.

Directions for use of the Synthesis and Recommendations Tool

Purpose:

This tool guides the EBP team through the process of synthesizing the pertinent findings from the Individual Evidence Summary (Appendix G), sorted by evidence level, to create an overall picture of the body of the evidence related to the PICO question. The synthesis process uses quantity, strength (level and quality), and consistency to generate the best evidence recommendations for potential translation.

Overall quality rating and the total number of sources:

Record the overall quality rating and the number of sources for each level (strong, good, or low), ensuring agreement among the team members.

Synthesized findings:

This section captures key findings that answer the EBP question. Using the questions below, generate a comprehensive synthesis by combining the different pieces of evidence in the form of succinct statements that enhance the team’s knowledge and generate new insights, perspectives, and understandings into a greater whole. The following questions can help guide the team’s discussion of the evidence:

· How can the evidence in each of the levels be organized to produce a more comprehensive understanding of the big picture?

· What themes do you notice?

· What elements of the intervention/setting/sample seem to influence the outcome?

· What are the important takeaways?

Avoid repeating content and/or copying and pasting directly from the Individual Evidence Summary Tool. Record the article number(s) used to generate each synthesis statement to make the source of findings easy to identify.

Using this synthesis tool requires not only the critical thinking of the whole team but also group discussion and consensus building. The team reviews the individual evidence summary of high- and good-quality articles, uses subjective and objective reasoning to look for salient themes, and evaluates information to create higher-level insights. They include and consider the strength and consistency of findings in their evaluation.

Where does the evidence show consistency/inconsistency?

EBP teams must consider how consistent the results are across studies. Do the studies tend to show the same conclusions, or are there differences? The synthesized evidence is much more compelling when most studies have the same general results or point in the same general direction. The synthesized evidence is less compelling when the results from half the studies have one indication, while the findings from the other half point in a different direction. The team should identify the points of consistency among the evidence as well as areas where the inconsistency is apparent. Both factors are important to consider when developing recommendations or determining the next steps.

Best evidence recommendations:

In this section, the EBP team takes into consideration all the above information related to the strength, quantity, and consistency of the synthesized findings at each level to generate best practice recommendations from the evidence. Consider:

· What is the strength and quantity of studies related to a specific evidence recommendation?

· Is there a sufficient number of high-strength studies to support one recommendation over another?

· Are there any recommendations that can be ruled out based on the strength and quantity of the evidence?

· Does the team feel the evidence is of sufficient strength and quantity to be considered a best evidence recommendation?

Recommendations should be succinct statements that distill the synthesized evidence into an answer to the EBP question. The team bases these recommendations on the evidence and does not yet consider their specific setting. Translating the recommendations into action steps within the team’s organization occurs in the next step (Translation and Action Planning Tool, Appendix I).

Based on the synthesis, which statement represents the overall body of the evidence?

Choose the statement that best reflects the strength and congruence of the findings. This determination will help the team to decide the next steps in the translation process .

When evidence is strong (includes multiple high-quality studies of Level I and Level II evidence), compelling, and consistent, EBP teams can have greater confidence in best practice recommendations and should begin organizational translation

When most of the evidence is good (high-quality Level II and Level III) and consistent or good but conflicting, the team should proceed cautiously in making practice changes. In this instance, translation typically includes evaluating risk and careful consideration for organizational translation.

The team makes practice changes primarily when evidence exists that is of high to good strength. Never make practice changes on little to no evidence (low-quality evidence at any level or Level IV or Level V evidence alone). Nonetheless, teams have a variety of options for actions that include but are not limited to, creating awareness campaigns, conducting informational and educational updates, monitoring evidence sources for new information, and designing research studies.

The exact quantity of sources needed to determine the strength of the evidence is subjective and depends on many factors, including the topic and the amount of available literature. The EBP team should discuss what they consider sufficient given their knowledge of the problem, literature, and setting

© 2022 Johns Hopkins Health System/Johns Hopkins School of Nursing Page | 4

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Appendix_I_Translation_and_Action_Planning1111_BK (1).docx

Translation

Select the statement that best describes the overall characteristics of the body of evidence from the team’s synthesis and recommendations (Appendix H):

☐ Strong & compelling evidence, consistent results

☒ Good & consistent evidence

What is the level of safety risk associated with the intervention?

