A brief description of the type of project, sample, and setting
This DNP project is a quality improvement project that will take place at one adult acute care unit in a small community hospital in Baltimore, Maryland. The project goal is to improve care by translating evidence into practice. This unit has been identified for inclusion on the basis of high volume of physical restraint use as compared to like units within the organization. It is a 40-bed adult care unit with an average census of 35.5 patients. Inclusion criteria for sample will include adult patients from all kinds of racial and gender background who suffer from cognitive impairment. The exclusion criteria will include pediatric and young patients as well as those without cognitive impairment. The unit is comprised of twenty private rooms and ten semi-private rooms. This small community hospital has an active patients’ safety committee that meets on a monthly basis to review all documented safety issues. The information gathered from the meeting helps the committee formulate appropriate mitigation strategies. The nurses in this unit work on the Shared Governance Council and Quality Improvement Committee to implement safety improvement practices within the department. This project will concentrate upon immediate outcome improvements as well as emphasize their sustainability.

Procedures and timeline plan- step by step based on maximum of 15 week timeline
The procedure and timeline will follow the Quality-Caring Model Framework of relationship-centered professional encounters.

Week 1 Through 3
The stage will be set up for project implementation. The plan will include discussion of the program with site leadership, recruitment of unit staff, training, distribution of handouts, and building of relationships with the stakeholders such as medical equipment vendors and frontline staff. All staff members will be educated through a mandatory in-service staff education package that has been developed by taking into account literature research, research team’s clinical experiences, and analysis of pre-intervention attitudes, beliefs, and behaviors of staff members regarding use of restraint. The education package will also focus on misconceptions and myths about restraint use as well as provide empirical evidence on restraint use. The instruction tools will include case studies, simulation exercises, and discussions to enhance the understanding of learning materials as well as demonstrate their application in the real world.

The program leader will identify train executive champion and form restraint reduction committee (RRC). This committee will be comprised of interdisciplinary team members in line with Duff Quality Model. RRC will be incorporated into weekly case conferences in the project unit. This committee will identify the circumstances leading to use of restraints, presence and feasibility of alternatives to restraints, and potential solutions during the case conferences. The train executive champions will be delineated as unit mentors and super users.

Week 4 through 12
This period will witness the introduction of nursing evidence based protocols (alternative approaches and organizational interventions) as the first and second line intervention strategies prior to use of restraint as advocated by Quality-Caring Model. It will also involve implementation of monitoring protocols for patients and documentations’ requirement for restraint episodes. Weekly RRC meetings, debriefing, unit rounds, and personal encounters between the unit staff and members of the project team will be scheduled. The DNP student will continue to monitor implementation of best practice evidence and continue to serve as a resource to unit’s champions, RRC committee, and unit staff throughout the implementation period.

Week 13 through 15
This will be post-implementation or evaluation period. The project leader will continue to track outcome metrics, finalize metric reporting system, and validate and establish outcome metrics throughout the evaluation period.

Data Collection
The outcome variables that will be collected are number of patients on restraint, number of restraint-related injuries and falls, and patients’ functional level while on restraint. These outcome data will be collected by direct observation and review of charts/incident reports. Staff and patient interviews will be conducted in case of discrepancies in the data. Demographic data and medical and health-related information will be collected during admission to the unit. The Cantonese version of the Mini-Mental State Examination (MMSE), the Morse Fall Scale (MFS), and the Modified Barthel Index (MBI) will be used to assess cognitive status, risks of fall, and functional level of patients, respectively. Patient’s quality of life will be measured through Flanagan Quality of Life Scale (QOLS). All these instruments have been found to have high reliability, validity, and utilization value. The baseline observed patient information and the outcome measures have been collected for 12 weeks during the NDNP practicum (January to April 2016). After introducing intervention, the pre and post interventions’ data will be compared to determine the impact on patient safety and quality of life.

Data analysis/Ethics
Since targeted outcomes for this QI project will be measured by direct observation or pulled from the organization’s data collection systems, all these measures are quantifiable and amenable to quantitative analysis. A statistical analysis will be deployed to ascertain the probability that any change was significant or possibly random. A p value analysis will be conducted where a value of p < 0.1 will point to the outcome being statistically significant and vice versa. The probability assessment will be conducted using Microsoft Excel 2013. Microsoft Excel’s functions include the ability to determine data set averages variability and t distributions. Finally, a control chart analysis will be conducted to examine the trends in data over time to discern if the average observed outcome will be stable or changing. The confidentiality measures will involve storing data in encrypted electronic systems and no names will be used in collecting and sharing the data. No efforts will be made to record patient identity during data collection or translation process. Patients’ privacy will be further enhanced by storing the data in a locked storage in the DNP student’s office. Confidentiality and protection of human subjects as mandated by HIPPA will be ensured. A description of this project will be submitted to the University of Maryland, Baltimore’s (UMB) Institutional Review Board (IRB) for a Non-Human Subjects Research (NHSR) determination. Sustainability The program will develop mechanisms for sustaining fidelity of interventions by developing communication and support mechanisms such as providing important web sites, learning communities, and regular meetings for administrators, implementation teams, and practitioners. A restraint reduction program will also be developed to sustain the program, and it will be part of the staff competency program. Furthermore, regular training, technical assistance, and coaching will be maintained for all units, and these targeted training, assistance, and coaching will address any decline in outcomes. In addition, evaluations of fidelity and achievement of outcomes will be built into on-going institutional monitoring and quality assurance mechanism.