Template_Explanation_on_the_Direct_Practice_Improvement_DPI

Template Explanation on the Direct Practice Improvement (DPI) Project

Proposal and the DPI Final Manuscript Template (all-in-one)

This template is used for both the DPI Project Proposal as well as the Final Manuscript.

You are required to refer to yourself as the Primary Investigator throughout the proposal and final manuscript. It is preferred that you write your manuscript in the third person, but when necessary, you must refer to yourself as the Primary Investigator.

In your proposal, you will write in the future tense (present tense, i.e., the purpose of this quantitative quasi-experimental project is to…). In contrast, in the final manuscript , you will write in the past tense (the purpose of this quantitative quasi-experimental project was to… as now you have implemented your project)

In DNP 955, you will be writing chapters 1-3 which also includes your 10-Strategic Points as an appendix. The learner is required to submit to AQR-1 by the due date week 8 (or you will not pass the course) with your manuscript in the present (future tense). In addition, in DNP 955, the appendices are as follows:

· Appendix A is your 10 Strategic Points – REQUIRED

· Appendix B is your instrument/tools -REQUIRED (if your project includes the use of an instrument/Tool)

· Appendix C is your permission to use your instrument/tools -REQUIRED (if your project includes the use of an instrument)

· Appendix D is a detailed process you as the learner will use to prepare staff/health care providers to implement the practice improvement intervention. This should include specific information obtained from the literature and from developers of the evidence-based practice guideline, protocol, toolkit, or screening tool, etc. An agenda may be included as well as an outline of materials to be used, delivery method, handouts, ppts., when, & where. Remember when you submit to AQR-1, you will include your completed cover page, abstract, TOC, chapters 1-3, and your appendices in the current APA edition.

DO NOT DELETE CHAPTERS 4 AND 5 FROM THE PAPER OR YOU WILL LOSE THE FORMATTING. THE REVIEWERS ARE AWARE THEY WILL BE INCLUDED BUT ARE NOT GOING TO BE REVIEWED DURING AQR-1.

In DNP 960, you are required to make all recommended changes listed within your AQR-1 review for chapters 1-3. This is not optional; failure to do so may result in a failing grade for DNP-960. Address all comments in the 10-Strategic Points. All edits from your AQR-1 revisions are to remain in the present (future tense) until you have received the written GCU DNP IRB Outcome Letter (typically between weeks 3-7). After you have begun implementation, you may start to write in the past tense for all 5 chapters. While waiting for the outcome letter, it is expected that all learners will write chapters 4 (including tables and figures) and 5 as a draft in preparation for the data they will be collecting in implementation.

In DNP 965, all writing in the manuscript is written in the past tense (as long as you have received the GCU DNP IRB Outcome Letter. Submission to AQR-2 occurs at the end of week 5 in DNP 965 (required to progress to final manuscript review, no AQR- 2= continuation course).

In this AQR-2 submission, you will submit all five chapters with the actual data (not the made update from DNP-960) along with your cover page, copywrite page, title page, abstract (paragraph form), TOC (updateable), the body of the manuscript, and all applicable appendices:

· Appendix A GCU IRB Outcome Letter

· Appendix B is your instrument/tools -REQUIRED (if your project includes the use of an instrument/Tool)

· Appendix C is your permission to use your instrument/tools -REQUIRED (if your project includes the use of an instrument)

· No other appendices are needed unless you have multiple tools (which is not recommended).

*Please make certain that you have used programs such as Grammarly (check into investing in Grammarly Premium), ThinkingStorm (GCU), an editor, a formatter, statistician, and any additional resources you feel like you need to be successful before you submit to AQR-2 and most importantly, before final manuscript review.

Feel free to contact the AQR Manager for any questions or concerns related specifically to AQR-1 or AQR-2. Meet regularly with your Chair, mentor, and/or content expert to ensure that your manuscript meets all requirements, deadlines, and revisions. Your DNP faculty, Chairs, and Program Lead want you to be successful and are here to support you each step of the way! Please use your University Policy Handbook on your chain of command and any appeal you feel you might need.

Blessed are those who have learned to acclaim you, who walk in the light of your presence, O Lord. – Psalm 89:15

DELETE THESE FIRST TWO PAGES!!!!!

The Direct Practice Improvement Project Title Appears in Title Case and Is Centered Comment by Author: NOTE: All notes and comments are keyed to the 7th edition of the Publication Manual of the American Psychological Association. American Psychological Associatio6n (APA) style is most commonly used to cite sources within the social sciences. This resource, revised according to the 7th edition of the Publication Manual of the American Psychological Association, offers examples for the general format of APA research papers, in-text citations, footnotes, and the reference page. For specifics, consult the Publication Manual of the American Psychological Association. For additional information on APA Style, consult the APA website: http://apastyle.org/learn/index.aspx GENERAL FORMAT RULES: Manuscripts must be 12-point Times New Roman typeface, double-spaced on quality standard-sized paper (8.5" x 11") with 1-inch margins on the top, bottom, and right side. For binding purposes, the left margin is 1.5 in.. To set this in Word, go to: Page Layout > Page Setup> Margins > Custom Margins> Top: 1” Bottom: 1” Left: 1.5” Right: 1” Click “Okay” Page Layout> Orientation> Portrait> NOTE: All text lines are double-spaced. This includes the title, headings, formal block quotes, references, footnotes, and figure captions. The first line of each paragraph is indented 0.5 inch. Use the tab key which should be set at 5 to 7 spaces. If a white tab appears in the comment box, click on the tab to read additional information included in the comment box. Please note: The section citations to APA Manual are provided in brackets throughout template. These brackets are not to be modeled for APA formatting. The information is included to help you locate material. Comment by Author: Formatting note: The effect of the page being centered with a 1.5" left margin is accomplished by the use of the first line indent here. However, it would be correct to not use the first line indent, and set the actual indent for these title pages at 1.5". Comment by Author: If the title is longer than one line, double-space it. As a rule, the title should be approximately 12 words. Titles should be descriptive and concise with no abbreviations, jargon, or obscure technical terms. The title should be typed in uppercase and lowercase letters.

Submitted by

Insert Your Full Legal Name (No Titles, Degrees, or Academic Credentials) Comment by Author: For example: Jane Elizabeth Smith

Equal Spacing Comment by Author: Delete yellow highlighted “Helps” as project develops.

~2.0” –

(7 lines)

A Direct Practice Improvement Project Presented in Partial Fulfillment

of the Requirements for the Degree

Doctor of Nursing Practice

Equal Spacing

~2.0” –

(7 lines)

Grand Canyon University

Phoenix, Arizona

[Insert Current Date]

© by Your Full Legal Name (No Titles, Degrees, or Academic Credentials), 2020 Comment by Author: NOTE: The copyright page is included in the final practice improvement project. Comment by Author: For example: © by Jane Elizabeth Smith, 2012 This page is centered. This page is counted, not numbered and should not appear in the Table of Contents.

GRAND CANYON UNIVERSITY

The Direct Practice Improvement Project Title Appears in Title Case and is Centered Comment by Author: If the title is longer than one line, double-space it. The title should be typed in upper and lowercase letters.

Insert Your Full Legal Name (No Titles, Degrees, or Academic Credentials) Comment by Author: For example: Jane Elizabeth Smith

has been approved

September 22, 2020 Comment by Author: Date of Dean’s signature. Until then, use the current date to fill this space. Upon final submission, this date should match the date on the title page.

APPROVED:

Full Legal Name, Ed.D., DBA, or Ph.D., DPI Project Chairperson

Full Legal Name, Ed.D., DBA, or Ph.D., DPI Project Mentor

Full Legal Name, Ed.D., DBA, or Ph.D., DPI Project Content Expert

ACCEPTED AND SIGNED:

________________________________________

Lisa Smith, PhD, RN, CNE

Dean and Professor, College of Nursing and Health Care Professions

_________________________________________

Date

Abstract Comment by Author: On the first line of the page, center the word “Abstract” (boldface font, italics, underlining, or quotation marks). Beginning with the next line, write the abstract. Abstract text is one paragraph with no indentation and is double-spaced. This page is counted, not numbered, and does not appear in the Table of Contents. Abstracts do not include references or citations. The abstract should be one page Comment by Author: Comment by Author: You will notice a difference between the proposal template and final manuscript template. The final template allows the option to remove headers if you need more room.

The first sentence or two outlines the problem; why is this being addressed? Do not make statements that require a citation as there are no citations in an abstract! The second statement is the supporting what is happening at the site. The purpose of this quantitative quasi-experimental project was to determine if or to what degree the implementation of _________________ (intervention) would impact ______________(what) when compared to current practice among ___________(population) in a ________ (setting i.e.: primary care clinic, ER, OR) in ________ (state) over four-weeks. State the nursing model/theory and other frameworks used in ONE SENTENCE! Data analysis and the sample size is next Now you want to state how the results were statistically and clinically significant. How did these results impact patient outcomes impact the practice at the site and recommendations for what should be done in the future based on the project findings Comment by Author: See the DC Network, Templated Abstract in writing resources Comment by Author: Whose intervenstion? Example: Sutter's Oral Hygeine Tool or the Institute of Medicinxes XYZ tool. Comment by Author: this is your measurable PATIENT outcome. Comment by Author: Make sure you take this statement and replace it throughout the manuscript to ensure it matches everywhere you discuss the purpose :) From this statement you will need to make certain that the problem statement and clinical questions match (align) with this statement as well. Comment by Author: - DO NOT SAY p> 0.05 or p<0.05 Must say p= VALUE (EXAMPLE: Data on the motivation to quit was measured by TTM and nicotine dependence was measured by the Fagerstrom Test for Nicotine Dependence (FTND) questionnaire in diabetic adult smokers aged 18 years and older, (n=16) were compared at baseline, two weeks, and four weeks post-implementation of the Five A's model. A paired t-test showed that there was a statistically significant improvement in patient's motivation to quit smoking (M=-2.86; SD=1.29; p=0.003), a substantial decrease in nicotine dependence (M= -1.86; SD=1.41; p=0.001), and 100% of the healthcare providers (n=6) were compliant in assessing tobacco use p=0.000). Comment by Author: (Based on the results, the Five A's model may result in increased patient motivation to quit smoking as well as a decrease in nicotine dependence. Recommendations include the continuation of the program and possible repetition of the project at another clinical site over an extended monitoring period as well as with larger sample sizes.) or maybe if there was no significance (Even though statistical significance was not found STATS, the INTERVENTION provided needed areas for reinforcement measurement and enhanced nursing staff awareness. Therefore, the findings suggest that continuous utilization of INTERVENTION may DO WHAT to IMPROVE WHAT. Replication of the project is needed in larger settings and over a longer period of time.)

Keywords: Abstract, theory, theorists, tools, instruments, assist future investigators, vital information Comment by Author: Make sure to add the keywords at the bottom of the abstract to assist future investigators.

Criterion Comment by Author: All of the criterion tables must be removed prior to all AQR, IRB, and final submissions.	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
The abstract provides a succinct summary of the project including the problem statement, clinical questions, methodology, design, data analysis procedures, location, sample, theoretical foundations, results, and implications.
The abstract is written in APA format, 1 paragraph, no indentations, double spaced with no citations, and includes key search words. The abstract is fully justified.
Abstract is written in a way that is well structured, has a logical flow, uses correct paragraph structure, uses correct sentence structure, uses correct punctuation, and uses correct APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1(unacceptable; needs substantial edits); 2 (present, but needs some editing); 3 (publication ready).

Comment by Author: Make sure to add the keywords at the bottom of the abstract to assist future investigators. Librarians and investigators use the keywords to catalogue and locate vital research material.

Dedication Comment by Author: Title in bold font

An optional dedication may be included here. While a practice improvement project is an objective, scientific document, this is the place to use the first person and to be subjective. The dedication page is numbered with a Roman numeral, but the page number does not appear in the Table of Contents. It is only included in the final practice improvement project and is not part of the proposal. If this page is not to be included, delete the heading, the body text, and the page break below. If you cannot see the page break, click on the ¶Show/Hide button (go to the Home tab and then to the Paragraph toolbar).

Acknowledgments Comment by Author: Title is bolded.

An optional acknowledgements page can be included here. This is another place to use the first person. If it applies, acknowledge and identify grants and other means of financial support. Also acknowledge supportive colleagues who rendered assistance. The acknowledgments page is numbered with a Roman numeral, but the page number does not appear in the Table of Contents. This page provides a formal opportunity to thank family, friends, and faculty members who have been helpful and supportive. The acknowledgements page is only included in the final practice improvement project, and is not part of the proposal. If this page is not to be included, delete the heading, the body text, and the page break below. If you cannot see the page break, click on the Show/Hide button (go to the Home tab and then to the Paragraph toolbar).

Table of Contents Chapter 1: Introduction to the Project 1 Background of the Project 5 Problem Statement 6 Purpose of the Project 7 Clinical Question(s) 9 Advancing Scientific Knowledge 11 Significance of the Project 13 Rationale for Methodology 14 Nature of the Project Design 15 Definition of Terms 17 Assumptions, Limitations, Delimitations 20 Summary and Organization of the Remainder of the Project 23 Chapter 2: Literature Review 25 Theoretical Foundations 27 Review of the Literature 30 Theme 1. 32 You may want to organize this section by themes and subthemes. To do so, use the pattern below. 32 Theme 2 33 Summary 37 Chapter 3: Methodology 41 Statement of the Problem 42 Clinical Question 43 Project Methodology 45 Project Design 48 Population and Sample Selection 50 Instrumentation or Sources of Data 52 Validity 54 Reliability 55 Data Collection Procedures 56 Data Analysis Procedures 58 Potential Bias and Mitigation 60 Ethical Considerations 64 Limitations 66 Summary 67 Chapter 4: Data Analysis and Results 69 Descriptive Data 70 Data Analysis Procedures 73 Results 74 Summary 80 Chapter 5: Summary, Conclusions, and Recommendations 82 Summary of the Project 83 Summary of Findings and Conclusion 84 Implications 86 Theoretical Implications 86 Practical Implications 86 Future Implications 86 Recommendations 87 Recommendations for Future Projects 88 Recommendations for Practice 89 References 91 Appendix A 93 The Parts of a Practice Improvement Project 93 Preliminary Pages 93 Main Text 93 Supplementary Pages 94 Appendix B 95 What is my DPI project design? 95 Appendix C 97 Power Analysis Using G Power 97 Appendix D 98 Example SPSS Dataset & Variable View 98 Appendix E 99 How to Make APA Format Tables and Figures Using Microsoft Word 99 Appendix F 109 Writing up your statistical results 109

List of Tables Comment by Author: This is an example of a List of Tables “boiler plate.” To create an automatic list of tables, go into the “References” tab on Word. For each table and figure, use the “Insert Caption” function. Choose “table” from the dropdown menu. Then, when your tables and figures have been inserted into the final manuscript, use the “Insert Table of Figures” tool in the Caption section. Choose “table” from the dropdown menu. The List of Tables follow the Table of Contents. The List of Tables is included in the Table of Contents and shows a Roman numeral page number at the top right. The page number is right justified with a 1 in. margin on each page. Dot leaders must be used. The title is bolded. On the List of Tables, single-space table titles, double-spaced between entries. See Chapter 7 of the APA Style Manual for details and specifics on Tables and Data Display. All tables are numbered with Arabic numerals in the order in which they are first mentioned.

Table 1 . Characteristics of Variables 42

Table 2 . Type of Methodology and Rationale for Selecting It 45

Table 3 . A Sample Data Table Showing Correct Formatting 71

Table 4 . t - Test for Equality of Emotional Intelligence Mean Scores by Gender 75

Table 5 . The Servant Leader 76

(Note: single-space table titles; use “Add a Space After Paragraph” (12pt) in Line Spacing Options between table titles)

List of Figures Comment by Author: This is an example of a List of Figures “boiler plate.” To create an automatic list of tables, go into the “References” tab on Word. For each table and figure, use the “Insert Caption” function. Choose “figure” from the dropdown menu. Then, when your tables and figures have been inserted into the final manuscript, use the “Insert Table of Figures” tool in the Caption section. Choose “figure” from the dropdown menu. The List of Figures follows the List of Tables. The List of Figures is included in the Table of Contents and shows a Roman numeral page number at the top right. The page number is justified with a 1 in. margin on each page. The title is bolded. Figures include graphs, charts, maps, drawings, cartoons, and photographs. In the List of Figures, single-space figure titles and double-space between entries. See 6APA Manual Chapter 7 for details and specifics on Figures and Data Display. All figures are numbered with Arabic numerals in the order in which they are first mentioned. The figure title included in the Table of Contents should match the title found in the text.

Figure 1. Approaches to C ollecting the D ata to A nswer the C linical Q uestions. 43

Figure 2. Parametric S tatistics for A nalysis of R atio or I nterval L evel D ependent V ariabl e 58

Figure 3. Non- P arametric S tatistics for A nalysis of N ominal or O rdinal L evel D ependent V ariable 59

Figure 4. Scattor Plot Example – Strong Negative Correlation 78

(Note: single-space figure titles; use “Add a Space After Paragraph” (12pt) in Line Spacing Options between table titles) double-space between entries)

Chapter 1: Introduction to the Project Comment by Author: This heading is tagged with APA Style Level 1 heading. Comment by Author: Headers 7th Edition

The Introduction section of Chapter 1 briefly overviews the project focus or practice problem, states why the project is worth conducting, and describes how the project will be completed. The introduction develops the significance of the project by describing how the project translates existing knowledge into practice, is new or different from other works and how it will benefit patients at your clinical site. This section should also briefly describe the basic nature of the project and provide an overview of the contents of Chapter 1. This section should be three or four paragraphs, or approximately one page, in length.

Keep in mind that you will write Chapters 1 through 3 as your direct practice improvement (DPI) project proposal and Chapters 1 through 5 for your final project manuscript. (see Appendix A) However, there are changes that typically need to be made in these chapters to enrich the content or to improve the readability as you write the final DPI project manuscript. Often, after data analysis is complete, the first three chapters will need revisions to reflect a more in-depth understanding of the topic, change the tense to past tense, and ensure consistency.

To ensure the quality of both your proposal and your final practice improvement project and reduce the time for Academic Quality Review (AQR) reviews, your writing needs to reflect standards of scholarly writing from your very first draft. Each section within the proposal or final DPI project should be well organized and presented in a way that makes it easy for the reader to follow your logic. Each paragraph should be short, clear, and focused. A paragraph should (a) be three to eight sentences in length, (b) focus on one point, topic, or argument, (c) include a topic sentence the defines the focus for the paragraph, and (d) include a transition sentence to the next paragraph. Include one space after each period. There should be no grammatical, punctuation, sentence structure, or American Psychological Association APA formatting errors. Be sure to use the check document feature in the Microsoft Word Review Menu. This feature will check for spelling errors and grammatical issues.

Verb tense is an important consideration for Chapters 1 through 3 versus the final manuscript. For the proposal, the investigator uses present tense (e.g., “The purpose of this project is to…”), whereas in the practice improvement final project, the chapters are revised into past tense (e.g., “The purpose of this project was to…”). Taking the time to put quality into each draft will save you time in all the steps of the development and review phases of the practice improvement project process. It will pay to do it right the first time. Comment by Author: Consider where you are in the process when determining past or present tense. If your project has been implemented, and you have finished your data collection, then the entire manuscript should be written in past tense.

As a doctoral investigator, it is your responsibility to ensure the clarity, quality, and correctness of your writing and APA formatting. The DC Network provides various resources to help you improve your writing. Neither your chairperson nor your committee members will provide editing of your documents, nor will the AQR reviewers provide editing of your documents. If you do not have outstanding writing skills, you will need to identify a writing coach, editor, or other resources such as GrammarlyTM or ThinkingstormTM (GCU service) to help you with your writing and to edit your documents. The most important outcome is a scholarly product.

The quality of a DPI project is not only defined by the quality of writing. It is also defined by the criteria that have been established for each section of the project. The criteria describe what must be addressed in each section within each chapter. As you develop a section, first read the section description. Then review the criteria contained in the table below the description. Use both the description and criteria as you write the section. It is important that the criteria are addressed in a way that it is clear to your chairperson, committee, and an external reviewer to illustrate that the criteria have been met. You should be able to point out where each criterion was met in each section. Prior to submitting a draft of your proposal or practice improvement project, or a single chapter to your chairperson, please assess yourself on the degree to which criteria have been met. There is a table at the end of each section for you to complete this self-assessment. Your chairperson may also assess each criterion when returning the document with feedback. The following scores reflect the readiness of the document: Comment by Author: Please complete the table below with your ratings to show achievement of the criterion.

· 3 = The criterion has been completely met. It is comprehensive and accurate. The section meeting the criterion is comprehensive and clear. The criterion information is very well written. The section addressing a criterion is located in a single spot; it is not distributed across various paragraphs. The criterion is immediately obvious to an external reviewer. In terms of writing, the section is perfect and ready to go into a journal article.

· 2 = The criterion is very close to being completely met. The section meeting the criterion is comprehensive but may need to be further clarified. The criterion information is fairly well written but may need minor editing. The section addressing a criterion is located in a single spot; it is not distributed across various paragraphs. It may not be obvious to an external reader and so may require some clarification. In terms of writing it is near perfect but may need minor edits for clarity or APA formatting.

· 1 = The criterion is present, but the section needs significant work to completely meet expectations. The section meeting the criterion is not comprehensive and may need to be further clarified. The criterion information is fairly well written but may need minor editing. The section addressing a criterion is not clearly located in a single spot; it appears to be distributed across various paragraphs. It may not be obvious to an external reader and requires some clarification. It needs some changes to the structure, flow, paragraph structure, sentence structure, punctuation, and APA format.

· 0 = The criterion is not addressed because it is missing or is not appropriate.

Once the document has been approved by your chairperson and your committee and is ready to submit for the AQR review, please remove all of these assessment tables from this document.

Criterion Comment by Author: All of the criterion tables must be removed prior to all AQR, IRB, and final submissions. ^ To remove the table, click on the icon noted when the table is clicked on. Right click on this icon and delete table.	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Introduction This section briefly overviews the project focus or practice problem, why this project is worth conducting, and how this project will be completed. (Three or four paragraphs or approximately one page)
A practice improvement project topic is introduced.
Discussion provides an overview of what is contained in the chapter.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

Background of the Project Comment by Author: This heading is tagged with APA Style Level 2 heading.

The background section of Chapter 1 explains both the history of and the present state of the problem and the DPI project focus. This section summarizes the Background section which will be expanded upon in Chapter 2 and is two or three paragraphs in length.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Background of the Project The background section explains both the history and the present state of the problem and project focus. This section summarizes the Background section from Chapter 2. (Two or three paragraphs)
This section provides an overview of the history of and present state of the problem and project focus.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

Problem Statement

This section of the final manuscript is two or three paragraphs long. It clearly states the problem or project focus, the population affected, and how the project will contribute to solving the problem. This section of Chapter 1 should be comprehensive yet simple, providing context for the practice project.

A well-written problem statement begins with the big picture of the issue (macro) and works to the small, narrower, and more specific problem (micro). It clearly communicates the significance, magnitude, and importance of the problem and transitions into the Purpose of the Project with a declarative statement such as “It is/was not known if or to what degree the implementation of ___________ (intervention) would impact ______________(outcome) when compared to current practice among ___________ (population). in (urban/rural)________ (state). Comment by Author: Problem statement format update from Revised Strategic Points.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Problem Statement This section includes the problem statement, the population affected, and how the project will contribute to solving the problem. (Two or three paragraphs)
This section states the specific problem for investigation by presenting a clear declarative statement that begins with “It is not known if and to what degree/extent...,” or “It is not known how/why and….”
This section identifies the need for the project.
This section identifies the broad population affected by the problem.
This section suggests how the project may contribute to solving the problem.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

Purpose of the Project

The Purpose of the Project section of Chapter 1 should be two or three paragraphs long, provide a reflection of the problem statement, and identify how the project will be accomplished. It explains how the project will contribute to the field. The section begins with a declarative statement, "The purpose of this project is....” Included in this statement are also the project design, population, variables to be investigated, and the geographic location. For example, “the purpose of this quantitative quasi-experimental project is to examine the impact of a preoperative anxiety assessment tool on non-pharmacologic anxiolytic interventions for a subset of pediatric patients in a midwestern academic medical center” (Overly, 2020). Further, the section clearly defines the dependent and independent variables, relationship of variables, or comparison of groups (comparison versus intervention) for quantitative analyses. Keep in mind that the purpose of the project is restated in other chapters of the practice improvement project and should be worded exactly as presented in this section of Chapter 1.

Creswell and Creswell (2018) provided a sample template for the purpose statements aligned with the quasi-experimental design. Please see the template for quantitative method as follows: The purpose of this quantitative quasi-experimental project is to determine if or to what degree the implementation of _________________ (intervention) would impact ______________(what) when compared to current practice among ___________(population) in a ________ (setting i.e.: primary care clinic, ER, OR) in ________ (state). The ________ (independent variable) will be defined/measured as/by _______ (provide a general definition). The (dependent variable) will be defined/measured as/by ______ (provide a general definition). This purpose statement aligns to the PICOT components from previous courses. Comment by Author: Please note that DPIs are quantitative. You may see reference to qualitative and mixed methodologies throughout the curriculum and in the templates as these are other methods. However, a DPI measures or tests an intervention on a patient outcome. Therefore, a quantitative method is the most feasilble method for doing so. Comment by Author: Please format your purpose statement to this templated declarative sentence and use throughout the manuscript.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Purpose of the Project The purpose statement section provides a reflection of the problem statement and identifies how the project will be accomplished. It explains how the project will contribute to the field. (Two or three paragraphs)
This section presents a declarative statement: "The purpose of this project is...." that identifies the project design, population, variables (quantitative) to be investigated, and geographic location.
This section identifies project method as quantitative and identifies the specific design.
This section describes the specific population group and geographic location for the project.
This section defines the dependent and independent variables, relationship of variables, or comparison of groups (quantitative).
This section explains how the project will contribute to the field.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

Clinical Question(s) Comment by Author: Make sure you customize this. It is either Clinical Question or Clinical Questions depending on whether or not you have more than one.

This section should be two or three paragraphs in length, narrow the focus of the project, and specify the clinical questions to address the problem statement. Based on the clinical questions, the section describes the variables or groups. The clinical questions should be derived from, and are directly aligned with, the problem and purpose statements, methods, and data analyses. The Clinical Questions section of Chapter 1 will be presented again in Chapter 3 to provide clear continuity for the reader and to help frame your data analysis in Chapter 4.

In a paragraph prior to listing the clinical questions, include a discussion of the clinical questions, relating them to the problem statement. Templated statement: To what degree does the implementation of _______________ (intervention) impact(s) __________________ (what) when compared to _____________ among _____________ (population) patients in a ______ (setting) in _______ (state) over four-weeks? Comment by Author: Format your clinical question in this manner.

Then, include a leading phrase to introduce the questions such as: The following clinical questions guide this quantitative project:

Q1:

Q2:

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Clinical Question(s) This section narrows the focus of the project and specifies the clinical questions to address the problem statement. Based on the clinical questions, it describes the variables or groups for a quantitative project. (Two or three paragraphs)
This section states the clinical questions the project will answer, identifies the variables, and predictive statements using the format appropriate for the specific design.
This section includes a discussion of the clinical questions, relating them to the problem statement.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

Advancing Scientific Knowledge

The Advancing Scientific Knowledge section should be two or three paragraphs in length, and specifically describe how the project will advance population health outcomes on the topic. This advancement can be a small step forward in a line of the current clinical site practice, but it must add to the current body of knowledge in the literature. This section also identifies the gap or need based on the current literature and discusses how the project will address that gap or need. This section summarizes the Theoretical Foundations section from Chapter 2 by identifying the theory or model upon which the project is built. It also describes how the project will advance that theory or model.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Advancing Scientific Knowledge This section specifically describes how the project will advance population health outcomes on the topic. It can be a small step forward in a line of current project, but it must add to the current body of knowledge in the literature. It identifies the gap or need based on the current literature and discusses how the project will address that gap or need. This section summarizes the Theoretical Foundations section from Chapter 2. (Two or three paragraphs)
This section clearly identifies the gap or need in the literature that was used to define the problem statement and develop the clinical questions.
This section describes how the project will address the gap or identified need in the literature.	.
This section identifies the theory or model upon which the project is built.
This section describes how the project will advance the theory or model upon which the project is built.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

Significance of the Project

This section identifies and describes the significance of the project. It also discusses the implications of the potential results based on the clinical questions and problem statement. Further, it describes how the project fits within and will contribute to the current literature or the clinical site practice. Finally, it describes the potential practical applications from the project. This section should be three or four paragraphs long and is of particular importance because it justifies the need for, and the relevance of, the project.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)
Significance of the Project This section identifies and describes the significance of the project and the implications of the potential results based on the clinical questions and problem statement. It describes how the project fits within and will contribute to the current literature or the clinical site practice. It describes potential practical applications from the project. (Three or four paragraphs)
This section provides overview of how the project fits within other current literature in the field, relating it specifically to other studies.
This section describes how addressing the problem will impact and add value to the population, community, or society.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

Rationale for Methodology

This section introduces the methodology for the DPI project and explains the rationale for selecting this quantitative methodology. The Rationale for Methodology section of Chapter 1 clearly justifies the methodology the investigator plans to use for conducting the project. It argues how the methodological framework is the best approach to answer the clinical questions and address the problem statement. Finally, it contains citations from textbooks and articles on the DPI project methodology or articles on related studies (Creswell & Creswell, 2018). DPI project are typically quantitative due to the nature of measuring a practice improvement.

