Name: _____________________
Star Point 1: Discovery (Identify topic and practice issue)
Identify the
topic and the
nursing practice issue related to this topic. (This MUST involve a nursing practice issue.)
Briefly describe your
rationale for your topic selection. Include the
scope of the issue/problem.
Star Point 2: Summary (Evidence to support need for a change)
Describe the
practice problem in your own words and formulate your PICOT question.
List the systematic review chosen from the CCN Library databases. Type the complete
APA reference for the systematic review selected.
List and briefly describe
other sources used for data and information. List any other
optional scholarly source used as a supplement to the systematic review in
APA format
.
Briefly
summarize the main findings (in your own words) from the systematic review and the
strength of the evidence
.
Outline one or two
evidence-based solutions you will consider for the trial project.
Star Point 3: Translation (Action Plan)
Identify
care standards, practice guidelines, or protocols that may be in place
to support your intervention planning (These may come from your organization or from the other sources listed in your Summary section in Star Point 2).
List your
stakeholders (by title and not names; include yourself) and describe their
roles and responsibilities in the change process (no more than 5).
What specifically is
your nursing role in the change process? Other nursing roles?
List your stakeholders by
position titles (charge nurse, pharmacist, etc.).
Why are the members chosen (stakeholders) important to your project?
What type of
cost analysis will be needed prior to a trial? Who needs to be involved with this?
Star Point 4: (Implementation)
Describe the
process for gaining permission to plan and begin a trial. Is there a specific group, committee, or nurse leader involved?
Describe the
plan for educating the staff about the change process trial and how they will be impacted or asked to participate.
Outline the
implementation timeline for the change process (start time/end time, what steps are to occur along the timeline).
List the
measurable outcomes
based on the PICOT. How will these be measured?
What
forms, if any, might be used for recording purposes during the pilot change process. Describe.
What resources are available to staff (include yourself) during the change pilot?
Will there be
meetings of certain stakeholders throughout the trial? If so, who and when will they meet?
Star Point 5: (Evaluation)
How will you
report the outcomes of the trial?
What would be the
next steps for the use of the change process information?
9.2019 Update. DLP
1