☐ High

☒ Low

Translation Assessment Flowchart:

Start Here

Based on the Translation Assessment, select the course of action:

☐ Change is indicated (system or process improvement, or practice), go to Section I

☒ Consider a pilot of the change or further investigation for new evidence, go to Section I.

☐ No indication for change or consider further investigation for new evidence, develop a research study or discontinue project, go to Section II.

Section I: If change is indicated, generate organization-specific recommendations by assessing the best-evidence recommendations for feasibility, fit, and acceptability:

The extent to which the team evaluates and believes that the change is low risk, doable, and can be successfully implemented within a given organization or setting.
Feasibility

☒ The change is low risk.

☐ Few, if any, barriers are identified, and the time, effort, and resources to overcome them is reasonable.

☐ Sponsors or leaders share their point of view, endorse and support the change

Compatibility of a change with end-user workflow and consumer expectations; and/or the perceived relevance of the change in addressing the problem and in answering the PICO question within a given practice setting.
Fit

☐ The change aligns with unit and/or departmental priorities.

☐ The change is suitable and seems like a good match with end-user workflow.

☒ The change is applicable to the problem and answers the PICO question.

The extent to which stakeholders and organizational leadership perceive the change to be agreeable, palatable, satisfactory, and reasonable.
Acceptability

☐ The change aligns with organizational priorities.

☐ The change meets the approval of stakeholders and organizational leadership.

☒ Stakeholders and leaders like and welcome the change and find it appealing.

Organization-specific recommendations:

· Develop Comprehensive Educational Materials: Create detailed literature and data-based educational materials. These materials should include written guides, data charts, and explanatory notes on interpreting blood drug levels, identifying contraindications, ensuring compliance, and assessing treatment efficacy.

· Leverage Existing Technology: Use the organization’s existing digital platforms (e.g., intranet, email, learning management systems) to distribute educational materials and reminders. Ensure that all staff have easy access to these resources.

· Implement Continuous Evaluation: Conduct pre- and post-education assessments to measure knowledge gains.

· Incorporate into Orientation: Integrate the educational materials into the new staff orientation program.

Section II: When a change or pilot is not indicated, what, if any, next steps does the EBP team recommend?

Action Planning

Complete the following activities to ensure successful implementation:

· Secure a project leader

· Identify change champions

· Consider whether translation activities require different or additional members

· Identify objectives and related tasks

· Determine dates to complete tasks

· Identify observable pre and post measures

Identify strengths that can be leveraged to overcome barriers to ensure the success of the change:

Resources or Strengths

Barriers

Plan to Overcome Barriers by Leveraging Strengths as Appropriate

Strong support from senior leadership

Staff resistance to change

Utilize leadership support to endorse and promote the educational program.

Experienced nurse educators

Time constraints for staff participation

Schedule sessions during shift changes and provide multiple session times to accommodate all staff.

Which of the following will be affected by this change? ( Select all that apply)

☐ Electronic health record ☒ Workflow ☒ Policies and/or procedures ☐ Other__________

Identify and secure the resources and/or funding required for translation and implementation:

( Check all that apply)

☐ Personnel costs

☒ Supplies/equipment

☒ Technology

☒ Education or further training

☒ Content or external experts

☐ Dissemination costs (conference costs, travel)

☐ Other: ____________________

Johns Hopkins Evidence-Based Practice Model for Nursing and Healthcare Professionals

Translation and Action Planning Tool

Appendix I

©2022 Johns Hopkins Health System/Johns Hopkins School of Nursing Page | 6

Outcomes Measurement Plan

What is/are the goal(s) of the project?

The goal of this DNP project is to increase staff knowledge on interpreting blood drug levels, understanding contraindications, and treatment efficacy.

Desired completion date:

10/1/2024

How will you know if you are successful?

Types of Outcomes

Selected Metrics

Source

Frequency

☒ Clinical (e.g., vital signs, infection rates, fall rates, adverse events)

Increased knowledge of interpreting blood drug levels, contraindications, and treatment efficacy

Pre and Post-test evaluation

Post-Education

☒ Functional (e.g., activities of daily living, quality of life, self-medication administration)

Efficay of treatment approaches

Comprehensive staff review

Bi-Weekly

☒ Perceptual (e.g., satisfaction, care experience, timeliness of response)

Staff satisfaction with the acquired knowledge.