This section describes the clinical questions the project will answer and identifies the variables using the format appropriate for the specific design. Finally, this section includes a discussion of the clinical questions, relating them to the problem statement. This section should be two or three paragraphs long and illustrate how the methodological framework is aligned with the problem statement and purpose of the project, providing additional context for the project.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Rationale for Methodology This section clearly justifies the methodology the investigator plans to use for conducting the project. It argues how the methodological framework is the best approach to answer the clinical questions and address the problem statement. It uses citations from textbooks and articles on DPI project methodology or articles on related studies. (Two or three paragraphs)
This section identifies the specific project method for the project.
This section justifies the method to be used for the project by discussing why it is the best approach for answering the clinical question and addressing the problem statement.
This section uses citations from textbooks or literature on the DPI project methodology to justify the use of the selected methodology.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

Nature of the Project Design

This section describes the specific project design (quasi-experimental) to answer the clinical questions and why this approach was selected. (see Appendix B) Here, the learner discusses why the selected design is the best design to address the problem statement and clinical questions as compared to other designs. You should be focusing on the design rather than the methodology in this section. Briefly describes how the design supports the intervention and solution to the practice problem. This section also contains a description of the project sample being investigated, as well as the process that will be used to collect the data on the sample. In other words, this section provides a preview of Chapter 3 and succinctly conveys the project approach to answer clinical questions.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Nature of the Project This section describes the specific project design to answer the clinical questions and why this approach was selected. It describes the project sample as well as the process that will be used to collect the data on the sample.
This section describes the selected design for the project.
This section discusses why the selected design is the best design to address the problem statement and clinical questions as compared to other designs.
This section briefly describes the specific sample and the data collection procedure to collect information on the sample. Briefly describes how the design supports the intervention and solution to the practice problem.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

Definition of Terms

The Definition of Terms section of Chapter 1 defines the project constructs and provides a common understanding of the technical terms, exclusive jargon, variables, phenomena, concepts, and sundry terminology used within the scope of the project. Terms are defined in lay terms and in the context in which they are used within the project. Each definition may be a few sentences to a paragraph in length. This section includes any words that may be unknown to a lay person (words with unusual or ambiguous meanings or technical terms) from the evidence or literature. It provides a rationale for each assumption and defines the variables.

Definitions must be supported with citations from scholarly sources. Do not use Wikipedia to define terms. This popular “open source” online encyclopedia can be helpful and interesting for the layperson, but it is not appropriate for formal academic scholarly writing. Additionally, do not use dictionaries to define terms. A paragraph introducing this section prior to listing the definition of terms can be inserted. However, a lead in phrase is needed to introduce the terms such as: "The following terms were used operationally in this project." This is also a good place to operationally define unique phrases specific to this project. See below for the correct format:

Term. Comment by Author: This is how each of your terms should be listed in this section.

Write the definition of the word. This is considered a Level 3 heading. Make sure the definition is properly cited (Author, 2010).

Clinical Significance.

Clinical significance (also known as clinical relevance) indicates whether the results of a project are meaningful or not for several stakeholders. Statistical significance does not assure that the results are clinically relevant. Indeed, the use of significance testing rarely determines the practical importance or clinical relevance of findings (Armijo-Olivo, 2018)

Comparison and Intervention Group.

Refers to the sample groups of data in your project as the comparison group and the intervention group. These groups can be used to compare the baseline practice to the direct practice improvement. There are two approaches to the data of these groups. Between-group differences show how two or more groups of the data are sampled or participants are different, whereas within-group differences show differences among data or participants who are in the same single group of the sample (Creswell & Creswell, 2018). Further, within-group differences can come to light when looking at the results of a between-groups approach including individual differences associated with the sample or group. (see Figure 1). Please note that there are no control groups in the DPI. If the learner writes control groups as a comparison group, the DPI will not move forward.

Statistical Significance.

Statistical significance shows a result is unlikely due to chance. It is a result which indicates a level of confidence a result did not occur solely from sample selection. The investigator determines the level of significance for the project (e.g. p<.05 or p<.01). The p-value is the probability of obtaining the difference measured from a sample if there really is not a difference for all users. If the p-value obtained is less than this level determined in the proposal by the investigator, it would be considered statistically significant. The investigator would infer the intervention caused the difference. Statistical significance is not clinical significance or whether the results of a project are meaningful or not for several stakeholders (Creswell & Creswell, 2018).

Terms often use abbreviations. According to APA (2010), abbreviations are best used only when they allow for clear communication with the audience. Standard abbreviations, such as units of measurement and names of states, do not need to be written out.

Only certain units of time should be abbreviated. Abbreviate hr. (hour), min (minute), ms (millisecond), ns (nanosecond), or s (second). However, do not abbreviate day, week, month, and year [4.27]. To form the plural of abbreviations, add “s” alone without apostrophe or italicization (e.g., vols., IQs, Eds.). The exception to this rule is not to add “s” to pluralize units of measurement (12 m not 12 ms) [4.29].

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Definitions of Terms This section defines the project constructs and provides a common understanding of the technical terms, exclusive jargon, variables, phenomena, concepts, and sundry terminology used within the scope of the project. Terms are defined in lay terms and in the context in which they are used within the project. (Each definition may be a few sentences to a paragraph in length.)
This section Defines any words that may be unknown to a lay person (words with unusual or ambiguous means or technical terms) from the evidence or literature.
This section defines the variables for a quantitative project.
Definitions are supported with citations from scholarly sources.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

Assumptions, Limitations, Delimitations

This section identifies the assumptions and specifies the limitations, as well as the delimitations, of the project. It should be four to six paragraphs in length.

An assumption is a self-evident truth. Assumptions are things that are accepted as true, or at least plausible, by other researchers, peers, and generally to most people will read your project. In other words, any scholar reading your paper will assume that certain aspects of your project are true given your population, statistical test, project design, or other delimitations. For example, if you tell your friend that your favorite restaurant is an Italian place, your friend will assume that you don’t go there for the sushi. It’s assumed that you go there to eat Italian food. Because most assumptions are not discussed in-text, assumptions that are discussed in-text are discussed in the context of the limitations of your project, which is typically in the discussion section. This is important, because both assumptions and limitations affect the inferences you can draw from your project.

This section should list what is assumed to be true about the information gathered in the project. State the assumptions being accepted for the project as methodological, theoretical, or topic specific. For each assumption listed, you must also provide an explanation. Provide a rationale for each assumption, incorporating multiple perspectives, when appropriate. For example, the following assumptions were present in this project:

1. It is assumed that survey participants in this project were not deceptive with their answers, and that the participants answered questions honestly and to the best of their ability. Provide an explanation to support this assumption.

2. It is assumed that this project is an accurate representation of the current situation in rural southern Arizona. Provide an explanation to support this assumption. Limitations are things that the investigator has no control over, such as bias.

It is important to remember that your limitations and assumptions should not contradict one another. Assumptions are also present with the statistical tests performed in the DPI. These assumptions refer to the characteristics of the data, such as distributions, trends, and variable type, just to name a few. Violating these assumptions can lead to drastically invalid results, though this often depends on sample size and other considerations.

Limitations are a systematic bias that you did not or could not control which could inappropriately affect the results. Delimitation is a systematic bias intentionally introduced into the study design or instrument by you. Possible limitations and delimitations in study design or impact and statistical or data limitations: For example, sample choice and size of the sample, the availability and reliability of data , access to protected or proprietary data, methods/instruments/techniques used to collect the data, the use of self‐reported data, time constraints or cultural and other communication issues.

Delimitations are things over which the investigator has control, such as location of the project, population and sample, and data collection tools like the electronic health record (EHR).

Identify the limitations and delimitations of the project design. Discuss the potential generalizability of the project findings based on these limitations. For each limitation and delimitation listed, make sure to provide an associated explanation. For example: The following limitations/delimitations were present in this project:

1. Lack of funding limited the scope of this project. Provide an explanation to support this limitation.

2. The survey of high school students was delimited to only rural schools in one county within southern Arizona, limiting the demographic sample. Provide an explanation to support this delimitation.

Identify the limitations of your project and explain the importance of each. Reflect on the nature of the limitations and justify the choices made during the project. Advance the evidence by suggesting how such limitations could be overcome in future.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Assumptions, Limitations and Delimitations This section identifies the assumptions and specifies the limitations, as well as the delimitations, of the project. (3-4 paragraphs)
This section states the assumptions being accepted for the project (methodological, theoretical, and topic-specific).
This section provides rationale for each assumption, incorporating multiple perspectives, when appropriate.
This section identifies limitations and delimitations of the project design.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

Summary and Organization of the Remainder of the Project

This section summarizes the key points of Chapter 1 and provides supporting citations for those key points. It then provides a transition discussion to Chapter 2 followed by a description of the remaining chapters. For example, Chapter 2 will present a review of current evidence on the centrality of the practice improvement project literature review and the existing evidence available to guide project preparation. Chapter 3 will describe the methodology, design, and procedures for this investigation. Chapter 4 details how the data was analyzed and provides both a written and graphic summary of the results. Chapter 5 is an interpretation and discussion of the results, as they relate to the existing body of evidence related to the practice improvement project topic.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Organization of the Remainder of the Project This section summarizes the key points of Chapter 1 and provides supporting citations for those key points. It then provides a transition discussion to Chapter 2, followed by a description of the remaining chapters.
This section summarizes key points presented in Chapter 1.
This section provides citations to support key points.
Chapter 1 summary ends with transition discussion to Chapter 2.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

Chapter 2: Literature Review Comment by Author: This section should be a minimum of 20-25 pages.

This chapter presents the theoretical framework for the project and develops the topic, specific practice problem, question(s), and design elements. In order to perform significant practice improvement projects, the learners must first understand the literature related to the project focus. A well-articulated, thorough literature review provides the foundation for substantial, contributory projects or evidence. The purpose of Chapter 2 is to develop a well-documented argument for the selection of the project topic, formulate the clinical questions, and justify the choice of methodology as introduced in Chapter 1. A literature review is a synthesis of what has been published on a topic by accredited scholars and investigators. It is not an expanded annotated bibliography or a summary of peer reviewed articles related to your topic.

The literature review will place the project focus into context by analyzing and discussing the existing body of knowledge and effectively presenting the reader with an exhaustive review of known information. The comprehensive presentation should include as much information as possible pertaining to what has been discovered in the evidence about that focus, and where the gaps and tensions in the evidence exist. As a piece of writing, the literature review must convey to the reader what knowledge and ideas have been established on a topic and build an argument in support of the practice problem.

This section describes the overall topic to be investigated, outlines the approach taken for the literature review, and defines the evolution of the problem based on the evidence to cover the gap or need to improve population health outcomes. Make sure the Introduction and Background section of your literature review addresses the following required components:

· Introduction: States the overall purpose of the project.

· Introduction: Provides an orienting paragraph so the reader knows what the literature review will address.

· Introduction: Describes how the chapter will be organized (including the specific sections and subsections).

· Introduction: Describes how the literature was surveyed, so the reader can evaluate the thoroughness of the review.

· Background: Provides a historical overview of the problem based on the gap or need defined in the literature and how it originated. This section must contain empirical (original research) citations. Present strong evidence for the intervention.

· Background: Discusses how the problem has evolved historically into its current form.

Criterion Comment by Author: All of the criterion tables must be removed prior to all AQR, IRB, and final submissions.	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Introduction (to the Chapter) and Background (to the Problem) This section describes the overall topic to be investigated, outlines the approach taken for the literature review, and defines the evolution of the problem based on the gap or need defined in the literature from its origination to its current form.
Introduction states the overall purpose of the project.
Introduction provides an orienting paragraph so the reader knows what the literature review will address.
Introduction describes how the chapter will be organized (including the specific sections and subsections).
Introduction describes how the literature was surveyed so the reader can evaluate the thoroughness of the review.
Background provides the historical overview of the problem based on the gap or need defined in the literature and how it originated.
Background discusses how the problem has evolved historically into its current form.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

Theoretical Foundations

This section identifies the nursing theories and evidence-based practice change models that provide the foundation for the Direct Practice Improvement (DPI) Project. It also contains an explanation of how the problem under investigation relates to the nursing theories and evidence-based practice change models. The seminal source for each nursing theory and evidence-based change model should be identified and described. Please note: models and theories are not capitalized in APA style.

The theories or models(s) guide the clinical questions and justify what is being measured (variables), as well as how those variables are related. This section also must include a discussion of how the clinical question(s) align with the a nursing theory or nursing model and illustrates how the project fits within other evidence, based on the theories or models. You are encouraged to use a change model to outline how the DPI project would be implemented in a healthcare organization. Please outline and define the change model steps or processes and how those steps are implemented for the DPI project. The learner should cite references reflective of the foundational, historical, and current literature in the field. Overall, the presentation should reflect that the learner understands the theory or model and its relevance to the project. The discussion should also reflect knowledge and familiarity with the historical development of the theories or models.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
theoretical Foundations This section identifies the nursing theory and (if used) change model that provide the foundation for the project. This section should present the theories or models(s) and explain how the problem under investigation relates to the theory or model. The theories or models(s) guide the clinical questions and justify what is being measured (variables) as well as how those variables are related.
This section identifies the nursing theory and (if used) change model that provide the foundation for the project.
This section identifies and describes the seminal source for each theory or model.
This section discusses how the clinical question(s) align with the respective theories or models.
This section illustrates how the project fits within other evidence-based literature on the theory or model.
This section reflects understanding of the theory or model and its relevance to the project.
This section cites references reflecting the foundational, historical, and current literature in the field.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

Review of the Literature

This section provides a broad, balanced overview of the existing literature related to the topic. It identifies themes, trends, and conflicts in methodology, design, and findings. It provides a synthesis of the existing literature, examines the contributions of the literature related to the topic, and presents an evaluation of the overall methodological strengths and weaknesses of the evidence. Through this synthesis, the gaps in evidence should become evident to the reader.

This section describes the literature in related topic areas and its relevance to the project topic. It provides an overall analysis of the existing literature examining the contributions of this literature to the field, identifying the conflicts, and relating the themes and results to the project. Citations are provided for all ideas, concepts, and perspectives. The investigator’s personal opinions or perspectives are not included.

The required components for this section include the following:

· Chapter 2 needs to be at least 20-25 pages in length. It needs to include a minimum of 50 scholarly sources with 85% of sources published within the past 5 years. Additional sources do not necessarily need to be from the past 5 years.

· Quantitative project: Describes each project variable in the project and discusses the prior evidence that has been done on the variable. Comment by Author: Please note that you may also use seminal works and other relevant literature that supports your topic concept.

· Discusses the various methodologies and designs that have been used to provide evidence on topics related to the project. Uses this information to justify the design.

· Relates the literature back to the DPI-project topic and the practice problem.

· Argues the appropriateness of the practice improvement project’s instruments, measures, or approaches used to collect data.

· Discusses topics related to the practice improvement project topic. This section may include (a) studies relating the variables (quantitative); (b) studies on related evidence-based research, such as factors associated with the topic; (c) studies on the instruments used to collect data; and (d) studies on the broad population for the project.

· Set of topics discussed in the Review of Literature demonstrates a comprehensive understanding of the broad area in which the project topic exists.

· Argues the appropriateness of the practice improvement project’s instruments, measures, or approaches used to collect data.

· Each section within the Review of Literature includes an introductory paragraph that explains why the particular topic was explored relative to the practice improvement project topic.

· Each section also requires a summary paragraph(s) that (a) compares and contrasts alternative perspectives on the topic, (b) provides a summary of the themes relative to the topic discussed that emerged from the literature, (c) discusses data from the various studies, and (d) identifies how themes are relevant to your practice improvement project topic.

· The types of references that may be used in the literature review include empirical (original research) articles (MUST HAVE) evidence-based research, meta-analysis, systematic reviews, randomized control trials, or seminal works, peer-reviewed or scholarly journal articles, and books that are cutting-edge views on a topic.

he body of a literature review can be organized in a variety of ways depending on the nature of the project. Work with your committee chairperson to determine the best way to organize this section of Chapter 2, as it pertains to your overall project design. This template organizes the evidence thematically as illustrated below.

Theme 1. Comment by Author: This heading is tagged with APA Style Level 3 heading [3.03]. To differentiate the Level 3 heading from the normal style of the text, write the Level 3 heading and tag it. Then, create the first paragraph of the subsection on the line below the theme heading. Then, place the cursor next to the theme heading. Hit the keys “cntrl + alt + enter.” This will create a “style break” so that the Level 3 heading and the normal paragraph do not connect but are formatted correctly on the same line. Comment by Author: Make sure you are replacing “Theme 1” (or subtheme) with the actual title of theme one. Do not include “Theme 1” in the title as it is just a placeholder.

You may want to organize this section by themes and subthemes. To do so, use the pattern below.

Subtheme 1. Comment by Author: This heading is tagged with APA Style Level 4 heading [3.03]. To differentiate the Level 4 heading from the normal style of the text, write the Level 4 heading and tag it. Then, create the first paragraph of the subsection on the line below the theme heading. Then, place the cursor next to the theme heading. Hit the keys “cntrl + alt + enter.” This will create a “style break” so that the Level 4 heading and the normal paragraph do not connect but are formatted correctly on the same line.

Grouped findings related to Theme 1.

Subtheme 2. Comment by Author: This heading is tagged with APA Style Level 4 heading [3.03]. To differentiate the Level 4 heading from the normal style of the text, write the Level 4 heading and tag it. Then, create the first paragraph of the subsection on the line below the theme heading. Then, place the cursor next to the theme heading. Hit the keys “cntrl + alt + enter.” This will create a “style break” so that the Level 4 heading and the normal paragraph do not connect but are formatted correctly on the same line.

Grouped findings related to Theme 1.

Subtheme 3. Comment by Author: This heading is tagged with APA Style Level 4 heading [3.03]. To differentiate the Level 4 heading from the normal style of the text, write the Level 4 heading and tag it. Then, create the first paragraph of the subsection on the line below the theme heading. Then, place the cursor next to the theme heading. Hit the keys “cntrl + alt + enter.” This will create a “style break” so that the Level 4 heading and the normal paragraph do not connect but are formatted correctly on the same line.

Grouped findings related to Theme 1.

In a concluding paragraph, provide a synthesis of the evidence studies presented in Theme 1. Discuss the strengths and weaknesses of each project, as well as the variables, instrumentation, and findings of each project as they relate to each other and use the findings of the studies in the subtheme to build an argument for your project. Discuss what is missing or how the design or methodology could have changed in studies to improve the quality of the project. Discuss inconsistencies or gaps that emerge in the evidence providing opportunity for additional projects. Provide a transition sentence to the next theme. Comment by Author: This was updated. please check formatting!

Theme 2.

Please follow the same Theme-subtheme process as outlined above.

Grouped findings related to Theme 2.

In a concluding paragraph, provide a synthesis of the evidence studies presented in Theme 2. Discuss the strengths and weaknesses of each project, as well as the variables, instrumentation, and findings of each project as they relate to each other and use the findings of the studies in the subtheme to build an argument for your project. Discuss what is missing or how the design or methodology could have changed in studies to improve the quality of the project. Discuss inconsistencies or gaps that emerge in the evidence providing opportunity for additional projects. Provide a transition sentence to the next theme. Need at least three themes.

Chapter 2 can be particularly challenging with regard to APA format for citations and quotations. Refer to your APA manual frequently to make sure your citations are formatted properly. It is critical that each in-text citation is appropriately listed in the References section.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Review of the Literature This section provides a broad, balanced overview of the existing literature related to the project topic. It identifies themes, trends, and conflicts in methodology, design, and findings. It describes the literature in related topic areas and its relevance to the project topic. It provides an overall analysis of the existing literature examining the contributions of this literature to the field, identifying the conflicts, and relating the themes and results to the project. Citations are provided for all ideas, concepts, and perspectives. The investigator’s personal opinions or perspectives are not included.
Chapter 2 needs to be at least 20-25 pages in length. It needs to include a minimum of 50 scholarly sources with 85% from the sources published within the past 5 years. Additional sources do not necessarily need to be from the past 5 years. It should not include any personal perspectives.
This section describes each variable in the project discussing the prior evidence that has been done on the variable.
This section Discusses the various methodologies and designs that have been used to understand evidence presented on topics related to the project. Uses this information to justify the design.
This section argues the appropriateness of the practice improvement project’s instruments, measures, and/or approaches used to collect data.
This section discusses topics related to the practice improvement project topic and may include (a) studies relating the variables (quantitative) or exploring related phenomena (qualitative), (b) evidence –based studies on related factors associated with the topic, (c) Relates the literature back to the DPI-project topic and the practice problem. d) studies on the instruments used to collect data, and (e) studies on the broad population for the project. Set of topics discussed in the Review of Literature demonstrates a comprehensive understanding of the broad area in which the topic exists.
Each section within the Review of Literature includes an introductory paragraph that explains why the particular topic was explored relative to the practice improvement project topic.
Each section within the Review of Literature requires a summary paragraph that (a) compares and contrasts alternative perspectives on the topic, (b) provides a summary of the themes relative to the topic discussed that emerged from the literature, and (c) identifies how themes are relevant to your practice improvement project topic.
The types of references that may be used in the literature review include empirical (original research) articles (MUST HAVE) evidence-based research, meta-analysis, systematic reviews, randomized control trials, or seminal works, peer-reviewed or scholarly journal articles, and books that are cutting-edge views on a topic.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

For a quote within a quote, use a set of single quotation marks. [4.08]. As a rule, if a quote comprises 40 or more words, display this material as a freestanding block quote. Start formal block quotes on a new line. They are indented one inch in from the left margin. The entire block quote is double-spaced. Quotation marks are not used with formal block quotes. The in-text citation is included after the final punctuation mark. [6.03]. Below is an example of a block quote: In an important biography, The First American: The Life and Times of Benjamin Franklin, historian H. W. Brands writes: Comment by Author: Caution! Make sure you do not overuse titles in the literature review. You can use them in certain instances, but do not rely on them to convey content.

In February 1731, Franklin became a Freemason. Shortly thereafter, he volunteered to draft the bylaws for the embryonic local chapter, named for St. John the Baptist; upon acceptance of the bylaws, he was elected Warden and subsequently Master of the Lodge. Within three years, he became Grandmaster of all of Pennsylvania's Masons. Not unforeseeable he—indeed, this was much of the purpose of membership for everyone involved—his fellow Masons sent business Franklin’s way. In 1734 he printed The Constitutions, the first formerly sponsored Masonic book in America; he derived additional [printing] work from his brethren on an unsponsored basis. (Brands, 2000, p. 113)

Summary

This section restates what was written in Chapter 2 and provides supporting citations for key points. It synthesizes the information from the chapter using it to define the “gaps” in or “project needs” from the literature, the theories or models to provide the foundation for the project, the problem statement, the primary clinical question, the methodology, the design, the variables or phenomena, the data collection instruments or sources, and population. It then provides a transition discussion to Chapter 3.

Overall, this section should:

· Synthesize the information from all of the prior sections in the literature review and use it to define the key strategic points for the project.

· Summarize the gaps and needs in the background and introduction and describe how it informs the problem statement.

· Identify the theories or models describing how they inform the clinical questions.

· Use the literature to justify the design, variables, data collection instruments or sources, and population to be evaluated.

· Relates the literature back to the DPI-project topic and the practice problem.

· Build a case (argument) for the project in terms of the value of the project and how the clinical questions emerged from the review of literature.

· Explain how the current theories, models, and topics related to the project will be advanced through your project.

· Summarize key points in Chapter 2 and transition into Chapter 3.

This section should help the reader clearly see and understand the relevance and importance of the project to be conducted. The Summary section transitions to Chapter 3 by building a case for the project, in terms of project design and rigor, and it formulates the clinical questions based on the gaps and tensions in the literature. Comment by Author: Use INSERTPage Break to set new page for new chapter. Do not use hard returns to get there.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Summary This section restates what was written in Chapter 2 and provides supporting citations for key points. It synthesizes the information from the chapter using it to define the “gaps” in or “evidence –based practice needs” from the literature, the theories or models to provide the foundation for the project, the problem statement, the primary clinical question, the methodology, the design, the variables or phenomena, the data collection instruments or sources, and population. It then provides a transition discussion to Chapter 3.
This section synthesizes the information from all of the prior sections in the Review of Literature and uses it to define the key strategic points for the project. This section summarizes the gaps and needs in the background and introduction and describes how it informs the problem statement. This section identifies the theories or models and describes how they inform the clinical questions. This section uses the literature to justify the design, variables or phenomena, data collection instruments or sources, and answer the clinical questions on your selected intervention protocol, clinical setting and patient population.be evaluated.
This section builds a case for the project in terms of the value of the project.
This section explains how the current theories, models, and topics related to the DPI project will be advanced through your intervention and outcomes.
This section summarizes key points in Chapter 2 and transition into Chapter 3.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

Chapter 3: Methodology

Chapter 3 documents how the project is conducted in enough detail so that replication by others is possible. The introduction begins with a summary of the project focus and purpose statement to reintroduce the reader to the need for the project. This can be summarized in three or four sentences from Chapter 1. Summarize the clinical questions in narrative format, and then outline the expectations for this chapter.

Remember, throughout this chapter depending on where you are in your project, the verb tense must be changed from present tense (proposal) to past tense (DPI Project manuscript). Furthermore, consider will happen during data collection and analysis as it is planned here. Sometimes, the DPI project protocol ends up being modified based on committee, Academic Quality Review (AQR), or Institutional Review Board (IRB) recommendations. After the practice project is complete, make sure this chapter reflects how the project was actually conducted.

Criterion Comment by Author: All of the criterion tables must be removed prior to all AQR, IRB, and final submissions.	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Introduction This section includes both a restatement of project focus and purpose statement for the project from Chapter 1, to reintroduce reader to the need for the project and a description of contents of the chapter.
A brief introduction to the chapter describes the chapter purpose and how it is organized and summarizes the project focus and problem statement to reintroduce reader to the need for the project.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

Statement of the Problem

This section restates the problem for the convenience of the reader. Copy and paste the Statement of the Problem from Chapter 1. Then, edit, blend, and integrate this material into the narrative. Change future tense to past tense for DPI Project manuscripts.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Statement of the Problem: This section restates the Problem Statement from Chapter 1.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

Clinical Question

This section restates the clinical question(s) for the project from Chapter 1. The following clinical questions guide this quantitative project:

Q1:

Q2:

It then presents the matching of the variables. This discussion includes the independent variable (intervention or practice change) and the dependent variable (outcome of the DPI) (see Table 1)

Table 1 Characteristics of Variables Comment by Author: This table is not required but does illustrate the different levels of measurement aligned to each type of variable. It is important for the doctoral learner explore the level of measurement of each variable so accurate statistical tests can be selected for analysis.

Variable	Variable Type	Level of Measurement
Project Groups (Pre-Intervention & Post Intervention)	Independent	Nominal
Rates or events (Outcome)	Dependent	Nominal
Socio-economic status or categories in order	Dependent	Ordinal
Time, Temperature	Dependent	Interval
Age, height, Scores of tests (Outcome)	Dependent	Ratio

Note: An outcome variable can be any of the four levels of measurement. (Creswell & Creswell, 2018).

The section also briefly reviews the approaches to collecting the data to answer the clinical questions (see Figure 1).

Figure 1

Approaches to Collecting the Data to Answer the Clinical Questions

Between-subjects (or between-groups) designs include different people or data in each collection so that each person is only in one group or the other. Within-subjects (or repeated-measures) design include the same person in all collections both before and after the intervention.

The section should describe the instrument(s) or data source(s) to collect the data for each variable. It also discusses why the design was selected to be the best approach to answer the clinical question(s).

