5 Direct Practice Improvement Project ProspectusAntim.docx

5
Direct Practice Improvement Project Prospectus
Antimicrobial Stewardship program (ASP): An evidence based
quality assurance measure in combating Healthcare Associated
Clostridium Difficile Infection in an acute care facility and the
role of the Staff Nurse.
Submitted by
Date
Insert Chairperson Name
Prospectus Instructions:
1. Read the entire Prospectus Template to understand the
requirements for writing your Prospectus. Each section contains
a narrative overview of what should be included in the section
and a table with criteria required for each section. These criteria
will be used to assess the prospectus for overall quality and
feasibility of the proposed research study.
2. As you draft each section, delete the narrative instructions
and insert your work related to that section. Use the criteria
table for each section to ensure that you address the
requirements for that particular section. Do not delete/remove
the criteria table as this is used by you and your Committee to
evaluate your prospectus.
3. Prior to submitting your prospectus for review by your Chair
or Methodologist, use the criteria table for each section to
complete a self-evaluation, inserting what you believe is your
score for each listed criteria into the Learner Self-Evaluation
column.
4. The scoring for the criteria ranges from a 0-3 as defined
below. Complete a realistic and thoughtful evaluation of your
work. Your Chair and Methodologist will also use the criteria

tables to evaluate your work.
5. Your Prospectus should be between 6-10 pages when the
tables are deleted.
Score
Assessment
0
Item Not Present
1
Item is Present, But Does Not Meet Expectations: Not all
components are present. Large gaps are present in the
components that leave the reader with significant questions. All
items scored at 1 must be addressed by learner per reviewer
comments.
2
Item Approaches Meeting Expectations, But Needs Revision:
Component is present and adequate. Small gaps are present that
leave the reader with questions. Any item scored at 2 must be
addressed by the learner per the reviewer comments.
3
Item Meets Expectations: Component is addressed clearly and
comprehensively. No gaps are present that leave the reader with
questions. No changes required.
2
Introduction
The world today is faced with very dangerous infectious

diseases due to antibiotic resistance and in the United States,
the Centers for Disease Control and Prevention (CDC), has
named this escalating antibiotic resistance as one of the top five
threats in the country (CDC, 2017). According to statistics from
the CDC, drug-resistant bacteria cause more than 20, 000 deaths
annually and result to 2 million cases of disease recurrence
annually (Lagier et al., 2015). For this reason, there is an
increased need to make changes to the clinical practice to
encourage appropriate use of antibiotics. In late 2014, the
President’s Council of Advisors on Science and Technology
(PCAST) published a report on how to combat antibiotic
resistance (Khoruts et al., 2014). The President then gave orders
to the health sector on the implementation of antibiotic
stewardship programs in the healthcare settings. In early 2015,
the White House gave out a National Action Plan on the
management of antibiotic-resistant bacteria that established
goals that slow the emergence and spread of resistant bacteria
and promote antibiotic stewardship in inpatient and outpatient
care settings, mandating this ASP to be in all acute care
facilities by 2020 (CDC, 2017).
There is a need to identify different approaches to motivate
staff nurses to take action to prevent health care associated
clostridium difficile infections and other health care-associated
infections. Nurses are on the forefront and they are the last
people who evaluate the medications before giving them to
patients, more so antibiotics. So they should be recognized and
utilized as members of ASPs by being trained and kept engaged
(Mostaghim et al, 2017). In their work on inpatient infections,
Monsees, Goldman, & Popejoy, (2017) developed an argument
that staff nurses should have awareness of the antimicrobial
stewardship measures. Their argument has relevance to the
present study which purpose is to create awareness regarding
the antimicrobial stewardship in clinical settings.
Criteria (Required Components): score 0-3
Learner Self-Evaluation Score
(0-3)

Chair or Reviewer Evaluation Score
(0-3)
Introduction
This section briefly overviews the research focus or problem,
why this study is worth conducting, and how this study will be
completed.
The recommended length for this section is one paragraph.
1. Dissertation topic is introduced.
2. Describes how the study extends prior research or fills a
“need” or “defined gap” from current literature.
NOTE: This Introduction section elaborates on Point #1(the
Topic) from the 10 Strategic Points. This Introduction section
provides the foundation for the Introduction section in Chapter
1 of the Proposal.
NOTE: When writing this section ensure it has a logical flow,
as well as uses correct paragraph structure, sentence structure,
tense, punctuation, and APA format.
Comments from the Evaluator:
Background of the Problem
Healthcare-associated infections (HAIs) are infections that
patients get while receiving care for a different diagnosis in
healthcare facilities. They affect 1 out of every 25 hospital
patients at any time. These infections have become a threat to
patients’ health because they have led to increased morbidity
and mortality, yet they can be preventable. Over 1million HAIs
occur across the U.S. health care system every year, leading to
the loss of tens of thousands of lives and adding billions of
dollars to health care costs (CDC, 2016). HAIs can happen in
any health care facility, including hospitals, ambulatory surgical

centers, end-stage renal disease facilities, and long-term care
facilities. HAIs can be caused by bacteria, fungi, viruses, or
other less common pathogens.
The risk factors to HAIs include: exposure to internal catheters
into bloodstream, endotracheal, urinary, surgeries, injections,
contaminated healthcare environments, communicable diseases
without proper personal protective equipment, and importantly
overuse or improper use of antibiotics. Some of the common
HAIs patients get while hospitalized include: Central-line
associated bloodstream infections (CLABSI), Catheter-
associated urinary tract infections (CAUTI), Ventilator-
associated Pneumonia (VAP), and Surgical site infections (SSI)
(CDC, 2017). All these infections are treated with antibiotics
which in the past century eradicated most of the diseases. But
now, we are seeing resistance to these antibiotics which are a
health epidemic to the entire world. Not only do these
antibiotics become resistant but because of their frequent use,
serious HAIs such as carbapenem-resistant Enterobacteriaceae
(CRE), Vancomycin resistant E (VRE), methicillin resistant
Staphylococcus aureus (MRSA), and Clostridium difficile have
emerged.
The Centers for Disease Control and Prevention (CDC)
estimates that drug-resistant bacteria cause two million illnesses
and approximately 23,000 deaths each year in the United States
alone. That is why this challenge led to an action plan, “the
National Action Plan for Combating Antibiotic-resistant
Bacteria, to provide a roadmap to guide the Nation in rising to
this challenge.” The National Action Plan, signed by President
Obama on September 18, 2014, outlines steps for implementing
the National Strategy for Combating Antibiotic-Resistant
Bacteria and addressing the policy recommendations of the
President’s Council of Advisors on Science and Technology
(PCAST) (The White House, 2015).
Although its primary purpose is to guide activities by the U.S.
Government, the National Action Plan is also designed to guide
action by public health, healthcare, and veterinary partners in a

