1. Fulton, Janet S. PhD, RN, ACNS-BC, ANEF, FCNS, FAAN

Article Content

Clinical nurse specialists (CNS) are involved in all manner of clinical projects including quality improvement initiatives, evidence-based practice changes, and clinical care program development. Disseminating project findings is important to the development of a body of knowledge about nursing practice. To the extent that similar problems are experienced in other practice settings, published reports can assist others with tackling like problems. Though project findings are not generalizable, reporting findings from research studies and projects share a common requirement - the report must present a logical line of reasoning binding the work together. That is, the problem is clearly stated, objectives are delineated, interventions or actions are designed to achieve intended objectives, and conclusions are grounded in data. In the end, the reader needs to be convinced by the data that the action or intervention "fixed" the problem.


While we may agree in principle, in practice CNSs too often follow a meandering route to problem solving, resulting in an obscure line of reasoning. Often, a problematic situation is identified and an intervention is implemented. This "begin in the middle" approach moves to a solution before the problem is clearly defined and validated. Maybe the solution works, but in the end, we can never be sure why or why not. Too often, the solution unravels shortly after implementation and the problem settles in to one of those recalcitrant, reoccurring aggravations frequently discussed but ever resolved. Surely, we could write volumes about things we tried to fix that never got fixed, ever.


The "begin in the middle" approach becomes evident in manuscripts. A quick review of a manuscript will reveal a mismatch between the problem and conclusions, usually with data unable to support the findings. Clinical projects are important, so how can projects and the corresponding reports be improved? Planning. Planning takes time, but it pays off in the end. Planning is critical for project integrity (and completion). Many a project never comes to fruition because it gets started without a plan. Projects typically bog down at some point along the way; a plan with a timeline keeps the project on track. It's possible to deviate from the plan, but that requires having a plan in the first place!


Clinicians are reluctant, in my experience, to write project proposals. A proposal entails thinking through the project. If the idea of writing provokes unpleasant memories of writing formal papers in graduate school, then use bullet points, improper referencing, and notes in the margin. Get words on paper. I encourage clear writing; it assists with thinking at a higher level. Of course, the better the proposal is written, the more helpful it will be in preparing a manuscript for publication. Once written, review the proposal for a line of reasoning. Make sure the parts of the proposal are connected logically and flow one from the other. Here's a brief proposal outline.


A. Working Title: A working title provides focus for the initiative. Naming the work moves it from vague, abstract ideas to a circumscribed project.


B. Introduction/Background: Introduce the topic as stated in the working title. Include relevant definitions, incidence/prevalence, evidence highlights such as research, government reports, unit/hospital metrics, and so forth. The background provides a project team and eventual manuscript reader with the information necessary to understand the problem.


C. Statement of the Problem: Given the background information, what is the inadequacy, failure, missing element, confusion, or other concern? How is nursing care delivery or clinical outcomes adversely affected? What benchmarks are not being met? The problem statement should be narrowly focused and specific.


D. Purpose: The purpose of the project is to "fix" the problem. Write the purpose statement using the same words and terms as in the problem statement. The problem statement and purpose statements should be parallel. Logic must prevail. Keep creative writing for novels. And never use a fancy word when a simple word will do. Fancy works are clutter.


E. Significance: Identify why the problem is important and what is to be gained from the project.


F. Objectives: Achieving the overall purpose usually requires achieving several smaller objectives, such as, in the case of a problem caused by a care product: 1) identify number and type of complications associated with current product; 2) explore alternative products to reduce the incidence of the problem; 3) evaluate products on one unit and 4) select the best product and implement on all units.


G. Methods: Methods is the "middle" so avoid starting a project with implementation before thinking through the problem. The methods section includes


a. Describe the intervention. Explain exactly what constitutes the intervention. Consider this a recipe for making the intervention. Be specific.


b. Describe procedural steps such as timing, frequency, how much, and by whom. A statement such as "cleanse the skin" is not specific. For how long? With what? How often? By whom?


c. Describe how the outcomes will be measured. Measurement provides the data to determine that the objectives were achieved. Select measures that provide data for each objective.


d. Describe implementation procedures, such as who will contact product suppliers, teach the staff to use the products, validate proper use by staff, stock the product, collect the data and so forth.


H. Analysis


a. Identify methods for data analysis. Depending on the volume of data, spreadsheets and data collection software can be used to both collect and analyze quantitative data. Plan for data management and analysis before data are collected! Never collect data that will not be included in analysis for the purpose of documenting achievement of the project purpose and objectives.



Setting up a project is an iterative process. Edit and rework the proposal until all the elements logically align and are achievable. Consider human subjects review when data is about patients or staff. Organizations differ in their procedures for protection of human subjects. Consult the organization's Institutional Review Board (IRB) or similar ethics committee. When publishing the project, include a statement about human subjects protection.


A clear, logical line of reasoning is central to successful projects and likewise successful publication. "Begin in the middle" is common mistake among busy clinicians, so when that happens, take a step back, reflect, and start writing a proposal. The more organized the proposal, the better chance for a successful project and ultimately a publication!