Standards For Quality Improvement Reporting Excellence Research Articles

Shedding new light for nurses: Enhancing pressure injury prevention across skin tones with sub-epidermal moisture assessment technology.

To assess the effectiveness of sub-epidermal moisture (SEM) assessment technology in the detection of early-stage pressure damage in a critical care unit (CCU) and dark skin tone patients and its impact on hospital-acquired pressure injury (HAPI) incidence. Quality improvement study employing Kurt Lewin's change model emphasizing planning, implementation, evaluation and sustainable change. The study evaluated 140 adult patients admitted to the CCU over a 24-week period, from July to December 2022. Retrospective analysis of standard PI care pathways was performed in 90 patients admitted during a 12-week pre-implementation period. Fifty patients were admitted through the subsequent 12-week implementation period. SEM assessments were performed daily at the sacrum and heels and interventions were applied based on SEM assessments; SEM delta ≥0.6 indicating localized oedema or persistent focal oedema. Statistical analyses were performed on anonymized data. Pre-implementation HAPI incidence was 8.9% (N = 8/90). All eight patients were African American with varying skin tones. A 100% reduction in HAPI incidence was achieved in the implementation period which included 35 African American patients. The relative risk of HAPI incidence was 1.6 times higher in the pre-implementation group. Implementing SEM assessment technology enabled equitable PI care for all population types and resulted in a 100% reduction of PIs in our CCU. Objective SEM assessments detected early-stage PIs, regardless of skin tone and enabled providing interventions to specific anatomies developing tissue damage as opposed to universal preventive interventions. PI care pathways relying on visual and tactile skin assessments are inherently biased in providing equitable care for dark skin tone patients. Implementing SEM assessments empowers healthcare practitioners in driving objective clinical interventions, eliminates bias and enables positive PI health outcomes. Implementing SEM assessment technology had three main effects: it detected early tissue damage regardless of skin tone (detection effect), enabled anatomy-specific interventions (treatment effect) and prevented PIs across all population types (prevention effect). The authors have adhered to the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guidelines. No patient or public contribution. What does this paper contribute to the wider global clinical community? Addressing health inequities in pressure injury prevention; Demonstrated effectiveness across patient populations; Resource optimization and enhanced patient safety.

Establishing a patient‐centered, multidisciplinary pharmacogenomics clinic in an academic health system: Successes, challenges, and future direction

AbstractIntroductionPharmacogenomics (PGx) testing uses a patient's deoxyribonucleic acid (DNA) profile to tailor medications with the goal of preventing adverse drug reactions and improving pharmacotherapy outcomes. Despite the availability of evidence‐based guidelines that assist with interpretation of PGx results, PGx testing has not been widely adopted.ObjectiveTo describe how a multidisciplinary PGx clinic was implemented within the University of Pennsylvania Health System (Penn Medicine) including the clinical workflow, challenges to implementation, and future directions.MethodsThis project qualified as Quality Improvement by the University of Pennsylvania's Institutional Review Board and adheres to the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guidelines. Clinic metrics were collected from February 2019 until December 2022. Data collected included patient demographics; the timing of PGx test ordering and appointments; number and frequency of actionable PGx phenotypes; number of current or historical medications impacted by PGx test results; and patient's out‐of‐pocket cost for PGx test.ResultsOf the 69 patients included, the majority were female (58%), white (84%), with a mean age of 48 years. The overall time between the dates of the PGx test order and clinic visit was 37 days. The time between the dates of the PGx test order and the PGx test results were generated was 18 days. All patients had at least one actionable PGx phenotype and 74% had three or more. The most frequent actionable phenotypes were found in the cytochrome P450 PC19 (CYPC19) (60%) and CYP2D6 (58%) genes. The percentage of patients that had drug‐gene interactions that affected their current medications and explained historical medication intolerances were 25% and 17%, respectively. Out‐of‐pocket costs were less than $300 for most patients who had a PGx test ordered by the clinic physician.ConclusionThis paper has established a sustainable PGx clinic workflow with dedicated personnel. In the future we intend to increase the availability of our services.

Mapping quality improvement education initiatives to Standards for QUality Improvement Reporting Excellence (SQUIRE) guidelines.