common effort to address urgent and serious drug-resistant
threats that affect people in the U.S. and around the world.
Implementation of the National Action Plan will also support
World Health Assembly resolution 67 .25 (Antimicrobial
Resistance), which urges countries to take urgent action at the
national, regional, and local levels to combat resistance. By
2020, implementation of the National Action Plan will lead to
major reductions in the incidence of urgent and serious threats,
including carbapenem-resistant Enterobacteriaceae (CRE),
methicillin resistant Staphylococcus aureus (MRSA), and
Clostridium difficile. The National Action Plan will also result
in improved antibiotic stewardship in healthcare settings,
prevention of the spread of drug-resistant threats, elimination of
the use of medically-important antibiotics for growth promotion
in food animals, and expanded surveillance for drug-resistant
bacteria in humans and animals (The White House, 2015)
Informed by this action plan, in the proposed study the
researcher will critically evaluate the Antimicrobial
Stewardship program in combating HAIs with emphasis on
Clostridium Difficile prevention and the nurses’ role.
Antimicrobial/Antibiotic Stewardship Program was put in place
as a set of inter-professional coordinated strategies that see to it
that practitioners and clinicians get involved in stopping the
spread of antibiotic infections in health care facilities. The
program can be defined as, “coordinated interventions designed
to improve and measure the appropriate use of antibiotic agents
by promoting the selection of the optimal antibiotic drug
regimen, including dosing, duration of therapy, and route of
administration.” (Fishman, 2012). There is evidence based
research that these programs can reduce microbial resistance,
decrease the spread of infections caused by multidrug-resistant
organisms (MDROs) and improve patient outcomes. “Antibiotic
stewardship programs significantly reduce the incidence of
infections and colonization with antibiotic-resistant bacteria and
C difficile infections in hospital inpatients” (Baur et al, 2017).
How does the performance of the government influence

antimicrobial/antibiotic stewardship programs? The CDC
recommends that ASP leadership consist of a program leader
(an ID physician) and a pharmacy leader, who co-lead the team.
In addition, the Joint Commission recommends that the
multidisciplinary team should include an infection preventionist
(i.e. infection control and hospital epidemiologist) and
practitioner. These specialists have a role in prevention,
awareness, and policy (Eckart, Hogan, Mao, Toscani, &
Brunetti, 2017). Nonetheless, with all these health
professionals there is one important person missing on this
team, who is underutilized and unrecognized but very important
for this ASP to function—the staff nurse. Hence the question:
Are the staff nurses being underutilized as members of the
antimicrobial stewardship program team related to the rise in
health care associated C. difficile?
Antimicrobial/antibiotic stewardship measures are enforced to
combat clostridium difficile infections but it is not known how
the rise in health care associated c-diff and its impact on
patients is related to the nurses being underutilized and not
recognized as members of the team. Nurses are on the forefront
and they are the last people who evaluate the medications
before giving them to patients, more so antibiotics. So they
should be recognized and utilized as members of ASPs by being
trained and kept engaged (Mostaghim et al, 2017). In their work
on inpatient infections, Monsees, Goldman, & Popejoy, (2017),
developed an argument that staff nurses should have awareness
of the antimicrobial stewardship measures. Their argument has
relevance to the present study which purpose is to create
awareness regarding the antimicrobial stewardship in clinical
settings.
Prior studies show that the role of inpatient staff nurses as
antimicrobial stewards is unexplored. Siegel & Kahn, (2014)
identified the need for future studies on how the rise in health
care associated c-diff and its impact on patients is related to the
nurses being underutilized and unrecognized as members of the
Antimicrobial Stewardship Program (ASP) team. A study by the

American Nurses Association (ANA) and the Centers for
Disease Control and Prevention (CDC) presents a strong
argument that “the urgent need to improve appropriate,
evidence-based antibiotic use cannot be overstated.” The
authoritative and informative report advises that “with the
current worldwide expansion of multidrug-resistant organisms,
the question is not whether to involve nursing in antimicrobial
stewardship, but how.” (ANA/CDC, 2017)
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Background of the Problem
The background section explains both the history of and the
present state of the problem and research focus.
The recommended length for this section is two-three
paragraphs.
1. Identifies the “need,” or “defined gap” that will lead to the
research problem statement in a following section. Citations
from the literature in the last 5 years describe the problem as a
current “need” or “gap” for further research.
2. Discusses how the “need” or “defined gap” has evolved
historically into the current problem or opportunity to be
addressed by the proposed study.
3. ALIGNMENT: The problem statement for the dissertation
will be developed from and justified by the “need” or “defined
gap” that is described in this section and supported by the
Literature.

NOTE: This Background of the Problem section uses
information from Point #2 (Literature Review) in the 10
Strategic Points. This Background of the Problem section
becomes the Background of the Study in Chapter 1 in the
Proposal. It is then expanded to develop the comprehensive
Background to the Problem section in Chapter 2 (Literature
Review) in the Proposal.
as well as, uses correct paragraph structure, sentence structure,
Theoretical Foundations and Review of the Literature/Themes
The pattern of analysis that will inform and guide the present
work is the Health Belief Model (HBM) and Nightingales
Theory. The HBM is by far the most commonly used theory in
health education and health promotion (Pamer, 2016). The HBM
model is considered to be an ideal explanatory framework for
the purpose to communicate research in health care. However,
its uses have been limited by theoretical limitations in this
field. Nonetheless, it is a psychological model that allows to
predict and further explain health behaviors. This is carried out
by directly focusing on an individual’s attitudes and beliefs.
The psychological model signifies that the health related
behaviors of an individual is dependent on the perception of
four critical areas: (a) severity of potential illness. (b) the
individual’s’ own susceptibility to that disease, (c) advantages
of taking preventive action, and (d) barriers for taking that
action.
The proposed study will adopt the HBM model to answer the
research question because it is a model often applied in nursing,
particularly in addressing issues related to patient compliance
and preventive health care practices. Thus, this model will be
used in the proposed study to explore the role of inpatient staff