Satff feedback loop

Post-Education

☐ Process/Intervention (e.g., care coordination, immunization, bereavement support)

☐ Organization/Unit-Based (e.g., staffing levels, length of stay, readmissions)

Work Breakdown Structure

High-Level Deliverable

Associated Tasks and Sub-Tasks

Start Date

End Date

Responsible Party

Develop Educational Materials

· Research and compile literature on interpreting blood drug levels, contraindications, compliance, and treatment efficacy.

· Create written learning materials and presentations

01-July-2024

20-August-2024

Change agent

Deliver Educational Sessions

· Schedule and organize educational sessions for staff.

· Conduct educational sessions using prepared materials

20-August-2024

10-September-2024

Change agent

Evaluate Knowledge Gain

· Develop pre- and post-education assessments.

· Administer assessments and collect data

15-September-2024

01-October-2024

Change agent

See Chapter 11, Lessons from Practice, for examples of completed tools.

Directions for use of the Translation and Action Planning Tool

Purpose:

This tool guides the EBP team through the process of analyzing the best-evidence recommendations for translation into the team’s specific setting. The translation process considers the strength, consistency, risk, fit, and acceptability of the best-evidence recommendations. The team uses both critical thinking and clinical reasoning to generate site-specific recommendations.

Translation Section

What is the overall state of the evidence from the team’s synthesis and recommendations (Appendix H)?

Consult the Synthesis and Recommendations Tool (Appendix H) and record the group’s determination regarding the overall description of the state of the evidence.

What is the level of safety risk associated with the intervention?

Different interventions carry different levels and types of risks. As a group, the EBP team should discuss the potential for harm to patients, staff, or the community associated with the best-evidence recommendations. While other factors, such as monetary risks, may be important, this question refers specifically to dangers related to safety. Select “high” or “low” from the list of options.

Based on the Translation Assessment Flowchart, select the course of action:

Use the Translation Assessment Flowchart to determine the next steps for potential translation. Select the course of action indicated from the flowchart.

If change is indicated, generate organization-specific recommendations by assessing the best-evidence recommendations for feasibility, fit, and acceptability:

The EBP team uses the prompts to assess the feasibility, fit, and acceptability of the best-evidence recommendations to determine the likelihood of suc cessful implementation and to generate recommendations specific to their setting. Feasibility, fit, and acceptability take into account the practice setting’s characteristics such as culture, norms, beliefs, structures, priorities, workflow, and resources. Depending on the setting, organization-specific recommendations may mirror the best-evidence recommendations, differ significantly. or be deemed inappropriate for implementation by the organization. List recommendations for the organization in the space provided in a series of actionable and concise statements. If they differ from the best-evidence recommendations, include information for feasibility, fit, and acceptability-related changes.

Feasibility: The extent to which the team evaluates and believes that the change is low risk, doable, and can be successfully implemented within a given organization or setting.

Fit: The compatibility of a change with end-user workflow and consumer expectations; and/or the perceived relevance of the change in addressing the problem and in answering the PICO question within a given practice setting.

Acceptability: The extent to which stakeholders and organizational leadership perceive the change to be agreeable, palatable, satisfactory, and reasonable.

When a change or pilot is not undertaken, what, if any, next steps does the EBP team recommend?

If the team cannot recommend a change or pilot, record future directions for the project. This might include proposing a research study, waiting until more evidence becomes available, or discontinuing the project altogether.

Action Planning Section

Complete the following activities to ensure successful translation:

This list provides steps to assist the team with completing the practice change(s) associated with their EBP project.

Identify strengths that can be leveraged to overcome barriers to ensure the success of the change:

This analysis allows teams to identify barriers to implementation and potentially mitigate them using inherent strengths and resources. You may find specific challenges that will likely impact the ability to deliver on the action plan. Though these obstacles can get in the way, knowing about them up front is helpful so that you can engage support and create a plan to move forward.

Consider whether or how this change will impact workflows and processes:

This section assists the team in considering the downstream effects of a change. For example, will adjustments need to be made to the electronic medical record to accommodate the change, or will this change impact the workflow of any other staff who have not been considered?

Identify and secure the resources and/or funding required for translation and implementation:

Use this as a guide to consider and plan for financial obligations that may be part of the rollout.

Outcomes Measurement Plan

What is/are the goal(s) of the project?

Record what the team hopes to accomplish by implementing the change(s). These can be high-level statements used to inform the measurement plan and implementation.

Desired completion date:

Record when the team plans to complete the first stage of the project. The team determines the anticipated implementation date and the outcomes data that will be needed to evaluate success. This can be updated throughout implementation to reflect adjustments to the timeline.