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Clinical Question(s) This section restates the clinical questions for the project from Chapter 1. It then explains the variables.
This section describes the approaches used to collect the data to answer the clinical questions. For a quantitative project, it describes the instrument(s) or data source(s) to collect the data for each variable.
This section discusses why the design was selected to be the best approach to answer the clinical questions.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

Project Methodology

This section describes the methodology for the DPI project and explains the rationale for selecting this quantitative methodology. It also describes why this methodology was selected as opposed to the alternative methodologies. (see Table 2) DPI projects are typically quantitative due to the nature of measuring a practice improvement.

Table 2

Type of Methodology and Rationale for Selecting It

Method	Rationale for Selection
Quantitative	The data from a quantitative method is in a numeric form and statistical tests can be applied in making statements about the data. Quantifiable, objective, and easy to interpret results. Identifying the scale of measurement (e.g. nominal, ordinal, interval, or ratio) helps determine how best to organize the data for analysis.
Qualitative	The data from a qualitative method is a description of the qualities or characteristics of something. Thematic, subjective and subject to interpretation are the results. These descriptions cannot be easily reduced to numbers—as the findings from quantitative methods can. Qualitative methods discover new perspectives and are not feasible for testing a DPI. Comment by Author: Not an approved design for the DPI
Mixed:	The data from a mixed method is a combination of the quantitative and qualitative method. Mixed method can use qualitative designs to identify the factors under investigation, then use that information to devise quantitative designs to further measure it. Or findings from quantitative methodology can be further explored using a qualitative method. Mixed methods can be time consuming and not feasible for testing a DPI. Comment by Author: Not an approved design for the DPI

Note: Quantitative methods are recommended for DPI projects due to feasibility and clinical relevance associated with the measurement of a practice improvement. Reference: Creswell, J.W. & Creswell, J.D. (2018). Research design: Qualitative, quantitative, and mixed methods approaches (5th ed.) Thousand Oaks: CA. Sage Publications.

This section should elaborate on the Methodology section (from Chapter 1) providing the rationale for the selected project method (e.g. quantitative). Arguments are supported by citations from articles and books on methodology or design. It is also proper in this section to outline the predicted or expected results in relation to the clinical questions based on the existing literature. Describe how the method selected supports the attainment of information that will answer the clinical questions.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Project Methodology This section elaborates on the Methodology section (from Chapter 1), providing the rationale for the selected project method (e.g. quantitative) and includes a discussion of why the selected method was chosen instead of another method. Arguments are supported by citations from articles and books on project methodology or design. Describe how the methodology selected supports the attainment of information that will answer the clinical questions.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

Project Design

This section elaborates on the nature of the Project Design section from Chapter 1. In most DPI projects, a quasi-experimental design is the recommended due to measurement of a direct practice improvement. If other methods are considered, it should be discussed with your chair/committee including the capacity to measure a practice improvement and time frame needed to complete it.

This section includes a detailed description of, and a rationale for, the specific design for the project. Quantitative designs include descriptive, correlation, quasi-experimental, and experimental designs (Creswell & Creswell, 2018). Each associated with an approach to the data being collected. See Appendix B for an algorithm to assist with design determination. Designs involving a practice change or intervention are either a quasi-experimental or experimental type. However, an experimental design is usually not feasible for a DPI due to the requirement for randomization and manipulation of the intervention within and between the project groups to address the statistical assumptions.

This section further describes how it aligns to the selected methodology indicated in the previous section. Additionally, it describes why the selected design is the best option to collect the data to answer the clinical need for the project.

The section explains exactly how the selected design will be used to collect data for each variable. It identifies the specific instruments and data sources to be used to collect all of the different data required for the project. Arguments are supported by citations from articles and books on DPI project method or design. This section should specify the independent, dependent, or classificatory variables, as appropriate. These variables should be defined in Chapter 1. Be sure to relate the variables back to the clinical questions. A brief discussion of the type of data collection tool chosen (survey, interview, observation, etc.) can also be included in this section as related to the variables. Collecting data using an instrument may require a consent versus collecting data from the EHR may require a HIPAA waiver. These considerations should be addressed later in the proposal.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Project Design This section elaborates on the Nature of the Project Design for the Project (from Chapter 1) providing the rationale for the selected project design and includes a discussion of why the selected design is the best one to collect the data needed. Arguments are supported by citations from articles and books on methodology or design.
This section describes how the specific selected DPI project design will be used to collect the type of data needed to answer the clinical questions and the specific instruments or data sources that will be used to collect or source this data. This section discusses why the design was selected to be the best approach to answer the clinical question(s).
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

Population and Sample Selection

This section discusses the setting, total population, project population, and project sample. The discussion of the sample includes the project terminology specific to the type of sampling for the project. This section should include the following components:

· Describes the characteristics of the total population and the project population from which the project sample (project participants) is drawn.

· Describes the characteristics of the project population and the project sample.

· Clearly defines and differentiates the sample for the project versus the number of people completing instruments on the project sample.

· Describes the project population size and project sample size and justifies the project sample size (e.g., power analysis) based on the selected design.

Clearly defines and differentiates between the number for the project population and the project sample versus the number for the people who will complete any instruments. Details the sampling procedure including the specific steps taken to identify, contact, and recruit potential project sample participants from the project population.

Describes the informed consent process, confidentiality measures, project participation requirements, and geographic specifics.

· Discusses the intervention protocol to answer the clinical question(s).

· If subjects withdrew or were excluded from the project, you must provide an explanation. This would be added for the final manuscript and would not be present in the proposal.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Population and Sample Selection This section discusses the setting, total population, project population, and project sample. The discussion of the sample includes the project terminology specific to the type of sampling for the project.
This section describes the characteristics of the total (general) population and the project (target) population from which the project sample (sample) (project participants) is drawn.
This section describes the characteristics of the project population and the project sample and clearly defines and differentiates the sample for the project versus the number of people completing instruments on the project sample.
This section describes the project population size and project sample size and justifies the project sample size (e.g., power analysis) based on the selected design. This section clearly defines and differentiates between the number for the project population and the project sample versus the number for the people who will complete any instruments.
This section details the sampling procedure, including the specific steps taken to identify, contact, and recruit potential project sample participants from the project population.
This section describes the informed consent process, confidentiality measures, project participation requirements, and geographic specifics.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

Instrumentation or Sources of Data Comment by Author: Clarify if the project is collecting data using instrumentation, a source of data from the EHR or existing records, or both. This heading should be accurate on which was used to collect data.

This section fully identifies and describes the types of data that will be collected, as well as the specific instruments and sources used to collect those data (tests, questionnaires, interviews, databases, media, etc.). Discuss the specific instrument or source to collect data for each variable or group. Use subheadings for each data collection instrument or source of data and provide a copy of all instruments in a separate appendix.

If you are using an existing instrument, make sure to discuss in detail the characteristics of the instrument. For example, on a preexisting survey tool describe the way the instrument was developed and constructed, the validity and reliability of the instrument, the number of items or questions included in the survey, and the calculation of the score as appropriate.

If you are using a source of data, discuss the detail on how the source of data was accessed, the validity and reliability of the source of data and how the information was collected and stored. If the learner is acquiring data from medical records or databases, e.g. electronic health records including being provided a delimited database of data, this access and permission should be specified and how the identifiable patient information is being protected within the project. A HIPAA waiver may be specified.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Instrumentation or Sources of Data This section describes, in detail, all data collection instruments and sources (tests, questionnaires, interviews, databases, media, etc.); the specific instrument or source to collect data for each variable or group (quantitative project)
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

Validity

This section describes and defends the procedures used to determine the validity of the data collected. Validity refers to the degree to which a project accurately reflects or assesses the specific concept that the investigator is attempting to measure. Ask if what is actually being measured is what was set out to be measured. As an investigator, you must be concerned with both external and internal validity.

For this section, provide specific validity statistics found in the literature for quantitative instruments, identifying how they were developed. NOTE: Learners should not be developing any quantitative instruments without permission from the DNP department.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Validity This section provides specific validity statistics for quantitative instruments, identifying how they were developed, and explains how validity will be addressed during data collection approaches. NOTE: Learners should not be developing nor modifying any quantitative instruments.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

Reliability

This section describes and defends the procedures used to determine the reliability of the data collected. Reliability is the extent to which an experiment, test, or any measuring procedure is replicable and yields the same result with repeated trials. For this section, provide specific reliability statistics for quantitative instruments, identifying how the statistics were developed from the literature.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Reliability This section provides specific reliability statistics for quantitative instruments, identifying how the statistics were developed, and explains how reliability will be addressed during data collection approaches.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

Data Collection Procedures

This section details the entirety of the process used to collect the data. Describe the step-by-step procedures used to carry out all the major steps for data collection for the project in a way that would allow another investigator to replicate the project. The key elements of this section include:

· A description of the procedures for project sample recruitment, sample selection, and assignment to groups (e.g. comparison versus intervention).

· A description of the procedures for obtaining informed consent and for protecting the rights and well-being of the project sample participants, as well as those completing instruments on them.

· A description of the procedures adopted to maintain data securely, including the length of time data will be retained, where the data will be retained, and how the data will be destroyed.

· A description of the procedures for data collection, including how each instrument or data source was used, how and where data were collected, and how data were recorded.

· An explanation of the independent and dependent variables (if applicable), and how the resulting change in those variables is measured (if applicable),

· An explanation of how variables were compared (if applicable).

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Data Collection Procedures This section details the entirety of the process used to collect the data. It describes each step of the data collection process in a way that another investigator could replicate the project.
This section describes the step-by-step procedures used to carry out all the major steps for data collection for the project in a way that would allow another investigator to replicate the project.
This section describes the procedures for project sample recruitment, sample selection, and assignment to groups (if applicable).
This section describes the procedures for obtaining informed consent and for protecting the rights and well-being of the project sample participants, as well as those completing instruments on them.
This section describes the procedures adopted to maintain data securely, including the length of time data will be retained, where the data will be retained, and how the data will be destroyed.
This section describes the procedures for data collection, including how each instrument or data source was used, how and where data was collected, and how data were recorded.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

Data Analysis Procedures

This section provides a step-by-step description of the procedures to be used to conduct the data analysis. The key elements of this section include:

· A description of how the data were collected and organized for each variable or group.

· A description of the type of data to be analyzed, identifying the descriptive, inferential, or nonstatistical analyses.

· Demonstration that the project analysis is aligned to the specific project design.

· A description of the clinical question(s).

· A detailed description of the relevant data collected and analyzed for each stated clinical question.

· A description of how the raw data were organized and prepared for analysis. Provides a step-by-step description of the procedures used to conduct the data analysis.

A detailed description of any statistical and nonstatistical analysis to be employed. (see Figure 2 & 3) A rationale is provided for each of the data analysis procedures (statistical and nonstatistical) employed in the project. A demonstration that the data analysis techniques align with the DPI project design. The level of the statistical significance used for the quantitative analyses is identified a priori (p<.05). References to the software used for the data analyses and assurance that the language used to describe the data analysis procedure is consistently used in Chapters 4 and 5.

Figure 2

Parametric Statistics for Analysis of Ratio or Interval Level Dependent Variable

Note. Image taken from Creswell and Creswell (2018). Comment by Author: Remove these figures from your manuscript. See APA 7th edition to format tables and figures.

The independent variable within a quasi-experimental design will be a nominal or categorical level variable identifying the sample or group associated with the intervention. It is the dependent variable’s level of measurement which will direct the type of statistical analysis e.g. parametric versus non-parametric. If the dependent variable is a ratio, interval, the test to be used would be a parametric one. If the dependent variable is an ordinal or nominal level, a non-parametric test would be used.

Figure 3

Non-Parametric Statistics for Analysis of Nominal or Ordinal Level Dependent Variable

Note. Image taken from Creswell and Creswell (2018). Comment by Author: Remove these figures from your manuscript. See APA 7th edition to format tables and figures.

Be specific on the type of analysis being performed, the type of variables analyzed, the level of measurement, and the statistical test performed to answer the clinical question.

Potential Bias and Mitigation

When we refer to bias in quantitative methodology, we are often referring to threats to the internal validity of a study. Internal validity is the degree to which the results are accurate and the procedures of the experiment support the ability to draw correct assumptions or inferences about the results (Roush, 2020). Bias can be intentional or unintentional, and intentional is not moral and invalidates your projects results. So let’s stick to how bias can occur!

Bias in sampling can occur. A sampling method is called biased if it systematically favors some outcomes over others. The following example shows how a sample can be biased, even though there is some randomness in the selection of the sample.

Example:

If my project employs an intranet survey and there are people who meet the criteria but do not have access to the internet to take the survey, I will miss all those people who met the criteria for participation!

Here are some common sources and consequences of bias:

Convenience samples:

Sometimes it is not possible or not practical to choose a random sample. In those cases, a convenience sample might be used. Sometimes it is plausible that a convenience sample could be considered as a random sample, but often a convenience sample is biased. If a convenience sample is used, inferences are not as trustworthy as if a random sample is used.

Bias may be present in data collection. While collecting data for the DPI, there are numerous ways by which the Learners may introduce bias to the project. If, for example, during patient recruitment, some patients are less or more likely to participate in the project such sample would not be representative of the population in which

this project is done (Roush, 2020). In that case, these subjects who are less likely to enter the study will be underrepresented and those who are more likely to enter the study will be over-represented relative to others in the general population, to which conclusions of the study are to be applied to (Roush, 2020). This is what we call a selection bias. To ensure that a sample is representative of a population, sampling should be random, i.e. every subject needs to have equal probability to be included in the DPI. It should be noted that sampling bias can also occur if sample is too small to represent the target population. For example, if the aim of the DPI is to assess the if motivational interviewing in psychiatric patients improves medication adherence the Learners may only be able to recruit otherwise healthy, stable patients during a regularly scheduled well check-up. By recruiting only well patients and the inability to use all psychiatric clients that can consent this is another bias.

Bias can also occur in the data analysis right? We often are only looking at data that gives preference to answering the clinical question. If the data is misrepresented or not fully reported or even manipulated this is a bias (Fox & Lash, 2020). Comment by Author: Make sure all citations are entered in the reference list as the reviewers will check all citations and references for accuracy.

Bias may occur in the data interpretation. It is imperative to run the correct statistical analysis (Fox & Lash, 2020). The data must be correctly analyzed and presented as is. Do not report only what was significant or discuss what was not significant. Consider a project where your pre and post-knowledge test for nurses did not show a statistical significance in using the tool. However, if the tool decreased readmission rates by 50% was it clinically significant? This observation should be discussed in detail.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Data Analysis Procedures and potential bias and mitigation This section describes how the data was collected for each variable or group. It describes the type of data to be analyzed, identifying the descriptive, inferential, or nonstatistical analyses. This section demonstrates that the project analysis is aligned to the specific project design.
This section describes the clinical question(s).
This section describes, in detail, the relevant data collected for each stated clinical question or variable.
This section describes how the raw data were organized and prepared for analysis.
This section provides a step-by-step description of the procedures used to conduct the data analysis.
This section describes, in detail, any statistical and nonstatistical analysis to be employed.
This section provides the rationale for each of the data analysis procedures (statistical and nonstatistical) employed in the project.
This section demonstrates that the data analyses techniques align with the DPI project research design.
This section states the level of statistical significance for quantitative analyses as appropriate.
POTENTIAL BIAS: This section describes the threats to the internal validity of a study. Bias can be intentional or unintentional, and intentional is not moral and invalidates your projects results.
Discuss any bias there may be in the projects sampling and how this was mitigated
Discuss possible bias the project’s data collection and how this was mitigated.
Discuss possible bias in data analysis and how this was mitigated.
Discuss how bias can occur in data interpretation and how this was mitigated.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

Ethical Considerations

This section discusses the potential ethical issues surrounding the project, as well as how human subjects and data will be protected. The key ethical issues that must be addressed in this section include:

· Identify how any potential ethical issues will be addressed.

· Provide a discussion of ethical issues related to the project and the sample population of interest, institution, or data collection process.

· Address anonymity, confidentiality, privacy, lack of coercion, informed consent, and potential conflict of interest.

· Demonstrate adherence to the key principles of the Belmont Report (respect, justice, and beneficence) in the project design, sampling procedures, and within the theoretical framework, practice or patient problem, and clinical questions.

· Discuss how the data will be stored, safeguarded, and destroyed.

· Discuss how the results of the project will be published.

· Discuss any potential conflict of interest on the part of the investigator.

· Reference IRB approval to conduct the project, which includes subject recruiting and informed consent processes, in regard to the voluntary nature of project.

· Include the IRB approval letter with the protocol number, informed consent/subject assent documents, or any other measures required to protect the participants or institutions in an appendix.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Ethical Considerations This section discusses the potential ethical issues surrounding the DPI project, as well as how human subjects and data will be protected. It identifies how any potential ethical issues will be addressed.
This section provides a discussion of ethical issues related to the project and the sample population of interest.
This section addresses anonymity, confidentiality, privacy, lack of coercion, informed consent, and potential conflict of interest.
This section demonstrates adherence to the key principles of the Belmont Report (respect, justice, and beneficence) in the project design, sampling procedures, and within the theoretical framework, problem, and questions.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

Limitations

While Chapter 1 addresses the broad, overall limitations of the project, this section discusses in detail the limitations related to the DPI project approach and methodology and the potential impacts on the results. This section describes any limitations related to the methods, sample, instrumentation, data collection process, and analysis. Other methodological limitations of the project may include issues with regard to the sample in terms of size, population and procedure, instrumentation, data collection processes, and data analysis. This section also contains an explanation of why the existing limitations are unavoidable and are not expected to affect the results negatively.

Here you need to consider potential limitations and delimitations, which could impact your proposed project’s implementation. Are the nursing staff resistant to change? Is there currently a culture inherent in the site where the use of evidence-based practice is openly used/welcomed by staff? What strategies might you use to overcome any barriers you might face? How will you capitalize upon any facilitators you have identified?

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Limitations This section discusses, in detail, the limitations related to the project approach and methodology and the potential impacts on the results.
This section describes any limitations related to the methods, sample, instrumentation, data collection process, and analysis. This section explains why the existing limitations are unavoidable and are not expected to affect the results negatively.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

Summary

This section restates what was written in Chapter 3 and provides supporting citations for key points. Your summary should demonstrate an in-depth understanding of the overall project design and analysis techniques. The Chapter 3 summary ends with a discussion that transitions the reader to Chapter 4. Comment by Author: Use INSERTPage Break to set new page for the reference list.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Summary This section restates what was written in Chapter 3 and provides supporting citations for key points.
This section summarizes key points presented in Chapter 3 with appropriate citations.
This section demonstrates in-depth understanding of the overall project design and data analysis techniques.
This section ends with a transition discussion focus for Chapter 4.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

Chapter 4: Data Analysis and Results

The purpose of this chapter is to summarize the collected data, how it was analyzed and then to present the results. This section of Chapter 4 briefly restates the problem statement, the methodology, the clinical question(s) or phenomena, and then offers a statement about what will be covered in this chapter. Chapter 4 should present the results of the project as clearly as possible, leaving the interpretation of the results for Chapter 5. Make sure this chapter is written in past tense and reflects how the project was actually conducted.

This chapter typically contains the analyzed data, often presented in both text and tabular or figure format. To ensure readability and clarity of findings, structure is of the utmost importance in this chapter. Sufficient guidance in the narrative should be provided to highlight the findings of greatest importance for the reader. Most investigators begin with a description of the sample and the relevant demographic characteristics presented in text or tabular format.

Ask the following general questions before starting this chapter: Comment by Author: Edit the style (FORMAT-->STYLE--> Modify-->(drop down box that says format)-->Paragraph--> set indentation Left 0.25", Special = hanging; by= 0.5" THEN click on TABS (lower left corner) and make sure it is set at .75" edit the style (FORMAT-->STYLE--> Modify-->(drop down box that says format)-->Paragraph--> set indentation Left 0.25", Special = hanging; by= 0.5" THEN click on TABS (lower left corner) and make sure it is set at .75"

Is there sufficient data to answer each of the clinical question(s) asked in the project? (see Appendix C) One procedure for determining a sample size ahead of the project is a power analysis.

Is there sufficient data to support the conclusions you will make in Chapter 5? (see Appendix D) If using SPSS version 26 to perform analyses, the data is entered and coded using numbers or numerical codes.

Is the project written in the third person? Never use the first person.

Is the data clearly explained using a table, graph, chart, or text? (see Appendix E)

Visual organizers, including tables and figures, must always be introduced, presented and discussed within the text first. Never insert them without these three steps. It is often best to develop all of the tables, graphs, charts, etc. before writing any text to further clarify how to proceed. Point out the salient results and present those results by table, graph, chart, or other form of collected data. See Appendix E for examples of APA formatted tables and figures.

Criterion Comment by Author: All of the criterion tables must be removed prior to all AQR, IRB, and final submissions.	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
INTRODUCTION (TOTHE CHAPTER) This section of Chapter 4 briefly restates the problem statement, the methodology, the clinical question(s) or phenomena, and offers a statement about what will be covered in this chapter.
Re-introduces the purpose of the practice project.
Briefly describes the project methodology and/or clinical question(s) tested.
Provides an orienting statement about what will be covered in the chapter.
Section is written in a way that is well structured, has a logical flow, uses correct paragraph structure, uses correct sentence structure, uses correct punctuation, and uses correct APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for review, please remove all of these assessment tables from this document. Score 0 (not present); 1(unacceptable; needs substantial edits); 2 (present, but needs some editing); 3 (publication ready).

Descriptive Data

This section of Chapter 4 provides a narrative summary of the population or sample characteristics and demographics of the participants in the project. It establishes the number of subjects, gender, age, education level or employee classification, (if appropriate), organization, or setting (if appropriate), and other appropriate sample characteristics (e.g. education level, program of project, employee classification etc.). The use of graphic organizers, such as tables, charts, histograms and graphs to provide further clarification and promote readability, is encouraged to organize and present coded data. Ensure this data cannot lead to anyone identifying individual participants in this section or identifying the data for individual participants in the data summary and data analysis that follows.

For numbers, equations, and statistics, spell out any number that begins a sentence, title, or heading – or reword the sentence to place the number later in the narrative. In general, use Arabic numerals (10, 11, 12) when referring to whole numbers 10 and above, and spell out whole numbers below 10. There are some exceptions to this rule:

If small numbers are grouped with large numbers in a comparison, use numerals (e.g., 7, 8, 10, and 13 trials); but, do not do this when numbers are used for different purposes (e.g., 10 items on each of four surveys).

Numbers in a measurement with units (e.g., 6 cm, 5-mg dose, 2%).

Numbers that represent time, dates, ages, sample or population size, scores, or exact sums of money.

Numbers that represent a specific item in a numbered series (e.g., Table 1).

A sample table in APA style is presented in Table 3. Be mindful that all tables fit within the required margins, and are clean, easy to read, and formatted properly using the guidelines found in Chapter 5 (Displaying Results) of the APA Publication Manual 6.0. Comment by Author: Each table must be numbered in sequence throughout the entire practice improvement project (Table 1, Table 2, etc.), or within chapters (Table 1.1, Table 1.2 for Chapter 1; Table 2.1, Table 2.2 for Chapter 2 etc.).

Table 3

A Sample Data Table Showing Correct Formatting

	Column A M (SD ) Comment by Author: Statistical symbols in tables must be italicized	Column B M (SD)	Column C M (SD)
Row 1	10.1 (1.11)	20.2 (2.22)	30.3 (3.33)
Row 2	20.2 (2.22)	30.3 ( 3.33)	20.2 (2.22)
Row 3	30.3 (3.33)	10.1 (1.11)	10.1 (1.11)

Note. Adapted from “Sampling and Recruitment in Studies of Doctoral Students,” by I.M. Investigator, 2010, Journal of Perspicuity, 25, p 100. Reprinted with permission. Comment by Author: Permission must be obtained to reprint information that is not in the public domain. Letters of permission are included in the appendix.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
DESCRIPTIVE DATA This section of Chapter 4 provides a narrative summary of the population or sample characteristics and demographics of the participants in the project. It establishes the number of subjects, gender, age, level (if appropriate), organization, or setting (if appropriate). The use of graphic organizers, such as tables, charts and graphs to provide further clarification and promote readability, is encouraged.
Provides a narrative summary of the population or sample characteristics and demographics.
Graphic organizers are used as appropriate to organize and present coded data, as well as descriptive data such as tables, histograms, graphs, and/or charts.
Section is written in a way that is well structured, has a logical flow, uses correct paragraph structure, uses correct sentence structure, uses correct punctuation, and uses correct APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for review, please remove all of these assessment tables from this document. Score 0 (not present); 1(unacceptable; needs substantial edits); 2 (present, but needs some editing); 3 (publication ready).

Data Analysis Procedures

This section presents a description of the process that was used to analyze the data. If clinical question(s) guided the project, data analysis procedures can be framed relative to each clinical question. Data can also be organized by chronology of phenomena, by themes and patterns, or by other approaches as deemed appropriate according for the project. The key components included in this section are:

A detailed description of the data analysis procedures.

An explanation of how the raw data relates to the clinical questions(s) asked in the project for a quantitative project.

A discussion of the identification of sources of error and their effect on the data.

An explanation and justification of any differences in why the data analysis section does not match what was approved in Chapter 3 (if appropriate).

An analysis of the reliability and validity of the data in statistical terms, for quantitative projects.

Criterion Comment by Author: All of the criterion tables must be removed prior to all AQR, IRB, and final submissions.	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
DATA ANALYSIS PROCEDURES This section presents a description of the process that was used to analyze the data. If clinical question(s) guided the project, data analysis procedures can be framed relative to each clinical question. Data can also be organized by chronology of phenomena, by themes and patterns, or by other approaches as deemed appropriate
Describes in detail the data analysis procedures.
Explains and justifies any differences in why the data analysis section does not match what was approved in Chapter 3 (if appropriate).
Provides validity and reliability of the data in statistical terms for quantitative methodology.
Identifies sources of error and potential impact on the data.
For a quantitative project, justifies how the analysis aligns with the clinical question(s) and is appropriate for the DPI project design.
Section is written in a way that is well structured, has a logical flow, uses correct paragraph structure, uses correct sentence structure, uses correct punctuation, and uses correct APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for review, please remove all of these assessment tables from this document. Score 0 (not present); 1(unacceptable; needs substantial edits); 2 (present, but needs some editing); 3 (publication ready).

Results Comment by Author: When reporting statistics in the narrative, be sure to italicize statistical and mathematical variables, e.g., F test, t test, population size N, p = .03. Use commonly accepted abbreviations for statistical symbols.

This section, which is the primary section of this chapter, presents a summary and analysis of the data in a non-evaluative, unbiased, organized manner that relates to the clinical question(s). List the clinical question(s) as you are discussing them in order to ensure that the readers see that the question has been addressed. Answer the clinical question(s) in the order that they are listed for quantitative studies. The key components included in this section are:

The data and the analysis of that data should be presented in a narrative, non-evaluative, unbiased, organized manner by clinical question(s).

The section should also include appropriate graphic organizers, such as tables, charts, graphs, and figures.

The amount and quality of the data or information is sufficient to answer the clinical question(s) is well presented, and is intelligently interpreted.

Quantitative: Findings are presented by clinical question using section titles. They are presented in order of significance, if appropriate.

Quantitative: Results of each statistical test are presented in appropriate statistical format with tables, graphs, and charts.

Quantitative: For inferential statistics, p-value and test statistics are reported.

Quantitative: Control variables (if part of the design) are reported and discussed. Outliers, if found, were reported.

The results must be presented without implication, speculation, assessment, evaluation, or interpretation. Discussion of results and conclusions are left for Chapter 5. Refer to the APA Style Manual for additional lists and examples. In quantitative practice improvement projects, it is not required for all data analyzed to be presented; however, it is important to provide descriptive statistics and the results of the applicable statistic tests used in conducting the analysis of the data. It is also important that there are descriptive statistics provided on all variables. Nevertheless, it is also acceptable to put most of this in the Appendix if the chapter becomes too lengthy.

Required components include descriptive and inferential statistics. Descriptive statistics describe or summarize data sets using frequency distributions (e.g., to describe the distribution for the IQ scores in your class of 30 pupils) or graphical displays such as bar graphs (e.g., to display increases in a school district's budget each year for the past five years), as well as histograms (e.g., to show spending per child in school and display mean, median, modes, and frequencies), line graphs (e.g., to display peak scores for the classroom group), and scatter plots (e.g., to display the relationship between two variables). Descriptive statistics also include numerical indexes such as averages, percentile ranks, measures of central tendency, correlations, measures of variability and standard deviation, and measures of relative standing.

Inferential statistics describe the numerical characteristics of data, and then go beyond the data to make inferences about the population based on the sample data. Inferential statistics also estimate the characteristics of populations about population parameters using sampling distributions, or estimation. Table 4 presents example results of an independent t test comparing Emotional Intelligence (EI) mean scores by gender.

