NURS 8740 Week 9 Project Limitations Memo Example

Memorandum

To: DNP project chair; second committee member

From: DNP student, project lead

Date: Month Day, Year

Re: Five limitations specific to the mobilization project, the direction each pushes the result and what the conclusion can still claim

Purpose

This memo lists the five limitations that matter most for the mobilization project's findings, in the order of how much each could change the main conclusion. Each entry says what happened, which way it pushes the result and what the project can still claim. Two of the five could not be mitigated and are stated as structural. Generic limitations that apply to any single-unit improvement project, such as a modest sample, are folded into the specific entries where they actually bite, because a reader learns nothing from a limitation that would be true of every project (Ogrinc et al., 2016).

1. Lighter Sedation Orders Started the Day Before the Protocol

What happened. The hospital's new sedation orders, which default to a lighter target, took effect on February 1. The protocol's first cycle began on February 2. Morning sedation scores of minus 2 or lighter went from 64% of assessments in the baseline to 76% once the protocol was running.

Direction. Upward. Lighter sedation makes more patients able to sit up, so part of the rise in sitting-up days may belong to the order set. Published guidelines treat sedation and mobilization as linked for exactly this reason (Devlin et al., 2018).

Mitigation. None possible after the fact. The project could not delay its start without losing its schedule, and the order set was a hospital decision. This limitation is structural.

What survives. The process measures show that the protocol's own steps happened: screens on 85% of days, and passed screens acted on 78% of the time. The project can claim that the protocol was delivered and that sitting-up days rose while it was; it cannot claim how much of the rise the protocol caused.

2. The Day Champion Both Delivered the Protocol and Checked the Data

What happened. The weekly bedside observation, which checks whether the recorded mobility level matches what happened, was usually performed by the day champion, who also paired with nurses on first sessions.

Direction. Toward overstating data quality. An observer invested in the protocol may score the same session the same way the nurse did, or nurses may record more carefully when they know the champion is watching. Agreement was 11 of 12 observations, which may be higher than an independent observer would find.

Mitigation. Partial. From April, the observation will alternate between the day champion and the unit educator, and agreement will be reported separately for each.

What survives. The outcome measure is based on the flowsheet for every qualifying day, not on the observations. The observation checks quality; it does not create the result.

3. Blank Levels Were Counted as Not Sitting Up

What happened. Fourteen qualifying days carried no level at all, ten of them after the protocol began and four before. The operational definition counts them as not reaching level 3.

Direction. Downward. If some of those days included sitting up, the true protocol-period figure is higher than reported. The rule was set before the data were seen, so it cannot have been chosen to favor the project.

Mitigation. Already applied, by keeping the rule fixed. A sensitivity check counting all fourteen as successes would raise the protocol figure from 40.3% to 45.7% and the baseline from 22.2% to 26.7%, so the direction of the finding does not depend on the rule.

What survives. The rise in sitting-up days holds under either treatment of blanks.

4. Seven Calls Cannot Estimate the Emergency Department Cost

What happened. The balancing measure for respiratory therapist response time rests on seven late-morning emergency calls in two months, compared with eight in the same months a year earlier.

Direction. Unknown. The median rose from 4 to 6 minutes, but with numbers this small the change could be noise, and one long call drove much of the range.

Mitigation. None that adds calls. The measure will continue monthly, and every call over fifteen minutes will be reviewed individually. This limitation is structural for the life of the project.

What survives. The project can report that no pattern of delay was detected and that one delay coincided with a session. It cannot claim the protocol has no cost to the emergency department.

5. The Weekday Result May Depend on Weekday Staffing

What happened. Sitting-up days doubled on weekdays and did not change on weekends, the days on which the unit runs without its physical therapist, with a respiratory therapist short and with a larger share of agency staff.

Direction. Toward overstating how well the protocol works as written. The overall figure of 40.3% blends a weekday protocol that works with a weekend protocol that mostly does not.

Mitigation. Reporting the two day types separately, which the results and displays already do, and designing a weekend cycle.

What survives. A clear weekday finding and a clear weekend gap, both of which are more useful to the unit than a single average.

Where This Material Goes

These five entries will be condensed into the limitations paragraph of the final report, in the same order. Entries 1 and 4 will also appear in the discussion, because they shape what the conclusion can claim, and entry 3's sensitivity check will appear as a sentence in the results. Pre-post designs without a concurrent comparison are always open to co-occurring changes and to regression toward usual levels (Portela et al., 2015), and the memo has tried to say exactly which of those threats applied here.

References

Devlin, J. W., Skrobik, Y., Gélinas, C., Needham, D. M., Slooter, A. J. C., Pandharipande, P. P., Watson, P. L., Weinhouse, G. L., Nunnally, M. E., Rochwerg, B., Balas, M. C., van den Boogaard, M., Bosma, K. J., Brummel, N. E., Chanques, G., Denehy, L., Drouot, X., Fraser, G. L., Harris, J. E., . . . Alhazzani, W. (2018). Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Critical Care Medicine, 46(9), e825-e873. https://doi.org/10.1097/CCM.0000000000003299

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

Portela, M. C., Pronovost, P. J., Woodcock, T., Carter, P., & Dixon-Woods, M. (2015). How to study improvement interventions: A brief overview of possible study types. BMJ Quality & Safety, 24(5), 325-336. https://doi.org/10.1136/bmjqs-2014-003620