Evidence-Based Practice Grant Application Form

 

| Resume a previously saved form
Resume Later

In order to be able to resume this form later, please enter your email and choose a password.








Projected Dates of Project:  We realize that you may not have precise dates at this time.  Your best guess will suffice.



PROJECT TEAM LEADER 







IF THERE ARE ADD'L PEOPLE ON YOUR TEAM - YOU MAY LIST UP TO 5 TOTAL

FIRST Team Member








SECOND Team Member









THIRD Team Member








FOURTH Team Member








FIFTH Team Member








AFFILIATED HOSPITAL/INSTITUTION INFORMATION







MAILING ADDRESS FOR PAYMENT OF GRANT






MAILING ADDRESS FOR PAYMENT OF GRANT









INSTITUTIONAL OFFICIAL 

If there is an Institutional Official (IO), who should receive copies of funding approval and report requests?









If you have a Project Mentor, please enter the information below:















PROPOSAL:

Please complete the following proposal. Use the APA format for references, citing the author and publication year in parentheses. (For example, Smith and Jones, 2012.) Then detail your references on an attachment. 

 

To determine the number of words you are using, type in a Word document first and use word count.  Then copy/paste into the form below.



NOTE ABOVE: Be as specific as you can (Example: Less strong: we want to determine if a patient/family education program works - Stronger: Determine if there is an improvement in patient/family satisfaction with discharge education after implementation of a computer based medication education program).

 

Include the patient/family Population (i.e., only matching DAISY Foundation mission), clinical Problem, evidence-based Intervention for the practice change and desired Outcome.



  • NOTE ABOVE

    • Describe the current clinical problem that you propose to change and cite appropriate evidence. Preliminary data
      from you organization may be included.
    • Who is the target audience? (e.g. what group of patients/family will be the focus of the project?)
    • Describe why this is a priority for these patients or families.
    • Describe how this project will benefit cancer or auto-immune disease patients and/or family, in keeping with DAISY Foundation’s stated goal, and how this project addresses the priorities of the J. Patrick Barnes Grant program.
    • Cite and summarize evidence (e.g., patient focused data from Quality Improvement/establishing a need, practice guidelines and more recently published research and research supporting the practice change) to support the need for a change, and also cite evidence to support the need for the initiative you are proposing.
    • Upload a list of references as an attachment to the application. (Uploading is explained below.)

 




  • NOTE ABOVE

     

    • List step-by-step how the change will be implemented. Please see the sample EBP proposal for ideas when describing the desired practice

    • Describe timing within patient encounters (e.g., week 4 of radiation therapy) and use of tools to engage patients and clinicians.

    • When will you evaluate the outcomes of the change?

    • This description should be detailed enough that another organization could independently replicate your project.

    • The tools of the practice change must be ready to use and attached.

 



NOTE ABOVE: 
  • Outline and use a phased implementation plan. A phased approach to implementation that prepares clinicians, assisting them with adoption of the EBP and re-infusion is required. One resource to provide direction is: Cullen, L. & Adams, S. (2012).  Planning for Implementation of Evidence-Based Practice. Journal of Nursing Administration 42(4), 222-230.
  • There is a difference between an implementation plan and project management. Click here to read the distinction.
  • Include a multi-faceted approach to implementation
  • Staff education can be included but must not be the only implementation strategY



 
NOTE ABOVE
  • Outcome measures include 1) a definition (e.g., patients will be asked to rate their fatigue on a 0-10 scale using Brief Fatigue Inventory (used with permission, The University of Texas MD Anderson Cancer Center, 1997), 2) how data will be collected (e.g., hard copy of patient questionnaire), 3) planned data analysis, and 4) reporting. Examples of outcome measures include patient symptoms related to cancer or cancer treatment.  



NOTE ABOVE

 

 

  • Describe in detail how you will evaluate the outcomes of your initiative. Be as specific as possible on what your outcome measures are (e.g, pre-to-post change in item 1-5 of the Brief Fatigue Inventory (include citation and permission) will be used to evaluate the effectiveness of the intervention).
  • Include a brief description of the sample size and identification of the usual care group and the EBP or practice change group.
  • Include a brief description of the sample and sample size for clinicians participating.
  • Process measures include clinician knowledge, clinician feedback on implementation with tools/resources, clinical practices used by clinicians, patient knowledge or patient health behaviors.
  • The process measures include 1) a general definition (e.g., patient activity practices will be collected by interviewing patients to obtain their self-reported frequency and time spent walking, gardening, doing household chores, work, and other forms of physical activity over the past week), 2) how data will be collected (e.g., patient interview), 3) planned data analysis (e.g., percent change in physical activity, paired t-test) and 4) reporting (e.g., report to unit council, quality committee).
  • Evaluation includes process measures (e.g., how you evaluated that the nurses’ were actually performing the change in practice) and outcome measures/endpoints in this section (e.g., pre-post evaluation of patient/family  symptoms)
  • Preliminary data may be helpful but is not required.