To explore the rigour of nurse-led quality improvement projects involving education, training or continuing professional development, and examine evaluation frameworks contained within. Healthcare organisations invest significantly in quality improvement in the pursuit of cost-effective, safe, evidence-based and person-centred care. Consequently, efforts to examine the success of investment in quality improvement activities are prominent, against a backdrop of rising healthcare expenditure, reforms, consumer expectations and feedback. A qualitative document analysis of quality improvement projects located in a local health district repository was undertaken. N=3004 projects were screened against inclusion criteria, with n=160 projects remaining for analysis. Projects were mapped to an adapted version of the Standards for QUality Improvement Reporting Excellence (SQUIRE), specifically the education extension (SQUIRE-EDU). Additionally, project evaluation frameworks were positioned within Kirkpatrick's four levels of training evaluation model. The SQUIRE checklist was also applied in line with EQUATOR guidelines. Of n=60 completed projects assessed against four broad SQUIRE-EDU categories and relevant criteria, n=36 were assessed not to have met any categories, n=14 projects met one category, n=8 projects met two categories, and n=2 projects met three categories. None of the completed projects met all four SQUIRE-EDU categories. There was insufficient documentation relating to evaluation frameworks in n=133 projects to position within Kirkpatrick's four levels of training evaluation. Scientific rigour should underpin all quality improvement efforts. We recommend that SQUIRE international consensus guidelines (full or abridged) should guide both the design and reporting of all local quality improvement efforts. To be of value to the expansion of evidence-based practice, quality improvement platforms should be designed to reflect the structural logic, rigour and reporting recommendations being advocated in consensus reporting guidelines. This may require investment in training and development programs, and identification of governance and support systems. No Patient or Public Contribution, as the study was retrospective in nature and involved a health service repository of quality improvement projects accessible to health service staff only.

Improving detection of undiagnosed HIV through routine screening in a central London emergency department

HIV is a global public health issue. Routine testing for HIV should be performed on all 16–59 years old attending emergency departments (EDs) in high-prevalence areas in the UK.In August...

Implementation of an evidence-based accidental tracheostomy dislodgement bundle in a community hospital critical care unit.

Tracheostomy dislodgment can lead to catastrophic neurological injury or death. A fresh tracheostomy amplifies the risk of such events, where an immature tract predisposes to false passage. Unfortunately, few resources exist to prepare healthcare professionals to manage this airway emergency. To create and implement an accidental tracheostomy dislodgement (ATD) bundle to improve knowledge and comfort when responding to ATD. A multidisciplinary team with expertise in tracheostomy developed a 3-part ATD bundle including (1) Tracheostomy Dislodgement Algorithm, (2) Head of Bed Tracheostomy Communication Tool and (3) Emergency Tracheostomy Kit. The team tested the bundle during the COVID-19 pandemic in a community hospital critical care unit with the engagement of nurses and Respiratory Care Practitioners. Baseline and post-implementation knowledge and comfort levels were measured using Dorton's Tracheotomy Education Self-Assessment Questionnaire, and adherence to protocol was assessed. Reporting follows the revised Standards for Quality Improvement Reporting Excellence (SQUIRE). Twenty-four participants completed pre-test and post-test questionnaires. The median knowledge score on the Likert scale increased from 4.0 (IQR=1.0) pre-test to 5.0 (IQR=1.0) post-test. The median comfort level score increased from 38.0 (IQR=7.0) pre-test to 40.0 (IQR=5.0) post-test). In patient rooms, adherence was 100% for the Head of Bed Tracheostomy Communication Tool and Emergency Tracheostomy Kit. The adherence rate for using the Dislodgement Algorithm was 55% in ICU and 40% in SCU. This study addresses the void of tracheostomy research conducted in local community hospitals. The improvement in knowledge and comfort in managing ATD is reassuring, given the knowledge gap among practitioners demonstrated in prior literature. The ATD bundle assessed in this study represents a streamlined approach for bedside clinicians - definitive management of ATD should adhere to comprehensive multidisciplinary guidelines. ATD bundle implementation increased knowledge and comfort levels with managing ATD. Further studies must assess whether ATD bundles and other standardised approaches to airway emergencies reduce adverse events. Relevance to Clinical Practice A streamlined intervention bundle employed at the unit level can significantly improve knowledge and comfort in managing ATD, which may reduce morbidity and mortality in critically ill patients with tracheostomy.

