DNP 851A Module 3 Implementation Log and Fidelity Example

Did We Deliver What We Promised? Six Weeks of Implementation Logs and Fidelity Monitoring for a Pediatric Asthma Program

Student Name

Doctor of Nursing Practice Program, Aspen University

DNP 851A: Project Implementation

Instructor Name

Month Day, Year

Did We Deliver What We Promised? Six Weeks of Implementation Logs and Fidelity Monitoring for a Pediatric Asthma Program

If a project's results are good, the committee will ask whether the intervention was delivered as planned; if they are poor, it will ask the same question for a different reason. Without a record of delivery, neither answer is possible. This paper describes the weekly log and the fidelity monitoring for my DNP project, in which clinic nurses complete written asthma action plans with families, coach inhaler and spacer technique to a set standard, offer to share the plan with the school nurse and call families two weeks later. It explains the framework behind the monitoring, presents six weeks of log entries, identifies where delivery slipped and describes what was done about it.

A Framework for Fidelity

Carroll et al. (2007) define implementation fidelity mainly as adherence: whether the content of an intervention was delivered, to the people it was meant for, as often and for as long as intended. They add moderators that explain why adherence varies, including how complex the intervention is, what support staff receive, the quality of delivery and how participants respond. The project uses that structure. Content means the four core elements of every visit: an action plan matched to the medicine list, technique coaching to the checklist standard, teach-back for both plan and device, and the school-sharing offer. Coverage means the share of eligible children reached. Frequency and duration mean one 40-minute visit and one call at two weeks. Proctor et al. (2011) place fidelity among a set of implementation outcomes, distinct from clinical outcomes, which is why it is reported separately. The core elements themselves come from the national guideline's advice that every child with asthma have a written plan and a check of device technique at visits (National Asthma Education and Prevention Program, 2007).

The Weekly Log

The log is a spreadsheet kept by the project lead and reviewed each Friday with the site mentor. It records, for each week, the visits scheduled and completed, the visits in which every core element was documented, the school plans sent, the two-week calls attempted and reached, the average visit length, and a free-text section for problems, changes and decisions. Each nurse also completes a one-page checklist after each visit, and the project lead audits one in five visits against the chart. The table shows the first six weeks.

Where Fidelity Held

Core visit content held well. Of 84 visits, 79 had every core element documented, and the five exceptions were two visits cut short by a sick sibling, two where the child had forgotten the inhaler and a placebo device was not available in the room, and one where the plan was completed but teach-back for the device was not documented. After week one, medical assistants began placing a placebo inhaler and spacer in every asthma visit room before the nurse arrived, and that error did not recur. Visit length fell from 52 minutes in week one to 41 in week six as nurses grew familiar with the template, which brought the visit close to its planned duration.

Where Fidelity Slipped

Two elements fell short. School plans were sent for 68% of children, not the 85% planned. The log's free-text notes showed two reasons: some parents declined, often because they were unsure the school would keep the plan private, and in the first two weeks several consents were signed but the plan was not sent because nobody had been assigned to send it. The second shortfall was the two-week call, reached for 78% of families. Missed calls clustered among families whose preferred language was Spanish and whose contact numbers had changed.

In the moderators' terms, the first problem was one of facilitation, a task with no owner, and the second was one of participant responsiveness shaped by access. Each called for a different fix.

What Was Done

For school sharing, the front-desk lead was made owner of sending plans on the day of the visit, with a daily list generated from the template. The consent script was revised to explain that the plan goes only to the school nurse and is kept in the health office. For the follow-up call, the community health worker began making the second attempt for Spanish-speaking families, and contact numbers were confirmed at check-in. The log will show whether these changes work over the next four weeks, and each change has been dated so that its effect can be read on the run charts.

What the Log Caught That Memory Would Have Missed

Without the log, the team would have remembered the program as going well, which it largely was. The log showed that the weakest element was not the demanding one, technique coaching, but an administrative step, sending the plan to school. It also showed that the follow-up gap fell on one group of families, which would have been invisible in an overall percentage. Both findings changed what the team did in week seven.

How the Log Feeds the Final Report

The log will provide the implementation results in chapter four: delivery by element and week, the changes made and their dates, and the audit's agreement between checklists and charts. In the first six weeks, the audit of 17 visits found the checklist and the chart in agreement on every core element in 16. That level of agreement allows the checklists to be used as the main fidelity source, with the audit as a check.

Conclusion

Six weeks of logs show that the core content of the visit is being delivered as planned in 94% of visits, while school sharing and the two-week call need work. Framing fidelity as adherence with moderators turned those shortfalls into specific problems with specific owners. The log will continue weekly until the last child's 12-week review.

References

Carroll, C., Patterson, M., Wood, S., Booth, A., Rick, J., & Balain, S. (2007). A conceptual framework for implementation fidelity. Implementation Science, 2, Article 40. https://doi.org/10.1186/1748-5908-2-40

National Asthma Education and Prevention Program. (2007). Expert panel report 3: Guidelines for the diagnosis and management of asthma (NIH Publication No. 07-4051). National Heart, Lung, and Blood Institute.

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