Development of the DNP Project Roadmap
The AACN (2015) DNP scholarly project guidelines, literature on DNP project criteria, and faculty project advisor expertise were used to create the roadmap. The DNP project advisement process was developed from practice-based knowledge from members of the Quality and Safety Education for Nurses DNP Leadership Taskforce that included faculty and practice mentor experiences with DNP project advisement and personal experiences as a DNP student.
Table A (available in the online version of this article) displays the project phases and descriptions aligned with the DNP scholarly project guidelines from the AACN (2015) Taskforce. The Problem Identification & Evidence Review, Project Planning, Implementation, and Evaluation phases follow the AACN project recommendations of evidence synthesis and translation, and implementation of a practice change that improves health outcomes for a system or population. In the Evaluation and Dissemination phases, students evaluate the practice change processes and/or outcomes and share the results locally, regionally, and nationally. The last column contains a place for the student to record the date the component was completed. A foundation for future practice scholarship is built as students successfully complete each roadmap phase.
Doctor of Nursing Practice Project Roadmap
Problem Identification and Evidence Review. In this first phase of the DNP Project Roadmap, faculty project advisors facilitate the process of problem identification by asking students to question their clinical practice (e.g., Is my practice based on best available evidence?) and to look for new or existing standards of care. Tools to facilitate problem identification and practice gaps include visual tools (e.g., Fishbone diagram) for categorizing potential causes of a problem ( https://asq.org/quality-resources/fishbone), diagramming a clinical care process (e.g., process map, flow chart), and identifying unit or organizational strengths, weaknesses, opportunities, and threats through tools such as a SWOT (Strengths, Weaknesses, Opportunities, Threats) analysis (Day, 2017; Marriott, 2018). Sources for new or existing standards of care may be practice organizations (e.g., American Nurses Association), government agencies (e.g., Agency for Healthcare Research and Quality), and health care leaders (e.g., Institute for Healthcare Improvement, Quality and Safety Education for Nurses).
Project advisement continues with faculty having students confirm that their project topic is aligned with the practice organizations' priorities. If not, the faculty project advisor may want to guide the student toward a topic that is a priority for the practice organization. Tools for answering “Is this an organization's priority?” can be found in the Iowa Model text (Cullen et al., 2018). Students should also inquire about potential individuals in the practice organization that can be mentors who can give them onsite support and guidance throughout the project phases.
Next steps include crafting a clinical question and searching relevant databases. If students use an established method to craft the question that includes identifying the population, intervention, comparison, and outcome such as PICO (Problem, Intervention, Comparison, Outcome), the search for relevant evidence is easier (Melnyk & Fineout-Overholt, 2019). McMaster University has an EBP guide with templates for building PICO questions ( https://hslmcmaster.libguides.com/c.php?g=306765&p=2044787). To hone their search skills, faculty project advisors should encourage their advisees to meet with the health science librarian in their academic or practice setting. There are also free tutorials for several of the major health care literature databases (e.g., PubMed®, EBSCO) on their websites.
Evidence-based practice or QI initiatives usually include an evidence review that differs from the more commonly known literature review. An evidence review includes critical appraisal, a process where students rate the strength (i.e., level and quality of evidence) and applicability of evidence using critical appraisal tools (Jones, 2010). In contrast, the purpose of a literature review is to identify what is known about a topic, formulate new questions that have not been answered, and make a case to address the gaps using research methods (Baker, 2016). Buccheri and Sharifi (2017) summarized tools and resources that faculty project advisors and students can use to learn and support the skill of appraising external evidence from research studies. Welk (2007) provided an overview of summary statistic terms (e.g., number needed to treat, risk ratio, odds ratio) commonly seen in the evidence-based literature.
In some project evidence reviews, it is equally important to collect and analyze internal evidence (e.g., performance metrics) from the organizational system to define the problem and to use these outcomes in the project evaluation (Alexandrov, Brewer, & Brewer, 2019). Sources of internal evidence may come from quality management, finance, human resources, and clinical systems.