Table 4

t-Test for Equality of Emotional Intelligence Mean Scores by Gender

	t test for equality of means
	t	Df	p
EI	1.908	34	.065

After completing the first draft of Chapter 4, ask these general questions: Comment by Author: Use Line Spacing Options to “Add a Space Between Paragraph” between tables and the text following it

1. Are the findings clearly presented, so any reader could understand them?

Are all the tables, graphics or visual displays well-organized and easy to read?

Are the important data described in the text?

Is factual data information separate from analysis and evaluation?

Are the data organized by clinical questions?

Chapter 4 can be challenging with regard to mathematical equations and statistical symbols or variables. When including an equation in the narrative, space the equation as you would words in a sentence: x + 5 = a. Punctuate equations that are in the paragraph, as you would a sentence. Remember to italicize statistical and mathematical variables, except Greek letters, and if the equation is long or complicated, set it off on its own line.

Refer to your APA manual for specific details on representation of statistical information. Basic guidelines include:

Statistical symbols are italicized (t, F, N, n)

Greek letters, abbreviations that are not variables and subscripts that function as identifiers use standard typeface, no bolding or italicization

Use parentheses to enclose statistical values (p = .026) and degrees of freedom t(36) = 3.85 or F(2, 52) = 3.85

Use brackets to enclose limits of confidence intervals 95% CIs [- 5.25, 4.95]

Make sure to include appropriate graphics to present the results. Always introduce, present, and discuss the visual organizers in narrative form. Never insert a visual organizer without these three steps.

A figure is a graph, chart, map, drawing, or photograph. Below is an example of a figure labeled per APA style. Do not include a figure unless it adds substantively to the understanding of the results or it duplicates other elements in the narrative. If a figure is used, a label must be placed under the figure. As with tables, refer to the figure by number in the narrative preceding the placement of the figure. Make sure a table or figure is not split between pages. Below is another example of a table and figure for you to review. (see Table 5 and Figure 4) Comment by Author: See Chapter 7 for details on correct APA style. Comment by Author: You must reference tables in the text prior to displaying the graphic.

Table 5

The Servant Leader Comment by Author: In addition to numbering the table, name the table.

Trait

Descriptors

Values People

By believing in people

By serving other’s needs before his or her own

By receptive, non-judgmental listening

Develops People

By providing opportunities for learning and growth

By modeling appropriate behavior

By building up others through encouragement and affirmation

Builds Community

By building strong personal relationships

By working collaboratively with others

By valuing the differences of others

Displays Authenticity

By being open and accountable to others

By a willingness to learn from others

By maintaining integrity and trust

Provides Leadership

By envisioning the future

By taking initiative

By clarifying goals

Shares Leadership

By facilitating a shared vision

By sharing power and releasing control

By sharing status and promoting others

Note. Derived from Laub, J. (1999). Assessing the servant organization: Development of the servant organizational leadership assessment (SOLA) instrument (Doctoral Practice improvement project). Available from ProQuest Practice improvement project and Theses Database. (UMI No. 9921922) Comment by Author: If at all possible, do not break a table across a page break.

Figure 4

Scattor Plot Example – Strong Negative Correlation

Note, An example of a strong negative correlation for SAT composite score and time spent on Facebook for 11th grade high school students enrolled in IMSmart SAT Prep Course.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
RESULTS This section, which is the primary section of this chapter, presents an analysis of the data in a nonevaluative, unbiased, organized manner that relates to the clinical question(s). List the clinical question(s) as you are discussing them in order to ensure that the readers see that the question has been addressed. Answer the clinical question(s) in the order that they are listed.
The analysis of the data is presented in a narrative, nonevaluative, unbiased, organized manner by clinical question(s).
Includes appropriate graphic organizers such as tables, charts, graphs, and figures.
The amount and quality of the data or information is sufficient to answer the clinical question(s) is well presented, and is intelligently analyzed.
Quantitative: Findings are presented by using section titles. They are presented in order of significance, if appropriate.
Quantitative: Results of each statistical test are presented in appropriate statistical format with tables, graphs, and charts.
Quantitative: For inferential statistics, p-value and test statistics are reported.
Quantitative: Control variables (if part of the design) are reported and discussed. Outliers, if found, were reported.
Section is written in a way that is well structured, has a logical flow, uses correct paragraph structure, uses correct sentence structure, uses correct punctuation, and uses correct APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for review, please remove all of these assessment tables from this document. Score 0 (not present); 1(unacceptable; needs substantial edits); 2 (present, but needs some editing); 3 (publication ready).

Summary

This section provides a concise summary of what was found in the project. It briefly restates essential data and data analysis presented in this chapter, and it helps the reader see and understand the relevance of the data and analysis to the clinical question(s). Finally, it provides a lead or transition into Chapter 5, where the implications of the data and data analysis relative to the clinical question(s) will be discussed. The summary of the data must be logically and clearly presented, with the factual information separated from interpretation. For quantitative studies, summarize the statistical data and results of statistical tests in relation to the clinical question(s). Finally, provide a concluding section and transition to Chapter 5. Comment by Author: Use INSERTPage Break to set new page for new chapter. Do not use hard returns to get there.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Summary This section provides a concise summary of what was found in the project. It briefly restates essential data and data analysis presented in this chapter, and it helps the reader see and understand the relevance of the data and analysis to the clinical question(s). Finally, it provides a lead or transition into Chapter 5, where the implications of the data and data analysis relative to the clinical question(s) will be discussed.
Summary of data is logically and clearly presented.
The factual information is separated from analysis.
Quantitative: Summarizes the statistical data and results of statistical tests in relation to the clinical question(s).
Provides a concluding section and transition to Chapter 5.
Section is written in a way that is well structured, has a logical flow, uses correct paragraph structure, uses correct sentence structure, uses correct punctuation, and uses correct APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for review, please remove all of these assessment tables from this document.

Chapter 5: Summary, Conclusions, and Recommendations

This section introduces Chapter 5 as a comprehensive summary of the entire project. It reminds the reader of the importance of the topic and briefly explains how the project intended to contribute to the body of knowledge on the topic. It informs the reader that conclusions, implications, and recommendations will be presented.

Chapter 5 is perhaps the most important chapter in the practice improvement project manuscript because it presents the investigator’s contribution to the body of knowledge. For many who read evidence-based literature, this may be the only chapter they will read. Chapter 5 typically begins with a brief summary of the essential points made in Chapters 1 and 3 of the original DPI project and includes why this topic is important and how this project was designed to contribute to the understanding of the topic. The remainder of the chapter contains a summary of the overall project, a summary of the findings and conclusions, recommendations for future practice, and a final section on implications derived from the project.

No new data or citations should be introduced in Chapter 5; however, references should be made to findings or citations presented in earlier chapters. The investigator can articulate new frameworks and new insights. The concluding words of Chapter 5 should emphasize both the most important points of the project and what the reader should take from them. This should be presented in the simplest possible form, making sure to preserve the conditional nature of the insights. Refer to the Grand Canyon University practice improvement project rubric for guidance on the content of this chapter.

Criterion Comment by Author: All of the criterion tables must be removed prior to all AQR, IRB, and final submissions.	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
INTRODUCTION Provides an overview of why the project is important and how the project was designed to contribute to our understanding of the topic.
Section is written in a way that is well structured, has a logical flow, uses correct paragraph structure, uses correct sentence structure, uses correct punctuation, and uses correct APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for review, please remove all of these assessment tables from this document. Score 0 (not present); 1(unacceptable; needs substantial edits); 2 (present, but needs some editing); 3 (publication ready).

Summary of the Project Comment by Author: This section should be a minimum of three paragraphs.

This section provides a comprehensive summary of the overall project that describes the content of the project to the reader in the simplest possible terms. It should recap the essential points of Chapters 1-3, but it should remain a broad, comprehensive view of the project. It reminds the reader of the clinical question(s) and the main issues being evaluated, and provides a transition, explains what will be covered in the chapter and reminds the reader of how the project was conducted.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
SUMMARY OF THE PROJECT Reminds the reader of the clinical question(s) and the main issues being evaluated.
Provides a transition, explains what will be covered in the chapter and reminds the reader of how the project was conducted.
Section is written in a way that is well structured, has a logical flow, uses correct paragraph structure, uses correct sentence structure, uses correct punctuation, and uses correct APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for review, please remove all of these assessment tables from this document. Score 0 (not present); 1(unacceptable; needs substantial edits); 2 (present, but needs some editing); 3 (publication ready).

Summary of Findings and Conclusion

This section of Chapter 5 is organized by clinical question(s), and it conveys the specific findings of the project. The section presents conclusions made based on the data analysis and findings of the project and relates the findings back to the literature, significance of the project in Chapter 1, advancing scientific knowledge in Chapter 1. Significant themes/ findings are compared and contrasted, evaluated and discussed in light of the existing body of knowledge. The significance of every finding is analyzed and related to the significance section and advancing scientific knowledge section of Chapter 1. Additionally, the significance of the findings is analyzed and related back to Chapter 2, and ties the project together. The findings are bounded by the DPI project parameters described in Chapters 1 and 3, are supported by the data and theory, and directly relate to the clinical question(s). No unrelated or speculative information is presented in this section. This section of Chapter 5 should be organized by clinical question(s), theme, or any manner that allows summarizing the specific findings supported by the data and the literature. Conclusions represent the contribution to knowledge and fill in the gap in the knowledge. They should also relate directly to the significance of the project. The conclusions are major generalizations, and an answer to the practice problem developed in Chapters 1 and 2. This is where the project binds together. In this section, personal opinion is permitted, as long as it is backed with the data, grounded in the project methods and supported in the literature.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Summary of Findings and Conclusions This section is organized by clinical question(s), and it conveys the specific findings of the project. It presents all conclusions made based on the data analysis and findings of the project. It relates the findings back to the literature, significant chapters in Chapter 1, and advancing scientific knowledge in Chapter 1.
Organized by the same section titles as Chapter 4, clinical question(s) or by themes.
Significant themes/ findings are compared and contrasted, evaluated and discussed in light of the existing body of knowledge.
Significance of every finding is analyzed and related to the significance section and advancing scientific knowledge section of Chapter 1.
The conclusion summarizes the findings, refers back to Chapter 1, and ties the project together.
The findings are bounded by the DPI project parameters described in Chapters 1 and 3.
The findings are supported by the data and theory, and directly relate to the clinical question(s).
No unrelated or speculative information is presented in this section.
Section is written in a way that is well structured, has a logical flow, uses correct paragraph structure, uses correct sentence structure, uses correct punctuation, and uses correct APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for review, please remove all of these assessment tables from this document. Score 0 (not present); 1(unacceptable; needs substantial edits); 2 (present, but needs some editing); 3 (publication ready).

Implications Comment by Author: This section should be a minimum of three paragraphs.

This section should describe what could happen because of this project. It also tells the reader what the DPI project results imply theoretically, practically, and for the future. Additionally, it provides a retrospective examination of the theoretical framework presented in Chapter 2 in light of the practice improvement project’s findings. A critical evaluation of the strengths and weaknesses of the project, and the degree to which the conclusions are credible given the methodology, project design, and data, should also be presented. The section delineates applications of new insights derived from the practice improvement project to solve real and significant problems. Implications can be grouped into those related to theory or generalization, those related to practice, and those related to future projects. Separate sections with corresponding headings provide proper organization.

Theoretical Implications Comment by Author: This heading is tagged with APA Style > Level 3, i.e., 12 pt Times New Roman, Flush left, Boldface, Italicized, Title case Heading.

Theoretical implications involve interpretation of the practice improvement project findings in terms of the clinical question(s) that guided the project. It is appropriate to evaluate the strengths and weaknesses of the project critically and include the degree to which the conclusions are credible given the method and data. It should also include a critical, retrospective examination of the framework presented in the Chapter 2 Literature Review section in light of the practice improvement project’s new findings.

Practical Implications

Practical implications should delineate applications of new insights derived from the practice improvement project to solve real and significant problems.

Future Implications

Two kinds of implications for future projects are possible: one based on what the project did find or do, and the other based on what the project did not find or do. Generally, future DPI projects could look at different kinds of subjects in different kinds of settings, interventions with new kinds of protocols or dependent measures, or new theoretical issues that emerge from the project. Recommendations should be included on which of these possibilities are likely to be most fruitful and why.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Implications This section should describe what could happen because of this DPI project results. It also tells the reader what the outcome and results implies theoretically, practically, and for the future.
Provides a retrospective examination of the theoretical framework presented in Chapter 2 in light of the practice improvement project’s findings.
Critically evaluates the strengths and weaknesses of the project, and the degree to which the conclusions are credible given the methodology, project design, and data.
Delineates applications of new insights derived from the practice improvement project to solve real and significant problems.
Section is written in a way that is well structured, has a logical flow, uses correct paragraph structure, uses correct sentence structure, uses correct punctuation, and uses correct APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for review, please remove all of these assessment tables from this document. Score 0 (not present); 1(unacceptable; needs substantial edits); 2 (present, but needs some editing); 3 (publication ready).

Recommendations

Summarize the recommendations that result from the project. Each recommendation should trace directly to a conclusion.

Recommendations for Future Projects

This section should contain a minimum of four to six recommendations for future DPI projects, as well as a full explanation for why each recommendation is being made. Additionally, this section discusses the areas of project that need further examination, or addresses gaps or new patient or system needs the project found. The section ends with a discussion of “next steps” in forwarding this line of DPI project evaluations. Recommendations relate back to the project significance and advancing scientific knowledge sections in Chapter 1.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Recommendations for Future PROJECTS This section should contain a minimum of four to six recommendations for future DPI projects, as well as a full explanation for why each recommendation is being made. The recommended project methodology/design should also be provided.
Contains a minimum of four to six recommendations for future projects.
Identifies and discusses the areas that need further examination, or addresses gaps or new patient or system needs the project found.
Suggests “next steps” in forwarding this line of evidence and clinical implications.
Recommendations relate back to the project significance and advancing scientific knowledge sections in Chapter 1.
Section is written in a way that is well structured, has a logical flow, uses correct paragraph structure, uses correct sentence structure, uses correct punctuation, and uses correct APA format.
NOTE: Once the document has been approved by your Chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1(unacceptable; needs substantial edits); 2 (present, but needs some editing); 3 (publication ready).

Recommendations for Practice

This section should contain two to five recommendations for future practice based on the results and findings of the project, as well as a full explanation for why each recommendation is being made. It provides a discussion of who will benefit from reading and implementing the results of the project and presents ideas based on the results that practitioners can implement in the work or educational setting. Unrelated or speculative information that is unsupported by data is clearly identified as such. Recommendations should relate back to the project significance section in Chapter 1.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Recommendations for Future Practice This section should contain two to five recommendations for future practice based on the results and findings of the project, as well as a full explanation for why each recommendation is being made.
Contains two to five recommendations for future practice.
Discusses who will benefit from reading and implementing the results of the project.
Discusses ideas based on the results that practitioners can implement in the work or educational setting.
Unrelated or speculative information unsupported by data is clearly identified as such.
Recommendations relate back to the project significance section in Chapter 1.
Section is written in a way that is well structured, has a logical flow, uses correct paragraph structure, uses correct sentence structure, uses correct punctuation, and uses correct APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for review, please remove all of these assessment tables from this document. Score 0 (not present); 1(unacceptable; needs substantial edits); 2 (present, but needs some editing); 3 (publication ready).

References Comment by Author: The Reference list should appear as a numbered new page at the end of the manuscript. The Reference heading is centered at the top of the page and is bolded. The Reference list provides necessary information for the reader to locate and retrieve any source cited in the body of the text. Each source mentioned must appear in the Reference list. Likewise, each entry in the Reference list must be cited in the text. Keep references whole and on one page This page must be entitled “References.” This title is centered at the top of the page. Do not use bold, underline, or quotation marks for this title. All text should be in 12-point Times New Roman font and double-spaced. NOTE: References must use a hanging indent of 0.5” and be double-spaced. Examples of common references are provided below. See APA (7th ed.), Chapter 9 for specific reference formatting instructions. For more information on references or APA Style, consult the APA website: at http://apastyle.org

American Psychological Association [APA]. (2019). Publication manual of the American Psychological Association (7th ed.). Washington, DC: Author.

Armijo-Olivo, S. (2018). The importance of determining the clinical significance of research results in physical therapy. Brazilian Journal of Physical Therapy, 22(3): 175-176. https://doi.org/10.1016/j.bjpt.2018.02.001 Comment by Author: must have https:// in front of th doi (lower case) DO NOT HYPERLINK GCU REQUIRMENT!

Brands, H. W. (2000). The first American: The life and times of Benjamin Franklin. New York, NY: Doubleday.

Creswell, J.W. & Creswell, J.D. (2018). Research design: Qualitative, quantitative, and mixed methods approaches (5th ed.). Thousand Oaks: CA. Sage Publications.

Nock, A. J. (1943). The memoirs of a superfluous man. New York, NY: Harper & Brothers.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
References
This section provides a minimum of 50 references with minimum of 85% of the 50 references published within the last 5 years. Additional references do not have to be published within the past 5 years.
Range of references includes founding theorists, peer-reviewed articles, books, and journals (approximately 90%).
Reference list is formatted according to current APA formatting. For every reference there is an in-text citation. For every in-text citation there is a reference.

NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

Appendix A Comment by Author: The appendices follow the reference list and typically include materials relevant to the DPI project and referenced in the main text, (e.g. raw data, letters of permission, institutional review authorization, surveys or other data collection materials). Each appendix must begin with a new page, have its own letter designation A, B, C…etc., and a descriptive title. The appendix heading is centered, with a 1” top margin and is upper and lower case. The content or text for each appendix follows right after the title and must fit the practice improvement project margins specifications: 1.5” left, 1” top, right, and bottom. Text spacing for appendix content depends on the nature of the appendix material. The format of the material should be clean and consistent. Comment by Author: Appendix A should be the Ten Strategic Points when submitting the proposal. When the final paper is submitted, the Ten Strategic Points should be deleted and the GCU IRB Letter of Approval or QI Determination Letter should be included as Appendix A.

The Parts of a Practice Improvement Project

GCU requires the Publication Manual of the American Psychological Association (7th ed.) as the style guide for writing and formatting Direct Practice Improvement (DPI) Projects. . A DPI Project has three parts: preliminary pages, main text, and supplementary pages. Some preliminary or supplementary pages may be optional or not appropriate to a specific project. The learner should consult with his or her practice improvement project chairperson and committee regarding inclusion or exclusion of optional pages.

Preliminary Pages

The following preliminary pages precede the main text of the practice improvement project.

Title Page

Approval Page

Abstract

Dedication Page (optional)

Acknowledgements (optional)

Table of Contents

List of Tables (if you have tables, a list is required)

List of Figures (if you have figures, a list is required)

Main Text

The main text is divided into five major chapters. Each chapter can be further subdivided into sections and subsections.

Chapter 1: Introduction to the Project

Chapter 2: Literature Review

Chapter 3: Methodology

Chapter 4: Data Analysis and Results (not included in the proposal)

Chapter 5: Summary, Conclusions, and Recommendations (not included in the proposal)

Supplementary Pages

Supplementary pages, which follow the body text, include reference materials and other required or optional addenda.

References

Appendices

Appendix A for the manuscript is the Grand Canyon University IRB Outcome Letter.

Appendix B is the Instruments/tool used

Appendix C is permission to use the instrument/tool

Appendix D is another tool if applicable (Appendix E is permission for second instrument/tool) otherwise you are done.

Keep in mind that most formatting challenges are encountered in the preliminary and supplementary pages. Allocate extra time and attention for these sections to avoid delays in the electronic submission process. In addition, as elementary as it may seem, run a spell check and grammar check of your entire document before submission.

Appendix B Comment by Author: Do not include your site authorization letter, site IRB letter, informed consent, recruitment materials, or any other documents that would implicate the site and/or participants. Your GCU IRB Letter of Approval or QI Determination Letter should be placed in Appendix A.

What is my DPI project design?

THIS IS NOT PART OF THE PAPER JUST A REFERENCE FOR THE LEARNER

Appendix C

Power Analysis Using G Power

Note: Public source G-Power Software available https://www.psychologie.hhu.de/arbeitsgruppen/allgemeine-psychologie-und-arbeitspsychologie/gpower.html

Appendix D

Example SPSS Dataset & Variable View

The SPSS database is set up with all variables coded to compare between or within the comparison groups. A comparison may be made within the same individual and it coded 1 for before and 2 after the intervention. Or if measuring between individuals, the data would be coded the same 1 for before and 2 after as noted in the Group Column. Software supplied by Grand Canyon University.

Appendix E

How to Make APA Format Tables and Figures Using Microsoft Word

Tables vs. Figures

0. See APA Publication Manual, Chapter 7 for additional details (APA, 2019).

0. Tables consist of words and numbers where spatial relationships usually do not indicate any numerical information.

0. Tables should be used to present information that would be too wordy, repetitive, or difficult to read as text.

0. Figures typically communicate numerical information using spatial relations. For example, as you move up the Y axis of bar graph the scores usually go up.

1. Examples of APA Tables

A. Descriptive table

Table 1

Characteristics of Variables

Variable	Variable Type	Level of Measurement
Group, Intervention or Tool	Independent	Nominal
Rates or events	Dependent	Nominal
Socio Economic Status or Categories in an order	Dependent	Ordinal
Time, Temperature	Dependent	Interval
Age, height, Scores of tests	Dependent	Ratio

Note. Add notes here = (Provide any reference, 2019).

Table 1

Number of Handoff Per Groups

Group	# of Handoffs (%)
Pre-Intervention Group (Baseline)	150 (50%)
SBAR Group	150 (50%)

Note. SBAR handoff was defined as …. (IHI, 2020)

Table 1

Number of Hours Per Week Spent in Various Activities

Group	Baseline (n = 30)	Post Intervention (n = 30)	Total Sample (n = 60)
	M (SD)	M (SD)	M (SD)
Schoolwork	18.23 (7.79)	16.23 (3.99)	17.63 (1.2)
Physical activities	19.54 (3.63)	14.23 (2.84)*	18.67 (1.0)
Socializing	16.23 (3.99)	17.63 (1.2)	18.23 (7.79)
Watching television	14.23 (2.84)	18.67 (1.0)	19.54 (3.63)
Extracurricular activities	19.54 (3.63)	18.23 (7.79)	19.22 (5.45)

Note. Schoolwork was defined as time spent doing class work outside of regular class time.

*statistically significant at p <.05

B. Chi-Square example (Group IV x Group DV)

Table 1

Crosstabulation of Gender and Chronic Pain

Chronic Pain	Gender
	Female	Male	χ2	Φ
Yes	2 (-2.7)	8 (2.7)	7.20**	,60
No	8 (2.7)	2 (-2.7)

Note. Adjusted standardized residuals appear in parentheses below group frequencies

**= p < .01.

C. t-Test Example (Dichotomous Group IV x Score DV) -Notice two separate t-test results have been reported.

Table 1

Chronic Paint Score and Exercise time for Males and Females

	Gender
	Female	Male	T	df
Pain Score	3.33 (1.70)	3.75 (1.79)	-2.20*	175
Exercise Time	4.28 (.7509)	3.87 (.9280)	4.2**	176

Note. Standard Deviations appear in parentheses below means.

* = p < .05, *** = p < .001.

D. One Way ANOVA with 3 Groups Example (Group IV x Score DV)

Remember with an ANOVA, you have to report paired comparisons associated with post hoc or planned comparisons) for significant analyses. The results of paired comparisons are indicated by the subscripts on the means within rows. Also, notice in this table that we report the results of four separate analyses. This is the real power of tables: we can convey a large amount of information very concisely.

Table 1

Analysis of Variance for Sleep Times and Experimental Groups

	Experimental Group
	Aerobic Exercise	Weight Lifting	No Exercise	F	η2
Total Sleep Time	8.23a (.55)	7.93b (.90)	7.73ab (.55)	3.98***	.18
Total Wake Time	3.58a (.70)	3.62a (.55)	3.54a (.90)	.03	.00
Total Light Sleep	3.19c (.73)	2.80a (.72)	3.02b (.49)	2.95*	.06
Total Deep Sleep	3.21b (.19)	3.10a (.28)	3.30a (.19)	.20	.01

Standard deviations appear in parentheses bellow means. Means with differing subscripts within rows are significantly different at the p < .05 based on Fisher’s LSD post hoc paired comparisons.

* = p < .05, *** = p < .001.

E. Factorial ANOVA Example 2 x 3 between subject’s design.

Notice that two tables are used here. The first table reports the overall results for the 2x3 factorial ANOVA, which includes the Main Effects for the two IV’s and the Interaction Effect for the two IV’s. The second table reports the means and simple effects tests for the significant interaction effect.

Table 1

Experimental Group x Sex Factorial Analysis of Variance for Sleep Scores

Source

η2

Experimental Group

7.93

.17

.001

Sex

31.41

.34

.001

Group x Sex (interaction)

7.85

.17

.002

Error (within groups)

Table 1

Analysis of Sleep Scores for Experimental Groups by Gender

Aerobic Exercise

Weight Lifting

No Exercise

Simple Effects:

F df (2, 30)

Males

10.37a

(2.50)

10.30a

(2.34)

10.33a

(1.63)

.04

Females

4.83a

(1.60)

10.50b

(2.59)

4.50a

(1.52)

15.74**

Simple Effects:

F df (1, 30)

23.56**

.00

23.56**

Note. Standard deviations appear in parentheses bellow means. Means with differing subscripts within rows are significantly different at the p < .05 based on Fisher’s LSD post hoc paired comparisons.

** = p < .01

Notice that the simple effect comparing the 3 experiment groups only for females, requires follow up tests in order to determine which groups are significantly different. In this case, Fisher’s LSD test was used, and the results are represented with the different subscripts for each mean. In this case, female participants in the Aerobic exercise group did not differ from the no exercise group so they are given the same subscript (a). However, women in the control group and women in the Weight lifting group significantly differed from the Aerobic watching group and so the Weight Lifting group was labeled with a different subscript (b). The male subjects did not differ from one another, so they all share the same subscript (a).

F. Correlations (Scores IV x Scores IV)

Table 1

Pearson’s Product Moment Correlations for Chronic Pain Score, Exercise Attitude Scores and Physical Activity

Demographic Influences on Exercise

Weight

Age

Chronic Pain Score

Pain Level

.39***

-.07

Pain Intensity

.15

.22*

Physical Exercise

Type of Exercise

-.26**

-.19†

Time of Exercise

-.13

-.21*

Intent to Exercise

.02

-.10

Note. N = 96 for all analyses.

† = p < .10, *= p < .05, **= p < .01, ***= p < .001.

1. Examples of APA Figures

Generally, the same features apply to figures as have been previously provided for tables: They should be easy to read and interpret, consistent throughout the document when presenting the same type of figure, kept on one page if possible, and supplement the accompanying text or table.

Figure 1

Graph of Scores Before and After

Note: Reprinted from S. GCU. Or Adapted from or www.website.com. Reprinted with permission.

If the figure is not your own work, note the source or reference where you found the figure. Write, “Reprinted from” or “Adapted from,” followed by the title of the book, article, or website where you found the figure. Include the page number where you found the figure as well if you are citing a figure from a book. If you are citing a figure from a website, you may write, “Reprinted from The Huffington Post.” Or include the author’s first and second initial as well as their surname. Use the author’s first and second initial, if available, rather than the author’s full first name. Note their last name as well.

References:

American Psychological Association [APA]. (2019). Publication manual of the American Psychological Association. (7th ed.). Washington, DC; Author

Microsoft Word ®. (2019). Retrieved from https://products.office.com/

Appendix F

Writing up your statistical results

Identify the analysis technique.

In the results section (Chapter 4), your goal is to report the results of the data analyses used to answer your project question. To do this, you need to identify your data analysis technique, report your test statistic, and provide some interpretation of the results. Each analysis you run should be related to your clinical question or PICOT. If you analyze data that is exploratory or outside your clinical question, you need to indicate this in the results.

Format test statistics.

Test statistics and p values should be rounded to two decimal places (If you are providing precise p-values for future use in meta-analyses, 3 decimal places is acceptable). All statistical symbols (sample statistics) that are not Greek letters should be italicized (M, SD, t, p, etc.).

Indicate the direction of the significant difference.

When reporting a significant difference between two conditions, indicate the direction of this difference, i.e. which condition was more/less/higher/lower than the other condition(s). Assume that your audience has a professional knowledge of statistics. Do not explain how or why you used a certain test unless it is unusual (i.e., such as a non-parametric test).

How to report p values.