nurses as antimicrobial stewards. The model further aids to
identify the rise in health care associated infections in hospitals
(Magill et al., 2014).
It is clear that this model that explains health behaviors can be
formulated in terms of how the staff nurses being underutilized
and not recognized as members of the antimicrobial/antibiotic
stewardship program team is related to the rise in health care
associated c-diff. The HBM model is considered as a great tool
for nurses, which offers them a theoretical framework to raise
questions about the problem of health care-associated
infections. The model allows nurses to help their patients in
preventing chronic diseases or, in case of having disease it aids
to improve quality of life (Lessa et al., 2015). In addition,
nurses could use this model to clarify risk perceptions of
patients and their behavior that is risky or harmful. This further
helps nurses to apply strategies that might influence patients in
making healthy lifestyle changes. The perceptions of patients
can be broadly affected by personality, age and sex.
Nightingales theory raised questions about the problem under
study. The theorist suggestion that nurses need to know about
the disease process will inform and guide the present work.
Katz and his fellow researchers alluded to a relationship
between Nightingales theory of nursing practice and preventing
hospital borne infections. “Does Nightingales theory of nursing
practice influence the staff nurses’ attitude and or believe that
antimicrobial stewardship is not their function because they do
not perceive themselves as antibiotic prescribers?” (Katz et al.,
2017).
The main focus of the Nightingale theory is on environment and
she provides an in depth description of every aspect of
environment. Nightingale believed that the role of the nurse was
to provide an environment to their patients in which perfection
might be achieved. Thus the role of the nurse as an
antimicrobial steward is considered important in combating
nosocomial infections. Nursing needs a specific educational
background and can be achieved by means of environmental

alterations.
Nosocomial Infections and Clostridium Difficile
In the US, Clostridium difficile infection (C. difficile, also
abbreviated as CDI) is one of the major nosocomial or hospital
acquired infections, mainly due to the increased use of
antibiotics. C. difficile infection is a disease that is common in
acute hospital settings and, in most cases, causes severe
diarrhea and weight loss. The disease is caused by the
disruption and destruction of the gastrointestinal microbiome.
C. difficile is an anaerobic, spore-forming bacillus that is
known for causing pseudomembranous colitis and diarrhea. C
difficile infection is fatal and is mostly caused by unsanitary
hospital settings (Karadshe & Sule, 2013).
The C. difficile incidences are on the increase and have
triggered an increase in the antibacterial-related diarrhea cases
and antibiotic-related pseudomembranous colitis cases. As
Karadshe & Sule (2013) noted, the major contributing factor to
the increasing incidences of C. difficile is the development of
new antibiotic-resistant viral strains. The disease is a major
health issue that has for long continued to cause deaths and
increased health costs to patients, yet, Sir Alexander Fleming,
the person who invented the penicillin antibiotic himself,
warned of this danger in his speech during his noble award in
1945.
But I would like to sound one note of warning. Penicillin is to
all intents and purposes non-poisonous so there is no need to
worry about giving an overdose and poisoning the patient. There
may be a danger, though, in under dosage. It is not difficult to
make microbes resistant to penicillin in the laboratory by
exposing them to concentrations not sufficient to kill them, and
the same thing has occasionally happened in the body. The time
may come when penicillin can be bought by anyone in the
shops. Then there is the danger that the ignorant man may easily
under dose himself and by exposing his microbes to non-lethal
quantities of the drug make them resistant (Fleming, 1945).
The incidences of C. difficile have been on the rise over the

past decade. In the US alone, more than 500,000 cases of the
infection are reported annually in acute healthcare settings. In
2010, for example, C. difficile incidences were approximated at
about 500, 000 cases, a mortality of 20, 000 to 50, 000, and the
cost of managing the disease at $ 1.2 billion. Over the past
years, there has been an increase in the incidences of C.
difficile in hospital settings, especially in acute healthcare
settings. Pepin et al. (2005) found that almost 18% of all deaths
among patients with C. difficile are directly attributed to the
infection. C. difficile is directly attributed to patient deaths in
acute healthcare settings.
Because of the continued deaths and morbidity due to C.
difficile, there has been advancement toward establishing more
effective prevention technologies and strategies. The process of
prevention and management of C. difficile, however, has not
been smooth and there have been numerous challenges. The
epidemiology of C. difficile has been changing and its
continued presence in the acute care environment is a concern
among health practitioners and policy makers. This has led the
healthcare practitioners to re-evaluate the strategies and
technologies used in the prevention and treatment of C. difficile
(Rao & Young, 2015). Hence the formation of
Antibiotic/Antimicrobial Stewardship Programs.
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Theoretical Foundations and/or Conceptual Framework
This section identifies the theory(s) or model(s) that provide the
foundation for the research. This section should present the
theory(s) or models(s) and explain how the problem under
investigation relates to the theory or model. The theory(s) or
models(s) guide the research questions and justify what is being
measured (variables) as well as how those variables are related

(quantitative) or the phenomena being investigated (qualitative).
Review of the Literature
This section provides a broad, balanced overview of the existing
literature related to the proposed research topic. It describes the
literature in related topic areas and its relevance to the proposed
research topic findings, providing a short one-two sentence
description of each theme/topic and identifies its relevance to
the research topic supporting it with at least one citation from
the literature.
The recommended length for this section is two-three
paragraphs
1. Theoretical Foundationssection identifies the theory(s),
model(s) relevant to the variables (quantitative study) or
phenomenon (qualitative study). This section should explain
how the study topic or problem coming out of the “need” or
“defined gap” in the Background to the Problem section relates
to the theory(s) or model(s). (One paragraph)
2. Review of the Literature Themes/Topics section: This section
lists the major themes or topics related to the research topic. It
provides a short one-two sentence description of each
theme/topic and identifies its relevance to the research topic
supporting it with at least one citation from the literature. (One
or two sentences per theme/topic).
3. ALIGNMENT: The Theoretical Foundations models and
theories need to be related to and support the problem statement
or study topic. The sections in the Review of the Literature are
topical areas needed to understand the various aspects of the
phenomenon (qualitative) or variables/groups (quantitative)
being studied; to select the design needed to address the
Problem Statement; to select surveys or instruments to collect
information on variables/groups; to define the population and