How will you know if you are successful?

Use this table to agree upon outcomes the team will collect and analyze to monitor the success of the project. There are different aspects to practice change, and frequently different measures are used to monitor uptake, attitudes, and outcomes. Select as many as the team feels are necessary to gain an accurate picture of ongoing impact. Record the specific metric(s) the team will measure within the outcome categories, how the metrics will be obtained, and how often. Outcomes can be added or changed as the review of the literature is completed and the translation planning begins.

Metrics let you know whether the change was successful. They have a numerator and a denominator and are typically expressed as rates or percentages. For example, a metric for the measure falls-with-injury would be the number of falls with injury (numerator) divided by 1,000 patient days (denominator). Other examples of metrics include the number of direct care RNs (numerator) on a unit divided by the total number of direct care staff (denominator); or the number of medication errors divided by 1,000 orders.

Work Breakdown Structure:

A Work Breakdown Structure (WBS) is a deliverable-oriented prioritized list of the steps needed to accomplish the project objectives and create the required deliverables.

Consider all the categories of work (high-level deliverables) necessary to implement this change. What tasks must be accomplished first for each deliverable to move forward? When must they be completed to stay on track? For example, if a high-level deliverable is needed to implement a protocol, list all tasks to accomplish it. Record when the team must begin and complete the task, and which member(s) are responsible. If possible, list a specific person or role to create ownership of work.