Report the exact p value (this is the preferred option if you want to make your data convenient for individuals conducting a meta-analysis on the topic).

Example: t(33) = 2.10, p = .03.

If your exact p value is less than .001, it is conventional to state merely p < .001. If you report exact p values, state early in the results section the alpha level used as a significance criterion for your tests. For example: “We used an alpha level of .05 for all statistical tests.”

If your results are in the predicted direction but are not significant, you can say your results were marginally significant. Example: Results indicated a marginally significant preference for pie (M = 3.45, SD = 1.11) over cake (M = 3.00, SD = .80), t(5) = 1.25, p = .08.

If your p-value is over .10, you can say your results revealed a non-significant trend in the predicted direction. Example: Results indicated a non-significant trending in the predicted direction indicating a preference for pie (M = 4.25, SD = 2.21) over cake (M = 3.25, SD = 2.60), t(5) = 1.75, p = .26.

Descriptive Statistics

Mean and Standard Deviation are most clearly presented in parentheses:

The sample as a whole was relatively young (M = 19.22, SD = 3.45).

The average age of students was 19.22 years (SD = 3.45).

Percentages are also most clearly displayed in parentheses with no decimal places:

Nearly half (49%) of the sample was married.

Frequencies or rates are reported including the range, mode, or median.

t-tests

There are several different designs that utilize a t-test for the statistical inference testing. The differences between one-sample t-tests, related measures t-tests, and independent samples t tests are clear to the knowledgeable reader so eliminate any elaboration of which type of t-test has been used. Additionally, the descriptive statistics provided will identify which variation was employed. It is important to note that we assume that all p values represent two-tailed tests unless otherwise noted and that independent samples t-tests use the pooled variance approach (based on an equal variances assumption) unless otherwise noted:

There was a significant effect for gender, t(54) = 5.43, p < .001, with men receiving

higher scores than women.

Results indicate a significant preference for pie (M = 3.45, SD = 1.11) over cake (M = 3.00, SD = .80), t(15) = 4.00, p = .001.

The 36 study participants had a mean age of 27.4 (SD = 12.6) were significantly older

than the university norm of 21.2 years, t(35) = 2.95, p = .01.

Students taking statistics courses in psychology at the University of Washington reported studying more hours for tests (M = 121, SD = 14.2) than did UW college students in general, t(33) = 2.10, p = .034.

The 25 participants had an average difference from pre-test to post-test anxiety scores of -4.8 (SD = 5.5), indicating the anxiety treatment resulted in a significant decrease in

anxiety levels, t(24) = -4.36, p = .005 (one-tailed).

The 36 participants in the treatment group (M = 14.8, SD = 2.0) and the 25 participants in the control group (M = 16.6, SD = 2.5), demonstrated a significance difference in

performance (t[59] = -3.12, p = .01); as expected, the visual priming treatment inhibited

performance on the phoneme recognition task.

UW students taking statistics courses in Psychology had higher IQ scores (M = 121, SD = 14.2) than did those taking statistics courses in Statistics (M = 117, SD = 10.3), t(44) =

1.23, p = .09.

Over a two-day period, participants drank significantly fewer drinks in the experimental group (M= 0.667, SD = 1.15) than did those in the wait-list control group (M= 8.00, SD= 2.00), t(4) = -5.51, p=.005.

ANOVA and post hoc tests

ANOVAs are reported like the t test, but there are two degrees-of-freedom numbers to report. First report the between-groups degrees of freedom, then report the within-groups degrees of freedom (separated by a comma). After that report the F statistic (rounded off to two decimal places) and the significance level.

One-way ANOVA:

The 12 participants in the high dosage group had an average reaction time of 12.3

seconds (SD = 4.1); the 9 participants in the moderate dosage group had an average

reaction time of 7.4 seconds (SD = 2.3), and the 8 participants in the control group had a

mean of 6.6 (SD = 3.1). The effect of dosage, therefore, was significant, F(2,26) = 8.76,

p=.012.

An one way analysis of variance showed that the effect of noise was significant, F(3,27) = 5.94, p = .007. Post hoc analyses using the Scheffé post hoc criterion for significance indicated that the average number of errors was significantly lower in the white noise condition (M = 12.4, SD = 2.26) than in the other two noise conditions (traffic and industrial) combined (M = 13.62, SD = 5.56), F(3, 27) = 7.77, p = .042.

Tests of the four a priori hypotheses were conducted using Bonferroni adjusted alpha

levels of .0125 per test (.05/4). Results indicated that the average number of errors was

significantly lower in the silence condition (M = 8.11, SD = 4.32) than were those in both

the white noise condition (M = 12.4, SD = 2.26), F(1, 27) = 8.90, p =.011 and in the

industrial noise condition (M = 15.28, SD = 3.30), F (1, 27) = 10.22, p = .007. The

pairwise comparison of the traffic noise condition with the silence condition was nonsignificant.

The average number of errors in all noise conditions combined (M = 15.2, SD

= 6.32) was significantly higher than those in the silence condition (M = 8.11, SD = 3.30),

F(1, 27) = 8.66, p = .009.

Multiple Factor (Independent Variable) ANOVA

There was a significant main effect for treatment, F(1, 145) = 5.43, p < .01, and a

significant interaction, F(2, 145) = 3.13, p < .05.

The cell sizes, means, and standard deviations for the 3x4 factorial design are presented

in Table 1. The main effect of Dosage was marginally significant (F[2,17] = 3.23, p =

.067), as was the main effect of diagnosis category, F(3,17) = 2.87, p = .097. The

interaction of dosage and diagnosis, however, has significant, F(6,17) = 14.2, p = .0005.

Attitude change scores were subjected to a two-way analysis of variance having two

levels of message discrepancy (small, large) and two levels of source expertise (high,

low). All effects were statistically significant at the .05 significance level. The main

effect of message discrepancy yielded an F ratio of F(1, 24) = 44.4, p < .001, indicating

that the mean change score was significantly greater for large-discrepancy messages (M =

4.78, SD = 1.99) than for small-discrepancy messages (M = 2.17, SD = 1.25). The main

effect of source expertise yielded an F ratio of F(1, 24) = 25.4, p < .01, indicating that the

mean change score was significantly higher in the high-expertise message source (M =

5.49, SD = 2.25) than in the low-expertise message source (M = 0.88, SD = 1.21). The

interaction effect was non-significant, F(1, 24) = 1.22, p > .05.

A two-way analysis of variance yielded a main effect for the diner’s gender, F(1,108) =

3.93, p < .05, such that the average tip was significantly higher for men (M = 15.3%, SD

= 4.44) than for women (M = 12.6%, SD = 6.18). The main effect of touch was nonsignificant, F(1, 108) = 2.24, p > .05. However, the interaction effect was significant,

F(1, 108) = 5.55, p < .05, indicating that the gender effect was greater in the touch

condition than in the non-touch condition.

Chi Square

Chi-Square statistics are reported with degrees of freedom and sample size in parentheses, the Pearson chi-square value (rounded to two decimal places), and the significance level:

The percentage of participants that were married did not differ by gender, X2(1, N = 90) = 0.89, p > .05.

The sample included 30 respondents who had never married, 54 who were married, 26

who reported being separated or divorced, and 16 who were widowed. These frequencies

were significantly different, X2 (3, N = 126) = 10.1, p = .017.

As can be seen by the frequencies cross tabulated in Table xx, there is a significant

relationship between marital status and depression, X2 (3, N = 126) = 24.7, p < .001.

The relation between these variables was significant, X2 (2, N = 170) = 14.14, p < .01.

Catholic teens were less likely to show an interest in attending college than were

Protestant teens.

Preference for the three sodas was not equally distributed in the population, X2 (2, N =

55) = 4.53, p < .05.

Correlations

Correlations are reported with the degrees of freedom (which is N-2) in parentheses and the significance level:

The two variables were strongly correlated, r(55) = .49, p < .01.

Regression analyses

Regression results are often best presented in a table. A

PA doesn't say much about how to report regression results in the text, but if you would like to report the regression in the text of your Results section, you should at least present the standardized slope (beta) along with the t-test and the corresponding significance level. (Degrees of freedom for the t-test is N-k-1 where k equals the number of predictor variables.) It is also customary to report the percentage of variance explained along with the corresponding F test.

Social support significantly predicted depression scores, b = -.34, t(225) = 6.53, p < .01. Social support also explained a significant proportion of variance in depression scores, R2 = .12, F(1, 225) = 42.64, p < .01.

Tables

Add a table or figure.

Adding a table of figure can be helpful to the reader. See the current APA Publication manual for examples. In reporting the results of statistical tests, report the descriptive statistics, such as means and standard deviations, as well as the test statistic, degrees of freedom, obtained value of the test, and the probability of the result occurring by chance (p value).

•APA style tables do not contain any vertical lines

•There are no periods used after the table number or title.

•When using columns with decimal numbers, make the decimal points line up.

•Use MS Word tables to create tables

American Psychological Association [APA]. (2019). Publication manual of the American Psychological Association (7th ed.). Washington, DC: Author.

Before 38 36 43 35 37 37 39 36.027027027027025 35.054054054054056 39 42.05263157894737 36 37 36 37 36 36.027027027027025 36 36 37 37 After 25 24 23 22 27 30 27 33 29 37 30 22 23 29 33 34 30 29 31 35 32

The impact of a DASH (Dietary Approach to Stop Hypertension) on African American patients diagnosed with hypertension. Comment by Sharina Sigur: The impact of a DASH what? Diet? Or should this just be the impact of DASH? Comment by Sharina Sigur: The title should be typed in uppercase and lowercase letters. i.e. The Impact of a DASH (Dietary Approach to Stop Hypertension) on African American Patients…

Submitted by

Maurice D. Graham Comment by Sharina Sigur: Revisions to line spacing required on the preliminary pages. Revisions to page margins throughout the manuscript also required. Refer to the DPI Final Manuscript Template and revise. Comment by Sharina Sigur: Highly recommend you seek assistance from an editor/formatter. Several error notes throughout the manuscript.

Direct Practice Improvement Project Presented in Partial Fulfillment

of the Requirements for the Degree

Doctor of Nursing Practice

Grand Canyon University

Phoenix, Arizona

February 10, 2021

GRAND CANYON UNIVERSITY Comment by Sharina Sigur: Revisions to line spacing required.

The impact of a DASH (Dietary Approach to Stop Hypertension) has on African American patients diagnosed with hypertension.

Maurice Graham

has been approved

February 10, 2021

APPROVED:

Ira L. Martin, DNP, FNP-BC, DPI Project Chairperson

Michelle R. Buchanan (Carter), MD, Project Content Expert

ACCEPTED AND SIGNED

_________________________________________

Lisa Smith, PhD, RN, CNE

Dean and Professor, College of Nursing and Health Care Professionals

_________________________________________

Date

Abstract Comment by Sharina Sigur: Correct the spacing between these lines. Significant revisions required to abstract. Refer to templated abstract in DC Network for guidance and examples.

Background: Hypertension (HTN) is the leading preventable cause of premature death worldwide. In hypertensive individuals, lifestyle modification can serve as initial treatment before the start of drug therapy and act as an adjunct to pharmacological therapy in persons already on drug therapy. An obstacle that medical providers encounter in effectively managing HTN is the lack of dietary lifestyle modification counseling. At the project site there is no lifestyle modification protocol in use for patients diagnosed with HTN. The purpose of this quantitative quasi-experimental project is to determine to what degree the implementation of a DASH (Dietary Approach to Stop Hypertension) education program would impact patients’ blood pressures compared to no education among African Americans diagnosed with hypertension in an outpatient setting in Washington, D.C. Pender’s health promotion model will be used as the theoretical framework for this practice change project. Descriptive statistics was used with 20 participants with statistical and clinical positive results. The results showed in increase in participants knowledge about the dash, better food choices and a decrease in systolic and diastolic blood pressures. These results had a positive impact on the outpatient clinic with recommendations to continue using the DASH program. Future recommendation is to duplicate this project on a larger scale. Comment by Sharina Sigur: The first sentence or two outlines the problem, why is this being addressed? Do not make statements that require a citation as there are no citations in an abstract Comment by Sharina Sigur: Refer to templated purpose statement. Four week timeframe is missing. Comment by Sharina Sigur: Change verb tense to past tense throughout the manuscript. The project has been implemented and is complete. Comment by Sharina Sigur: What about the ACE Star Model described in chapter 2? Comment by Sharina Sigur: State the model or theory using the author and how it applies to the project ONE SENTENCE! Example: Prochaska and DiClemente’s transtheoretical model (TTM) was utilized to evaluate patient motivation to quit smoking and determine appropriate cessation interventions. Comment by Sharina Sigur: This is underdeveloped. Where are the results? Explanation of clinical significance and statistical significance is missing. Refer to templated abstract in the DC Network for guidance and for examples.

Keywords: DASH diet, African Americans, Education, Hypertension, blood pressure, pre-posttest. Comment by Sharina Sigur: Include theoretical model Comment by Sharina Sigur: This doesn’t appear to be a relevant keyword.

Table of Contents Comment by Sharina Sigur: The automatic TOC included in the template was not used. Significant revisions required.

Chapter 1: Introduction to the Project…………………………...……………………………………1

Background of the Project………………………………………...………………………………2

Problem Statement…………………………...……………………………………………………4

Purpose of the Project ……………………..………………………………………………………4

Clinical Question……………………………………………………………………………….....5

Advancing Scientific Knowledge…………………………………………………………………5

Significance of the Project………………………………………………………………………...7

Rationale for Methodology………………………………………………………………………..9

Nature of Design…………………………………………………………………………………10

Definition of Terms………………………………………………………………………………10

Assumptions, Limitations, Delimitation…………………………………………………………11

Chapter 2: Literature Review………………………………………………………………………...14

Theoretical Foundations………………………………………………………………………….15

Application to change……………………………………………………………………18

Star point 1: Discovery Evidence………………………………………………………..18

Star point 2: Evidence Summary………………………………………………………...18

Star point 3: Translation to Guidelines…………………………………………………..18

Star point 4: Practice Integration………………………………………………………...19

Star point 5: Evaluation………………………………………………………………….19

Review of the Literature…………………………………………………………………………20

Dash Diet………………………………………………………………………………...23

Patient Education………………………………………………………………………...28

Summary…………………………………………………………………………………………30

Advantages and Disadvantages of Findings……………………………………………..30

Utilization of Findings in Practice……………………………………………………….31

Chapter 3: Methodology……..………………………………………………………………………33

Statement of the Problem………………………………………………………………………...33

Clinical Question………………………………………………………………………………...34

Project Methodology…………………………………………………………………………….36

Population and Sample Selection………………………………………………………………...36

Instrumentation or Sources of Data………………………………………………………....…...37

Validity…………………………………………………………………………………………..37

Reliability………………………………………………………………………………………...37

Data Collection Procedures………………………………………………………………………38

Data Analysis Procedures………………………………………………………………………..39

Ethical Considerations…………………………………………………………………………...40

Limitations……………………………………………………………………………………….41

Delimitations…………………………………………………………………………….……….41

Summary…………………………………………………………………………………………42

Chapter 4: Data Analysis and Results………………………………………………………………..44

Descriptive Data…………………………………………………………………………………45

Data Analysis Procedures………………………………………………………………………..46

Demographics, Results and Findings……………………………………………………………47

Figure 1…………………………………………………………………………………..47 Comment by Sharina Sigur: Tables and figures are included on a separate page. Refer to template.

Figure 2…………………………………………………………………………………..47

Table 1…………………………………………………………………………………...48

Figure 3………………………………………………………………………………..…49

Figure 4……………………………………………………………………………….….49

Figure 5…………………………………………………………………………….…….50

Figure 6…………………………………………………………………………………..51

Figure 7………………………………………………………………………………..…51

Figure 8…………………………………………………………………………………..52

Table 3…………………………………………………………………………………...53

Table 4…………………………………………………………………………………...53

Table 5…………………………………………………………………………………...54

Summary…………………………………………………………………………………………55

Chapter 5 Summary, Conclusions and Recommendations…………………………………………..56

Summary of the Project………………………………………………………………………….56

Summary of Findings and Conclusions………………………………………………………….57

Implications………………………………………………………………………………………58

Theoretical Implications…………………………………………………………………58

Practice Implications……………………………………………………………………..59

Future Implications………………………………………………………………………59

Recommendations………………………………………………………………………………..60

Recommendations for Future Projects…………………………………………………...60

Recommendations for Practice…………………………………………………………..61

References ……………………………………………………………………………………………63

Appendix A…………………………………………………………………………………………..75

10 Point Strategic Points…………………………………………………………………………75

Appendix B…………………………………….………………...…………………………………..80

DASH diet Education Information………………………………………………………………80

Appendix C…………………………………...…………………………………………….………..81

Intake Survey Tool……………………………………………………………………………….81

Appendix D……………………………….………………………..………………………………...82

Statistics………………………………………………………………………………………….82

Appendix E……………………………….………………………………………………………….84

Food Frequency Questionnaire Approval………………………………….…………………….84

Appendix F………………………………………………………………………………………...…85

Food Frequency Questionnaire…………………………………………………………………..85

Appendix G…………………………………………..……………………………………………....90

DASH Diet Education Session Schedule……………………………………………...…………90

Appendix H…………...…..………………………………………………………………………….91

DASH Education Pamphlets…………………………………………………………….……….91

Appendix I……………………………………………………………………………….…………..92

IRB Approval…………………………………………………………………………………….92

Appendix J………………………………………………………………………………..………….93

Site Approval…………………………………………………………………………………….93

Appendix K…………………………………………………………………………………………..94

What Is My Project Design………………………………………………………………………94

Chapter 1: Introduction to the Project Comment by Sharina Sigur: Line spacing between paragraphs is formatted incorrectly. Significant formatting errors noted throughout manuscript. Refer to template and seek assistance from editorial services. Revise where needed throughout the manuscript.

A clinical practice change project will be designed and implemented to educate patients about a dietary approach to stop hypertension (DASH). This practice change project will increase patient’s knowledge and willingness for dietary change to reduce their blood pressures. Comment by Sharina Sigur: Revisions to verb tense required throughout the manuscript. This is no longer the proposal. Comment by Sharina Sigur: If referring to multiple patients, change to plural possessive (i.e. patients’).

According to the American Heart Association (AHA, 2015), hypertension is one of the leading health issues contributing to cardiovascular disease that is a leading cause of morbidity and mortality. Understanding that hypertension is a risk factor that can be modified, 54% of an estimated one million adults that are diagnosed with hypertension are poorly controlled (Center for Disease Control, 2017). Healthcare providers are at the forefront for counseling patients on preventive services (Jarl et al., 2014). Educating patients on a lifestyle modification, such as the DASH has demonstrated a proven strategy to reduce the blood pressures of patients diagnosed with hypertension. The literature strongly suggests that interventions are needed for adherence to the DASH diet among patients diagnosed with hypertension (Jarl et al., 2014).

Patients will be recruited from an outpatient clinic at a private historically black university in Washington, D.C. The participants will consist of African American patients between the age of 18 and 65 diagnosed with hypertension at a primary care clinic in Washington D.C. A pre-posttest designed by DASH will be utilized to gain knowledge of patients before and after the DASH education session, and the practice change will be guided by the Pender's health promotion model for change. Before and after the implementation of the DASH education session, the patients' blood pressures will be measured.

Health education can reduce chronic disease mortality and morbidity (Jarl et al., 2014). Although some studies describe how providers provide health education, few studies have examined how doctors, physician assistants, and nurse practitioners differ in health education delivery. Patients with chronic disease receive health education from physician assistants and nurse practitioners more frequently than physicians, but none of the three categories of clinicians consistently offered health education. Possible reasons include variations in preparation, different positions per form of provider within a clinic, or increased clinical demands on providers. More research is needed to understand the causes of these differences and potential opportunities to provide patients with condition-specific education (Ritsema et al., 2014).

Education meetings alone or in conjunction with other interventions can improve patients’ knowledge and increase patient outcomes. By using a pre-posttest questionnaire to evaluate needs, educators can develop programs that address the information needs and issues of learners more effectively and ultimately help patients (Ebell et al., 2011).

Background of the Project

African Americans are at an increased risk for developing HTN at an early age due to a gene that increases their sensitivity to salt (American Association for the Advancement of Science [AAAS], 2004; Rigsby, 2011). This population is disproportionately affected by HTN when compared to other ethnicities (Rigsby, 2011). As a result, African Americans with HTN have an increased rate of stroke (80%) and heart disease (50%) when compared to other ethnicities (AAAS, 2004). Asante (2015) reported that 84% of African Americans did not understand HTN and chronic diseases related to lack of therapy. Hypertension occurs when the force of the blood flowing through a person’s blood vessels is consistently too high (AHA, 2017). The Center for Disease Control [(CDC], 2018) defines normal blood pressure (BP) as a systolic B/P less than120 mmHg and diastolic B/P less than 80 mm Hg. Hypertension is the leading preventable cause of premature death worldwide (Mills et al., 2016). The principal health issues of four or more office visits to health care providers in the U.S. is for HTN with an estimated direct and indirect cost of $51.billion (CDC, 2019).

According to Healthy People 2020, their goal is to increase compliance and control of hypertension among adults from 43.7% to 61.2% by 2020. This initiative would take place with increased coordinated health promotion along with disease prevention to improve patients’ outcomes. (Healthy People, 2020). This would be a significant increase in controlled blood pressures compared to years 2005-2008 (Healthy People, 2020). Comment by Sharina Sigur: Citation must be included in sentence.

Adopting the DASH diet, a mixed diet of fruits, vegetables, nuts, whole grains, lean fish, poultry, and low-fat dairy foods, contributes to lower blood pressure (NHLBI, 2015). The diet requires reducing less saturated fat, total fat, and cholesterol. In a random control experiment, the diet decreased BP (Appel et al., 1997). Participants adopting the DASH diet systolic blood pressure decreased by an average of 7.7 mm Hg, and average blood pressure decreased by 3.6 mm Hg (Blumenthal et al, 2010). Comment by Sharina Sigur: iIf the name of the group first appears in parentheses, put the abbreviation in brackets after it, followed by a comma and the year for the citation. 1. Example: Children should learn about family finances in age-appropriate ways (American Psychological Association [APA], 2011). Comment by Sharina Sigur: Notice revision made here. Revise where needed.

According to Kim and Andrade (2016), there are major health issues contributed to non-adherence to dietary recommendations and that non-adherence rates are on the decline. There are many barriers that contribute to preventing patients from adhering to a healthy diet although the DASH has proven to reduced blood pressures among patients (Viera et al., 2007). Currently, there are barriers during office visits with patients, such as time restraints, that contribute to limited resources available to educate patients (Matyas et at., 2011). Another barrier would be motivating patients to modify their diets for better hypertension control (Samadian et al., 2016).

The primary objective of this DPI is to investigate if a DASH education intervention for patients would impact patient outcomes by reducing hypertension in African American patients at a primary health clinic in Washington, D.C. Comment by Sharina Sigur: Aim for three to five or more sentences per paragraph. Revise where needed.

Problem Statement

It is not known if or to what degree the implementation of a DASH would impact the patients’ blood pressures when compared to no intervention among African American patients diagnosed with hypertension in an outpatient clinic in Washington, D.C.

High blood pressure (HBP) prevalence in African Americans in the US is among the world's highest. Much of non-Hispanic African American men and women have high blood pressure. High blood pressure also occurs earlier in life and is typically more extreme for African Americans (Maraboto & Ferdianand, 2020). Comment by Sharina Sigur: According to what source? Include citation to support this statement and any other statements that require citations.

Uncontrolled hypertension (HTN) in the USA is particularly prevalent and devastating among Black people who are more vulnerable than people from other racial / ethnic groups to the effects of this disease. Moreover, the findings of many research studies in this population are frequently underrepresented in cardiovascular clinical trials, restricting their ability to accurately apply them. In this analysis, we summarize and examine the information that is currently available regarding risk factors, manifestations, complications and HTN management in this often difficult to treat population (Maraboto & Ferdiannand, 2020). This practice change project seeks to better understand to what degree of increasing patient’s knowledge on the DASH diet is a best approach for treatment of patients with hypertension (Maraboto & Ferdianand, 2020). Comment by Sharina Sigur: We? Who is this referring to? Is this a direct quote from Maraboto and Ferdiannand? If so, this is not formatted correctly.

Purpose of the Project Comment by Sharina Sigur: This section is underdeveloped. Refer to template and DNP DPI project guide for section requirements.

The purpose of this quantitative quasi-experimental project is to determine if or to what degree the implementation of a Dietary Approach to Stop Hypertension education intervention for patients would impact the patients’ blood pressure when compared to no intervention among African American patients diagnosed with hypertension in an outpatient clinic in Washington, D.C.

The independent variable will be defined as the implementation of a Dietary Approach to Stop Hypertension education for patients at a primary care clinic in Washington D.C. The dependent variable will be better management of patients diagnosed with hypertension measured by lowering their blood pressure.

Clinical Question Comment by Sharina Sigur: This section is underdeveloped.

To what degree does the implementation of a Dietary Approach to Stop Hypertension education intervention impact blood pressure of patients diagnosed with hypertension when compared to no intervention among African American patients in an outpatient clinic in Washington, D.C.? This practice change project will take place over a four-week period and aims to reduce the development and increase the management of HTN among African Americans.

The following clinical question guides this quantitative project:

CQ: Does the implementation of a Dietary Approach to Stop Hypertension education intervention impact African American patients diagnosed with hypertension at a primary health clinic in Washington, D.C. over a four-week period?

The independent variable will be defined as the implementation of a Dietary Approach to Stop Hypertension education session for patients that are diagnosed with HTN. The dependent variable will be the blood pressures measurements of patients identified in the QI project at a primary health clinic in Washington, D.C. over a four-week period.

Advancing Scientific Knowledge

This DPI will increase strategies to help patients control their blood pressure (BP) by lowering systolic and diastolic. The goal is to implement education programs for patients in the clinic setting to increase better hypertension management and increase patient outcomes. Dramatic improvement in public health could be gained from enhanced hypertension control (AHA, 2015). Effectiveness and implementation of the DASH intervention by providers will add to ways to effectively increase community efforts to achieve blood pressure control throughout the population and especially among African Americans.

The theoretical framework chosen for this DPI is the Nolan Pender’s health promotion model. According to Petirin (2015), Pender’s health model focuses on changing the unhealthy behaviors of patients and improving patient outcomes. This falls directly in line with educating patients about the use of a DASH diet by increasing their knowledge about dietary intake and the effects that it can have on their blood pressure. Pender’s model has the potential to change this behavior and improve patient outcomes by better management of their hypertension.

This DPI practice change project can further advance the Pender’s health promotion model by showing a successful hypertension management and control. Pender’s health promotion modes could be applicable as a theoretical framework to identify major determinants of adherence to hypertension control recommendations. Future findings of this DPI could possibly represent more legitimacy surrounding self-care practices in hypertension if there is a large enough sample size.

The conceptual-theoretical-empirical (CTE) structure is a system of nursing knowledge that requires attention to elements of substance and process as well as considerable thought, careful planning, and commitment to evidence-based practice that typically changes nursing practice and sets the standard for providing quality patient care (Fawcett & Desanto-Madeya, 2012). The project implementer (PI) will utilize the Health Promotion Model (HPM) by Nola Pender and the ACE Star Model of Knowledge Transformation to guide this project. Pender’s health promotion model (HPM) is one of the widely used models to plan for and change unhealthy behaviors and promote health (Petirin, 2015). Comment by Sharina Sigur: Models/theories are not capitalized in APA. Revise where needed. Comment by Sharina Sigur: This was not included in the abstract..

Using the health promotion model is more advantageous as compared to other strategies since the HPM does not only give findings of research but also aims at improving the health condition of patients and their families. For this DPI project, the primary goal is to provide an alternative way of HTN management with a DASH diet and lifestyle practices to reduce patients’ blood pressure. If the project is successful, it will help people diagnosed with HTN to manage the condition with dieting and exercises, which will enable them to live long, healthy lives.

Significance of the Project

African Americans are identified as a high-risk population for the treatment and management of HTN. This is a multifactorial problem that requires a comprehensive education and treatment program. There are disparities in health care and access to care in African Americans (AHA, 2017). To effectively treat and impact this population, an educational intervention aimed at diet and lifestyle modifications and HTN management is required. A multidisciplinary patient-centered medical approach that incorporates the healthcare provider, nurses, case managers, pharmacists, and dieticians will have the most significant impact on improving patient outcomes.

The significance of this DPI project is to increase patients’s knowledge and behaviors toward change to help reduce HTN cases among African Americans individuals who are at a higher risk of developing HTN. HTN does not always require medical intervention, and quantitative data has provided sufficient evidence that indicates the condition can be managed and prevented using other measures, such as dieting and change to healthier lifestyle practices. The DPI project will also help in the prevention of hypertension in the community and globally, which will significantly reduce the mortality of cardiovascular-related complications around the world.