Optimizing the productivity and placement of NPs and PAs in outpatient primary care sites.

Organizational leaders must continually assess the productivity, turnover, and vacancies of physician assistants (PAs) and NPs. Optimizing the feasibility, effect, strategic placement, and monitoring increases patient access, improves wait times and affordability, and increases revenue. This quality improvement project sought to develop a systematic, data-driven approach to optimize productivity and placement of NPs and PAs in outpatient primary care sites. Results from this project are reported using the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE) framework. Postformation of a quality improvement team, a gap analysis, and action plans were developed and implemented. Priority areas requiring action included the development of an integrated position justification algorithm and tracking form addressing NP and PA placement, establishing consistent patient contact hours, setting workload expectations, and consistently communicating these via an organization-specific situation, background, assessment, and recommendation communication tool. Healthcare leaders should leverage the talents of NPs and PAs meeting organizational benchmarks and goals as well as the needs of patients. NP and PA leaders should focus on benchmarking performance and analyzing barriers to optimization. These efforts are most beneficial when multidisciplinary in nature.

Identify Early and Involve Everyone: Interdisciplinary Comprehensive Care Pathway Developed for Inpatient Management and Transitions of Care for Heart Failure Patients Reported Using SQUIRE 2.0 Guidelines.

IntroductionHeart failure accounts for 1-2% of overall healthcare costs. While the link between re-hospitalization and mortality is unclear, care pathways that standardize inpatient management and establish outpatient follow-up improve patient outcomes and reduce morbidity.AimTo implement a comprehensive interdisciplinary care pathway for heart failure patients with the goal of optimizing inpatient management and improving transitions of care.MethodsTo address this clinical need, New York-Presbyterian Brooklyn Methodist Hospital (NYP-BMH) identified resources needed to optimize patient care, developed an inpatient admission order set (so-called “power plan”), and implemented a multidisciplinary clinical care pathway. The Plan-Do-Study-Act cycle addressed the implementation obstacles. Interdisciplinary rounds guided day-to-day management and addressed barriers. Our team developed a sustainable care pathway, and measured the utilization of pharmacy, nutrition, physical therapy, case management, and social work resources; outpatient appointments were made prior to discharge. We used the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guidelines to guide our planning and evaluation of this quality improvement initiative.ResultsOur intervention markedly increased the number of heart failure hospitalizations that were identified on admission, and the use of pharmacy/nutrition services was greater after the intervention. The utilization of our “power plan” promoted adherence to a series of evidence-based best practices, but these measures had no significant impact on readmissions as a whole. The involvement of the case management support team increased outpatient appointments made for patients prior to discharge and aided in the transition of care from inpatient to outpatient management.ConclusionThe management of heart failure patients starts in the hospital and continues in the community. Patients who are treated in a standardized dedicated care pathway have reduced morbidity and better outcomes. Identifying these patients early, involving a comprehensive team, and transitioning their care to the outpatient setting improves the quality of care in these patients.

Utilization of a National Registry to influence opioid prescribing behavior after hernia repair.

Despite progress toward curtailing opioid prescribing, physicians are often slow to adopt new prescribing practices. Using the Abdominal Core Health Quality Collaborative (ACHQC), we aimed to demonstrate the ability of a national, disease-specific, personalized registry to impact opioid prescribing. Using a collaborative and iterative process, a module was developed to capture surgeon opioid prescribing, patient-reported consumption, and risk factors for opioid use. Study reported according to the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guidelines. Six months after implementation of the ACHQC opioid module, we assessed participation, prescribing and patient consumption patterns. For ventral hernia repair (VHR; n = 398), 23 surgeons reported prescribing > 20 pills (43%), 11-20 (40%), and < 10 (18%). In contrast, patients (n = 217) reported taking < 10 pills in 65% and only 20% reported taking > 15. For inguinal hernia repair (IHR; n = 443) 37 surgeons reported prescribing > 20 tablets (22%), 11-20 (32%), and < 10 (44%). Patients (n = 277) reported taking < 10 pills in 81% of cases, including 50% reporting zero, and only 13% taking > 15. We identified barriers to practice change and developed a strategy for education, provision of individualized data, and encouraging participation. Surgeon participation has since increased significantly (n = 65 for VHR; n = 53 for IHR), and analysis of the impact of this process is ongoing. Quality improvement requires physician engagement, which can be facilitated by meaningful and actionable data. The specificity of the ACHQC and the ability to provide surgeons with individualized data is a model method to incite change in physician behavior and improve patient outcomes.