 



NOTE ABOVE: Describe in detail how clinical/staff nurses will be involved in this study. E.g. in conceptualization, data collection, analysis, reporting. This is a very important component of your proposal.


Timeline:  Detail your proposed step-by-step timeline, following this example. Your plan should not exceed 12 months.

Proposed Study Duration:

Example: 12 months

Time Frame (Weeks)

Task

Example: Weeks 1-6

Prepare all study materials

Example: Weeks 6-20

Recruit participants

Example: Weeks 21-30

Collect data

Example: Weeks 30-52 

Data analysis and preparation of final report

Example: Week X

Progress report due to DAISY Foundation

Example: Week Y

Final report due to DAISY Foundation

Your Timeline:

Create a spreadsheet identical to the one above to present your project’s timeline. Include additional steps from the EBP process model you identified previously as guiding this project work.  Please upload your timeline at the end of this application.


Proposed Budget:   Funds are available for direct expenses only. Institutional overhead may not be included. Provide budget using the following chart, and describe/provide justification for how you will use the grant funding to support your project (e.g., cost for reproduction of booklets - 500 booklets @ $2/booklet = $1000).  If the funding level offered by The DAISY Foundation is not adequate for your project, please email bonniebarnes@DAISYFoundation.org to discuss.

Budget Item Requested

Detail

Cost

Justification: Why this is needed

Example:

Reproduction of  booklets

500 booklets @ $2.00

$1,000

This is for the family education piece whose effectiveness we are studying

Example:

Supplies

Paper and copying

$250

 

Example:

Statistician

To analyze data and prepare final report.

10 hours @$50 per hour

$500

Professional statistical help required to ensure integrity of findings

Your Budget:

Create a spreadsheet identical to the one above to present your project’s budget.  Please upload your budget at the end of this application. 


DOCUMENTATION – Upload the documents listed below. Your Application Number must be on every page of every document. (Please save your documents using the following simple naming convention for each one you upload: JPB-xxx-A Budget or JPB-xxx-A  Timeline, JPB-xxx-A Interview Guide, etc.):

-  Timeline

-  Budget

-  Letter of Agreement (see below)

-  Consent Forms - if consent forms are required for IRB approval, they must be submitted with this application

-  Interview formats, discussion guides, etc.

-  References (detail the sources of your assumptions and literature review)

-  For EBP grants, Applicant's resume or CV. Please highlight funded and unfunded studies and EBP projects.

- If you have a Mentor, the Mentor's biosketch or abbreviated CV. This should include the Mentor's accomplishments/experience/academic training as they relate to this project. 

- Proof of IRB approval or letter of exemption if you have it. If you do not have input from your IRB, you may apply and provide the approval prior to DAISY's funding of the grant.



Application Checklist

Now that you have completed your proposal, please review it and check off each of the following requirements:

 

Ÿ       _____ Your project is ready to go, as soon as you receive IRB approval and funding from DAISY

Ÿ        

___  _____ Your project is an Evidence-based Practice Project (EBP), not a Quality Improvement project (QI) 

 

Ÿ       _____ Your Purpose statement contains the patient population matching The DAISY Foundation's mission, clinical problem, evidence-based intervention or practice change and desired outcome.

 

Ÿ       _____ Your Team includes staff nurses in project leadership roles, change agent(s) and an EBP expert as a mentor.

 

Ÿ       _____ Your Background describes why this is a priority for patients/families and the organization.

 

Ÿ       _____ Your Background describes a synthesis of the evidence establishing the need to address the clinical issue (e.g., cited prevalence of the clinical problem), the benefit of the intervention, and expected impact on process and outcome indicators. Evidence is cited that is current and comprehensive. If a practice guideline is part of the evidence synthesis you include a brief summary of the strengths and limitations as identified by your critique (e.g., using the AGREE Instrument - link to http://www.agreetrust.org/ or http://www.agreetrust.org/wp-content/uploads/2013/10/AGREE-II-Users-Manual-and-23-item-Instrument_2009_UPDATE_2013.pdf). If a practice guideline is used, you include a synthesis of more recent evidence (including research and EBP) that has been reported subsequent to the date of the evidence review within the guideline.

 

__   _____ Your EBP Process Model provides direction for project development and planning. Commonly-used models include the Iowa Model, Johns Hopkins Model, or another model used in your organization.