sample for the study; to describe components or factors that
comprise the phenomenon; to describe key topics related to the
study topic, etc.
NOTE: The two parts of this section use information from Point
#2 (Literature Review) from the 10 Strategic Points.This
Theoretical Foundations section is expanded upon to become the
Theoretical Foundations section in Chapter 2 (Literature
Review). The Theoretical Foundations section is also used to
help create the Advancing Scientific Knowledge section in
Chapter 1. This Review of Literature Themes/Topics section is
expanded upon to provide the Review of the Literature section
in Chapter 2 (Literature Review). The Review of the
LiteratureThemes/Topics section is also used to provide the
basis for the Significance of the Study section in Chapter 1.
Problem Statement
Antimicrobial stewardship measures are enforced to combat
clostridium difficile infections but it is not known how the rise
in health care associated c-diff and its impact on patients is
related to the nurses being underutilized and not recognized as
members of the ASP. Antimicrobial stewardship education is
very important for every health care worker, legislators, policy
makers for public health, and the public at general. It should not
be for only physicians. Olans, Olans & DeMaria (2016)
researched the topic and concluded that “As the largest single
group of healthcare providers, nurses should be included in this
educational effort.” The authors urged that “Antimicrobial
stewardship education is particularly important for nurses,

however, who may not identify themselves as antibiotic
prescribers, and therefore not view their activities as
contributing to antimicrobial stewardship”.
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Problem Statement
This section includes the problem statement, the population
affected, and how the study will contribute to solving the
problem.
1. Presents a clear declarative statement that begins with either:
“It is not known how or why…” (qualitative),
or
“It is not known if or to what degree/extent…” (quantitative).
2. Clearly describes the magnitude and importance of the
problem, supporting it with citations from the literature.
3. ALIGNMENT: The problem statement is developed from and
justified by the “need” or “defined gap” defined by the
Literature that is discussed in the Background to the Problem
section above.
NOTE: This section elaborates on Points #3 (Problem
Statement) from the 10 Strategic Points. This section becomes
the foundation for the Problem Statement section in Chapter
1(and other Chapters where appropriate) in the Proposal.

tense, punctuation, and APA format
Comments from Evaluator:
Research Questions, Hypotheses, and Variables
Research Question
PICOT: P) For staff nurses in an acute care hospital being
underutilized and not recognized as members of the
antimicrobial stewardship program team I) take an educational
intervention program C) compared to nurses in another acute
care hospital without taking the educational intervention
program, O) related to the rise in health care associated c-diff
in acute care hospitals T) within three months.
Hypothesis
If staff nurses in inpatient hospitals are being underutilized and
not recognized as members of the antimicrobial stewardship
program then this may lead to the ineffectiveness of
antimicrobial stewardship programs and infection or disease
control measures, which may contribute to a rise in health care
associated c-diff.
Sub-Research Questions and Associated Hypotheses
Sub-question 1: Are the staff nurses in inpatient hospitals being
antimicrobial stewardship program? Additionally are the staff
nurses in inpatient hospitals not familiar with the concept of
antimicrobial stewardship?
H1A: There would be a significant correlation between the staff
nurses in inpatient hospitals being underutilized and not
recognized as members of the antimicrobial/antibiotic
stewardship program and the rise in health care associated c-
diff.
H10: There would be no significant correlation between the
staff nurses in inpatient hospitals being underutilized and not
diff.

Sub-question 2: Are the staff nurses in inpatient hospitals not
being engaged as members of the antimicrobial stewardship
program?
nurses in inpatient hospitals not being engaged as members of
the antimicrobial/antibiotic stewardship program and the rise in
health care associated c-diff.
staff nurses in inpatient hospitals not being engaged as members
of the antimicrobial/antibiotic stewardship program and the rise
in health care associated c-diff.
Sub-question 3: Is the problem of the staff nurses in inpatient
hospitals being underutilized and not recognized as members of
the antimicrobial stewardship program impacting the health of
the inpatients,
the antimicrobial/antibiotic stewardship program and the health
of the inpatients.
of the antimicrobial/antibiotic stewardship program and the
health of the inpatients.
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Research Question(s) and/or Hypotheses
This section narrows the focus of the study and specifies the
research questions to address the problem
statement. Based on the research questions, it describes the
variables or groups and their hypothesized
relationship for a quantitative study or the phenomena under
investigation for a qualitative study.

(2-3paragraphs)
· The recommendation is a minimum of two research questions
along with related hypotheses and variables is required for a
quantitative study.
· Also recommended is a minimum of two research questions
along with the phenomenon description is required for a
qualitative study.
· Put the Research Questions in the appropriate Table in
Appendix B based on whether the study is qualitative or
quantitative.
1. Qualitative Designs: States the research question(s) the study
will answer, and describes the phenomenon to be studied.
or
2. Quantitative Designs: States the research question(s) the
study will answer, identifies the variables, and presents the
hypotheses.
3. ALIGNMENT: The research questions are based on both the
Problem Statement and Theoretical Foundation model(s) or
theory(s). There should be no research questions that are not
clearly aligned to the Problem Statement.
NOTE: This section elaborates on Points #5 (Research
Questions) & #6Hypothesis/variables or Phenomena) from the
10 Strategic Points. This section becomes the foundation for the
Research Question(s) and/or Hypotheses section in Chapter 1 in
the Proposal.
Significance of the Study

A review of the available literature shows that there is little
information on the roles of the inpatient nurses in antimicrobial
stewardship. Additionally, there is little information that can
help determine whether the staff nurses are underutilized (Olans
et al., 2016). For this reason, this study will seek to offer a
guide on the role of the nurses as part of the antimicrobial
stewardship program that will be used to guide the clinical
practice, inform hospital management and give focus to the
nursing education.
This research will (a) demonstrate the relationship between staff
nurses actively participating in Antimicrobial stewardship
programs and preventing health care associated clostridium
difficile infections and also empower nurses in facilitating open
communication with physicians regarding antibiotic
prescriptions, (b) Remind and educate nurses on infection
control practices such as i) hand hygiene, ii) Isolation protocols
and proper donning of PPE, (c) Remind and educate nurses on
types of antibiotics and their indications, emphasizing
multidrug resistance organisms, (d) Empower nurses in
participating in ASP in hospital setting to advocate for a
stronger nursing presence. “All healthcare facilities are
encouraged to begin to make responsible utilization of
antimicrobial drugs the responsibility of every healthcare
provider” (Hamilton, Gerber, Moehring, Anderson, Calderwood,
Han, … Lautenbach, 2015).
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Significance of the Study
This section identifies and describes the significance of the
study and the implications of the potential results based on the
research questions and problem statement, hypotheses, or the