Changing clinical practice is a challenging task, best demonstrated by the time gap between evidence and usage in practice and the widespread use of low-value treatment. Established frameworks concentrate primarily on obstacles to new information learning and implementation. However, improvements to clinical practice not only entail learning new practices, but also unlearning old and obsolete information. This DPI practice change aims to explain the experience of having to leave old dietary habits in the past and its association with new learning. When a change is introduced, whether through the introduction of new directives or self-imposed changes, patients face different struggles to successfully change their health management practices (Gupta et al., 2017).

Health associations encourage healthcare providers to engage in patients ' blood pressure management services (CDC, 2017). Lifestyle improvements include weight control, exercise, and diet guidelines for HTN management (Matyas et al., 2011). Because of lack of knowledge, many patients do not obey the guidelines. Education of patients regarding improvements in lifestyle may have a big influence on their confidence in DASH diet education regarding HTN, (Matyas et al., 2011). Kwan et al. (2013) reported that a lack of education is a common factor that patients do not adopt dietary education.

Lifestyle improvements with a heavy emphasis on dietary activity focus on the treatment of HTN based on CDC guidelines (2017). The EJNC (2014) has increased its focus on the shift in the lifestyle of hypertension prevention and treatment and listed the DASH diet on hypertension algorithm lifestyle medication. Comment by Sharina Sigur: ??

Rationale for Methodology Comment by Sharina Sigur: This section is underdeveloped.

The participants for this DPI project will be from a primary health clinic in Washington, D.C. The initial group will consist of individuals who are all from the primacy care clinic, African American and have been diagnosed with hypertension. The quantitative DASH education pre-post-test approach will be utilized in measuring before and after the education session for a DASH diet (Harrison, 2014). In addition, patients' blood pressure will be measured before and after provider to patient counseling of the DASH diet to see if there is a correlation between increasing patient knowledge and patient outcomes. Comment by Sharina Sigur: Rephrase for clarity.

The best approach for this DPI project is a quantitative pre-posttest to answer the clinical question. A pre-post-test by design covers will be used for the DPI project because it will cover all the topics which a participant will be learning for the DASH education sessions. While taking the pre-test at the beginning, patients are not expected to know the answers to all the questions; however, they should be expected to utilize previous knowledge to predict rational answers. When taking the same test called a post-test at the end of a DASH education, participants should be expected to answer more questions correctly based on an increase in knowledge and understanding. Comment by Sharina Sigur: Discussion related to project design belongs in the next section.

Investigators can assess reliability by comparing the answers respondents give in one pretest with answers in another pretest. Then, a survey question's validity is determined by how well it measures the concept(s) it is intended to measure. Both convergent validity and divergent validity can be determined by first comparing answers to another question measuring the same concept, then by measuring this answer to the participant's response to a question that asks for the exact opposite answer (Dimitrov & Rumrill, 2003).

Nature of the Design Comment by Sharina Sigur: This section is underdeveloped.

The focus for this quasi-experimental design DPI project is to administer a DASH five-question pre-and-post measuring patients’ knowledge before and after the DASH education to determine effectiveness. Everyone will be granted free access to the pre posttest tool; access and usage of the tool was not required. Guide for Effective Nutrition Interventions and Education (GENIE) developed by the Academy of Nutrition and Dietetics (AND) has been evaluated for its effectiveness (GENIE, 2019). GENIE is a validated online resource tool that offers evidence-based guidelines needed for the implementation of useful nutrition education programs (GENIE, 2019).

By using pre-post test questions to evaluate needs, educators can develop programs that address the information needs and issues of learners more effectively and ultimately help patients (Ebell et al., 2011).

For this DPI Project, patients diagnosed with HTN will be the main participants. They will be asked a series of questions to measure their knowledge of HTN and the DASH diet. This practice change project would broaden their knowledge on the best approaches regarding the effectiveness of a DASH diet thus improving patient outcomes with improved management of HTN. Patients’ blood pressures will be measured before and after the provider to patient DASH counseling and pre-posttest.

Definition of Terms

Below is a list of terminologies encompassed in the DPI project. It relates to providers educating patients on the adoption of the DASH diet to guide them in managing their hypertension.

Hypertension. Is blood pressure greater than 120/80 mm Hg. It is also known as high blood pressure and is responsible for increasing pressure on the blood vessels, (AHA, 2017).

Sodium. A major cation of extracellular fluid in human cells (Chobanian et al., 2003). Iodized sodium chloride is commonly known as salt and is used in food. It is found in many foods as it is essential for the nerve and muscle function in the human body.

Dietary Approach to Stop Hypertension (DASH). Designed to help treat, manage, or prevent hypertension. DASH diet is a meal plan that is designed to lower the blood pressure (Challa et al., 2020). The diet comprises fruits, vegetables, and low-fat dairy products.

Pender's Health Promotion Model. A health promotion model that defines health as a positive dynamic state instead of terming it as the absence of disease. It is also directed at enhancing a patient's level of well-being (Petirin, 2015).

Conceptual Theory Empirical. It is relative to the conceptual framework providing concrete and specific results through various theoretical frameworks derived from empirically tests from experiments (McConnel, 2015).

ACE Star Model of Knowledge. Describes five significant points in the transformation of knowledge into practice (Stevens, 2013). It begins at the top point where discoveries are made, and it serves as the focal point of the project.

Guide for Effective Nutrition Intervention and Education (GENIE). This is a qualitative tool used to design, modify, or compare effective nutrition education programs (GENIE, 2019). Comment by Sharina Sigur: Was this tool used in the project? This project must be quantitative, not qualitative.

Assumptions, Limitations, Delimitations Comment by Sharina Sigur: This section is extremely underdeveloped.

This DPI project assumes that all participants will answer the DASH pre and posttest questions truthfully. The participants will engage in the DASH educational program. Other assumptions are that all participants will answer DASH protest questions truthfully. Limitations are the population sample size and the use of only one primary care clinic for the DPI project. Additional limitations would be the use of a convenience sampling of 20 participants reducing the generalizability no control group and time frame to conduct DPI project may be short.

Delimitations include only using one primary care cline and all participants will be African American, no other ethnic group will be asked to participate in the DPI project. The outpatient clinic patient population is made up of 95% African American.

Summary and Organization of the Remainder of the Project Comment by Sharina Sigur: This section is underdeveloped.

In the United States, the prevalence of hypertension in blacks is among the highest in the world. Blacks develop hypertension at a younger age, their average blood pressure is much higher compared to whites, and they suffer worse severity of the disease (AHA, 2017). As a result, African Americans have 1.3 times higher rates of nonfatal stroke, 1.8 times higher rates of fatal stroke, 1.5 times higher rates of death from heart disease, 4.2 times higher rates of end-stage kidney disease, and 50% higher rates of heart failure; overall, hypertension mortality and its effects are four to five times more common in African Americans than in whites (CDC, 2015). A combination of genetic and most likely, environmental factors is responsible for the increased prevalence of hypertension and excessive target organ damage (AHA, 2017).

A healthy diet and portion control are promoted by the DASH diet. It supports the introduction into your daily diet of more fruits and vegetables, whole-grain foods, fish, poultry, nuts, and fat-free or low-fat milk items (DASH, 2013). Foods high in saturated fat, cholesterol, trans fats, candy, sugary beverages, sodium (salt), and red meat should be reduced (DASH, 2013). Owing to family background, some individuals have high blood pressure (DASH, 2013). For some it may be to blame for unhealthy diets, lack of exercise, or another medical problem. People who have hypertension also take medication. However, diet and exercise, even if it is part of your family background, can help lower high blood pressure (DASH, 2013)

A pre-and post-test, defined as a before & after assessment will be used to measure whether the anticipated improvements will take place in the participants in the DASH education. Program, it is the simplest evaluation design appropriate for the intended DPI project. A standard test questionnaire is applied (pre-test or baseline) and re-applied after a given time or at the end of the program (post-test or end line). The pre- and post-tests will be given in writing.

The value of hypertension understanding continues to be emphasized by existing recommendations on hypertension management. To improve treatment effectiveness, more effort should be made to increase patient knowledge and patients' willingness to comply with physical examinations (Harrison, 2014). As clinicians, if we want to convince patients to concentrate on their long-term wellbeing, we need to build a relationship of confidence. By sharing as much of our information as possible, the trust will be strengthened (Harrison, 2014).

African Americans are identified as high-risk HTN treatment and management populations (AHA, 2017). This is a multi-factor challenge involving a robust education and care program. In African Americans, there are inequalities in health insurance and access to treatment. To treat this population effectively, an educational intervention to modify diet and lifestyle and to manage HTN is needed. Increased screening and more rigorous recommendations in this population are required. The biggest effect on better patient outcomes would be the multidisciplinary patient-centered medical approach involving a primary care professional, nurse, case managers, pharmacists, and dietitians. The DPI project will take place of a four-week period of time. The next chapter will further discuss the review of literature, the methodology in which the DPI project will use, purpose of the DPI project and practice implications. The primary objective of this DPI is to investigate if a DASH education intervention for patients would improve the management of patients diagnosed with HTN at a primary health clinic in Washington, D.C. Comment by Sharina Sigur: Carefully review all comments and revisions made in the abstract and chapter 1. These same errors may exist throughout the remaining chapters without reviewer revisions/comments. Follow the feedback in the abstract and chapter 1 and apply to all remaining chapters.

Chapter 2: Literature Review Comment by Sharina Sigur: This chapter should be minimum 20 pages

Early onset HTN is a significant contributor to a shortened life expectancy of African American men (AHA, 2017). Hypertension is one of the leading factors for cardiovascular disease and is the leading risk factor for the overall global burden of diseases. Evidenced data has demonstrated that lifestyle modification and changes are known to reduce blood pressure (BP) (AHA, 2015). The purpose of this chapter is to provide an integrative review of literature identifying the best evidence-based literature to support lifestyle modification interventions in hypertensive African Americans to increase knowledge and decrease blood pressure.

A literature search was performed using Cumulative Index and Allied Health Literature (CINAHL), American Heart Association, Google Scholar, Medline, and PubMed. Keywords included HTN, DASH diet, patient knowledge, African Americans, lifestyle modification, provider education, and various combinations of the aforementioned. The search focused on evidence-based nursing articles and quantitative studies that had human peer reviewed, used English language, were full text, and within the last fifteen years. The search criteria were used to obtain the current body of literature and ascertain if an evidence-based practice change was supported.

The literature search resulted in approximately 60 articles. Articles were reviewed for relevance to PICO, inclusion, and exclusion criteria and 20 articles remained. The level of evidence were determined from (Fineout-Overholt’s, 2015) evidence hierarchy (1) Level I: Evidence from systematic review or meta-analysis of all random clinical trials (RCT), (2) Level II Evidence obtained from well-designed RCTs, (3) Level III Evidence obtained from well-designed controlled trials without randomization, (4) Level IV Evidence from well-designed case control and cohort studies, (5) Level V Evidence from systematic reviews and descriptive and qualitative studies (6) Level VI Evidence from single descriptive or qualitative studies, and (7) Level VII Evidence from the opinion of authorities and/ or reports of expert committees. The studies with evidence rated I through IV were utilized. Inclusion criteria used to select articles included studies that focused on lifestyle modification or nonpharmacological management of HTN, knowledge and education, management, or self-management in reference to or combination of HTN in African Americans, education for patients and patients attitudes toward change. Exclusion criteria included participants under 18 years of age. Comment by Sharina Sigur: This section is underdeveloped. Where is the background information?

Theoretical Foundations Comment by Sharina Sigur: Review all sentences for structure and flow. Ensure information presented is clear to the reader.

The Nola Pender’s health promotion model (HPM) and the ACE star model of knowledge transformation will be utilized to guide this project. Pender’s health promotion model (HPM) is one of the widely used models to plan for and change unhealthy behaviors and promote health (Petirin, 2015). The use of evidence-based practice (EBP) and national guidelines improve the quality of patient care and close the gap between quantitative patient outcomes and practice (Dontje, 2007). The conceptual-theoretical-empirical (CTE) structure is a system of nursing knowledge that requires attention to elements of substance and process as well as considerable thought, careful planning, and commitment to evidence-based practice that typically changes nursing practice and sets the standard for providing quality patient care (Fawcett et al., 2012). An EBP model or theory is used to guide the process of translating quantitative evidence into clinical practice. The clinical problem identified was hypertension in African American adults. The PICO question identified for this EBP is as follows; in African American patients diagnosed with hypertension, does an educational overview regarding a Dietary Approaches to Stop Hypertension (DASH) diet improve patient outcomes by lowering blood pressures? The purpose of this chapter is to analyze a conceptual-theoretical-empirical (CTE) structure and theory that supports or guides the implementer’s EBP. Health promotion is defined as lifestyle modification and behaviors recommended by the healthcare provider to promote one’s health and prevent disease. Health promotion is imperative in EBP to decrease blood pressure and increase patient knowledge while improving patient health outcomes. Health promotion as a concept is supported by Nola Pender’s health promotion model (HPM) that is directed toward positive health outcomes, such as optimal well-being, healthy eating habits, and regular exercise (Tomey & Alligood, 2002). The project implementer (PI) will explore this concept even further by focusing on healthy eating diet plans for hypertensive patients.

The project intervention is a pretest-posttest design guided by the theoretical framework Pender’s health promotion model. The tool chosen was validated in a pilot study of the DASH “Fruits and Vegetables” classroom lesson included a five question pre- and posttest as a tool for measuring the effectiveness of the lesson plan (Apovian et al., 2010). Hypertension is a chronic disease that is in the top three diagnosis of all outpatient clinic visits annually (Mahmood et al., 2018). The current body of evidence supports the integration of an educational overview on DASH to increase patient knowledge and management of HTN. This model was chosen to guide this EBP because healthcare providers are the most influential in motivating others to change their lifestyle (Petirin, 2015). Therefore, by implementing an educational intervention to patients on the benefits of DASH in controlling HTN has the potential to reduce healthcare cost associated with co-morbid chronic health conditions to include morbidity, mortality, coronary artery disease, renal disease, cerebrovascular accidents (Jiang et al., 2015). The patients will gain a better understanding of nutritional knowledge of the DASH, influence lifestyle change, and create a more accepting and empathic learning environment with the implementation of this EBP (Petirin, 2015).

Pender invented the original HPM described in the first edition of the text, Health Promotion in Nursing Practice, published in 1982 (Tomey & Alligood, 2002). The significance of this model is to assist patients in understanding the significant determinants of health behaviors as a basis for promoting healthy lifestyles (Petirin, 2015). Tomey & Alligood (2002) suggest the importance of Pender’s health promotion model is directed toward positive health outcomes such as optimal well-being, healthy eating habits, and regular exercise. Pender believed that prevention of these health problems could improve the patient's quality of life, and health care dollars could be saved by the promotion of healthy lifestyles (Petirin, 2015).

The HPM motivates people to make lifestyle modifications for a healthy lifestyle (Petirin, 2015). People are more likely to commit to and engage in health-promoting behaviors when significant others model the behavior, expect the behavior to occur, and aid and support to enable the behavior (Tomey & Alligood, 2002). The HPM is an excellent theoretical choice for the project because the evidence reports that hypertension affects more than 50 million people in the United States with health care costs totaling 42.9 billion in 2010 (Sacks et al., 2001).

Hypertension (HTN), also known as the “silent killer,” affects one out of every three African Americans. The reason for higher incidence of high blood pressure (B/P) in African Americans is unknown. On average, African Americans with high blood pressure have a much higher rate of stroke, heart failure, and other diseases than whites (CDC, 2018).

A clinical practice change project will be designed and implemented to educate patients about a Dietary Approach to Stop Hypertension (DASH). This project focuses on increasing patient knowledge and improving HTN management by lowering patient blood pressures. Patients will be recruited from an outpatient clinic in Washington D.C. The participants will consist of approximately 30 African American patients diagnosed with hypertension. A pre-posttest design will be utilized and guided by the Nola Pender health promotion model.

The ACE star model of knowledge transformation was developed to offer a comprehensive yet straightforward approach to translate evidence into practice. The model emphasizes five crucial steps to convert one form of knowledge to the next and incorporate the best quantitative evidence with clinical experts and patient preference thereby achieving evidence-based practice (Stevens, 2013). This model was chosen to guide the EBP in all phases.

Application to practice change. The model emphasizes crucial steps that will be used to allow evidence that can be translated into daily practice such as DASH education. The ACE Star Model is one of the most used models when transforming evidence into daily practice (Star Model, 2015).

Star point 1: Discovery Evidence. This is the knowledge-generating stage (Star Model, 2015). In this phase, the PI will conduct a thorough integrative literature review that resulted in supporting this EBP. EBP quantitative data is a continuous process that will continue throughout the life of the practice change project.

Star point 2: Evidence Summary. A systematic review and synthesis of research is performed, and knowledge is generated (Star Model, 2015). In this phase, the PI will spend quality time analyzing and reviewing the latest evidence and research supporting of the evidence-based clinical change project. A summary and synthesis of the findings indicate a DASH diet has been established as an effective modality to reduce blood pressure. Current evidence supports the lack of provider counseling on DASH and patient lack of knowledge concerning DASH benefits.

Star point 3: Translation to Guidelines. This point requires two stages that include a translation into practice recommendations and integration into practice. The aim is to provide a useful and relevant package of summarized evidence to patients in a form that suits the time, cost, and care standard (Star Model, 2015). This phase will include an educational overview to patients on the DASH diet, selection of the best questionnaire to assess patient’s knowledge on DASH, and utilization of the most current guidelines for HTN management using JNC8 guidelines. The data supports the need to educate patients on effective HTN management and recommend incorporating DASH into their daily lifestyle (Schwingshackl & Hoffmann, 2015).

Star point 4: Practice Integration. This point involves changing both individual and organizational practices of HTN management incorporating the DASH diet into daily practice (Star Model, 2015). This phase included an educational overview on DASH diet to patients, educational posters, patient education booklets, and statistical data analysis where the PI will make recommendations in support of the EBP to result in improved patient outcomes by bringing the best evidence into practice (Star Model, 2015).

Star point 5: Evaluation. The impact of evidence-based practice on patient satisfactory, provider satisfactory, patient health outcomes, economic analysis, efficiency, efficacy, and health status will be measured and analyzed. In this stage, there will be an evaluation of the success or failure, strengths, and weakness of the project. This practice change project will be focused on lowering patients' blood pressures after receiving education by providers on how a DASH diet can help with the management of their hypertension. Patients knowledge will be measured using five question posttests. Questions will be analyzed by comparing aggregate pre- and post-means. Also, individual question item analysis will be completed to determine which questions the participants scored the highest and lowest on. The benchmark for this outcome is a 20% increase in posttest scores and a decrease in patients’ blood pressure after the intervention. A four-week posttest will be administered. The DASH test aggregate means will be computed. These means will be compared with the first post-test results. The benchmark for the retention of knowledge is 80%. The findings related to this outcome will be visually displayed by using bar graphs. The PI will assess patient willingness to incorporate the DASH diet. The PI will also analyze patients’ blood pressures before and after the intervention. This outcome will be measured by a 5-point Likert-style question on each pre and post-test. The pre and posttest will measure patient’s knowledge about the DASH before and after the education session; The benchmark associated with this outcome is 50%. The findings related to this outcome will be visually displayed by using graphs (Apovian et al., 2010). Comment by Sharina Sigur: Should this be satisfaction?

In conclusion, a C-T-E structure will be created to support the evidence-based practice change project. The concept, health promotion is any activity that tries to improve one’s health by providing increased awareness through education on the risk factors of hypertension and healthy eating habits. The chosen theory, Pender’s HPM, empowers individuals to make healthy lifestyle modifications (Petirin, 2015). A DASH developed questionnaire will be utilized as the empirical indicator to evaluate the change in health promotion with African Americans diagnosed hypertension. The ACE Star model of knowledge transformation will guide the process. The CTE structure and evidence-based practice theory in this chapter provided a clear definition pathway of the concept, theory, and empirical indicator to support the practice change project (Petirin, 2015).

Review of the Literature Comment by Sharina Sigur: This chapter is extremely underdeveloped. It should provide adequate support from scholarly research/literature for the DPI project. (2-3 themes; then 2-3 subthemes for each theme) Chapter 2 needs to include a minimum of 50 scholarly sources with 85% from the past 5 years. Additional sources do not necessarily need to be from the past 5 years. It should not include any personal perspectives. Review sentences for structure and flow. Several paragraphs are underdeveloped. Formatting errors noted.

Review and synthesis of the literature revealed that education and the implementation of a healthy lifestyle is imperative in managing HTN and improving patient outcomes. The DASH was created 20 years ago, and over 30 clinical trials support DASH effectiveness in lowering blood pressure across a diverse range of patients with HTN and pre-hypertension (Steinberg et al., 2017). In the United States (US) dietary patterns contribute to the incidence of HTN (Steinberg et al., 2017). The optimal goal in the management and treatment of HTN is to educate and treat patients to achieve and maintain blood pressure however, a key obstacle is the lack of knowledge in patients diagnosed early with appropriate interventions including therapeutic lifestyle changes (Apple, 1997). The DASH diet is particularly beneficial in all populations and has proven to reduce systolic blood pressure (SBP) and diastolic blood pressure (DBP) respectively by 13.2 mmHg and 6.1 mmHg among African American participants with HTN (Jiang et al., 2015).

In a systematic review and random effects meta-analysis of 17 randomized controlled trials (RCT) Saneei et al. (2014), there was an evaluation conducted on the effects of the DASH used as a management tool for patients’ blood pressure and the results revealed the DASH diet had a beneficial effect on both systolic and diastolic BP. This study evaluated the effectiveness of the DASH diet in 2561 participants. Meta-analysis showed that the DASH diet significantly reduced systolic blood pressure by 6.74 mmHg and diastolic blood pressure by 3.54 mmHg. The blood pressure reducing impact from the DASH diet was more significant among men (Saneei et al., 2014). Harrison (2014) conducted an exploratory observational study with 114 participants to test a companion (web-based learning) to classroom nutrition education on DASH diet knowledge using this tool. At the completion of the study’s pre-and posttest, average scores ranged from approximately 34% to 78% respectively. Comment by Sharina Sigur: Rephrase for clarity.

Providers should strongly recommend the DASH diet to all African American patients, with or without high blood pressure, and provide educational materials, which are readily available (Jiang et al., 2015). Barriers to patients incorporating DASH diet into their hypertensive management is lack of provider knowledge and training, and patients lack awareness of potential DASH benefits. Challenges that providers incur in nutritional counseling are an overbooked clinic, lack of DASH knowledge, increased willingness to prescribe medications rather than provide counsel of DASH (Steinberg et al., 2017).

Hicks and Murano (2016) conducted an exploratory study with a convenience sample (n=54) to ascertain if Texas physicians incorporated dietary counseling into their medical plan. Results revealed 89% of physicians do not incorporate nutritional counseling into their medical practice. The lack of dietary counseling by physicians can be explained by the fact that one-half of all medical schools offer 17 hours or less of nutritional education and 9% of medical schools have no nutritional based training incorporated into the curriculum. Nutrition education is harder to obtain after medical school graduation (Aggarwal et al., 2018). Over half of the physicians surveyed (52%) reported that their practice did not counsel or promote patient nutritional counseling. There is evidence that supports a lack of physician patient directed nutritional counseling (Hicks and Murano, 2016). Continuing Medical Education (CME) nutritional offerings, as well as evidence based nutritional class, can bridge the gap in knowledge and increase nutritional interventions. Valderrama et al. (2010) conducted a survey (n=5,399) 25.8% had HTN with 79.8% taking medications with only 21% reported nutritional counseling by their provider. The DASH diet has been utilized in the clinical setting to improve HTN; however, lack of provider patient counseling results in inadequate patient knowledge. Therefore, dietary modalities are not being utilized as a modality to reduce HTN.

Several lifestyle interventions have been proven to reduce blood pressure (Weber et al., 2014). Favorable effects on SBP and DBP in adults due to DASH diet are of considerable public health importance because this dietary pattern can be easily adopted, has the greatest effect on men and is cost effectively aids in the prevention of HTN and its complications (Saneei et al., 2014). A DASH-like diet can knowingly reduce the risk for cardiovascular disease (CVD), coronary heart disease (CHD), stroke, and heart failure (HF) by 20%, 21%, 19%, and 29% respectively (Salehi-Abargouei et al., 2013). Effective HTN management must include DASH counseling as a proven modality to prevent and aid in HTN treatment. Incorporating DASH counseling with HTN patients gives them the best possible chance to control and reduce their blood pressure, which will reduce end organ disease. For all persons with hypertension, the potential benefits of a healthy diet can improve BP control and even reduce medication needs (James et al., 2014).

Dash diet. The first DASH diet clinical project by Apple et al. (1997) was a multicenter 11-week feeding study that assessed the effects of dietary patterns on blood pressure. The participants in the study included 459 adults over the age of 22 with systolic blood pressures of less than 160 mm Hg and diastolic blood pressures of 80-95 mm Hg (Apple et al., 1997).

At the beginning of the study, all participants consumed a control diet low in fruits, vegetables, and dairy products for three weeks (Apple et al., 1997). For the next eight weeks, the participants received either the control diet, a diet rich in fruits and vegetables, or a combination diet that included fruits, vegetables, and low-fat dairy with decreased total fat (Apple et al., 1997). The blood pressure reduction began within two weeks of initiation of the diet and was maintained for six weeks (Apple et al., 1997).

The blood pressure realized with the combination diet was similar in magnitude to that observed in trials of drug monotherapy for mild hypertension.

The results of the DASH trial showed that a diet rich in fruits, vegetables, and low-fat dairy products, with reduced statured and total fat, lowered systolic blood pressure by 5.5 mm Hg and DBP by 3.0 mm Hg more than the control diet. The DASH diet emphasizes foods rich in protein, fiber, potassium, magnesium, and calcium, such as fruits, vegetables, beans, nuts, whole grains, and low-fat dairy products. The study concluded that the DASH diet reduces blood pressure.

Another RTC by Blumenthal et al. (2010) compared the DASH diet to a control diet randomized into two groups. The first group was the DASH diet alone, and the other group was the DASH diet with weight management. The DASH alone group received only guidelines for their diet and were asked not to exercise. The DASH weight management group received a controlled menu plan with cognitive behavior weight loss intervention and supervised exercise program sessions. The controlled group consisted of the participants’ usual diet. These participants were instructed to maintain normal diets for four months. The study spanned two weeks and included 144 participants over the age of 35 in a tertiary medical facility. Blood pressure measurement in the clinic was obtained using a manual cuff method. Measurement was obtained four times daily in each individual’s home environment with an automatic blood pressure machine and twice at night. The mean BP was used.

Food frequency questions were used for nutritional assessment. The questionnaire

recalled typical consumption in a four-week period and four-day food diary. This study found that the DASH diet both significantly lowered SBP (p < 0.001) and DBP (p < 0.001), compared to a control group. DASH with weight management also lowered SBP (p = 0.10) and DBP (p = 0.06). At the end of the study, six participants were clarified as hypertensive in the DASH with a weight management group and seven in the DASH alone group. This study concluded that DASH was more effective in lowering blood pressure with exercise, but that DASH alone was effective in lowering blood pressure as well.

Another study that evaluated the effects of the DASH diet was conducted by Azadbakht et al. (2005). It examined the effects of the DASH diet on patients with metabolic syndrome. This study was different because the patients used a weight management intervention with the DASH diet. This study enrolled 116 patients (34 men and 82 women) with metabolic syndrome. Three diets were prescribed for six months: a control diet, a weight-reducing diet, and the DASH diet with a sodium restriction to 2,400 mg daily. The participants were overweight or obese and had not participated in weight reduction during the past six months. The study spanned six months of interventional feedings, and the patients were followed monthly. The DASH diet resulted in higher HDL cholesterol (7 and 10 mm/dl), lower triglycerides (-18 and -14 mg/dl), lower systolic blood pressure (12- and -11-mm Hg), lower diastolic blood pressure (-6- and -7-mm Hg), and decreased weight (-16 and -15 kg) respectively (p <0.001). This study concluded the DASH diet could likely reduce metabolic risk in men and women with metabolic syndrome.

Seangpraw et al. (2018) performed another study that evaluated the effects of the DASH diet. This study used behavior modification instead of weight management intervention. A quasi-experimental study was employed with two groups of elderly patients aged 60-80 in a rural community in Thailand. Ninety participants were in the intervention group, and 80 were in the controlled group.