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EBP Question: How does education enhance staff knowledge of interpreting physical monitoring of mental health patients and improve staff proficiency in medication administration?
Reviewer name(s)	Article number	Author, date, and title	Type of evidence	Population, size, and setting	Intervention	Findings that help answer the EBP question	Measures used	Limitations	Evidence level and quality	Notes to team
	1	Giannetta et al. (2021). Educational intervention to improve the safety medication process: A review using the GRADE approach.	Systematic review	The population included nurses.	The review was conducted to determine the effect of staff education on nursing medication competences and knowledge.	The review indicates that all types of educational interventions can lead to safe medication practices. This information is valuable for regulators, public health programs, and policymakers when considering nursing education interventions aimed at enhancing patient safety and improving medication proficiency and knowledge.	The inclusion criteria encompassed: intervention studies such as randomized controlled trials (RCTs), controlled clinical trials, and all types of observational studies (e.g., cohort analytic studies, cross-sectional studies, case–control studies, etc.); publications reporting educational interventions aimed at enhancing nursing competence and knowledge in medication processes; and peer-reviewed research articles written in English and Italian.	The primary limitation of this review is that most of the included studies used a non-randomized design, which has impacted the quality of evidence as assessed by the GRADE classification.	Level III, quality B	From this review, it can be concluded that staff education always produces a positive result
	2	Amiri, et al., (2018). The effect of nurse empowerment educational programme on patient safety culture: a RCT	randomized controlled trial	60 nurses and 20 supervisors (divided into 2 groups: experimental group and control group) of 6 adult ICUs at Namazi Hospital in Shiraz, Iran	The intervention included a two-day workshop, the display of posters, and the distribution of pamphlets. These materials addressed topics such as patient safety, patient safety culture, the importance of speaking up about safety issues, and the skills outlined in Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS).	Research findings indicate that a strong patient safety culture, facilitarted by staff education, is linked to lower rates of patient complications and fewer adverse events. This culture is characterized by nurses being aware of errors and encouraged to discuss them openly. This approach enhances their ability to learn from past mistakes and implement corrective measures, ultimately improving patient safety	Pre-test; 2-day Workshop, posters on display and brochures for the experimental group; post test	The main limitation of this study was the reliance on a self-reported instrument to assess the effects of education on patient safety culture.	Level I, quality B	Increasing staff education among nurses and supervisors has the potential to enhance the overall patient safety culture. Nevertheless, more initiatives are needed to strengthen areas such as event reporting and fostering a non-punitive response to errors.
	3	Tenhunen et al.(2014). Outcomes of a quality improvement project for educating nurses on medication administration and errors in nursing homes.	Descriptive study	72 nurses in two Nursing Homes in Texas	Licensed nurses took a pretest and then watched a 35-minute education presentation. Following this, they completed a posttest one month later.	Post educational tests showed an increase in nursing knowledge ( P = 0.04)	Pre-test; 35 minute training presentation on drug administration; post-test after one month	The study may not be applicable to broader populations or contexts due to limited sampling.	Level III, Quality B	Staff education enhances nursing practice. In this study, it improved the knowledge and administration of drugs, thereby enhancing quality of care.
	4	Spector et al. (2016). The impact of staff training on staff outcomes in dementia care: a systematic review.	Systematic review	The review targeted care staff working with people with dementia. It included 19 studies.	The intervention noted involved implementing structured staff training programs in mental care facilities aimed at enhancing staff knowledge in dementis care strategies.	Providing training to staff can effectively enhance well-being, with programs aimed at managing challenging behaviors showing the greatest benefits.	Patient care quality indicators, observational data, pre- and post-training knowledge assessments	The review mentions variability in the quality of the studies reviewed. This could affect the reliability and generalizability of the findings, as studies with lower quality may have biases or methodological flaws that influence outcomes.	Level III, quality B	Incorporate both quantitative measures (e.g., pre- and post-training assessments, patient care quality indicators) and qualitative feedback (e.g., staff surveys, focus groups) to gather comprehensive insights.
	5	Ellison & Dufresne (2015). A review of the clinical utility of serum clozapine and norclozapine levels.	Nonexperimental	General population, primarily patients with schizophrenia	Interpreting blood drug levels for clozapine and norclozapine	Interpreting and monitoring blood levels of clozapine helps optimize dosage, reduce relapse rates, and ensure efficacy.	Serum levels of clozapine and norclozapine	The sstudy is limited to specific antipsychotic drugs and genetic variations; may not apply to all patients or settings.	Level III, Quality B	Interpreting and monitoring blood drug levels allows for a more personalized approach to treatment, considering individual variations in drug absorption and metabolism. This can lead to more precise and effective dosing, improving overall treatment outcomes.
	6	Schoretsanitis et al (2020). Blood levels to optimize antipsychotic treatment in clinical practice: a joint consensus statement of the American Society of Clinical Psychopharmacology and the CNS.	Consensus statement	N/A	Monitoring blood levels of antipsychotic medications to optimize treatment	Proper interpretation and regular monitoring of blood drug levels helps in determining the optimal dosage of antipsychotic medications, reducing the risk of relapse and enhancing therapeutic outcomes.	Blood drug levels, patient outcomes	Consensus statements often synthesize existing research and expert opinions rather than presenting new empirical data.	Level V, Quality A	Emphasize the importance of individualized treatment plans based on pharmacogenetics and therapeutic drug interpretation and monitoring
	7	Smith et al., 2020, "Understanding Contraindications in Psychopharmacology: A Review of Best Practices"	Systematic Review	N/A	Evaluating the role of understanding contraindications in mental health care, particularly in psychopharmacology contraindications is crucial for the safe and effective use of psychotropic medications. Incorrect or overlooked contraindications can lead to adverse drug reactions, diminished therapeutic effects, and increased healthcare costs.	The review emphasizes that a thorough understanding of contraindications is crucial for the safe and effective use of psychotropic medications. Incorrect or overlooked contraindications can lead to adverse drug reactions, diminished therapeutic effects, and increased healthcare costs.	Analysis of adverse drug reactions, treatment outcomes, healthcare costs, and CDSS implementation efficacy	The review is based on existing literature, which may include studies with varying methodologies and quality.	Level III, quality B	Understanding contraindications is vital for enhancing the efficacy and safety of mental health treatments. Healthcare providers should prioritize regular training and utilize clinical decision support systems to stay informed about contraindication guidelines.

EBP Question: How does education enhance staff knowledge of interpreting physical monitoring of mental health patients and improve staff proficiency in medication administration?
Strength	Number of Sources (Quantity)	Synthesized Findings With Article Number(s) (This is not a simple restating of information from each individual evidence summary—see directions)
Level	Overall Quality Rating (Strong, good, or low)