Care bundles to reduce unplanned extubation in critically ill children: a systematic review, critical appraisal and meta-analysis

ObjectiveTo assess the current evidence for the efficacy of care bundles in reducing unplanned extubations (UEs) in critically ill children.DesignSystematic review according to the Cochrane guidelines and meta-analysis using random-effects...

Measuring and publishing quality improvement

Misalignment of measures, measurement and analysis with the goals and methods of quality improvement efforts in healthcare may create confusion and decrease effectiveness. In healthcare, measurement is used for accountability,...

Survey of Nursing Faculty Preparation for Guiding DNP Quality Improvement Projects.

Quality improvement (QI) projects comprise the majority of University of Maryland School of Nursing (UMSON) Doctor of Nursing Practice (DNP) projects. An online survey was completed by 51% (n = 38) of faculty, who teach or mentor DNP students, and was analyzed using quantitative and descriptive methods. Faculty were somewhat or not familiar with developing a QI charter 68.4%, human error theory and error proofing 63.2%, driver diagrams 60.5%, characteristics of high-reliability organizations 60.5%, and Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines 55.3%. The faculty were most interested in learning more about (n = 97 responses) were human error theory and error proofing (28.9%), SQUIRE guidelines (26.3%), statistical process control (21.1%), and implementation strategies and tactics (21.1%). The most commonly identified challenges included identifying QI projects (24%), project time constraints (16%), keeping up-to-date on QI concepts, methods, and tools (12%), and balancing professional workload (10%). Gaps in self-reported QI knowledge indicate there is a need for further development of DNP and PhD prepared faculty at the UMSON.

Transfer and Implementation Process of a Good Practice in Workplace Health Promotion.

The procedure developed by the European Joint Action CHRODIS PLUS (JAC+) to transfer and implement good practices from one setting to another was tested in the context of a workplace health promotion good practice identified in the Region of Lombardy (Italy) and transferred and implemented in two organisations in Andalusia (Spain). This article provides a detailed account on how the JAC+ implementation methodology, which included the use of the SQUIRE (Standards for QUality Improvement Reporting Excellence) guidelines, was applied. It offers a practical overview for the uptake of this methodology and of the good practice itself. The account of how this systematic and rigorous implementation reporting model was applied can be of value to those with an interest in workplace health and in the transfer of good practice and implementation sciences.

Vaccinations, Not Vaccines, Save Lives: Quality Improvement for Newborn Vaccination.

Across the world, in medical journals, news media, social media, and personal discussions, one of the hottest topics of discussion is the coronavirus disease 2019 (COVID-19) vaccine. The rapid development of effective vaccines for COVID-19 is a remarkable success story of modern science, and it is a reminder for all of us about the significant health benefits of vaccines in general, benefits we often take for granted. Although the COVID-19 vaccine is the media star of the day, children receive numerous other routine vaccinations, including the hepatitis B vaccine, which significantly reduces the risk of hepatitis B virus infection. However, with all vaccines, including the hepatitis B vaccine, there are significant gaps in coverage, with high percentages of eligible children either not receiving the vaccine at all or receiving it late, thus exposing them to the risk of infectious diseases. A quotation from Orenstein1 has recently surfaced in discussions about the COVID-19 vaccine: “vaccines don’t save lives, vaccinations save lives.” Gaps in vaccine coverage generate the need for quality improvement (QI) projects to close these gaps. In this issue of the journal, Sarathy et al2 describe the results of a QI project in which they aimed to increase the monthly percentage of eligible newborn infants receiving the first dose of the hepatitis B vaccine within 24 hours of life to ≥80% within 9 months of project initiation. This article contains some important lessons that deserve to be highlighted about the conduct, description, and publication of QI projects. In 2008, the Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines were first published. They were updated in 2015 as the SQUIRE …

Adopting the Fall Tailoring Interventions for Patient Safety (TIPS) Program to Engage Older Adults in Fall Prevention in a Nursing Home.

