NURS 8512 Week 10 DNP Project Proposal Example

Asking, Advising and Connecting: A DNP Project Proposal to Bring Alcohol Screening and Brief Intervention Into Routine Annual Visits at a Rural Family Medicine Clinic

Student Name

College of Nursing, Walden University

NURS 8512: DNP Project and Practicum I

Instructor Name

Month Day, Year

Asking, Advising and Connecting: A DNP Project Proposal to Bring Alcohol Screening and Brief Intervention Into Routine Annual Visits at a Rural Family Medicine Clinic

Glossary of Defined Terms

The following terms are used throughout the proposal with these meanings only. Eligible visit: any annual preventive or wellness appointment for a patient 18 years of age or above. Screening: an AUDIT-C total entered in the dedicated record field, or, until that field exists, the items and total written into the visit note. Positive screen: AUDIT-C of 4 or more for men, 3 or more for women. Referral criterion: AUDIT-C of 8 or more. Brief intervention: documented feedback on the score with advice or discussion about reducing drinking, at the screening visit. Referral offer: documented offer of a visit with the clinic's behavioral health counselor.

Problem

The approved problem statement, reproduced exactly in Appendix A, describes a gap on three fronts: roughly three of every four adult annual visits pass with no validated alcohol screen on record, and adults whose screens are positive seldom have brief intervention or a referral offer in their charts. That pattern falls short of the federal task force's advice for primary care (US Preventive Services Task Force et al., 2018). The clinic, a composite of small rural practices, has no standard process for either.

Purpose and Aims

This project will put in place, and then evaluate, a workflow in which nurses support screening adults at annual visits with a validated instrument, the AUDIT-C, following each positive result with a brief intervention and extending a counselor referral wherever the score reaches the referral criterion, over a twelve-week implementation period beginning April 1.

Aim 1: documented screening at 80% or more of eligible visits. Aim 2: a brief intervention recorded during the screening visit for at least 70% of positive results. Aim 3: a counselor referral offer recorded at no fewer than 80% of visits that reach the referral criterion. Each target is to be reached by the end of the implementation period.

Frameworks

Three frameworks guide the project, each for a different purpose. The Iowa Model of evidence-based practice organizes the overall process, starting with the concern that prompted it, moving through appraisal of evidence and a trial run, and ending with a judgment on whether to keep the change (Iowa Model Collaborative, 2017). The updated Consolidated Framework for Implementation Research organizes the analysis of what in the clinic could help or hinder the change (Damschroder et al., 2022). Donabedian's structure, process and outcome categories organize the evaluation measures (Donabedian, 1988).

Evidence Summary

An appraisal of twelve sources supported five claims. Unhealthy alcohol use warrants attention in primary care, as national guidance states. The AUDIT-C is a brief, validated screen in primary care populations (Bush et al., 1998; Bradley et al., 2007). Brief intervention in primary care reduces drinking, based on consistent Level I evidence (Kaner et al., 2018). Delivery depends on workflow, role clarity, time and training, as qualitative and implementation reviews show (Johnson et al., 2011; Williams et al., 2011). And brief intervention alone does not reliably lead patients to specialty treatment (Glass et al., 2015), which is why the workflow walks patients directly to the in-house counselor as its method for acting on referral offers. The evidence is strong on whether the intervention works and moderate on how to deliver it in a small rural practice, which is the situation a pilot is designed for.

Setting and Stakeholders

The practice serves as the sole source of primary care for a rural county of roughly 14,000 residents. Its team includes a physician, two nurse practitioners, a pair of registered nurses, a pair of medical assistants, front desk staff and a counselor on site Tuesdays and Thursdays. It sees about 12 eligible visits a day. Its electronic record is run by a regional network. The CFIR analysis identified facilitators, including a small, close team and an engaged nurse manager, and barriers, including tight rooming time, a nurse phone-coverage rotation, one skeptical provider, medical assistant discomfort with alcohol questions and dependence on the network's build queue for the structured field.

Intervention

The workflow has five steps. (1) During rooming, a medical assistant reads the AUDIT-C items from a standard script and enters the total. (2) The score appears in the provider's view before the provider enters the room. (3) For a positive screen, the provider delivers the brief intervention or, if running late, asks the nurse to do so before the patient leaves. The intervention covers four elements: the score and its meaning, advice on lower-risk limits, the patient's view and an agreed next step. (4) For a score meeting the referral criterion, the clinician offers a visit with the counselor; on counselor days, the patient is walked to her office, and on other days, the patient is added to her callback list. (5) The front desk schedules any follow-up. Training for all roles will be completed in the two weeks before launch, and the nurse's brief intervention role will begin on non-phone days.

Evaluation

Structure measures are training completion and the date the structured field goes live. Process measures correspond to the three aims, with numerators and denominators as defined in the glossary. A proximal outcome, counselor visits completed within thirty days of a referral offer, will be tracked. Rooming time is the balancing measure. Process measures will be displayed on run charts and reported with their counts. Fidelity of the brief intervention will be assessed by chart review for the four elements and by monthly observation of two interventions, using adherence as the core fidelity dimension (Carroll et al., 2007). Changes in patients' drinking are not measured, since they take longer to appear than the implementation period allows.