Evidence summary and recommendations refer to the process of synthesizing information from external and internal sources that address the clinical question and making a decision on whether or not to translate the evidence into practice (Dearholt & Dang, 2018). Synthesis tables are a clear, concise way to display the evidence strength (e.g., Level I, II, or III) and direction (i.e., improving selected outcomes) (Melnyk & Fineout-Overholt, 2019, p. 183). Synthesis tables are visual tools that support recommendations to make or not to make a practice change. When synthesis tables reveal a lack of sufficient evidence to support a recommendation, more research needs to be performed. In these situations, faculty project advisors should develop a new plan with the student to meet the AACN DNP scholarly project recommendations. At this point in the DNP Project Roadmap, students that have identified a sufficient body of evidence to recommend a practice change are ready to move to the next phase of project planning.
Project Planning. In the project planning phase of the DNP roadmap, students begin by determining the intended outcomes of the project using established goal setting criteria that facilitate accountable project goals. Defining outcomes using SMART (Specific, Measurable, Achievable, Relevant, and Timely) goals is one commonly used approach. Templates to use for SMART goals are available (Ogbeiwi, 2017).
During project planning, students select a model and/or framework to guide the project implementation (e.g., EBP, QI, change and implementation models). Common models for EBP implementation include The Iowa EBP model (Buckwalter et al., 2017), advancing research and clinical practice through close collaboration model (Melnyk & Fineout-Overholt, 2019), and the Johns Hopkins nursing EBP model (Dearholt & Dang, 2018). Models that merge EBP with QI and include the Plan, Do, Study, Act approach are the evidence-based practice improvement model (Levin et al., 2010), and the Institute for Health-care Improvement model for improvement. Examples of change models are Kotter's 8-steps for change (Appelbaum, Habashy, Malo, & Shafiq, 2012) and Lewin's change theory (Shirey, 2013). Tucker (2019) stressed that using a toolbox of implementation strategies that include leadership, coaching, communication, reinforcement, recognition, measurement, and reporting improve the success of implementing EBP changes. Faculty project advisors can direct students to literature that provides an overview of implementation models and frameworks (Day, 2017; Mitchell, 2013; Picarillo, 2018; Tucker, 2018). Students should consider using implementation strategies as suggested by Tucker (2019) with any of these models and frameworks.
Powell et al. (2015) and the National Implementation Research Network offer additional strategies to ensure a smooth implementation process. Powell et al. (2015) provided a collection of 73 implementation strategies including the importance of stakeholders (e.g., opinion leaders, project champions, patients), use of audit and feedback, cues to action, and training the project team. The National Implementation Research Network is an interactive website that addresses implementation drivers with a compilation of leadership, organizational, and competency factors, and their influence on the implementation process.
Project planning continues with a description of the context (e.g., circumstances or conditions of setting in which the practice change will occur), the evidence-based strategy (e.g., intervention description or new or revised policy), and key stakeholders or champions who can help to facilitate the practice change. Students create an evaluation plan that may include both process and outcome measures, data tracking tools, and methods for data analysis and interpretation. Identifying possible barriers to implementation and sustainability should be identified and strategies for mitigating these barriers complete the planning process. Tools to support these project planning activities are found in the DNP project toolbox (Moran, Burson, & Conrad, 2019) and several articles on QI methods for evaluating improvement projects (Brady, Tchou, Ambroggio, Schondelmeyer, & Shaughnessy, 2018; Picarillo, 2018; Shaughnessy, Shah, Ambroggio, & Statile, 2018).
Students should be advised to create a realistic time line for completion of the project that meets the practice setting's needs and the academic institution's requirements. The Gantt chart is an example of a popular tool used during project planning (Shirey, 2008). Resources needed to conduct the project are described in the project planning phase, and this information will be used in the evaluation phase when students calculate the return on investment (ROI) (Garrison & Beverage, 2018; Opperman, Liebig, Bowling, Johnson, & Harper, 2016).
Typically, DNP projects that are EBP or QI initiatives must be reviewed according to the practice site and academic institution policies before implementation can occur. Review requirements for EBP or QI projects may vary widely by practice site and academic institution and may range from institutional review board review to organization-level feasibility review that vets the proposed practice change before implementation can occur. The faculty project advisor can help students navigate the academic institution review and the practice site mentor can help with the practice site review. Once the review process is complete, students can move on to the implementation phase.