Level I · Experimental studies	Strong quality	1	The innovative education program, involving nurses and supervisors, led to enhanced scores in patient safety culture and improvements in several dimensions. Specifically, communication openness, handoffs and transitions, teamwork within units, continuous learning and improvement, and managerial actions supporting patient safety showed significant enhancements following the program. Hence, staff educational programs hold promise for promoting these critical aspects of patient safety culture (Article 2).
Level II · Quasi-experimental studies	No Level II evidence
Level III · Nonexperimental, including qualitative studies	Strong quality	5	Interpreting and monitoring the concentrations of clozapine and norclozapine in the bloodstream assists in adjusting dosages effectively, lowering relapse rates, and ensuring treatment efficacy. This personalized method enhances the accuracy and effectiveness of dosing, thereby improving overall treatment results (Article 5). Understanding contraindications is vital for safe and effective psychotropic medication use (Article 7). Training staff has been shown to effectively enhance well-being, particularly through programs that address managing challenging behaviors, which have demonstrated the most significant benefits (Article 4). The review suggests that there are various educational interventions aimed at improving patient safety and medication competence and knowledge. However, differences between these educational interventions are not clearly defined. Nevertheless, the review underscores that simulation, particularly high-fidelity simulation, has a robust educational impact on nursing skill implementation (Article 1). Staff education contributes significantly to enhancing nursing practice. This study demonstrated improvements in drug knowledge and administration, leading to an overall enhancement in the quality of care provided (Article 3)
Level IV · Clinical practice guidelines or consensus panels	No level IV evidence
Level V · Literature reviews, QI, case reports, expert opinion	Good quality	1	Interpretation and regular monitoring of antipsychotic blood levels is crucial for optimizing treatment (Article 6).


Translation
Select the statement that best describes the overall characteristics of the body of evidence from the team’s synthesis and recommendations (Appendix H):
☐ Strong & compelling evidence, consistent results ☒ Good & consistent evidence
What is the level of safety risk associated with the intervention?
☐ High	☒ Low
Translation Assessment Flowchart:
Start Here
Based on the Translation Assessment, select the course of action:
☐ Change is indicated (system or process improvement, or practice), go to Section I ☒ Consider a pilot of the change or further investigation for new evidence, go to Section I. ☐ No indication for change or consider further investigation for new evidence, develop a research study or discontinue project, go to Section II.
Section I: If change is indicated, generate organization-specific recommendations by assessing the best-evidence recommendations for feasibility, fit, and acceptability:
The extent to which the team evaluates and believes that the change is low risk, doable, and can be successfully implemented within a given organization or setting. Feasibility	☒ The change is low risk. ☐ Few, if any, barriers are identified, and the time, effort, and resources to overcome them is reasonable. ☐ Sponsors or leaders share their point of view, endorse and support the change
Compatibility of a change with end-user workflow and consumer expectations; and/or the perceived relevance of the change in addressing the problem and in answering the PICO question within a given practice setting. Fit	☐ The change aligns with unit and/or departmental priorities. ☐ The change is suitable and seems like a good match with end-user workflow. ☒ The change is applicable to the problem and answers the PICO question.
The extent to which stakeholders and organizational leadership perceive the change to be agreeable, palatable, satisfactory, and reasonable. Acceptability	☐ The change aligns with organizational priorities. ☐ The change meets the approval of stakeholders and organizational leadership. ☒ Stakeholders and leaders like and welcome the change and find it appealing.
Organization-specific recommendations:
· Develop Comprehensive Educational Materials: Create detailed literature and data-based educational materials. These materials should include written guides, data charts, and explanatory notes on interpreting blood drug levels, identifying contraindications, ensuring compliance, and assessing treatment efficacy. · Leverage Existing Technology: Use the organization’s existing digital platforms (e.g., intranet, email, learning management systems) to distribute educational materials and reminders. Ensure that all staff have easy access to these resources. · Implement Continuous Evaluation: Conduct pre- and post-education assessments to measure knowledge gains. · Incorporate into Orientation: Integrate the educational materials into the new staff orientation program.
Section II: When a change or pilot is not indicated, what, if any, next steps does the EBP team recommend?

Action Planning
Complete the following activities to ensure successful implementation:
· Secure a project leader · Identify change champions · Consider whether translation activities require different or additional members · Identify objectives and related tasks · Determine dates to complete tasks · Identify observable pre and post measures
Identify strengths that can be leveraged to overcome barriers to ensure the success of the change:
Resources or Strengths	Barriers	Plan to Overcome Barriers by Leveraging Strengths as Appropriate
Strong support from senior leadership	Staff resistance to change	Utilize leadership support to endorse and promote the educational program.
Experienced nurse educators	Time constraints for staff participation	Schedule sessions during shift changes and provide multiple session times to accommodate all staff.



