DNP 851A Module 4 Barriers and Small Tests of Change Example

Four Small Tests and One That Failed: Addressing Early Barriers in a Nurse-Led Pediatric Asthma Program

Student Name

Doctor of Nursing Practice Program, Aspen University

DNP 851A: Project Implementation

Instructor Name

Month Day, Year

Four Small Tests and One That Failed: Addressing Early Barriers in a Nurse-Led Pediatric Asthma Program

No implementation goes exactly as planned. What distinguishes a well-run project is how quickly problems are seen and how carefully the fixes are tested. This paper reports the barriers that appeared in the first five weeks of my DNP project, a nurse-led program in a pediatric primary care clinic that gives children with persistent asthma a written action plan and coached inhaler technique, and describes the plan-do-study-act cycles used to address them. It sorts the barriers with an implementation framework, sets out four test cycles with their predictions and results, explains one that failed, and draws lessons for the rest of the implementation.

The Barriers

Barriers were identified from the weekly log, the morning huddles and a short conversation with each nurse at the end of week two. Each was placed in a domain of the updated Consolidated Framework for Implementation Research, whose five domains cover the change being introduced, the settings outside and inside the organization, the people carrying it out and the way it is rolled out (Damschroder et al., 2022). Five barriers stood out. In the innovation domain, visits ran well over 40 minutes in the first two weeks. In the inner setting, the asthma control questionnaire was often not completed before the nurse entered the room, and placebo inhalers were missing from rooms in several visits. Also in the inner setting, no one owned the task of sending action plans to schools. In the process domain, two-week follow-up calls often failed to reach Spanish-speaking families.

Designing the Tests

Each barrier was addressed with a small test rather than a clinic-wide rule. A review of published plan-do-study-act projects found that many reported cycles without predictions, without iteration and without data collected over time, which weakens what can be learned from them (Taylor et al., 2014). The project set three rules in response. Every cycle would state a prediction in numbers before it began. Every cycle would be small, one nurse or one day, before any spread. And each cycle would close by recording in the log whether the change was kept, modified or dropped.

Four Cycles

The table summarizes the four cycles. The longest-running barrier, visit length, was addressed by the two cycles that changed room preparation and the questionnaire, since both had been adding minutes to each visit.

The Test That Failed

The fourth cycle did not meet its prediction. The community health worker reached only three of seven families. The log showed why: four numbers were disconnected or belonged to a relative, so the problem was not who made the call but whether the number was right. The cycle was adapted rather than abandoned. In the next test, front-desk staff confirmed the best number and the preferred time at check-in, and a text in Spanish went out the day before the call. In that second week, six of eight families were reached. A failed prediction was useful here because it showed that the cause had been misread.

Effect on Visit Length

Visit length is not a patient outcome, but it decides whether the program can continue once the project ends. Average visits shortened by eight minutes between the first and fourth weeks, to 44, after cycles one and two removed time spent looking for teaching devices and completing the questionnaire in the room. The remaining gap above 40 minutes was mostly technique coaching for younger children, which the team judged to be time well spent. The planned visit length will be kept at 40 minutes for older children and set at 45 for children under eight.

What Did Not Change

None of the cycles changed the core of the intervention. Every child still received a written, symptom-based action plan matched to the medicine list, coaching to the checklist standard with teach-back, the offer of school sharing and a follow-up call, the elements the national guideline recommends for every child with asthma (National Asthma Education and Prevention Program, 2007). The tests changed only how and by whom supporting tasks were done. Keeping that line clear matters for the evaluation, because the results must describe a single intervention delivered in adapted ways, not a series of different interventions.

Lessons for the Remaining Weeks

Three lessons will shape the rest of implementation. First, the barriers that cost the most were administrative, not clinical, and they yielded to assigning an owner. Second, a problem that looked like a language barrier was partly a data problem, and testing revealed that. Third, predictions made the cycles honest. Without a number to beat, the fourth cycle might have been judged a partial success and repeated unchanged. The team will continue one or two small tests at a time, recorded in the log, and review them at the midpoint.

Conclusion

Five early barriers were identified and sorted by framework domain, and four small tests of change addressed them. Three met their predictions and were adopted or adapted; one failed and, once its cause was understood, was redesigned. The intervention's core stayed fixed while its delivery improved, and visit length moved toward a level the clinic can sustain.

References

Damschroder, L. J., Reardon, C. M., Widerquist, M. A. O., & Lowery, J. (2022). The updated Consolidated Framework for Implementation Research based on user feedback. Implementation Science, 17, Article 75. https://doi.org/10.1186/s13012-022-01245-0

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.

Taylor, M. J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D., & Reed, J. E. (2014). Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Quality & Safety, 23(4), 290-298. https://doi.org/10.1136/bmjqs-2013-001862