investigated phenomena. It describes how the research fits
within and will contribute to the current literature or body of
research. It describes potential practical applications from the
research.
1. Describes how the proposed research will contribute to the
Literature, relating it specifically to other studies from the
Background to the Problem and Problem Statement above.
2. Describes how the proposed research will contribute to the
literature on the selected theory(s) or model(s) that comprise the
Theoretical Foundation for the study.
3. Describes how addressing the problem will have practical
value for the real world considering the population, community,
and/or society.
4. ALIGNMENT:
Part 1 is based on specific studies from the Background to the
Problem and Problem Statements sections above and identifies
how this research will contribute to that Literature. Part 2 is
based on specific model(s), theory(s) or variables from the
Theoretical Foundations section above and identifies how this
research will contribute to the knowledge on those model(s) or
theory(s). Part 3 reflects on potential practical applications of
the potential research findings based on Literature in the field
of practice.
NOTE: This section does not directly come from any section of
the 10 Strategic Points. However it does build on the
Background to the Problem, Problem Statement and Theoretical
Foundations sections that are developed from the 10 Strategic

Points. This section becomes the Significance of the Study
section in Chapter 1 in the Proposal.
Rationale for Methodology
The methodology will be quantitative using a Quasi-
Experimental Design which seeks establishing a relationship
that is cause-effect between two or more variables and using a
two tail t-test (Creswell & Creswell, 2018). A quantitative study
methodology assesses what it is presumed to be a statistic
reality with the expectation of coming up with universal laws
(Flick, 2015). Conversely, the qualitative research method
purposes to discover what is presumed dynamic reality while
centering majorly on comprehending essentials in contrast to
generalizing collective laws of behavior. The purpose of this
study is to determine the role of the nurses in the antimicrobial
stewardship program. The researcher will employ non-
probability sample through a purposive sample. Information will
be obtained through semi-structured interviews and
questionnaires (Wilson, 2010). The information obtained will be
recorded and transcribed. The researcher will review the
transcripts used in the interviews and the questions used in the
questionnaires to aid in the identification of the roles of the
nurses in the antimicrobial stewardship programs before and
after the educational intervention program. The researcher will
be comparing the before and after of the survey results at the
two hospital sites, comparing the rates before and after training
of the C. Difficile infections. Next, the researcher will compare
the two sites to see if there is a significant difference between
the rates of C. Difficile infections.

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Rationale for Methodology
This section clearly justifies the methodology the researcher
plans to use for conducting the study. It argues how the
methodological framework is the best approach to answer the
research questions and address the problem statement. It uses
citations from textbooks and articles on research methodology
and/or articles on related studies.
The recommend length for this section is one paragraph and
completion of Table 1 (quantitative) and/or Table 2 (qualitative)
in Appendix B.
1. Identifies the specific research methodology for the study
(quantitative, qualitative, or mixed).
2. Justifies the research methodology to be used for the study by
discussing why it is the best approach for answering the
research question and addressing the problem statement. Uses
citations from original sources in the literature on the specific
research methodology to support the arguments. (NOTE: Books
such as those by Creswell, which are secondary sources
summarizing others approaches to research, may not be used as
sources in this section).
3. ALIGNMENT: The selected methodology should be justified
based on the Problem Statement and Research Questions.
NOTE: This section elaborates on the methodology part of Point
#7(Methodology and Design) in the 10 Strategic Points.
This section becomes the foundation for the Research
Methodology in Chapter 1 of the Proposal and the basis for
developing Chapter 3, Research Methodology.

tense, punctuation, and APA format
Nature of the Research Design for the Study
two tail t-test (Creswell & Creswell, 2018). The tools for data
collection that the researcher will employ, will include a
questionnaire and interviews that consist of open-ended
questions and interview questions to the nurses on their
reflections on their role in the antimicrobial stewardship
programs (Easterby-Smith & Thorpe, 2008). The target
population will be the staff nurses in two hospitals within the
Napa County, one hospital receiving the educational
interventional program and the other with no educational
intervention. A sample size of 50 nurses will be selected from
the hospitals. Nurses’ knowledge and attitudes on ASP with C-
diff rates will be assessed before and after the educational
intervention program.
This study will also use the deductive approach. Flick (2015)
defines this approach as one that involves testing principles
against known theories while showing facts. This research
design will be most appropriate to respond to the question on
the role of the staff nurses in the antimicrobial stewardship
program. The deductive approach will test the hypothesis of the
study against the theories while at the same time showing the
results of the study. The dependent variable will be the increase
in the level of the healthcare-associated Clostridium difficile
infections and the independent variables will be the engagement
of the staff nurses as antimicrobial stewards, familiarity of the
nurses to the concept of antimicrobial stewardship, the security

nurses have on their knowledge on antibiotic and microbiology
use, the perceived impact of the nurses on the antimicrobial
stewardship programs and the attitude of the nurses towards the
antimicrobial stewardship programs and the education.
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Nature of the Research Design for the Study
This section describes the specific research design to answer the
research questions and why this approach was selected. It
describes the research sample being studied as well as the
process that will be used to collect the data on the sample.
The recommend length for this section is one paragraph and
in Appendix B.
1. Identifies the specific type of research design chosen for the
study as well as a sample appropriate for the design. (e.g.,
Quantitative designs include descriptive/survey, correlational,
causal-comparative, quasi-experimental, and experimental.
Qualitative designs include case study, narrative, grounded
theory, historical, and phenomenological.) Although other
designs are possible, these are the designs GCU recommends
doctoral learners use to help ensure a doable study.
2. Discusses why the selected design is the best design to
address the research questions as compared to other designs.
3. ALIGNMENT: The selected Research Design should be
justified based on the research questions as well as the
hypotheses/variables (quantitative) or phenomenon
(qualitative). It should also be aligned with the selected