*Which of the following will be affected by this change? ( Select all that apply)*
☐ Electronic health record ☒ Workflow ☒ Policies and/or procedures ☐ Other__________
Identify and secure the resources and/or funding required for translation and implementation: *( Check all that apply)*
☐ Personnel costs ☒ Supplies/equipment ☒ Technology ☒ Education or further training	☒ Content or external experts ☐ Dissemination costs (conference costs, travel) ☐ Other: ____________________

Outcomes Measurement Plan
What is/are the goal(s) of the project?	The goal of this DNP project is to increase staff knowledge on interpreting blood drug levels, understanding contraindications, and treatment efficacy.	Desired completion date:	10/1/2024
How will you know if you are successful?	Types of Outcomes	Selected Metrics	Source	Frequency
	☒ Clinical (e.g., vital signs, infection rates, fall rates, adverse events)	Increased knowledge of interpreting blood drug levels, contraindications, and treatment efficacy	Pre and Post-test evaluation	Post-Education
	☒ Functional (e.g., activities of daily living, quality of life, self-medication administration)	Efficay of treatment approaches	Comprehensive staff review	Bi-Weekly
	☒ Perceptual (e.g., satisfaction, care experience, timeliness of response)	Staff satisfaction with the acquired knowledge.	Satff feedback loop	Post-Education
	☐ Process/Intervention (e.g., care coordination, immunization, bereavement support)
	☐ Organization/Unit-Based (e.g., staffing levels, length of stay, readmissions)
Work Breakdown Structure
High-Level Deliverable	Associated Tasks and Sub-Tasks	Start Date	End Date	Responsible Party
Develop Educational Materials	· Research and compile literature on interpreting blood drug levels, contraindications, compliance, and treatment efficacy. · Create written learning materials and presentations	01-July-2024	20-August-2024	Change agent
Deliver Educational Sessions	· Schedule and organize educational sessions for staff. · Conduct educational sessions using prepared materials	20-August-2024	10-September-2024	Change agent
Evaluate Knowledge Gain	· Develop pre- and post-education assessments. · Administer assessments and collect data	15-September-2024	01-October-2024	Change agent

DNP Project

Appendix_B_Question_Development.docx

What is the problem?

What are the data and sources of information that validate the problem?

Why is the problem important and relevant? What would happen if it were not addressed?

What is the current practice?

Is this a background question to establish the evidence on a topic (with no comparison group) or a foreground question to compare specific interventions?

What are the PICO components?

Initial EBP Question:

Appendix_C_Stakeholder_Analysis.docx

Stakeholder Analysis

Identify the key stakeholders:

Stakeholder analysis matrix: (Adapted from http://www.tools4dev.org/)

Stakeholder Name and Title:

Role: (select all that apply)

Responsibility, Approval, Consult, Inform

Impact Level: How much does the project impact them? (minor, moderate, significant)

What matters most to the stakeholder?

How could the stakeholder contribute to the project?

How could the stakeholder impede the project?

Strategy(s) for engaging the stakeholder:

CEO

Approval, Inform

Significant

Significant

Strategic alignment with organizational goals and financial implications.

Provide approval and support for resources.

Lack of approval or support could delay project implementation.

Present summary of the project plan and the project’s benefits. Also provide regular updates

Managing Director

Approval, Inform

Significant

Significant

Overall project success and alignment with organizational objectives.

Provide strategic direction and support.

Lack of strategic alignment and direction could hinder project progress.

Ensure alignment with organizational goals, offer regular progress reports.

Nursing Staff

Inform

Significant

Moderate

Practicality and clarity of education content

Implementation of new knowledge and practices.

Resistance to change or inability to learn new information.

Enable flexible scheduling for delivering staff education

Nurse Manager

Responsibility, Approval

Significant

Significant

Ensuring staff competency and patient safety

Provide support for training sessions and ensure staff participation.

Lack of engagement or support could hinder staff participation.

Regular meetings to update on project progress and address any concerns.

Appendix_G_Individual_Evidence_Summary.docx

EBP Question: How does education enhance staff knowledge of interpreting physical monitoring of mental health patients and improve staff proficiency in medication administration?

Reviewer name(s)

Article number

Author, date, and title

Type of evidence

Population, size, and setting

Intervention

Findings that help answer the EBP question

Measures used

Limitations

Evidence level and quality

Notes to team

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Appendix_H_SynthesisandRecommendationsTool_.docx

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Appendix_I_Translation_and_Action_Planning1111_BK (1).docx

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Organizational Readiness to Implement Change Assessment ,,,,,,,.doc