The intervention group used behavior modification guidelines of the DASH program with self-efficacy for three months, including a 45-minute group education meeting, a 25-minute group activity training session, and a 15-minute individual checklist. The controlled group received no intervention. The DASH diet, along with behavior modification, showed increased self-efficacy while SBP and DBP had decreased (p = 0.002). The results showed that self- efficacy increased, as did awareness regarding the severity of complications of hypertension.

In a 3-period randomized crossover trial in free-living healthy individuals who consumed in random order a control diet, a standard DASH diet, and a higher-fat, lower-carbohydrate modification of the DASH diet (HF-DASH diet) for 3 week each, separated by 2-wk washout periods. Laboratory measurements, which included lipoprotein particle concentrations determined by ion mobility, were made at the end of each experimental diet. Thirty-six participants completed all 3 dietary periods. Blood pressure was reduced similarly with the DASH and HF-DASH diets compared with the control diet. The HF-DASH diet significantly reduced triglycerides and large and medium very-low-density lipoprotein (VLDL) particle concentrations and increased LDL peak particle diameter compared with the DASH diet (Chiu et al, 2016). The DASH diet, but not the HF-DASH diet, significantly reduced LDL cholesterol, HDL cholesterol, apolipoprotein A-I, intermediate-density lipoprotein and large LDL particles, and LDL peak diameter compared with the control diet. In conclusion, the HF-DASH diet lowered blood pressure to the same extent as the DASH diet but also reduced plasma triglyceride and VLDL concentrations without significantly increasing LDL cholesterol (Chiu et al, 2016).

Ozemek et al. (2018) noted that appropriate prevention and management of hypertension was supported by adopting a diet rich in plant-based foods with whole grains, low-fat dairy products, and low sodium in accordance with the recommendations of the DASH diet. The Ozemek et al. (2018) review also found the DASH diet was more effective when paired with dietary counseling. In comparison, three studies found benefits from the DASH diet. In two studies, lifestyle modifications were added to the DASH diet intervention and found a greater reduction in the systolic and diastolic blood pressures. The original DASH study showed favorable effects on the reduction of BP but did not test diet adherence. All studies found the DASH diet to be effective in lowering blood pressure in participants. This was consistent with a meta-analysis conducted by Ndanuko et al. (2016), who compared several studies of dietary patterns in lowering blood pressure and concluded that the DASH diet lowers blood pressure.

In a recent RCT investigating the effects of the DASH diet on cardiovascular risk factors and providing information on the energy and macronutrient contents of both DASH and control interventions were included in the meta-analysis. The minimum duration of the RCT for inclusion in the meta-analysis was 2 weeks. An important inclusion criterion was that the DASH and control diet interventions had to be comparable in terms of energy intake and other lifestyle interventions, e.g. physical activity. In other words, RCT were included only if both control and DASH diet interventions involved a similar degree of energy restriction and/or physical activity to avoid the confounding effects of changes in body weight on cardiovascular risk factors. In addition, RCT were included if they altered minor components of the DASH interventions (e.g. modified DASH) but retained the core characteristics of the archetypical DASH dietary plan (Bricarello et al., 2018). Examples of DASH dietary plan modifications include reduction of salt intake, increased consumption of lean red meat, and combination with other interventions such as weight loss or physical activity. Similarly, RCT having either a typical dietary pattern or a healthier dietary pattern (healthy diet) as a control were included, provided that these patterns matched the DASH intervention in terms of both energy intake and physical activity level. Finally, RCT were not excluded according to dietary Na intake, as information regarding this variable was not consistently reported across trials; this approach was intended to minimize the risk of publication bias (Bricarello et al., 2018).

In conclusion, the DASH diet interventions resulted in significant improvements in systolic and diastolic BP along with significant reductions in total cholesterol and LDL concentrations. However, these interventions did not affect TAG, glucose, and HDL concentrations (Bricarello et al., 2018). The responses of both systolic and diastolic BP to the DASH diet were greater in participants with higher BP or BMI at baseline. The responses appeared to be independent of differences in dietary Na intake. Importantly, measures of the effectiveness of the DASH diet were not modified by the type of study design or feeding protocol and the characteristics of control diet (Bricarello et al., 2018).

According to Challa et al., (2020), the DASH diet is an essential strategy for lowering blood pressure in patients with diabetes mellitus type 2. The American Diabetic Association recommends that patients with diabetes who are at risk should achieve the US Department of Agriculture’s Dietary Reference Intake (DRI) for fiber, whole grains, and macronutrients. Moreover, these patients should limit saturated fat to < 7% total daily calories, reduce trans-fat intake, reduce cholesterol to < 200 mg/day, and limit sugar-sweetened beverages. Because the DASH diet meets these recommendations, adherence in patients with diabetes mellitus should be advocated for adequate blood pressure control (Challa et al., 2020).

Based on these studies, it is safe to say that when combined with pharmacological intervention, DASH can be a very useful tool for physicians to tackle these diseases more efficiently (Challa et al., 2020). When compared to some other diet patterns, it has an added advantage of having clear guidelines on the serving sizes and food groups, which makes it easier for the physicians to prescribe and monitor their patient's improvement (Challa et al., 2020).

Patient education. There are several methods of offering patient education. One of the most cost-effective means is face-to-face counseling. This technique lets provider’s answer questions without delay in communication. According to Magadza et al. (2009), a pamphlet is a cost-effective way to provide education in summary. Magadza et al. (2009) evaluated the patient’s understanding of HTN using motivational intervention questions. In their study, 45 patients were interviewed and completed a questionnaire. This study showed that educational intervention could positively impact patient adherence. The participants received a questionnaire pre- and post-education. The questionnaire was composed of four parts: the concept of HTN, antihypertensive medication, adherence to medication, and diet and lifestyle recommendations. In their case-controlled study, they found motivational interviewing and questionnaires increased participant knowledge about HTN and the importance of medication. These findings suggest that patient education provides patients with the opportunity to have questions answered, thus improving adherence to education.

Delichatsios and Weity (2005) performed a study on providing participants with resources to improve dietary habits. The resource was a dietary patient education booklet that focused on fruits and vegetables, red meat, and dairy foods. Booklets were mailed to patients’ homes. The patient then had two motivational counseling sessions by telephone at two-week and four-month intervals. For the control group, their servings were increased by an average of 1.1 servings per day compared to 0.3 serving per day for the intervention group. The finding showed no changes in the amount of red and processed meats.

The intervention group increased fiber by 1 gram per day. The study concluded that 71% of the participants discussed the educational booklets with their primary care providers. This study addressed a lack of time in the primary care setting and alternative means of educating by mailing booklets and having telephonic follow up (Delichatsios & Weity, 2005).

Wong et al. (2015) performed a study on 556 Chinese patients who were newly diagnosed with hypertension. The participants received DASH-based dietary counseling tailored to a Chinese diet and were given 25-minute dietary counseling and DASH diet pamphlets. The outcome data were evaluated after six months and showed lower blood pressure. Wong et al. (2015) concluded that a self-monitoring tool that reinforces the implementation of dietary counseling would be more effective.

Summary

A literature review provides a more comprehensive understanding of the healthcare problem for this chapter. A review and synthesis of the current literature support the DASH as an evidence-based patient education tool used in the management of patients with HTN to improve patient outcomes. The DASH is an effective way to reduce blood pressure. Lifestyle modifications recommendations of diet and exercise can be difficult if patients are not given specific guidelines. Diet and lifestyle changes are more effective when healthcare providers give patients clear and concise guidance. The DASH intervention offers patients clear dietary guidance and assists with meal planning. The DASH can significantly impact on HTN especially in the African American population and should be used as a primary intervention to decrease HTN.

Hypertension continues to be a worldwide health problem. HTN is one of the most common conditions treated in primary care and can lead to myocardial infarction, stroke, renal failure, and death if not detected early and treated appropriately (Oza & Garcellano, 2015). Quantitative data suggests that HTN rates in African Americans is higher than any other ethnic group, and BP control remains inadequate in this population. The DASH dietary pattern can be easily educated and adopted by all population groups offering the most cost-effective intervention to serve as the primary and secondary prevention of elevated blood pressure and its complications (Saneei et al, 2014).

Advantages and disadvantages of findings. The DASH diet has been shown to reduce both systolic and diastolic blood pressure in hypertensive and pre-hypertensive patients across subgroups, genders, races, and ethnicities. Further studies have found that adherence to the DASH diet improves changes in cholesterol and reduce the risk of coronary heart disease and stroke. The DASH diet has shown eating whole foods, rather than processed foods, lowers blood pressure due to their lower sodium content. The DASH diet is beneficial, is well tolerated in these studies, and has yielded results with positive health outcomes in reducing blood pressure, with or without other interventions. The literature review of the DASH diet, however, has shown that the DASH diet is not well followed and that there is low adherence to the DASH diet. Increasing adherence to the DASH diet and improving education and implementation of the diet poses a challenge. Comment by Sharina Sigur: Are these subsections of the summary?

Utilization of findings in practice. Promoting a DASH diet education is vital for the clinician to encourage and motivate patients to make lifestyle changes in dietary choices and to develop ways to improve adherence and education on the DASH diet. One can tailor these implementation strategies to improve adherence by translating some of the clinical findings into practice. One way to do this is by providing more DASH diet educational material to patients. Another suggestion is to provide more DASH diet education on initial clinic visits. A further solution is to offer DASH diet educational counseling, along with DASH diet material, to improve knowledge and awareness of the DASH diet. These DASH diet pamphlets can be reproduced and utilized in other outpatient clinics.

Providing patient education in a primary care setting through face-to-face counseling is a cost-effective means. This technique allows providers to answer questions without delay in communication and to follow the discussion with a pamphlet. Providing a pamphlet while imparting educational information lifestyle changes increases the retention of information (Magadza et al., 2009).

Many healthcare providers are not educating patients on the recommended dietary guidelines for HTN (Sessoms, Reid, Williams, & Hinton, 2015). Therefore, the clinician needs to encourage patients to make lifestyle changes in dietary choices and to develop a DASH diet education session, along with pamphlets that will increase DASH diet knowledge and awareness for both patients and providers. Implementing this project will be beneficial to patients in the outpatient clinic setting, and it will increase their knowledge and awareness about DASH and will subsequently improve hypertension outcomes.

Chapter 3: Methodology

Hypertension (HTN) is the leading preventable cause of premature death worldwide (Mills et al., 2016). In hypertensive individuals, lifestyle modification can serve as initial treatment before the start of drug therapy and act as an adjunct to pharmacological therapy in persons already on drug therapy (Appel, 1997). An obstacle that medical providers encounter in effectively managing HTN is the lack of dietary lifestyle modification counseling. According to the AHA, 2015, hypertension is one of the leading health issues contributed to cardiovascular disease that is a leading cause of morbidity and mortality. Also, these major health issues are contributed to non-adherence which has been linked to time constraints for providers to provide education to patients during their clinic visit (Kim & Andrade, 2016). The purpose of this quantitative quasi-experimental project is to determine if or to what degree the implementation of a Dietary Approach to Stop Hypertension education intervention for patients would impact the blood pressure readings of patients diagnosed with hypertension at an outpatient health clinic in Washington, D.C. over a four-week period of time. Comment by Sharina Sigur: This is not formatted correctly.

Statement of the Problem

Uncontrolled hypertension (HTN) in the USA is particularly prevalent and devastating among Black people who are more vulnerable than people from other racial / ethnic groups to the effects of this disease. Moreover, the findings of evidenced based data in this population are frequently underrepresented in cardiovascular clinical trials, restricting their ability to accurately apply them. In this analysis, we summarize and examine the information that is currently available regarding risk factors, manifestations, complications and HTN management in this often difficult to treat population. This practice change project seeks to better understand to what degree of increasing patient’s knowledge on the DASH diet is a best approach for treatment of patients with hypertension (Maraboto & Ferdianand, 2020)

Health organizations urge healthcare providers to participate in programs that help patients control high blood pressure (CDC, 2017). Lifestyle changes recommendations to treat HTN include weight management, exercise, and diet (Yang et al., 2015). Many patients do not adhere to the recommendations because of insufficient education. Educating patients about lifestyle modifications can have a significant impact on their beliefs about hypertension (Yang et al., 2015). Patel et al. (2016) indicated that lack of education was a common reason that patients did not adhere to diet education.

There are many barriers to the management of patients with hypertension, and one that is see daily by health care providers is lack of patient education. It was not known if or to what degree the implementation of a Dietary Approach to Stop Hypertension (DASH) intervention education program would impact the patients’ blood pressure when compared to no intervention among African American patients diagnosed with hypertension in an outpatient clinic in Washington, D.C.

Clinical Question

The primary objective of this practice change project is to determine if a diet approach that emphasizes rich fruits, vegetables, and low fat significantly reduces the development and increased the management of HTN among African Americans. The study also evaluates if lifestyle practices such as exercise and physical therapy significantly reduce the development and management of HTN among black Americans. The PICOT question is: Does the implementation of a Dietary Approach to Stop Hypertension education intervention for patient’s impact blood pressure readings for patients diagnosed with hypertension at an outpatient clinic in Washington, D.C. over a four-week period of time?

The following clinical question guides this quantitative project:

CQ: To what degree does the implementation of a Dietary Approach to Stop Hypertension education intervention for patient’s impact blood pressure readings for patients diagnosed with hypertension at an outpatient clinic in Washington, D.C. over a four-week period?

The independent variable will be defined as the implementation of a Dietary Approach to Stop Hypertension education for approximately 30 African American adult patients with hypertension. The dependent variable will be defined as mean systolic and diastolic blood pressure before and after the intervention. The question leads to a search for the best evidence that can contribute to a decision about the patient’s care (Harmic, 2009).

This DPI project will employ a pretest posttest design guided by the theoretical framework Pender’s health promotion model. All patients will be given a 20-minute educational overview on HTN and the effectiveness of the DASH diet. There will be a 5-question pre-posttest designed by DASH “Fruits and Vegetable” given to patients about the DASH diet. Provider will then counsel and educate patients with hypertension about the DASH and patients' blood pressures will be evaluated before and after the intervention of the DASH diet. The DASH was created 20 years ago, and quantitative data demonstrates it consistently lowers BP across a diverse range of patients with HTN and prehypertension (Steinberg, Bennett, & Sevetkey, 2017). Barriers to patients incorporating the DASH diet into their hypertensive management could possibly be lack of provider knowledge and training, and patients lack awareness of the potential benefits of the DASH diet as a means of hypertension management.

Project Methodology Comment by Sharina Sigur: This section is underdeveloped.

A clinical practice change project will be designed and implemented to educate patients about a dietary approach to stop hypertension (DASH) diagnosed with hypertension. This project focuses on increasing patient knowledge and improving HTN management. Patients will be recruited from an outpatient clinic in Washington, D.C. The participants will consist of approximately 10 African American adults diagnosed with hypertension. A pre-posttest design will be utilized and guided by Nolan Pender health promotion model.

Quantitative methods are most appropriate in the following circumstance: a) clearly defined study variables. b) large sample size available in a cost-effective manner, c) validated instrument available for data collection, and d) a desire to generalize study findings (Leedy, Ormrod, & Johnson, 2019). Quantitative data follow a linear sequence in obtaining answers to quantitative questions (Polit & Beck, 2017). Quantitative methodology is most appropriate for this DPI project, as the focus of quantitative data is to determine the relationship or trends between independent and dependent variables (Polit & Beck, 2017).

Population and Sample Selection Comment by Sharina Sigur: Underdeveloped.

The target population for this EBP practice change are African American patients between the age of 18 to 65, patients diagnosed with hypertension. The beneficiaries seen in this clinic include all patients that have been diagnosed and currently being treated for HTN. The clinic is made up of 95% African Americans. A convenience sample of 10 patients diagnosed with hypertension will be the target goal on a volunteer basis from an outpatient clinic in Washington, D.C.

Participant’s personal information nor protected data will be recorded. The targe patients will be identified through the clinic’s electronic health record reports. Only patients that are fluent in English will be asked to participate in the project. Medical contraindications for blood pressure measurements in either arm (i.e., double mastectomy, poor circulation, arteriovenous shunt) will be excluded from the DPI.

Recruitment strategies will include email, verbal and written announcements, and invitations. Patients will be emailed through the patient portal in the electronic health record by clinical staff. Other strategies included posters that will posted outside the clinic door and building.

Instrumentation, Validity and Reliability Comment by Sharina Sigur: This should be 3 separate sections. Refer to template. Underdeveloped.

The evidenced based evaluation tool that will be used in this quality improvement project is a validated food frequency questionnaire from the DASH Eating Plan manual from the National Institute of Health (NIH, 2006). The pre-intervention questionnaires are to assess their knowledge and belief of the DASH diet pre-intervention. The post-intervention questionnaires are to evaluate the effectiveness of education by re-evaluating knowledge and belief after DASH education. The post-intervention questionnaires are to be administered at the end of the 4-week session. The post-intervention evaluates the effectiveness of the DASH diet session. Blood pressure measurement is taken pre-and post-educational intervention. Blood pressure will be measured pre-intervention and post-intervention to allow adequate time for adjustment. The blood pressure is taken using a mercury manual sphygmomanometer. A blood pressure reading by auscultation is considered the gold standard according to (NHLBI, 2017). Blood pressure will be measured in the left and right arms in the sitting position. Medical contraindications for blood pressure measurements in either arm (i.e., double mastectomy, poor circulation, arteriovenous shunt) will be excluded from the DPI. Blood pressures will be taking in the morning on arrival. The patient’s blood pressure will be documented in the electronic health record in the vital signs section. The blood pressure will be measured to evaluate if the significant reduction in blood pressure is obtained in the patients that followed the DASH. Blood pressure will be recorded on paper, then entered on an Excel flow sheet in the computer system. Comment by Sharina Sigur: In general, APA style recommends using words to express numbers below 10 and using numerals when expressing numbers 10 and above.

The plan for evaluation of this practice change project is to administer a five question pre-and post-test measuring the effectiveness of the lesson, educating patients on the use of the DASH diet for HTN management and measuring patients’ blood pressures before and after the intervention. The validated DASH pre-post-test tool is free to use and does not require the author’s permission to use it. The DASH questionnaire, created by the DASH for Health team, was initially used in an online format and validated against the well-known Block Food FFQ by Apovian et al. (2010). The Block FFQ and the DASH online questionnaire (OLQ) were found to have significant positive correlations among all eleven DASH food groups (Apovian et al., 2010). Weighted kappa statistics found the level of alignment between the DASH OLQ and the Block FFQ by energy level to have a value of 0.48 (95% CI 0.38, 0.57; P < 0.0001) meaning moderate agreement was observed (Apovian et al., 2010). The DASH questionnaire is based on a diet recall from the previous 24 hours only and encompasses 11 dietary categories with additional questions to determine sodium and fat intake (Apovian et al., 2010). The estimated time for the questionnaires would take participants approximately 20 minutes to complete and would not feel burdensome and could be given on paper. The DASH questionnaire tools, are free for public use (NHLII, 2006).

Data Collection Procedures Comment by Sharina Sigur: Underdeveloped.

The DPI student will oversee storing and securing the intake data for all participants. The demographic data collected for this project will include the following: 1) age, 2) ethnicity, and 3) gender. Other demographics that will be collected for the electronic health record is the participants systolic and diastolic numbers of patients that are diagnosed with hypertension and will participate in the DPI. Onsite de-identified data will be collected by the clinical staff. The clinical staff will provide the education intervention and give the pre-posttest to patients before and after the education intervention. The clinical staff will also obtain de-identified blood pressures from patients at the beginning and end of quality improvement project. Data collection will also include the number of hypertension patients that received the counseling for the DASH diet during their visit to the clinic. Clinical staff will include Registered Nurses and Medical Assistants.

The questionnaires will be placed in a labeled folder and placed, secured, and locked in a file cabinet. The intake surveys and questionnaires will be coded with number and each participant will be given a separate number that will not contain any identifying patient’s information. All data collected will remain secured until the data can be entered into the Excel spreadsheet and the SPSs program. Once the DPI project has completed, the pre-post questionnaires will be shredded in the office locked shred box 6 months after intervention and sent out for bulk disposal. The SPSS Excel information will be stored on the designated office computer that requires username and password for access. The Excel spreadsheet will also be password protected.

Data Analysis Procedures Comment by Sharina Sigur: This section is underdeveloped.

To answer the clinical question, “Does the implementation of a Dietary Approach to Stop Hypertension education intervention impact African American patients diagnosed with hypertension at a primary health clinic in Washington, D.C. over a four-week period?”, SPSS statistical software will be used examine the correlation between the independent and dependent variables. Comment by Sharina Sigur: Indent the first line of each paragraph of text 0.5 in. from the left margin.

The patient's blood pressures before and after the intervention will be entered into an Excel spreadsheet. Data analysis will be performed using SPSS statistical software. The research department of clinical investigation at the clinical site will provide statistician assistance. At the end of the four-week evaluation, the posttest scores will be compared to prior posttest scores using descriptive statistics and T-test to compare retained knowledge and rate of DASH counseling with a percentage value of .05 as the benchmark. This project may not reach statistical significance therefore a percentage change will be collected from the pre-and post-test to determine the amount of knowledge gained and the number of patients' blood pressures that will be measured. This data will provide the information to ascertain if the intervention of the DASH from patients had a positive patient outcome for those patients diagnosed with HTN over the four-week period.

Collected data will be presented in tables and pie and chart graphs and analyzed by the computer software statistical package (SPSS version 27) using appropriate statistical methods. Frequency means and standard deviation will be used to summarize the data. Categorical data will be analyzed by using chi-square test. Descriptive frequency and statistics will be used to compute Demographics.

Ethical Considerations Comment by Sharina Sigur: Potential Bias and Mitigation section is missing.

The principles of the Belmont Report; respect, beneficence, autonomy, and justice will always be implemented (Polit & Beck, 2017). Anonymity will be achieved with de-identifiers to protect patient Health Information Portability Privacy Act (HIPPA) protected health data. All data collected will be kept in a locked drawer in the PI’s office until project completion. De-identified data will be transferred from the EHR to a password protected Excel spreadsheet for storage. Any protected health information will be shredded using the clinical practice site resources.

This DPI project involves minimal risk, with the design (Polit & Beck, 2017). This DPI project does not increase risk to participants any more than the standard of care. The purpose of this quantitative quasi-experimental project is to determine if or to what degree the implementation of a DASH education intervention for patients would impact blood pressure readings for patients diagnosed with hypertension at an outpatient clinic in Washington, D.C. over a four-week period of time. The quasi-experimental project was chosen to evaluation if patient education about the DASH diet decreases blood pressures in patients with HTN. Patient information with be collected for the electronic health record which requires a password to gain access. IRB and site approval in appendix J.

Limitations and Delimitations Comment by Sharina Sigur: Refer to template for correct section titles. Underdeveloped and written as proposal.

With the ongoing global pandemic, there is limited access to healthcare facilities; hence the desired number of participants may not be obtained. There may also be an issue regarding patients not completing the necessary pre-posttests needed for the DPI or DASH education to patients during their visit. The location was also limited to one clinic.

Delimitations include the DPI only being conduct at one outpatient clinic. Also, only African Americans adults between the age of 18 and 65 years of age enrolled at the university with no prior education about the DASH diet will be participants in the project. Patients with contraindications (i.e., doble mastectomy, poor circulation) will be excluded from the project. The clinic patient population is 95% African Americans.

Summary

In conclusion, a C-T-E structure was created to support an evidence-based practice change project. The concept, health promotion is any activity that tries to improve one's health by providing increased awareness through education on the risk factors of hypertension and healthy eating habits. The chosen theory, Pender's HPM, empowers individuals to make healthy lifestyle modifications. The DASH food frequency questionnaire served as the empirical indicator to evaluate patient knowledge and examine how it relates to the change in health promotion with African Americans diagnosed with hypertension.

The ACE Star model of knowledge Transformation will guide the process. The CTE structure and evidence-based practice theory in this chapter will provide a clear definition pathway of the concept, theory, and empirical indicator to support the practice improvement project. Hopefully, in the future the project will seek to eliminate limitations and improve the data collection methods. The entire project advocates for proper dietary habits and healthy lifestyle to reduce the risks of getting hypertension and improving the management of hypertension.

The purpose of this chapter was to provide an overview of the pre-implementation process for this EBP. Hypertension is a common diagnosis within this outpatient clinic. DASH diet has been established as a useful modality to reduce blood pressure. Current evidence supports lack of provider counseling on DASH and patient lack of knowledge concerning DASH benefits. This clinical site was assessed for its HTN population and current treatment modalities. Through a retrospective chart review it was identified that HTN patients were being managed primarily with pharmacological agents with little or no documentation on diet and lifestyle modifications. Addressing conjunctive HTN management such as DASH gives the patients a better chance at optimal blood pressure instead of pharmacological agents alone. This EBP has support of key stakeholders and the opportunity to improve patient outcomes.

Chapter 4: Data Analysis and Results

The quality improvement project aimed to evaluate the effectiveness of DASH diet education into the nutritional plans of hypertensive patients at an outpatient primary care clinic. The project increased patient awareness and knowledge of the DASH diet, and its relationship with blood pressure improvements, food selection and DASH awareness. This project determined that DASH education was effective in implementing a change in diet education in the outpatient clinic and increased self-efficacy in hypertensive patients by changing food habits that can promote better blood pressure management.

The practice change project’s primary objective was to determine if a diet approach that emphasizes rich fruits, vegetables, and low fat significantly reduces the development and increased the management of HTN among African Americans. The quality improvement project also evaluated if lifestyle practices such as healthy food options significantly reduce the development and management of HTN among black Americans. The PICOT question is: Does the implementation of a DASH program intervention for patient’s impact blood pressure readings for patients diagnosed with hypertension at an outpatient clinic in Washington, D.C. over a four-week period of time?

A clinical practice change project was designed and implemented to educate patients about a dietary approach to stop hypertension (DASH) for hypertension patients. This project focused on increasing patient knowledge and improving HTN management. Patients were recruited from an outpatient clinic in Washington, D.C. The participants consisted of approximately 20 African American adults diagnosed with hypertension. A DASH pre-posttest design was utilized and guided by Nolan Pender health promotion model. Comment by Sharina Sigur: Rephrase. Comment by Sharina Sigur: How many participants were there? The project is complete. You have the final number.

This chapter will discuss the methodology or design as to exactly how the project study was carried out. It includes: 1) project purpose; 2) project management, that will cover organizational readiness for change, interprofessional collaboration, and organization approval process; 3) informational technology that was used to implement the project; 4) plans for Institutional Review Board approval and process obtained; 5) project evaluation that include demographic information collected; 6) defining and discussing the outcome measurements; and 7) a discussion of the evaluation tool used to evaluate outcomes. Comment by Sharina Sigur: Be sure that you change wording from “study” to “project” throughout document and avoid referring to the project as research or you as the researcher.

Descriptive Data Comment by Sharina Sigur: Where is the narrative summary of the population, sample characteristics, and demographics? Where are the graphic organizers for the descriptive data?

The project participants recruited were African American adult patients that use the primary care clinic with a diagnosis of hypertension identified through the electronic medical records quality improvement reports. The project was limited to English speaking African American adult patients with a diagnosis of hypertension. The participant's age, race, and ethnic background was be collected. The participants were asked to provide gender identity. This information was collected using an intake survey tool. The results are illustrated with the use of graphs, bar charts, pie charts, and a table format. Comment by Sharina Sigur: Age group?

The purpose of collecting data was 1) to determine if the nutritional educational intervention had a significant effect on knowledge, understanding, and retention of the DASH diet. 2) To determine if the intervention will increase patient educational knowledge of DASH. 3) To determine the likelihood that patients will follow DASH recommendation. 4) To determine if the patient will be able to adopt recommendations. 5) To evaluate the effectiveness of an education program in changing patient behavior 6) To determine if a decrease in systolic and diastolic blood pressure could be achieve post DASH education. Evidence has shown that lifestyle change and teaching of the DASH improved a patient’s hypertensive state, increased knowledge about the DASH and increases healthier food choices. These outcome measures are to promote healthy eating following the DASH diet education to improve blood pressure from patients that follow the diet plan. Blood pressure will be taken pre-DASH diet initiation and post-DASH diet initiation. Studies have shown that following the DASH diet has lowered blood pressure systolic and diastolic in people with hypertension. According to NHLBI (2017), there could be and 8-14 mm Hg reduction in blood pressure. Lifestyle modification has been useful in the control of hypertension through a healthy diet (AHA, 2015). Comment by Sharina Sigur: This is confusing. The purpose of collecting patients’ demographic data helped to determine and evaluate all of this information?

Data Analysis Procedures Comment by Sharina Sigur: This section is underdeveloped.

