DNP 752 Week 5 Limitations, Implications and Sustainability Example

What This Pilot Cannot Claim, What It Means for Practice and How It Will Keep Running: Limitations, Implications and a Sustainability Plan for Diabetes Distress Screening

[Student Name]

University of Phoenix

DNP/752: DNP Applied Project III

Week 5 Assignment: Limitations, Implications and Sustainability

[Instructor Name]

[Date]

The health center, staff and figures are composites written for a model paper.

What the Pilot Can and Cannot Claim

The pilot can claim that a distress screening pathway was introduced at one clinic, reached most eligible visits within 12 weeks, was followed up promptly in most cases and was judged acceptable by staff. It can claim that distress scores fell among patients who were reassessed. It cannot claim that the pathway caused that fall, that the results would be the same at another clinic, or that A1C improved because of it. Keeping those boundaries in view protects the recommendation that follows from being read as more than it is.

Limitations of Design

The design had no comparison group. Any outside influence during the pilot, such as a change in the season, a new insurance benefit or a staffing change, could have affected distress and process measures alike. For the process measures this matters less, because the run chart signals line up with specific changes made by the team. For distress scores it matters more. Patients entered the distress analysis because they scored high, and high scores tend to fall on remeasurement; this regression effect almost certainly made the pathway look more effective than it was.

Limitations of Measurement

Distress was measured by self-report on validated instruments, which is appropriate, but patients answered on a tablet in the exam room, and some may have underreported to avoid a longer visit. That would bias the positive rate downward. Rooming time was measured on a sample of 60 visits timed by the champion, not on every visit, and the champion knew the purpose of the timing, which could have encouraged faster rooming on timed visits. Staff surveys were anonymous, but staff at a small site may still have been reluctant to criticize a colleague's project, which would bias implementation scores upward.

Limitations of Sample

A repeat score exists for 44 of the 57 patients assessed at entry. Those lost started higher and were more often Spanish-speaking, and excluding them probably exaggerated the average improvement; a sensitivity check that assumed no change for them reduced the mean fall from 0.54 to about 0.42 points. The pilot ran at one clinic with its own staff, culture and population, so its findings describe that clinic.

Limitations of Implementation

The project lead worked at the site as a nurse practitioner, and staff knew the lead personally. Although data reports were run by the quality coordinator and fidelity was observed by the champion, a colleague's presence may have raised effort during the pilot in ways that will fade.

Implications for Nursing Practice

The clearest implication is that registered nurse care managers, already present in many primary care teams, can take on distress follow-up with a short response guide and modest added time, turning a national standard of diabetes care into routine nursing work. Matching the response to the dominant subscale gave care managers a way to start conversations that had previously ended in reassurance. The larger fall in regimen distress than in emotional burden suggests that the problem-solving part of the role is where nurses can help most quickly, while emotional burden needs partnership with behavioral health.

Implications for the Health Center

The pathway met its adoption rules at the east side clinic. Before spread, the health center needs more behavioral health capacity, since referrals doubled, and a Spanish-speaking follow-up option, since Spanish speakers were screened less often and lost to follow-up more often.

Implications for Policy and Future Inquiry

Federal quality measures for health centers include glycemic control but not psychosocial care. The pilot suggests that a process measure, the share of patients with diabetes screened for distress in a year, would be feasible to report from routine data. For future inquiry, a stepped-wedge rollout across the health center's three sites would give a stronger test of the pathway's effect on distress and, over a longer period, on A1C.

Implications for Nursing Education

The pilot also suggests something for how nurses are prepared. Care managers said they had learned to screen for depression in school and at work but had never been taught about diabetes distress, and the one-hour training was their first exposure to its subscales. Prelicensure and graduate curricula that cover diabetes self-management education could add distress as a named concept, with practice in responding to regimen-related and emotional distress differently.

Recommendations for Spread

Spread to the health center's other two sites should wait for three conditions: behavioral health capacity for about four extra referrals a week per site, a Spanish-speaking follow-up option, and a second quarter of stable dashboard results at the east side clinic. When those are met, each new site should begin with its own first improvement cycle using one medical assistant and one clinician, rather than adopting the final east side workflow whole, since rooming routines differ between sites.

Planning for Sustainability

Wiltsey Stirman et al. (2012) reviewed the empirical literature on sustaining new programs in health care and found that few interventions were fully sustained, that partial sustainment was common, and that influences included fit with the organization, ongoing funding and support, leadership, and whether the program was adapted to the setting. They also noted that sustainment was often measured poorly, a gap echoed by Proctor et al. (2011), who list sustainability as an implementation outcome in its own right, to be defined and measured rather than assumed. The Iowa Implementation for Sustainability Framework describes a final phase of pursuing integration and sustained use, with strategies such as building the change into policies and job descriptions, monitoring performance and celebrating results (Cullen et al., 2022).

The Sustainability Plan

Owner: the nurse practitioner lead for the site, with the medical director as sponsor. Embedding: the screen is now in the rooming protocol, the response guide in the care manager job description and the behavioral health handoff in the site's referral policy. Monitoring: the monthly quality dashboard now carries both process rates, updated by the quality coordinator, with a review at the quarterly quality meeting. Support: the champion role continues with one hour a week of protected time, and new medical assistants learn the screen during orientation. Adaptation: the Friday huddle becomes a monthly review with authority to adjust the workflow. Resources: no new funding is needed at this site; spread depends on behavioral health capacity, which the medical director will raise in the next budget cycle.

One-Year Plan

Month 3: first dashboard review; target screening above 80%. Month 6: staff implementation scores repeated. Month 9: decision on a Spanish-speaking follow-up option. Month 12: sustainment review against the dashboard and a decision on spread to a second site.

Summary

The pilot's claims are modest and bounded by its design, sample and setting, but its implications for nursing practice are clear and its sustainability plan rests on roles, routines and measures rather than on the project lead.

References

Cullen, L., Hanrahan, K., Edmonds, S. W., Reisinger, H. S., & Wagner, M. (2022). Iowa Implementation for Sustainability Framework. Implementation Science, 17, Article 1. https://doi.org/10.1186/s13012-021-01157-5

Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., Griffey, R., & Hensley, M. (2011). Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health and Mental Health Services Research, 38(2), 65-76. https://doi.org/10.1007/s10488-010-0319-7

Wiltsey Stirman, S., Kimberly, J., Cook, N., Calloway, A., Castro, F., & Charns, M. (2012). The sustainability of new programs and innovations: A review of the empirical literature and recommendations for future research. Implementation Science, 7, Article 17. https://doi.org/10.1186/1748-5908-7-17