Research Methodology.
NOTE: This section also elaborates on the Design part of Point
#7 (Methodology and Design) in the 10 Strategic Points. This
section provides the foundation for Nature of the Research
Design for the Study in Chapter 1.
Comments from Evaluator:
Purpose of the Study
The purpose of this quantitative Quasi-Experimental Design
study is to examine to what extent the level of staff nurses
being underutilized and unrecognized in Antimicrobial
Stewardship programs is a factor that affects the rise in health
care associated clostridium difficile infections in acute care
facilities. The dependent variable will be the increase in the
level of the healthcare-associated Clostridium difficile
infections and the independent variables will be the engagement
of the staff nurses as antimicrobial stewards, familiarity of the
nurses to the concept of antimicrobial stewardship, the security
nurses have on their knowledge on antibiotic and microbiology
use, the perceived impact of the nurses on the antimicrobial
stewardship programs and the attitude of the nurses towards the
antimicrobial stewardship programs and the education.
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Purpose of the Study
The purpose statement section provides a reflection of the

problem statement and identifies how the study will be
accomplished. It explains how the proposed study will
contribute to the field.
The recommend length for this section is one paragraph.
1. Presents a declarative statement: “The purpose of this
_______study is….” that identifies the research methodology,
research design, target population, variables/groups
(quantitative), or phenomena (qualitative) to be studied, and
geographic location. It often includes a version of the Problem
Statement as a way to define the phenomenon or
variables/hypotheses.
2. ALIGNMENT: The Purpose Statement includes: Research
Methodology, Research Design, and Problem Statement from
the previous sections. It also includes the target population,
which should be of sufficient size to provide a large enough
sample to complete the study and provide significant
(quantitative) or meaningful (qualitative) results.
NOTE: This section elaborates on Points #8 (Purpose
Statement) in the 10 Strategic Points. This section becomes the
foundation for the Purpose of the Study in Chapter 1 of the
Proposal.
Instrumentation
The primary materials that will be used in the study will be the
questionnaires and the interview questions. The questions will
be designed to assist with the collection of data that would aid

in the determination of the role of the nurses in the
antimicrobial stewardship programs. The semi-structured
interviews and the questionnaires contained questions will cover
the research questions and objectives stated in the study to
facilitate a discussion on the topic. The questionnaires will
contain both closed-ended and open-ended questions that will
offer focus to the participants and allow the researcher to
examine a broad array of topics (Doody & Noonan, 2013). The
study objectives will be to determine the role of the nurses in
ASP’s as well as the perspectives, attitudes, and knowledge and
determine how the role of the nurses can be supported and
developed to ensure achievement of the antimicrobial
stewardship programs.
a. Dependent Variable: The rise in health care associated
clostridium difficile infections will be measured by the CDC
Vital Signs Scale (CDC, 2017).
b. Independent variables: Staff nurses underutilized and
unrecognized in clostridium difficile infections control. Data
will be collected using one of the standard instruments/surveys
currently used for similar studies that measure inpatient hospital
care (The CDC National Hospital Care Survey) (CDC, 2017).
c. Independent variables: Staff nurses not being engaged as
members of the antimicrobial/antibiotic stewardship program.
Data will be collected using one of the standard
instruments/surveys currently used for similar studies that
measure inpatient hospital care (The CDC National Hospital
Care Survey) (CDC, 2017).
d. Independent variables: Staff nurses unfamiliar with the
concept of antimicrobial stewardship. Data will be collected
using one of the standard instruments/surveys currently used for
similar studies that measure inpatient hospital care (The CDC
National Hospital Care Survey) (CDC, 2017).
e. Independent variables: Staff nurses being insecure about their
knowledge of microbiology and antibiotic use. Data will be
collected using one of the standard instruments/surveys

f. Independent variables: Staff nurses’ attitude that
not perceive themselves as antibiotic prescribers. Data will be
g. Independent variables: The lack of metrics that quantify
nurses’ impact on stewardship efforts. Data will be collected
National Hospital Care Survey).
h. Independent variable: Age
i. Independent variable: Education
j. Independent variable: Location
k. Independent variable: Gender
l. Independent variable: Years of practice/experience
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Instrumentation or Sources of Data
Describes, in detail, all data collection instruments and sources
(tests, questionnaires, interviews, data bases, media, etc.).
Discusses the specific instrument or source to collect data for
each variable or group (quantitative study). Discusses specific
instrument or source to collect information to describe the
phenomena being studied (qualitative study).
The recommend length for this section is one paragraph AND
in Appendix B.
1. Identifies and describes the types of data that will be
collected to answer each Research Question for a qualitative
study. Identifies the data that will be collected for each

Variable/Group in a quantitative study.
2. Identifiestools, instruments, or databases to be used to collect
the data (e.g., observations, interviews, questionnaires,
documents, media (qualitative), standardized tests, surveys, and
databases (quantitative)). For a qualitative study, identify the
specific tools, instruments, or databases for each research
question in a qualitative study. For a quantitative study, identify
the name of the specific “validated” and “previously used in
quantitative research” survey or data source to be used to
collect data for each variable, providing a citation for the
instrument or data source.
3. ALIGNMENT: Aligns with the Research Questions
(qualitative) or Variables (quantitative) previously described in
the Research Question(s) and Phenomena or Research
Questions, Hypotheses, and Variables section above.Identifies
and describes the data and data source that will be used to
answer each Research Question for a qualitative study.
Identifies, describes, and names the type of numerical data and
specific data collection instrument or source that will be used
for each variable and group in a quantitative study.
NOTE: This section elaborates on Point #9 (Data Collection)
from the 10 Strategic Points.
This information is summarized high level in Chapter 1 in the
Proposal in the Nature of the Research Design for the Study
section. This section provides the foundation for
Instrumentation (quantitative) or Sources of Data (qualitative)
section in Chapter 3.

Data Collection Procedures
1. Descriptive statistics will be used to summarize the sample
descriptive data and the data on the variables, with a sample
size of 100 Nurse participants
a. To test the hypotheses and research questions, inferential
statistics will be calculated for the hypothesis (H1A, H2A,
H3A. tested using simple linear regression analysis.
b. A test for univariate outliers will be conducted to determine
if any cases may not statistically be part of the sample
collected.
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Data Collection Procedures
This section details the entirety of the process used to collect
the data. It describes each step of the data collection process in
a way that another researcher could replicate the study.
NOTE: It is recommended that the researcher get written
approval (or at the very least unofficial approval) to conduct
their research study in their selected organization. Ensure the
person (who is usually a school superintendent, school boards,
or corporate officer) providing approval is authorized by the
organization to grant approval for research. Do not assume your
organization will allow you to collect data since many
organization do not allow research to be completed within the
organization.
The recommended length for this section is two paragraphs.