Falls are the leading cause of injury-related hospitalizations and deaths among older adults globally. About 24% of Canadian nursing home residents fall annually. This quality improvement project evaluated the impact of the Fall Tailoring Interventions for Patient Safety (TIPS) program on preventing falls and fall-related injuries among older adult nursing home residents in a subacute care unit in Canada. We used the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guidelines for reporting. The intervention site is a 15-bed subacute care unit within a government-funded nursing home. The Fall TIPS program was adapted to a nursing home setting to prevent falls. It provides fall prevention clinical decision support at the bedside. The rates of falls and injuries decreased after implementing the Fall TIPS intervention. Engaging nursing home older adult residents in fall prevention is crucial in translating evidence-based fall prevention care into clinical practice.

An initiative to evaluate the safety of maternal bonding in patients with SARS-CoV-2 infection

Background In the last two decades, the world faced three epidemics caused by novel coronaviruses, namely, SARS-CoV in 2002, MERS-CoV in 2012, and the ongoing SARS-CoV-2 that started in late 2019. Despite a growing understanding of SARS-CoV-2 virology, epidemiology, and clinical management strategies, other aspects, such as mode of delivery, vertical transmission, and maternal bonding, remain controversial. The question we faced upon the decision to separate the neonates of SARS-CoV-2 positive mother is whether we follow the principle of “do no harm”? Methods This is a quality improvement project that analyzed all cases of SARS-CoV-2 positive pregnancies that delivered at a major health care system from March 1, 2020 to June, 1 2020. The article was prepared following Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guidelines. Data were prospectively collected and entered into the Research Electronic Data Capture (REDCap). Maternal bonding was defined by events such as rooming-in, skin to skin contact (STSC), and breastfeeding. Descriptive analysis was performed using the same software platform. Intervention We compared neonatal transmission rates between those neonates who experienced bonding versus those who were separated. Results A total of 1989 women were screened for SARS-CoV-2, from which 86 tested positive. Out of 31 analyzed pregnancies, five women (16%) were admitted to ICU and required mechanical ventilation. From the remaining 26 (84%), 17 (65%) opted for rooming-in, 12 (46%) for STSC, and 16 (61%) fed the infants with breastmilk (11 direct breastfeedings and five pumped the breast milk). All neonatal tests for SARS-CoV-2 returned negative. Conclusion Our results have illustrated that maternal bonding appears safe in neonates born to mothers that are SARS-CoV-2 positive.

An Evaluation of Reporting Guidelines and Clinical Trial Registry Requirements Among Addiction Medicine Journals.

Robust methodology and ethical reporting are paramount for quality scientific research, but recently, that quality in addiction research has been questioned. Avenues to improve such research quality include adherence to reporting guidelines and proper usage of clinical trial registries. Reporting guidelines and clinical trial registries have been shown to lead researchers to more ethical and transparent methodology. To investigate the reporting guideline and clinical trial registration policies of addiction research journals and identify areas of improvement. We used Google Scholar Metrics' h-5 index to identify the top 20 addiction research journals. We then examined the instructions for authors from each journal to identify whether they required, recommended, or made no mention of trial registration and reporting guidelines, including the Consolidated Standards of Reporting Trials (CONSORT), Meta-Analysis of Observational Studies in Epidemiology (MOOSE), Quality of Reporting of Meta-analyses (QUOROM), Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), Standards for Reporting Diagnostic Accuracy Studies (STARD), Strengthening the Reporting of Observational Studies in Epidemiology (STROBE), Animal Research: Reporting of In Vivo Experiments (ARRIVE), Case Reports (CARE), Consolidated Health Economic Evaluation Reporting Standards (CHEERS), Standards for Reporting Qualitative Research (SRQR), Standards for Quality Improvement Reporting Excellence (SQUIRE), Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT), Consolidated Criteria for Reporting Qualitative Research (COREQ), Transparent Reporting of a Multivariate Prediction Model for Individual Prognosis or Diagnosis (TRIPOD), Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P), and the International Committee of Medical Journal Editors (ICMJE) guidelines. We performed the same analysis regarding requirements for clinical trial registration. Of the 20 journals included in this study, 10 journals (50%) did not require adherence to any reporting guidelines. Trial registration followed a similar trend; 15 journals (75%) did not mention any form of trial or systematic review registration, and ClinicalTrials.gov was only recommended by only 1 journal (5%). Among top addiction medicine journals, required adherence to reporting guidelines and clinical trial registry policies remains substandard. A step toward fulfilling the National Institute on Drug Abuses' call for improvement in transparency and reproducibility within addiction research should include all journals adopting a strict reporting guideline and clinical trial registry adherence policy.