 

Ÿ       _____ Your Proposed change describes the procedure for the use of the evidence-based practice being introduced such that any nurse reader would be able to use the procedure as intended. Please see the sample EBP proposal for ideas when describing the desired practice, timing within patient encounters (e.g., week 4 of radiation therapy) and use of tools to engage patients and clinicians.

 

_________ Your Implementation Plan describes a multi-faceted approach to engage clinicians and patients in use of the practice change.  Do not limit implementation to education of clinicians, as additional implementation strategies will be needed.  Consider a reinfusion plan along with a plan to promote initial adoption.

 

Ÿ       _____ Your Process evaluation is included in the evaluation plan  and describes the key process measures/indicators including a general definition (e.g., patient activity practices will be collected by interviewing patients to self-report the frequency and time spent walking, gardening, household chores, work, and other forms of physical activity over the past week), how data will be collected, planned data analysis and reporting. Examples of process measures include clinician knowledge, clinician feedback on implementation tools, clinical practices used by clinicians, patient knowledge or patient health behaviors. Preliminary data may be helpful but is not required.

 

 

Ÿ       _____ Your Outcome evaluation is included in the evaluation plan and describes the key outcome measures/indicators including a definition (e.g., patients will be asked to rate their fatigue on a 0-10 scale using Brief Fatigue Inventory (used with permission, The University of Texas MD Anderson Cancer Center, 1997), how data will be collected, planned data analysis and reporting. Examples of outcome measures include patient symptoms related to cancer or cancer treatment. Preliminary data may be helpful but is not required.

 

Ÿ       _____ Your Attachments include ALL the tools to assist the clinician in engaging patients to participate in the practice change.

 

Ÿ       _____ Your Attachments include ALL the tools used for data collection.

 

Ÿ       _____ Your Attachments include all letters granting permission for use of tools

 

Ÿ       _____ Your Attachments includes a timeline that uses the format described above.  It includes the steps of the EBP process following development of the tools supporting the practice change (i.e., Copying of patient materials, copying of data collection tools, staff training about practice change, core group work to promote adoption of the practice change, reinfusion plans, monitoring progress, data collection, data entry, data cleaning and analysis, Interim and Final Reports to The DAISY Foundation, etc.)

 

Ÿ       _____ Your Attachments include a budget for materials and tools needed to engage patient in the practice change, train clinicians and complete the evaluation. You have used the format described above.

 

Ÿ       _____ Your Attachments include one addressing IRB approval (with the consent) or determination that the project is not human subjects research.

 

Ÿ       _____ Your Attachments includes the letter of agreement with The DAISY Foundation, signed by you and your CNO or other administrative leader.

 

Ÿ       ___ Your Attachments includes the list of references cited within the application.

 

Ÿ       ___ Your Attachments include the CV of the applicant and EBP mentor.


LETTER OF AGREEMENT: Please copy and paste this onto your institution’s letterhead.  Fill in the blanks, print it out and sign it. Your Chief Nursing Officer or other Senior Administrator's signature is also required as an indication of her/his support of your work.  

Then scan it into your computer, and upload with this application.  Your application is not complete without this document.

I, __________________________________________, Team Leader/Project Leader/Principal Investigator of the  project entitled _________________________________________________, commit the following to The DAISY Foundation in return for funding I request of $____________:

  • That funds will be used only for direct expenses as detailed in the budget provided in my application
  • That I will inform The DAISY Foundation of the actual start date of this study
  • That a check for any unused funds will be sent to The DAISY Foundation within 90 days of the project’s completion
  • That I will communicate in writing to The DAISY Foundation if my project is terminated before completion
  • That an interim report will be submitted 6 months after funding and a final report submitted within 90 days of the project’s completion. These reports will be submitted through The DAISY Foundation website.
  • That the report of my study may be posted on The DAISY Foundation website, if the Foundation chooses to do so.
  • That the DAISY Foundation is permitted to use my name/those of my team members and institution and the title and summary of my study in their marketing materials to help promote the grant program. 
  • That I will credit funding from The DAISY Foundation upon publication/presentation of this research.
  • That The DAISY Foundation may not be held liable for any risk to the subjects of this study.

 

 

Signed __________________________                            Date_______________

 

FOR YOUR CHIEF NURSING OFFICER OR OTHER SENIOR ADMINISTRATOR:

I fully support __________________________________, Principal Investigator of the study entitled ___________________________________________________ in her/his implementation of this project. 

Furthermore, I attest to the fact that nurse clinicians/staff nurses will be involved in this work, as described in the application.

Signed__________________________________________________

Title____________________________________________________

Date___________________________________________________


If you have trouble submitting and get an error message, please check that you have completed all required fields (noted with an asterisk) and that your phone numbers follow the prescribed format (555-555-5555).
 


Need assistance with this form?