1. Defines the target population and the expected sample size,
which comprises the people or organizations being studied, as
defined in the problem statement. For quantitative studies, it
justifies why the target population and expected sample size
(final number of people or organizations being studied for
which data will be collected) is large enough to produce
statistically significant results (quantitative) or meaningful
results (qualitative).
2. Provides an overview the proposed step-by-step procedure to
collect data using the tools, instruments, or databases from the
section above. Includes the steps (e.g., obtaining initial
informed consent from participating organization; IRB review;
sample selection; groupings; protecting rights/well-being;
maintaining data security; sample recruitment; data collection
instruments and approaches; field testing instruments; notifying
participants; collecting the data, etc.) in a way another
researcher can replicate the study. Steps may be provided in a
list format.
3. ALIGNMENT: Shows the steps and approach to collect data
for each and every data source identified in the Instrumentation
or Sources of Data section. Defines the sample as the set of
people or organizations being studied for which data will be
collected. The sample size must be correct for the type of
design selected to get statistically significant (quantitative) or
meaningful (qualitative) results.
NOTE: This section elaborates on Points #4 (Sample and
Location) and #9 (Data Collection) in the 10 Strategic Points.
This section provides the foundation for the Data Collection
Procedures section in Chapter 3 in the Proposal. And it is

summarized high level in Chapter 1 in Nature of the Research
Design for the Study in the Proposal.
Data Analysis Procedures
The data obtained from the interviews will be transcribed from
voice to print. The researcher will listen to the voice recordings
and write them down immediately after the interviews.
Additionally, the data that will be obtained from the
questionnaires will be fed into excel sheet. The researcher will
listen to the recordings more than twice then record the
responses. According to Elo and Kynga (2008), repeated
listening of the recordings allows the researcher to record the
accurate data contained in the responses of the participants.
The t- tailed test will be used to compare the two groups of
nurses. The data that will be obtained will then be categorized
according to the themes of the study which include the clinical
skills, monitoring, advocacy, attitudes, knowledge, and
collaboration as well as communication.
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Data Analysis Procedures
This section describes how the data were collected for each
variable or group (quantitative study) or for each research
question (qualitative study). It describes the type of data to be
analyzed, identifying the descriptive, inferential, and/or non-
statistical analyses. Demonstrates that the research analysis is
aligned to the specific research design.

The recommend length for this section is one paragraph AND
in Appendix B.
1. Describes the analysis to examine each stated research
question and/or hypothesis. For quantitative studies, describes
the analyses including the inferential and/or descriptive
statistics to be completed. For qualitative studies, describes the
specific analytic approach appropriate for the Research Design
and each research question to be completed. In qualitative
research the different research questions may require different
approaches to doing qualitative data analysis, as well as
descriptive statistics.
2. ALIGNMENT: For qualitative studies, there is a clear and
obvious alignment between each research question, data to be
collected, tool or data source, as well as data analysis to
understand/explain the phenomenon. For quantitative studies,
there is a clear and obvious alignment between each variable,
data to be collected, instrument or data source, as well as data
analysis for each hypothesis.
NOTE: This section elaborates on Point #10 (Data Analysis)
from the 10 Strategic Points. This section provides the
foundation for Data Analysis Procedures section in Chapter 3 in
the Proposal.
Ethical Considerations

It is essential to undertake ethical guidelines while carrying out
any research (Östlund et al. 2011). Some of the ethical factors
that the researcher will take into consideration include
confidentiality, security, and consent. The role of ethical
consideration is to protect the rights of the experimental
subjects. Permission will be sought from the Grand Canyon
University ethics committee and the IRB. Additionally, the
researcher will educate the participants on the importance of
taking part in the research while introducing the study. The
researcher also will give the participants the freedom to choose
whether to participate in the study or not and they will be
informed that the information collected will be confidential and
only utilized for the study purposes (Wilson, 2010).
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Ethical Considerations
This section discusses the potential ethical issues surrounding
the research, as well as how human subjects and data will be
protected. It identifies how any potential ethical issues will be
addressed.
1. Discusses potential ethical concerns that might occur during
the data collection process.
2. Describes how the identities of the participants in the study
and data will be protected.
3. Describes subject recruiting, informed consent and site
authorization processes.

4. ALIGNMENT: Ethical considerations are clearly aligned
with, and relate directly to the specific Data Collection
Procedures. This section also identifies ethical considerations
related to the target population being researched and
organization or location as described in the Purpose Statement
section.
NOTE: This section does use information from any of the 10
Strategic Points.
This section provides the foundation for Ethical Considerations
section in Chapter 3 in the Proposal.
2
Appendix A
The 10 Strategic Points for the Prospectus, Proposal, and

Dissertation
DPI Project Milestone: 10 Strategic Points Revised Working
Draft
Grace Senoga
Grand Canyon University
DNP 820
Research Topic
Antimicrobial Stewardship program: An evidence based quality
assurance measure in combating Healthcare Associated
Infections (HAI) with emphasis in Clostridium Difficile
prevention. An Educational Tool Kit for staff nurses becoming
more engaged and taking a leadership role in HAI programs.
Literature Review
Background of the problem/gap
i. Prior studies show that “the role of inpatient staff nurses
as antimicrobial stewards is unexplored” identified the need for
future studies on how the rise in health care associated c-diff
and its impact on patients is related to the nurses being
underutilized and unrecognized as members of the Clostridium
Difficile Infections Antimicrobial Stewardship (AMS) team.
(Monsees, E. et al., 2017). “Good nursing is good antibiotic
stewardship” (Olans, Olans, & Witt, 2017).
ii. A study by the American Nurses Association (ANA) and
the Centers for Disease Control and Prevention (CDC) presents
a strong argument that “the urgent need to improve appropriate,
evidence-based antibiotic use cannot be overstated.” The
authoritative and informative report advises that “with the
current worldwide expansion of multidrug-resistant organisms,
the question is not whether to involve nursing in antimicrobial
stewardship, but how.” (ANA/CDC, 2017)
iii. Antimicrobial stewardship education is very important for
every health care worker, legislators, policy makers for public
health, and the public at general. It should not be for only
physicians. Olans, Olans & DeMaria (2016) researched the topic