Agreement between a single, self-defined burnout item and the ProQOL burnout subscale for behavioural health staff.

Burnout in the field of behavioural health care is widespread. Occupational burnout can negatively impact providers' well-being and patient care, as well as lead to substantial fiscal cost to healthcare institutions. The objective of this quality improvement project was to develop a single-item survey to rapidly assess individual burnout and workforce well-being among behavioural health staff in our urban, safety-net hospital. We examined the degree of agreement between a single, self-defined burnout item from the Mini-Z and the ProQOL burnout subscale among one hundred and thirty-five nurses, behavioural technicians and administrative staff. Our findings indicate that ProQOL and Mini-Z have a low-to-moderate correlation at a baseline (k=0.52, 95% CI 0.26, 0.69). However, using a modified ProQOL cut-off score with a binary classification of both surveys yields a moderate-to-high agreement (K=0.67, 95% CI 0.54, 0.80). To our knowledge, this is the first published comparison of the Mini-Z with the ProQOL instrument. The project adheres to the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 reporting guidelines for quality improvement (Ogrinc et al., 2016). A single, validated question measuring burnout allows for more rapid assessment and the maximization of response rates, both of which are important steps in evaluating the level of burnout of the collective whole.

How to rapidly design and operationalise PPE donning and doffing areas for a COVID-19 care facility: quality improvement initiative

IntroductionEffective implementation of standard precautions specific to COVID-19 is a challenge for hospitals within the existing constraints of time and resources.AimTo rapidly design and operationalise personal protective equipment (PPE) donning...

Effectiveness of Clinical Nurses’ interventions in reducing medication errors in a paediatric ward

To evaluate a bundle of interventions, developed and implemented by nurses, to reduce medication administration error rates and improve nurses' medication administration practice. Medication administration errors are a problematic issue worldwide, despite previous attempts to reduce them. Most interventions to date focus on isolated elements of the medication process and fail to actively involve nurses in developing solutions. An Action Research (AR) three-phase quantitative study. Phase One aimed to build an overall picture of medication practice. Phase Two aimed to develop and implement targeted interventions. During this phase, the research team recruited six clinical paediatric nurses to be part of the AR Team. Five interventions were developed and implemented by the clinical nurses during this phase. The interventions were evaluated in Phase Three. Data collection included medication incident data, medication policy audits based on hospital medication policy and Safety Attitudes Questionnaire. Quantitative analysis was undertaken. The Standards for QUality Improvement Reporting Excellence (SQUIRE) checklist was followed in reporting this study. Postimplementing the interventions, medication error rates were reduced by 56.9% despite an increase in the number of patient admissions and in the number of prescribed medications. The rate of medication errors per 1,000 prescribed medications significantly declined from 2014 to 2016. The ward nurses were more compliant with the policy in postintervention phase than preintervention phase. The improvement in SAQ was reported in five of the seven domains. Clinically based nurse's participation in action research enabled practice reflection, development and implementation of a bundle of interventions, which led to a change in nursing practice and subsequent reduction in medication administration error rates. Active engagement of nurses in research empowers them to find solutions that are tailored to their own practice culture and environment.

Modifications Needed: Additional Strategies to Transform DNP Projects into Publishable Manuscripts

Modifications Needed: Additional Strategies to Transform DNP Projects into Publishable Manuscripts