Collected data is presented in tables and pie and chart graphs and analyzed by the computer software statistical package (SPSS version 27) using appropriate statistical methods. Frequency means and standard deviation will be used to summarize the data. Categorical data will be analyzed by using chi-square test. Descriptive frequency and statistics will be used to compute Demographics.

All intake data was stored and secured. The Primary Investigator placed both the pre-questionnaire and post questionnaire in a vanilla folder and place them in the locked filed cabinet with a secured, locked door. The intake surveys and questionnaire where were coded with a letter and numbers and each participant will be given a separate number. The questionnaire was stored in a secured place until the data was collected and entered in the Excel spreadsheet and the SPSS program. The pre/post questionnaires will be shredded in the private office shredder and sent out for bulk disposal 60 days after the project is completed. The SPSS and excel information were stored on the department private drive.

Demographics, Results and Findings Comment by Sharina Sigur: This is not a section title. Refer to template for guidance. Why aren’t the demographic data included in the descriptive data section? Lots of information presented here, but where are the actual statistical findings? Lots of revisions required here. Refer to template and DNP DPI project guide.

The DASH project showed an increase in the participants' knowledge and awareness of DASH and its relationship to blood pressure and a decrease in participants systolic and diastolic blood pressures. The DASH intervention was structured to support the needs of the participants. Post- DASH food frequency questionnaires indicated that participants had changed some dietary habits during their participation in the DASH education.

Figure 1. The age range of the DASH participants at the clinic site.

Figure 2. The age groupings of DASH participants.

Table 1 Comment by Sharina Sigur: This should not be double spaced. Revise where needed.

Participants Pre- and Post-DASH Intervention Blood Pressure Measurements

Participant Number	Pre-Education Systolic BP	Post-Education Systolic BP	Percentage Of Systolic Change	Pre-Education Diastolic BP	Post- Education Diastolic BP	Percentage Of Diastolic Change
H001	140	136	-2.86	100	96	-4.00
H002	130	126	-3.08	98	94	-4.08
H003	128	124	-3.13	86	78	-9.30
H004	132	130	-1.52	88	88	0.00
H005	130	130	0.00	92	88	-4.34
H006	146	138	-5.48	104	96	-7.69
H007	124	126	1.61	86	82	-4.65
H008	118	122	3.39	84	86	2.38
H009	136	130	-4.41	100	92	-8.00
H010	140	132	-5.71	100	94	-6.00
H011	144	136	-5.56	102	98	-3.92
H012	132	134	1.52	86	84	-2.33
H013	146	140	-2.74	98	92	-6.12
H014	124	128	3.23	82	84	2.44
H015	138	138	0.00	88	90	2.27
H016	136	130	-4.41	88	84	-4.55
H017	130	132	-1.54	90	90	0.00
H018	128	122	-4.69	96	94	-4.17
H019	130	128	-1.54	96	90	-6.25
H020	142	144	1.41	102	104	1.96
Note. Gray cells indicate the percentage of reduction of BP measurements pre- and post-intervention. 13 participants had lower systolic measurements and 14 participants had lower diastolic measurements post DASH intervention.

Considering the above table of descriptive statistics. The sample consists of 20 individuals whose systolic BP and diastolic BP is recorded, once before the education and once after the education.

Figure 3 Comment by Sharina Sigur: This is not formatted correctly. Refer to template for guidance.

Figure 4

Figure 5

Looking at the Systolic BP levels, the sample had a mean of 133.70, before undergoing the education. The sample mean for systolic BP declined to 131.30 levels post the education program. The median systolic BP level also declined by 2 units post the education for the sample. The mode systolic BP level remained unchanged at 130, that means most people having 130 level of systolic BP level in our sample, in the pre-education and post education. If we look at the percentage change in Systolic BP levels of the sample from pre-education to post education periods, we observe that the mean change of Systolic BP declined by about 1.78%. Thus, the education reduces the levels of systolic BP by about 2% for the sample observations.

Figure 6

Figure 7

Figure 8

Now, considering the Diastolic BP levels, the diastolic BP level mean declines from 93.40 to 90.20, after the education program. The median diastolic BP levels also fall post education by almost 4 units. The mode diastolic BP levels decline from 86 to 84, which is also a great sign for the education program. Looking at the percentage change, the mean change of diastolic BP levels declined by 3.3%. This shows how effective the education program was.

The standard deviation for post education program, for both diastolic and systolic BP levels decline meaning, the data tends to get more towards the mean, which is a great sign, and the probability of eliminating outliers is high once the individuals go through the education program.

Table 3

Pre-DASH Education Questionnaire Responses

Questions 1-5	Completely Disagree	Somewhat Disagree	Neither Agree Nor Disagree	Somewhat Agree	Completely Agree
I know what DASH stands for	12	4	1	2	1
I know about The benefits of DASH diet	10	6	0	3	1
I can identify Foods in the DASH diet	8	6	1	3	2
It is important to understand DASH diet	6	1	7	1	6
Following the DASH diet can improve my blood pressure	6	2	5	2	5
Note. Number represents the number of participants who chose the response on a 5-point Likert-type scale that elicited baseline DASH knowledge.

Table 4

Post-DASH Education Questionnaire Responses

Questions 1-5	Completely Disagree	Somewhat Disagree	Neither Agree Nor Disagree	Somewhat Agree	Completely Agree
I know what DASH stands for	2	2	0	12	4
I know about The benefits of DASH diet	0	0	0	11	9
I can identify Foods in the DASH diet	0	0	0	9	11
It is important to understand DASH diet	0	0	0	6	14
Following the DASH diet can improve my blood pressure	0	0	0	5	15
Note. Number represents the number of participants who chose the response on a 5-point Likert-type scale after the DASH Intervention.

Before the DASH program intervention, following was the statistics observed. Before the education program most participants did not have any idea about what DASH stood for. Post the education program, most participants knew somewhat what DASH meant, thus the program bought about awareness among sample observations on what DASH meant.

Before the program, most participants did not know the benefits of DASH. Post the awareness program on DASH, majority people understood the benefits of DASH. Most people could not identify foods with DASH before the program, but they started understanding that post the program. Participants did not feel there was a need to understand DASH diet before the program, but post the program, they agreed to the importance of understanding the DASH diet.

Very importantly, before the education program, only a few strongly agreed to the fact that DASH diet could improve BP levels. But post the education program, almost half the sample shifted to strong agreement that DASH diet could in fact improve BP levels.

Table 5

Response to Food Frequency Questionnaire Pre and Post DASH Intervention

Participants Self-Reported Daily Food Intake by Food Group
	1 Serving	2 Servings	3 Servings	4 or more Servings
	Pre Post	Pre Post	Pre Post	Pre Post
Grains	13 8	5 6	2 3	0 2
Vegetables	15 6	4 6	1 6	0 2
Fruits	16 8	2 9	0 1	2 2
Note. Numbers represent the number of participants who chose the number of daily servings for each food group.

Observation showed that grain consumption mean increases from 1.45 times to 2.05 times, and the median increases from 1 to 2. This shows more people are inclined towards consuming more times grains during a day. The mean and median consumption times for Vegetables also increases from pre-event to post event. Consequently, more people are preferring high times consumption of fruits post event than pre-event. Thus, the event generated awareness about the health benefits of consuming fruits, vegetables and grains more times in a day to better BP levels and health of individual.

Summary Comment by Sharina Sigur: Underdeveloped.

There were improvements in the participants' responses to increasing daily servings of grains, vegetables, and fruits. The results of the pre- and-post-questionnaires showed that DASH education enhanced participants' knowledge, awareness, and the likelihood of making dietary changes. The DASH education also showed there was a significant decrease in participants systolic and diastolic blood pressures post DASH program intervention. The findings indicated that the structured DASH educational intervention presented increases the knowledge, awareness, and attitudes of change in nutritional habits after the DASH intervention.

Chapter 5 Comment by Sharina Sigur: Refer to template for correct title. This chapter requires revisions to include discussion related to statistical findings.

Hypertension remains a growing problem among the African American workforce, especially in production facilities, where there is limited access to healthy food choices due to long shifts and short break periods. According to Blumenthal et al. (2010), lifestyle modification, such as the adoption of the Dietary Approach to Stop Hypertension (DASH) diet has the potential to reduce blood pressure. Dietary modification is often discussed with patients and can provide a significant benefit in blood pressure management. The objective of this quality improvement was to determine whether post DASH education will show a reduction in the participants’ systolic and diastolic blood pressure. This project was centered around a DASH diet intervention aimed to improve awareness and knowledge of nutritional components in hypertensive African American patients in an outpatient clinic.

This project implementation introduced the DASH diet and education on the nutritional components of DASH at an outpatient primary care clinic. This chapter will discuss the significance of the findings, strengths, weaknesses, and challenges that took place during the planning and implementation of this DPI project in the clinic.

Summary of the Project

The strategies that were implemented through this quality improvement project focused on the contributions that nutritional education and subsequent adoption of the DASH program can play in blood pressure reduction for individuals. The results of this project answered the clinical question; “To what degree does the implementation of a Dietary Approach to Stop Hypertension program impact blood pressure of patients diagnosed with hypertension when compared to no intervention among African American patients in an outpatient clinic in Washington, D.C.?” and showed that some participants exhibited a reduction in blood pressure and low to moderate modifications in daily servings of grains, vegetables, fruits and increased knowledge about the DASH.

The increase in the food frequency intake as recommended by the DASH diet could demonstrate improved nutritional knowledge and awareness of the benefits of increasing servings in grain, fruits, and vegetables, which are essential components of the DASH. The findings indicated that some individuals simply lacked knowledge about dietary benefits prior to the DASH education program. Once the education was provided, these individuals used their newly acquired education to increase their daily intake of beneficial foods. These findings have the potential to support a need for ongoing structured nutritional education programs for pre-hypertensive and hypertensive patients in the outpatient clinic setting. The aim of this quality improvement project was to show that participants will be better prepared to adopt some recommendations of the DASH diet, including appropriate amounts of sodium, potassium, calcium, magnesium, and fiber. All these components affect blood pressure.

Studies have shown that DASH diet adherence reduces hypertension and can lower cardiovascular risk factors such as strokes, heart attacks, and congestive heart failure, which are high dollar emergency room visits (CDC, 2017). As such, patient’s understanding of the DASH diet can reduce the long-term disease burden of hypertensive diagnoses. The goals for this quality improvement project were to show there is a need for expanding the services of the outpatient clinic to include nutritional education with patients. This quality improvement project has improved patient activation for self-management of hypertension.

Summary of Findings and Conclusions

Hypertension continues to be a growing problem in America. There is an increasing need to reduce the burden of chronic disease associated with hypertension, including the increased risk of death and the costs related to treating and managing the hypertension-related disease. According to NHLBI (2015), initiating lifestyle modification, such as dietary changes, can have a significant effect on the reduction of blood pressure.

This quality improvement project demonstrated an effective way to increase patient’s knowledge and adherence of the DASH diet for participants in an outpatient primary are clinic. Another aim for this quality improvement project was for patients to have a lower diastolic or systolic blood pressures at the end of the 4-week DASH diet education series. This was an indication of positive benefits from the DASH education program for patients diagnosed with hypertension. This project provided participants with face-to-face education on hypertension and the DASH diet, as well as DASH diet pamphlets that could be used to guide food choices.

The DASH program provided education sessions that were interactive and motivational. Based on participants’ self-report, the project goal was to enhance participant knowledge, adherence, and self-efficacy in making meaningful changes in dietary habits. Sustainability of this project required interprofessional team, minimal financial resources, and increased staff support to provide patients with ongoing DASH education in the primary care clinic.

Implication

Theoretical Implications. The HPM that is used universally for science, education, and practice was developed by Pender. The aim of this model used in this DPW was to help people achieve higher levels of well-being and to recognize background factors influencing health behavior. It promotes the provision of supportive services by health providers to help patients make specific behavioral improvements. Using the model in the outpatient clinic setting and working with the patient/client in partnership, the provider and other clinic staff can encourage the client to adjust habits and maintain a healthier lifestyle. The HPM's goal, therefore, is not only to help patients avoid disease through their actions, but to look at ways a person can pursue better health, specifically better hypertension management.

Practice Implications. Teaching the DASH eating plan as a health promotion initiative can support healthy dietary habits that patients can use throughout life. Education on the DASH has been shown to prevent other serious medical conditions such as heart attack, strokes, heart failure, kidney disease, and colon cancer (CDC, 2017). Creating a structured approach to educating patients on this diet is an easy, low-cost health promotion initiative for any size outpatient primary care clinic. While DASH is primarily known to lower blood pressure, it may also promote weight loss (CDC, 2017). This could help decrease healthcare costs associated with obesity and obesity-related diagnoses. An additional benefit of DASH diet education is the mental and physical health benefits experienced by patients due to increased energy from proper nutrition. Improved nutrition could help to combat stress-related work-life balances.

Future Implications. This DASH education quality improvement project can be a lifelong eating plan that focuses on consuming fruits, vegetables, lean proteins, whole grain, and the reduction of foods high in sugar or sodium. Providing nutritional education in the clinic increases accessibility to patients during their visit. Another benefit is participants were distributed DASH diet pamphlets that can be used as ongoing guides to assist in maintaining adherence to DASH diet recommendations. Outpatient clinic interventions, such as those used in this quality improvement project, can improve the provider-patient relationship, which can increase the likelihood that patients will maintain healthy eating habits.

Recommendations

Recommendations for Future Projects. After implementation, data recommended that this quality improvement project be replicated at other clinics as an intervention to increase participants’ motivation and self-efficacy toward pre-hypertension and hypertension self-management. The result of this project could bridge the gap to offer a more structured nutritional program to empower patients to optimize wellbeing through dietary choices. This project could open a collaboration with health insurance companies to negotiate nutritional services to be covered in an outpatient clinic. Outpatient primary care clinic settings should include prevention of chronic disease and other health promotion activities, as well as treatment and management of chronic diseases.

At the end of this quality improvement project, it is recommendation that an interprofessional group provide education and counseling sessions to assist patients in changing dietary habits that contribute negatively to pre-hypertension and hypertension. It is also recommended that patients be given time during their office visit to receive or attend education and counseling sessions. This will likely maximize patient participation. Empowering patients to optimize their wellbeing through diet education would be best achieved with the addition of health coaches or nutritional coaches. Health coaches promote wellness and lifestyle changes, including dietary counseling, lifestyle modification through behavior change, and chronic disease self-management sessions.

Another recommendation would be the onboarding of nutritional health promotion through telephonic or virtual nutritional counseling. Providing service at this level could support the health, nutrition, and stress management of the employees. This could allow patient spouses and family to be integrated into the nutritional education process; spouses may be shopping for food or preparing the meals. Providing spouses with nutritional counseling could have a direct impact on family health. Costs for the nutritional health promotion staff could be minimized by other clinic staff members such as nurse educators, nursing students or interns.

Recommendations for Practice. Interprofessional collaboration for improving patient and population health outcomes is essential. The focus would be on inter-professional collaboration with inter-professional teams to improve patient, population, and health care delivery system outcomes (AACN, 2006). The growing complexity of health care often requires a collaborative approach to best address patient needs. The successful implementation of this project could possibly involve collaboration between providers and the health system, specifically the primary care outpatient clinics and a DNP prepared clinical education director.

Communication with leaders of the organization was necessary to be granted permission to implement this project at the outpatient clinic locations. Clinical prevention and population health for improving the nation’s health. After the quality improvement project, the investigator was able to analyze data on individual and population health and synthesize concepts related to health promotion and illness prevention (AACN, 2006). Healthcare providers will be able to use education on the DASH diet to address health promotion and population health among a hypertensive and pre-hypertensive population in the outpatient wide health care settings. The risks associated with hypertension are significantly reduced when blood pressure is decreased. This quality improvement project has shown that it could contribute to decreasing the burden of hypertension through participants' awareness of the DASH diet as lifestyle modification.

The project’s goal was to increase dietary knowledge, adherence and increase patient self-efficacy of hypertension, and self-management through education on the DASH eating plan. The application of this knowledge resulted in improvements in systolic and diastolic blood pressure, increased knowledge of the DASH and improved patient food choices. The work that was invested in this quality improvement project enhanced my current knowledge of nutrition and uncovered new knowledge because of the DASH diet education. This DPI project has generated new knowledge for practice through the integration of systematic literature review and utilizing clinical expertise and patient preference to make changes in the outpatient care clinics. These changes lead to improved patient hypertensive outcomes and increase providers professional development.

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Appendix A 10 Strategic Points Comment by Sharina Sigur: Appendix A is the 10 Strategic Points for the proposal and then, it is replaced with the GCU QI/IRB determination (approval) letter for final manuscript

	10 Strategic Points	Comments/Feedback
Broad Topic Area	The impact of a DASH (Dietary Approach to Stop Hypertension) has on African American patients diagnosed with hypertension African Americans are at an increased risk for developing HTN at an early age due to a gene that increases their sensitivity to salt (American Association for the Advancement of Science (AAAS), 2004; Rigsby 2011). This population is disproportionately affected by HTN when compared to other ethnicities (Rigsby, 2011). As a result, African Americans with HTN have an increased rate of stroke (80%) and heart disease (50%) when compared to other ethnicities (AAAS, 2004). Asante (2015) reported that 84% of African Americans did not understand HTN and chronic diseases related to lack of therapy. Hypertension occurs when the force of the blood flowing through a person’s blood vessels is consistently too high (AHA, 2017). The Center for Disease Control ([CDC], 2019) defines normal blood pressure (BP) as a systolic B/P less than120 mm Hg and diastolic B/P less than 90 mm Hg. Hypertension is the leading preventable cause of premature death worldwide (Mills et al., 2016). The principal health issues of four or more office visits to health care providers in the US is for HTN with an estimated direct and indirect cost of in 2014 is $51.0billion (CDC, 2019). The main reason HTN goes untreated is that it can be asymptotic, thus affecting multiple organs and leading to chronic disease (Zollellner et al., 2014). Uncontrolled HTN increases morbidity and mortality systemically, causing cardiovascular (CV) disease (heart failure, heart attack), cerebrovascular (stroke. transient ischemic attack), and end-organ damage (left ventricular hypertrophy (LVH), hypertensive retinopathy and peripheral arterial disease. (Chobanian et al., 2003). An analysis from the Framingham Heart Study showed that compared with those with optimal blood pressure (BP) (SBP120/b80mm Hg), persons with BP in the prehypertension range (systolic BP 130-139 mm Hg, diastolic BP 85-89 mm Hg) had a higher 10-year incidence of cardiovascular disease (CVD; hazard ratios of 1.6 for men) (Vason et al., 2001). The United States prevalence of hypertension is 43.0% among African American men compared with 33.9% among Caucasian men (Chobanian et al., 2003). Practical use of dietary interventions in patients with pre-hypertension could lead to more optimal pressure (Ard, Sevetkey, & Durham, 2005). A 5 mm Hg reduction in systolic blood pressure (SBP) in the population would lead to a 9% to 14 % reduction in CVD related mortality rates (Suhui, Bruen, Lantz, & Mendez, 2015).
Literature Review	Background of the problem/Gap: A literature review provides a more comprehensive understanding of the healthcare problem for this chapter. A review and synthesis of the current literature support the DASH as an evidence-based patient education tool used in the management of patients with HTN to improve patient outcomes. The DASH is an effective way to reduce blood pressure. Lifestyle modifications recommendations of diet and exercise can be difficult if patients are not given specific guidelines. Diet and lifestyle changes are more effective when healthcare providers give patients clear and concise guidance. The DASH intervention offers patients clear dietary guidance and assists with meal planning. The DASH can have a significant impact on HTN especially in the African American population and should be used as a primary intervention to decrease HTN. Hypertension continues to be a worldwide health problem. It is the most common condition treated in primary care and can lead to myocardial infarction, stroke, renal failure, and death if not detected early and treated appropriately (Oza & Garcellano, 2015). Research suggests that HTN rates in African Americans is higher than any other ethnic group, and BP control remains inadequate in this population. The DASH dietary pattern can be easily educated and adopted by all population groups offering the most cost-effective intervention to serve as the primary and secondary prevention of elevated blood pressure and its complications (Saneei et al.,2014). Theoretical Foundation Pender’s Health Promotion Model. This model focuses on behavioral change and improving patient outcomes.
Problem Statement	It was not known if or to what degree the implementation of dietary approach to stop hypertension (DASH) practice change would impact the patients’ blood pressure when compared to no intervention among African American patients diagnosed with hypertension in an outpatient clinic in Washington, D.C.
Clinical/PICO Questions	Does an educational overview regarding Dietary Approaches to Stop Hypertension (DASH) diet increase patient knowledge thus improving patient’s management of hypertension?
Sample	· Patients between the age of 18 and 65 years old. · Patients diagnosed with hypertension. · Patients that are African American. · Patients that are fluent in English. · Patients with no history of other medical conditions that might alter their blood pressure (i.e., double mastectomy, poor circulation, arteriovenous shunt). · Informed consent needed as data will be collected by clinical staff and given to principal investigator for quality improvement project.
Define Variables	Independent Variable: DASH diet intervention Dependent Variable: Patients blood pressure readings before and after the DASH diet intervention.
Methodology and Design	This project will use a quantitative methodology with a quasi-experimental.
Purpose Statement	Is to determine if or to what degree the implementation of a Dietary Approach to Stop Hypertension education intervention for patients would impact the patients’ blood pressure and dietary compliance when compared to no intervention among African American patients diagnosed with hypertension in an outpatient clinic in Washington, D.C.
Data Collection Approach	· Onsite de-identified data collection from staff (Demographic questionnaire) · Utilize the clinical staff to provide the education intervention to patients. · Utilize the clinical staff to give pre-posttest to patients before and after the education intervention. · Work with the clinical staff to obtain de-identified blood pressure measurements from patients at the beginning and end of the quality improvement project. · Access to the clinic’s Electronic Health Record (EHR) to review charts to collect de-identified data. · Clinical staff will include Registered Nurses and Medical Assistants. Data will be collected for 4 weeks and destroyed 6 months post intervention by locked shredder box.
Data Analysis Approach	IBM SPSS Statistical Software for percentage change of blood pressures from the pre-and-post test of DASH and to determine the amount of knowledge gained.

Appendix B Comment by Sharina Sigur: This should be bolded. Refer to template and revise where needed. Comment by Sharina Sigur: Is this a consent form? Informed consent is not included as an appendix (it is located in IRB packet) Appendix B is the resource/instrument (toolkit, screening tool, clinical practice guideline, etc.) used in the evidence-based intervention

DIETARY APPROACH TO STOP HYPERTENSION (DASH) Diet Program Comment by Sharina Sigur: This should not be in all caps.

The is a quality improvement education project to improve your knowledge of the DASH diet recommendation. This information may improve your blood pressure outcomes because you have high blood pressure or want knowledge on ways to prevent high blood pressure. By participating in this project, I hope that you learn that the DASH diet education may have a significant impact on your dietary compliance to prevent or improve your blood pressure.

The education session will be weekly for a total of four sessions. The total amount of time for each session should be about 45 minutes. Your blood pressure will be taken at the beginning of the first session and at the end of the fourth. You will be asked to complete a pre- and post-education questionnaire. No identifying or confidential data will be shared.

Thank you for your participation,

Participant’s Name (Print)___________________________________

Participant’s Name (Signature)________________________________

Clinical Staff (Signature)______________________________

Appendix C Comment by Sharina Sigur: Appendix C is the evidence of permission to use the resource/instrument Additional appendices may include other resources/instruments; permissions to use resources/instruments as applicable; and educational material that is relevant to the intervention

Intake Survey Tool

CODE#_______

1. What is your age?

a. 21-29

b. 30-39

c. 40-49

d. 50-59

e. 60-69

f. 70 or older

2. What is your Gender?

a. Male

b. Female

3. What is your race?

a. White

b. African American

c. Asian or Pacific Islander

d. American Indian

e. Other. Please specify__________

Appendix D Comment by Sharina Sigur: Descriptive title is missing. Why isn’t this included in chapter 4?

Statistics
	Pre-Education Systolic BP	Post-Education Systolic BP	Percentage Of Systolic Change	Pre-Education Diastolic BP	Post- Education Diastolic BP	Percentage Of Diastolic Change
N	Valid	20	20	20	20	20	20
	Missing	0	0	0	0	0	0
Mean	133.70	131.30	-1.7755	93.30	90.20	-3.3175
Median	132.00	130.00	-2.1400	94.00	90.00	-4.1250
Mode	130	130	-4.41a	86a	84a	.00
Std. Deviation	7.767	6.027	2.92208	6.997	6.187	3.66082
Skewness	-.036	.310	.345	-.035	.121	.354
Std. Error of Skewness	.512	.512	.512	.512	.512	.512
Kurtosis	-.628	-.450	-1.040	-1.535	.127	-.937
Std. Error of Kurtosis	.992	.992	.992	.992	.992	.992
Minimum	118	122	-5.71	82	78	-9.30
Maximum	146	144	3.39	104	104	2.44
a. Multiple modes exist. The smallest value is shown
Statistics
	Before event Grain Consumption	Before event Vegetable consumption	Before event Fruits consumption	After event Grains Consumption	After event Vegetables consumption	After event Fruits consumption
N	Valid	20	20	20	20	20	20
	Missing	0	0	0	0	0	0
Mean	1.45	1.30	1.40	2.05	2.20	1.85
Median	1.00	1.00	1.00	2.00	2.00	2.00
Mode	1	1	1	1	1a	2
Minimum	1	1	1	1	1	1
Maximum	3	3	4	4	4	4
a. Multiple modes exist. The smallest value is shown

Statistics
	N	Mean	Median	Mode	Minimum	Maximum
	Valid	Missing
Before event I know what DASH stands for	20	0	1.80	1.00	1	1	5
Before event I know about The benefits of DASH diet	20	0	1.95	1.50	1	1	5
Before event I can identify Foods in the DASH diet	20	0	2.25	2.00	1	1	5
Before event It is important to understand DASH diet	20	0	2.90	3.00	3	1	5
Before event Following the DASH diet can improve my blood pressure	20	0	2.90	3.00	1	1	5
After event I know what DASH stands for	20	0	3.70	4.00	4	1	5
After event I know about The benefits of DASH diet	20	0	4.45	4.00	4	4	5
After event I can identify Foods in the DASH diet	20	0	4.55	5.00	5	4	5
After event It is important to understand DASH diet	20	0	4.70	5.00	5	4	5
After event Following the DASH diet can improve my blood pressure	20	0	4.75	5.00	5	4	5

Sample size 20.

n = 20

d = 0.5

sig.level = 0.05

power = 0.337939

alternative = two.sided

NOTE: n is number in *each* group

Power for T Test would be 0.33 for sample size.

Appendix E

Appendix F

DASH Diet Food Frequency Questionnaire tool

Appendix G

DASH Diet Education and DASH Education Sessions

Session 1 (Week 1)

· Introduction

· Blood pressure checks

· Prequestionnaire distributed

· Distribute handouts

· Overview of hypertension

· Summarize material and answer questions

Session 2 (Week 2)

· Review any questions from the initial session

· Prequestionnaire distributed if not completed the last session

· Distribute handouts

· Overview of sodium (salt)

· Comparing and Reading food labels

· Summarize material and answer questions

Session 3 (Week 3)

· Review any questions from the previous session

· Distribute handouts

· Introduction to DASH diet eating plan

· Overview of Grains, Vegetables, Fruits and Meats

· Plan recipes and review creating a menu

· Distribute DASH diet pamphlets

Session 4 (Week 4)

· Review any questions from the last session

· Discussion about DASH diet menus created

· Overview of the other components of DASH

· Discuss Nuts, Low fat dairy, Sweets and Oils

· Blood pressure checks

· Summarize DASH recommendations

· Complete post-education questionnaires.

Appendix H

Appendix I Comment by Sharina Sigur: Site authorization letter is not included as an appendix.

Appendix J Comment by Sharina Sigur: Site authorization letter is not included as an appendix.

Appendix K Comment by Sharina Sigur: This can be removed.

Racial Diversity of DASH Participants African American Caucasians Hispanics Asian or Pacific Islanders American Indian 20 0 0 0

Age Range of DASH Participants 18-29 30-39 40-49 50-59 60 and Over 7 6 5 2 0

What is my DPI project design? Does the project have a practice improvement or intervention? YESIs the treatment tightly controlled by the investigator? YESWill a randomly assigned control group be uses? NOQuasi-Experimental DesignNon-Randomized Control Group Design.

What is my DPI project design?

Does the project have a practice improvement or intervention?

YES

Is the treatment tightly controlled by the investigator?

YES

Will a randomly assigned control group be uses?

Quasi-Experimental Design

Non-Randomized Control Group Design.

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