DNP 851B Module 6 Implementation Strengths and Weaknesses Example

How Delivery Shaped the Results: Strengths and Weaknesses of Implementing a Pediatric Asthma Program

Student Name

Doctor of Nursing Practice Program, Aspen University

DNP 851B: Project Data Analysis

Instructor Name

Month Day, Year

How Delivery Shaped the Results: Strengths and Weaknesses of Implementing a Pediatric Asthma Program

Results depend on what was actually delivered. A program that worked well in its later weeks and poorly in its first may produce an average that describes neither. This paper examines the strengths and weaknesses of how my DNP project was implemented and asks how each affected the results. The program combined a nurse visit, a written plan, coached device use, a school link and a follow-up call, and the analysis found improvements in asthma control and acute care over 12 weeks. The analysis uses a fidelity framework, compares early and late cohorts, looks at one element that some children did not receive and draws out implications for broader use. Figures come from the locked data set and the implementation log.

A Framework for Judging Delivery

Carroll et al. (2007) treat adherence to the intervention's content, coverage, frequency and duration as the core of fidelity and name moderators, such as facilitation and participant responsiveness, that explain variation. Proctor et al. (2011) add that implementation outcomes such as acceptability and feasibility can themselves shape clinical results. The analysis below asks, for each strength and weakness, which part of delivery it touched and whether it could plausibly have changed the outcomes.

Strengths

Four strengths stand out. The core visit was delivered with high fidelity: every core element was documented in 94% of visits, and the action plans themselves were accurate on audit. The program was delivered in the family's language, with plans and coaching in Spanish for two families in five, and results were similar in both language groups. Data were monitored weekly, so missing or wrong entries were caught early. And the team adapted delivery quickly through small tests of change while keeping the core fixed, which let later families receive a more reliable program. These strengths make the results more credible, because the outcomes describe a program that was largely delivered as designed.

A fifth strength was the clinic's support, which protected nurse time throughout.

Weaknesses

Four weaknesses matter. Enrollment started slowly because one nurse was not signed off in time. Sending plans to school fell short in the first six weeks, before a named owner took the task. Two-week calls reached Spanish-speaking families less often at first, because contact numbers were out of date. And inhaler technique slipped by 12 weeks in about a third of the earliest children, until reinforcement was added at the midpoint. Each of these weaknesses touched a specific element of delivery, which allows their effect to be examined.

A fifth, the reliance on two nurses for most visits, left the program exposed to a single absence.

Early and Late Cohorts Compared

Children enrolled in the first four weeks received the program before most adaptations; children enrolled in weeks five to eight received it after the school-sharing fix and closer to the reinforcement of technique. The table compares the two cohorts among the 91 children with complete data.

The later cohort did better on every measure, most clearly on technique and on school receipt of the plan, the two elements the adaptations targeted. The difference in control was smaller, five percentage points, and with groups this size it could be chance. The pattern is consistent with the program becoming more effective as its delivery improved, which suggests that the overall result slightly understates what the mature program can do.

When the Plan Reached School

Among the 91 children, the plan reached school for 66. Of those, 42 had well-controlled asthma at 12 weeks, 64%, against 10 of the 25 whose plan did not reach school, 40%. This comparison is tempting but weak. Families who agreed to share the plan may differ from those who declined, for example in their confidence with the school or in how carefully they manage asthma at home, so the difference cannot be credited to school sharing alone. It does support keeping the element and studying it more carefully.

Weaknesses in Measurement

Some weaknesses touched measurement rather than delivery. The check-in tablet's failure with Spanish entries cost four baseline scores, all from Spanish-speaking families, which slightly reduces what can be said about that group. Three children aged 12 were first given the childhood test and had to repeat the correct one by telephone, a small inconsistency in how baseline was collected. Acute visits outside the health system were found only after a parent mentioned one, and the regional exchange was added partway through; visits before that change may be slightly undercounted, which would make the fall in acute care look smaller than it was rather than larger. None of these problems is large, but each is reported so that the committee can judge them.

Implications for Broader Application

Three implications follow for other clinics. Programs of this kind need named owners for administrative steps from the first day, since the steps without owners were the ones that failed. Reinforcement of inhaler technique should be built in from the start, consistent with evidence that the benefits of technique education fade without it (Klijn et al., 2017). And delivery in the family's language appears feasible and effective, which matters for safety-net clinics like this one.

Each implication has already been adopted by the clinic.

Conclusion

Implementation was strong in its core and weaker in its supporting steps early on. The comparison of early and late cohorts suggests that the weaknesses reduced the program's effect slightly and that the adaptations recovered most of it. The results should be read as those of a program that was still improving during the project, delivered with high fidelity to its core.

Chapter four will report these points alongside the results.

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

Klijn, S. L., Hiligsmann, M., Evers, S. M. A. A., Román-Rodríguez, M., van der Molen, T., & van Boven, J. F. M. (2017). Effectiveness and success factors of educational inhaler technique interventions in asthma & COPD patients: A systematic review. NPJ Primary Care Respiratory Medicine, 27, Article 24. https://doi.org/10.1038/s41533-017-0022-1

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