Project Determination and Protection of Information

The work fits the definition of quality improvement: it implements an evidence-based practice in one clinic to improve local care, uses data collected in routine care and does not assign patients to conditions to produce generalizable knowledge. The proposal has been submitted to the university's and the clinic's review processes for a determination, and no data will be collected until that determination is documented. Evaluation data will carry study numbers only, and the key linking them to records will stay at the clinic and be destroyed at project end.

Timeline

Before launch: determination documented, structured field requested or tablet workaround tested, training completed and baseline chart review conducted for January through March. Weeks 1 to 4: launch at annual visits, weekly data review, first improvement cycle. Weeks 5 to 8: second cycle focused on whichever aim lags, midpoint report. Weeks 9 to 12: stabilization, sustainment planning and, if aim 1 has met its target for four consecutive weeks, a planned expansion to chronic disease follow-up visits as agreed with the medical director. After the period: final report.

Limitations and Expected Contribution

The project is a single-site improvement effort without a comparison group, so it can show whether practice changed but not prove that the workflow alone caused the change. Small numbers of positive screens and referral-criterion visits will limit conclusions about aims 2 and 3. Screening counts will switch from note review to a field report partway through, and every report will say so. Within those limits, the project can show whether a nurse-supported workflow brings screening, brief intervention and referral offers closer to national guidance in a small rural clinic, a setting underrepresented in the evidence.

References

Bradley, K. A., DeBenedetti, A. F., Volk, R. J., Williams, E. C., Frank, D., & Kivlahan, D. R. (2007). AUDIT-C as a brief screen for alcohol misuse in primary care. Alcoholism: Clinical and Experimental Research, 31(7), 1208-1217. https://doi.org/10.1111/j.1530-0277.2007.00403.x

Bush, K., Kivlahan, D. R., McDonell, M. B., Fihn, S. D., & Bradley, K. A. (1998). The AUDIT alcohol consumption questions (AUDIT-C): An effective brief screening test for problem drinking. Archives of Internal Medicine, 158(16), 1789-1795. https://doi.org/10.1001/archinte.158.16.1789

Carroll, C., Patterson, M., Wood, S., Booth, A., Rick, J., & Balain, S. (2007). A conceptual framework for implementation fidelity. Implementation Science, 2, Article 40. https://doi.org/10.1186/1748-5908-2-40

Damschroder, L. J., Reardon, C. M., Widerquist, M. A. O., & Lowery, J. (2022). The updated Consolidated Framework for Implementation Research based on user feedback. Implementation Science, 17, Article 75. https://doi.org/10.1186/s13012-022-01245-0

Donabedian, A. (1988). The quality of care: How can it be assessed? JAMA, 260(12), 1743-1748. https://doi.org/10.1001/jama.1988.03410120089033

Glass, J. E., Hamilton, A. M., Powell, B. J., Perron, B. E., Brown, R. T., & Ilgen, M. A. (2015). Specialty substance use disorder services following brief alcohol intervention: A meta-analysis of randomized controlled trials. Addiction, 110(9), 1404-1415. https://doi.org/10.1111/add.12950

Iowa Model Collaborative. (2017). Iowa model of evidence-based practice: Revisions and validation. Worldviews on Evidence-Based Nursing, 14(3), 175-182. https://doi.org/10.1111/wvn.12223

Johnson, M., Jackson, R., Guillaume, L., Meier, P., & Goyder, E. (2011). Barriers and facilitators to implementing screening and brief intervention for alcohol misuse: A systematic review of qualitative evidence. Journal of Public Health, 33(3), 412-421. https://doi.org/10.1093/pubmed/fdq095

Kaner, E. F. S., Beyer, F. R., Muirhead, C., Campbell, F., Pienaar, E. D., Bertholet, N., Daeppen, J. B., Saunders, J. B., & Burnand, B. (2018). Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database of Systematic Reviews, 2018(2), Article CD004148. https://doi.org/10.1002/14651858.CD004148.pub4

US Preventive Services Task Force, Curry, S. J., Krist, A. H., Owens, D. K., Barry, M. J., Caughey, A. B., Davidson, K. W., Doubeni, C. A., Epling, J. W., Kemper, A. R., Kubik, M., Landefeld, C. S., Mangione, C. M., Silverstein, M., Simon, M. A., Tseng, C.-W., & Wong, J. B. (2018). Screening and behavioral counseling interventions to reduce unhealthy alcohol use in adolescents and adults: US Preventive Services Task Force recommendation statement. JAMA, 320(18), 1899-1909. https://doi.org/10.1001/jama.2018.16789

Williams, E. C., Johnson, M. L., Lapham, G. T., Caldeiro, R. M., Chew, L., Fletcher, G. S., McCormick, K. A., Weppner, W. G., & Bradley, K. A. (2011). Strategies to implement alcohol screening and brief intervention in primary care settings: A structured literature review. Psychology of Addictive Behaviors, 25(2), 206-214. https://doi.org/10.1037/a0022102