NURS 8720 Week 1 Project Classification Post Example

Week 1 Discussion: Initial Post

Improvement, Not Research: Classifying a Nurse-Led Early Mobilization Project in a Fourteen-Bed Community ICU, and Where the Line With Evaluation Falls

My project is quality improvement. It introduces a nurse-led protocol for mobilizing ventilated patients in a 14-bed community hospital ICU, where a baseline audit found that only 9 of 40 recent ventilated patients were ever helped to sit up at the bedside during their time on the ventilator. The protocol is not new to the world: it applies published safety criteria for mobilizing ventilated adults (Hodgson et al., 2014) and records each patient's highest daily activity on the ICU Mobility Scale, an eleven-level scale developed for that purpose. What is new is that bedside nurses, rather than a dedicated mobility team, will carry it out in a unit where mobilization has been rare. The aim is to change practice in this unit, and the unit will use what it learns to adjust the protocol as it goes.

The boundary with evaluation is the harder one, and I think it turns on who the finding is for. Evaluation answers a question for someone outside the work, often a sponsor or administrator deciding whether a program should continue, expand or be funded, and it typically judges a program against criteria set in advance. Improvement answers a question for the people doing the work, here the ICU's nurses and its medical director, who want to know whether their practice is changing and what to try next. My project will report results to the hospital's quality committee, which gives it an evaluative flavor, but nobody is deciding whether to fund or end a program on the basis of it. The primary audience is the unit itself, and the design will change as cycles of testing reveal problems. That makes it improvement.

The boundary with research is clearer, and I rule research out on three grounds. First, nothing unfamiliar is introduced: mobilization within published safety criteria is established practice, and the evidence review showed it improves short-term function where baseline mobilization is low. Second, no patient is assigned to receive or not receive the protocol; every eligible patient in the unit will be assessed under it, which is how standard care changes. Third, the project is not designed to produce knowledge that generalizes beyond the unit; it is designed to improve care here. Ethics guidance on quality improvement draws the line in similar terms, while warning that improvement work can still carry risks and needs its own oversight (Lynn et al., 2007). The project will go to the hospital's quality improvement review process, which will decide whether ethics board review is needed.

My classification: improvement, because the finding is for the unit, the protocol follows existing evidence and no one is assigned to a condition. Where would you put the line between improvement and evaluation for your own project?

Reply to Danielle

Danielle, you argued that my project is really an evaluation, because I will report to a quality committee and will compare the unit before and after the protocol. That is the strongest version of the objection, and I agree the before-and-after comparison is evaluative in form. Where I disagree is about purpose. An evaluation's comparison would be fixed in advance and used to judge the program, while mine will be read monthly and used to change the protocol between cycles. If the committee later asked me to judge whether the protocol should be adopted across the hospital's other units, that would be an evaluation, and I would design it differently. Would you accept that the same data can serve improvement or evaluation, depending on the decision they feed?

Reply to Kenji

Kenji, you went the other way, suggesting that because I plan to publish, the project crosses into research. I take the point that intent to publish once seemed to decide the question, but guidance on improvement ethics has moved away from that test, noting that publishing improvement results does not by itself turn improvement into research (Lynn et al., 2007). Reporting standards for improvement work exist precisely because such work is published (Ogrinc et al., 2016). What would change my classification is if I began withholding the protocol from some patients to create a comparison group, or tested something not already supported by evidence. Neither is planned. Do you think publication should still matter for how a project is reviewed?

References

Hodgson, C. L., Stiller, K., Needham, D. M., Tipping, C. J., Harrold, M., Baldwin, C. E., Bradley, S., Berney, S., Caruana, L. R., Elliott, D., Green, M., Haines, K., Higgins, A. M., Kaukonen, K.-M., Leditschke, I. A., Nickels, M. R., Paratz, J., Patman, S., Skinner, E. H., . . . Webb, S. A. (2014). Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults. Critical Care, 18(6), Article 658. https://doi.org/10.1186/s13054-014-0658-y

Lynn, J., Baily, M. A., Bottrell, M., Jennings, B., Levine, R. J., Davidoff, F., Casarett, D., Corrigan, J., Fox, E., Wynia, M. K., Agich, G. J., O'Kane, M., Speroff, T., Schyve, P., Batalden, P., Tunis, S., Berlinger, N., Cronenwett, L., Fitzmaurice, J. M., . . . James, B. (2007). The ethics of using quality improvement methods in health care. Annals of Internal Medicine, 146(9), 666-673. https://doi.org/10.7326/0003-4819-146-9-200705010-00155

Ogrinc, G., Davies, L., Goodman, D., Batalden, P., Davidoff, F., & Stevens, D. (2016). SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised publication guidelines from a detailed consensus process. BMJ Quality & Safety, 25(12), 986-992. https://doi.org/10.1136/bmjqs-2015-004411