Implementation. During the implementation phase, the DNP student performs the practice change guided by the selected implementation framework and monitors the progress of the change by collecting data and tracking deviations from the original project plan. Students need leadership and communication skills to promote the success of the project implementation (Reavy, 2016). This is an optimal time for faculty project advisors to remind DNP students that as project managers, it is their responsibility to champion the implementation process and take project ownership and seek guidance as needed from the practice site mentor. Students should be advised that communication with stakeholders during key checkpoints of the project is essential to keep all individuals involved and informed of the roll out progress. Key checkpoints with the project team include at the beginning of the project (i.e., setting expectations), several midway check-ins (i.e., to see if the project is going as planned), and at the conclusion of the project (Reavy, 2016).
An important project management role for the DNP student is to provide ongoing oversight, support, and assistance to the project team and monitor the degree of project progress. The project manager can use three questions to guide ongoing process evaluation of the project:
- Is the project progressing according to the plan and expected time line?
- Have unexpected barriers delayed the project?
- How will the implementation strategies need to be modified based on identified barriers?
Given the dynamic nature of project implementation and sustainment, students may need to revise the strategies identified in the project planning phase and try new strategies. Moran et al. (2019) and Zaccagnini and White (2017) offered additional tools and suggestions to support implementation.
Evaluation. In phase four, evaluation of the DNP project roadmap, students display process and outcome data and interpret these data. Reavy (2016) offered an extensive review of qualitative and quantitative data analysis methods for practice change projects. The Institute for Healthcare Improvement has a comprehensive free QI tool kit that provides an overview of 10 commonly used tools for data display and interpretation ( http://www.ihi.org/resources). Similarly, Brady et al. (2018) and Shaughnessy et al. (2018) demonstrated how to display and analyze QI results with attention to common cause (i.e., expected) and special cause (i.e., unexpected, indicating either a process change or an unstable process) variation.
Faculty project advisors may want to discuss with their students the scope of the evaluation and clinical meaningfulness related to EBP or QI projects. Faculty can use the following questions to frame the discussion:
- Was the plan implemented?
- Was the practice/policy change effective/did it fix the problem?
- What was the extent to which the desired outcomes were achieved?
- What do the findings mean to the stakeholders (e.g., health care services, professionals, staff, patients, families)?
Implementing a practice change that improves a process outcome or patient care outcome may be deemed a success; however, the outlay of resources must be examined for cost effectiveness. Calculating the ROI is one way to determine the financial impact of the practice change (Cullen et al., 2018). The resources (e.g., indirect and direct) that were identified during project planning phase are used to determine the ROI. Opperman et al. (2016) provided the formula for determining the cost analysis and specific steps to calculate the ROI. Once the evaluation phase is complete, students can move on to the final phase of dissemination.
Dissemination. The dissemination phase is the final phase of the roadmap, where DNP students share project findings locally, regionally, nationally, or internationally in traditional and nontraditional forms. The AACN (2018) white paper Defining Scholarship for the Discipline of Nursing broadened the definition of scholarship to specifically include practice scholarship-like DNP projects. The faculty project advisor role is crucial in terms of building writing skills for traditional practice scholarship dissemination (Murphy, Staffileno, Hinch, & Carlson, 2018).
Traditional dissemination forms may include an electronic poster or an executive summary as the deliverable for the project site. The executive summary may be used as the basis of an abstract to submit for a poster or paper presentation at a professional conference. Siedlecki (2017) and Wood and Hollier (2017) provided resources on how to create a poster and present a professional presentation. Additionally, the Navy and Marine Corps published a guide for writing executive summaries (Navy and Marine Corps Public Health Center, n.d.).
Dissemination can take the form of a publication in a peer-reviewed journal (Morton, 2016). One strategy for DNP program faculty to consider is moving the structure of the final project paper to a journal article format. The faculty project advisor can be a key resource to guide the student through the process of writing for publication. Resources exist for journal selection ( http://jane.biosemantics.org), how to write an abstract (Pearce & Ferguson, 2017), and reporting guidelines for EBP and QI projects (Milner, 2016).
Nontraditional forms of practice scholarship dissemination are gaining acceptance and support as expressions of scholarship (AACN, 2018). Nontraditional dissemination includes social media, blogs, and op-eds. Betz, Smith, Melnyk, and Tassa (2019), as well as Dearholt and Dang (2018), offered guides to nontraditional dissemination.