DNP 852A Module 8 The Completed Final Chapter Example

Chapter Five: Discussion of a Nurse-Led Asthma Plan and Technique Program in a Pediatric Safety-Net Clinic

Student Name

Doctor of Nursing Practice Program, Aspen University

DNP 852A: Project Manuscript

Instructor Name

Month Day, Year

Chapter Five: Discussion of a Nurse-Led Asthma Plan and Technique Program in a Pediatric Safety-Net Clinic

Chapter Five: Discussion

This chapter considers what the project found and what it means. The project set out to learn whether a structured nurse visit could close the gap between asthma guidelines and care at a pediatric clinic where most families are publicly insured and many speak Spanish. After the visit, children's asthma was more often well controlled, their inhaler technique was more often correct and fewer of them needed emergency or urgent care. The chapter interprets those findings, weighs the project's limits, draws out implications, describes how the change will be sustained and suggests what should be studied next.

Summary of the Project

During the eight-week enrollment period, 104 school-age children and teenagers received a nurse visit that combined a written, symptom-based plan in the family's language, hands-on coaching with a spacer until the child could demonstrate it, an offer to forward the plan to school, and a telephone contact two weeks later. Supporting tasks were adapted six times as problems surfaced; the core visit was not. Twelve weeks later, the children with complete data had better control on both age-specific tests, and clinic-wide plan coverage had shifted upward.

Interpretation

The direction of every main finding agrees with systematic reviews. Pediatric trials of written plans have shown fewer acute visits and fewer symptoms, with symptom-based plans outperforming those built on peak flow (Zemek et al., 2008). Educational programs for inhaler use improve technique quickly but see their gains fade unless technique is checked again (Klijn et al., 2017), which is what this project observed before it added brief checks to routine contacts. School-based self-management programs have been found to reduce unplanned care modestly in disadvantaged populations (Harris et al., 2019), and the project's link with school nurses was a lighter form of that idea. The size of the project's changes, however, exceeds what trials report. Poorer control at the start, the absence of a concurrent comparison group, controller medicines started during follow-up and a short observation period all probably contributed, so the effect a similar clinic could expect is likely smaller.

Unexpected Findings

Two results were not anticipated in the proposal. Children whose plan reached the school nurse had better control at 12 weeks than those whose plan did not, but families decided whether to share, so the difference probably reflects who chose to share as much as what sharing did. And children enrolled later in the project held correct technique more often than those enrolled first, which suggests the program strengthened as its supporting steps were fixed. Both findings are treated as prompts for further work rather than as conclusions, and neither changes the main interpretation.

Limitations

A before-and-after design with one group leaves open whether improvement would have come without the intervention (Harris et al., 2006). Regression to the mean, the attention of being enrolled and new controller prescriptions would each make the benefit look larger. Two limitations work the other way: follow-up ran into the autumn season, and some outside emergency visits early on were missed until the regional exchange query began, so the reduction in acute visits may be understated. Thirteen children lacked paired data, but sensitivity analyses left the conclusion unchanged. The project took place in one clinic over 12 weeks, which limits how widely and how long the findings apply.

Implications

For practice, a template-supported nurse visit is a workable way to give every child a current plan, and brief technique checks at routine contacts appear worth their small cost. Administrative links to schools and families need owners from the start. For policy, the project raises questions about standard agreements for sharing plans with schools, payment for nurse education visits and funding for language access. For nursing education, both device technique and teach-back deserve to be taught against a checklist and demonstrated back, and simulation with a parent actor is an efficient way to do it.

Sustainment

The clinic will keep the visit in two half-day sessions a week, keep the registry flag and front-desk process for school plans and make technique checks part of rooming. Following a view of sustainment as continued adaptation rather than fixed repetition (Chambers et al., 2013), delivery may change while the core stays. Each continuing element has an owner, a monthly measure and a trigger, and the quality committee will review them at three and six months.

Recommendations for Future Work

Three questions deserve further study. Does the improvement persist across a full year and through winter? Would a staggered start at the health system's second pediatric clinic, compared with the first over the same months, confirm the effect with a stronger design? And would a closer partnership with school nurses, in which they reinforce technique and review the plan, add benefit beyond sending the plan?

A cost analysis of nurse time against avoided emergency visits would also help leaders decide on spread, and the clinic's billing data could support one within a year.

Reflection on the Process

Looking back, three decisions shaped the project more than any other. Keeping a weekly log from the first day made problems visible while they could still be solved. Separating the fixed core of the visit from its adjustable supporting tasks allowed quick changes without undermining the evaluation. And writing the analysis rules before looking at outcomes protected the results from hopeful interpretation. If the project were repeated, the main change would be to build technique reinforcement into the design from the start rather than adding it at the midpoint.

Conclusion

A nurse visit built around a written plan and coached technique, with school and telephone follow-through, was followed by better asthma control and less acute care among children in a safety-net clinic, with similar results in both languages. The design cannot prove cause, and the true effect is probably smaller than observed. The findings nonetheless support keeping the program, reinforcing inhaler technique and testing the model further.

The committee is asked to approve the chapter for the defense.

References

Chambers, D. A., Glasgow, R. E., & Stange, K. C. (2013). The dynamic sustainability framework: Addressing the paradox of sustainment amid ongoing change. Implementation Science, 8, Article 117. https://doi.org/10.1186/1748-5908-8-117

Harris, A. D., McGregor, J. C., Perencevich, E. N., Furuno, J. P., Zhu, J., Peterson, D. E., & Finkelstein, J. (2006). The use and interpretation of quasi-experimental studies in medical informatics. Journal of the American Medical Informatics Association, 13(1), 16-23. https://doi.org/10.1197/jamia.M1749

Harris, K., Kneale, D., Lasserson, T. J., McDonald, V. M., Grigg, J., & Thomas, J. (2019). School-based self-management interventions for asthma in children and adolescents: A mixed methods systematic review. Cochrane Database of Systematic Reviews, 2019(1), Article CD011651. https://doi.org/10.1002/14651858.CD011651.pub2

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

Zemek, R. L., Bhogal, S. K., & Ducharme, F. M. (2008). Systematic review of randomized controlled trials examining written action plans in children: What is the plan? Archives of Pediatrics & Adolescent Medicine, 162(2), 157-163. https://doi.org/10.1001/archpediatrics.2007.34