and concluded that “As the largest single group of healthcare
providers, nurses should be included in this educational effort.”
The authors urged that “Antimicrobial stewardship education is
particularly important for nurses, however, who may not
identify themselves as antibiotic prescribers, and therefore not
view their activities as contributing to antimicrobial
stewardship”.
“The CDC estimates that 1.7 million hospital-associated
infections, from all types of bacteria combined, cause or
contribute to 99,000 deaths each year. That puts hospital-
acquired infections in the ten top category of leading causes of
death in the US.” (CDC, 2017)
iv. The CDC reports that “C. difficile has become the most
common microbial cause of healthcare-associated infections in
U.S. hospitals and costs up to $4.8 billion each year in excess
health care costs for acute care facilities alone.” (CDC, 2015).
v. “Nursing’s perspective and active engagement are crucial
for successful antibiotic stewardship programs”(Manning,
2016).
Theoretical foundations
i. “The Health Belief Model (HBM) is by far the most
commonly used theory in health education and health
promotion” (Glanz, Rimer, & Lewis, 2002).
ii. Nightingales Theory: The theorist suggestion that nurses
need to know about the disease process will inform and guide
the present work. “How does this theory influence the evidence
based staff nurses’ attitude and or believe that antimicrobial
stewardship is not their function because they do not perceive
themselves as antibiotic prescribers?” (Petiprin, 2016).
Review of Literature topics with key theme
“Focused consideration to empower and educate staff nurses in
antimicrobial management is needed to strengthen collaboration
and build an inter professional stewardship workforce”
(Monsees, E. et al., 2017).
Summary
i. Gap/problem: There is a need to identify different

approaches to motivate staff nurses to take action to prevent
health care associated clostridium difficile infections and other
health care-associated infections.
ii. The way to prevention of health care associated
clostridium difficile infections, other health care-associated
infections, and antibiotic resistance is to engage staff nurses as
active participants in the AMS and other related safety
measures.
iii. Quantitative study: Instruments and sources of data exist
to collect survey data on the twelve variables.
iv. Significance: research will (a) demonstrate the relationship
between staff nurses actively participating in health care-
associated infections stewardship programs and preventing
health care associated clostridium difficile infections. (b) add to
the broad area of superbugs in hospitals, (c) identify specific
approaches as educational tool kit for nurses to be used by
hospital administrators to protect patients from deadly
superbugs.
Problem Statement
Antimicrobial stewardship measures are enforced to combat
clostridium difficile infections but it is not known how the rise
in health care associated c-diff and its impact on patients is
related to the nurses being underutilized and not recognized as
members of the ASP. Antimicrobial stewardship education is
very important for every health care worker, legislators, policy
makers for public health, and the public at general.
Sample and location
a. Location: Napa County, California, United States
b. Population: Staff nurses in two Acute care hospitals in
Napa county
c. Sample: The survey will be conducted on 100 participants.
The sample sizes as representative of the study population and
large enough to make accurate statistical conclusions.
Research Question
PICOT: P) For staff nurses in an acute care hospital being

antimicrobial stewardship program team, I) take an educational
intervention program C) compared to nurses in another acute
care hospital without taking the educational intervention
program, O) related to the rise in health care associated c-diff
in acute care hospitals T) within three months.
Hypothesis
If staff nurses in inpatient hospitals are being underutilized and
not recognized as members of the antimicrobial stewardship
program then this may lead to the ineffectiveness of
antimicrobial stewardship programs and infection or disease
control measures, which may contribute to a rise in health care
associated c-diff.
Sub-Research Questions and Associated Hypotheses
Sub-question 1: Are the staff nurses in inpatient hospitals being
antimicrobial stewardship program? Additionally are the staff
nurses in inpatient hospitals not familiar with the concept of
antimicrobial stewardship?
diff.
diff.
Sub-question 2: Are the staff nurses in inpatient hospitals not
program?

Sub-question 3: Is the problem of the staff nurses in inpatient
hospitals being underutilized and not recognized as members of
the antimicrobial stewardship program impacting the health of
the inpatients
of the inpatients.
Methodology and Design
two tail t-test (Creswell & Creswell, 2018).
Purpose Statement
The purpose of this quantitative method using a Quasi-
Experimental Design study is to examine to what extent the
level of staff nurses being underutilized and unrecognized in
Antimicrobial/Antibiotic Stewardship programs is a factor that
affects the rise in health care associated clostridium difficile
infections.
Data Correction
a. Dependent Variable: The rise in health care associated
clostridium difficile infections will be measured by the CDC
Vital Signs Scale (CDC, 2017).
b. Independent variables: Staff nurses underutilized and
unrecognized in clostridium difficile infections control. Data
will be collected using one of the standard instruments/surveys

c. Independent variables: Staff nurses not being engaged as
members of the antimicrobial/antibiotic stewardship program.
Data will be collected using one of the standard
instruments/surveys currently used for similar studies that
measure inpatient hospital care (The CDC National Hospital
Care Survey) (CDC, 2017).
d. Independent variables: Staff nurses unfamiliar with the
concept of antimicrobial stewardship. Data will be collected
National Hospital Care Survey) (CDC, 2017).
e. Independent variables: Staff nurses being insecure about
their knowledge of microbiology and antibiotic use. Data will
be collected using one of the standard instruments/surveys
f. Independent variables: Staff nurses’ attitude that
not perceive themselves as antibiotic prescribers. Data will be
g. Independent variables: The lack of metrics that quantify
nurses’ impact on stewardship efforts. Data will be collected
National Hospital Care Survey).
h. Independent variable: Age
i. Independent variable: Education
j. Independent variable: Location
k. Independent variable: Gender
l. Independent variable: Years of practice/experience
Data Analysis
a. Descriptive statistics will be used to summarize the sample
descriptive data and the data on the variables
b. To test the hypotheses and research questions, inferential

statistics will be calculated for the hypothesis (H1A, H2A,
H3A. H4A, H5A, H6A, H7A, H8A, H9A, H10A, H11A, H12A)
tested using simple linear regression analysis.
c. A test for univariate outliers will be conducted to
determine if any cases may not statistically be part of the
sample collected.
Appendix B
Research Questions:
State the research Questions
Hypotheses:
State the hypotheses to match each Research question
List of Variables/Groups to Collect Data For:
Independent and Dependent Variable(s)
Instrument(s)
To collect data for each variable
Analysis Plan
Data analysis approach to (1) describe data and (2) test the
hypothesis
1. Are the staff nurses in inpatient hospitals being underutilized
and not recognized as members of the antimicrobial stewardship
program? Additionally are the staff nurses in inpatient hospitals
not familiar with the concept of antimicrobial stewardship?

diff.
diff.
The dependent variable will be the increase in the level of the
healthcare-associated Clostridium difficile infections
The independent variables will be the engagement of the staff
nurses as antimicrobial stewards, familiarity of the nurses to the
concept of antimicrobial stewardship, the security nurses have
on their knowledge on antibiotic and microbiology use, the
perceived impact of the nurses on the antimicrobial stewardship
Questionnaires and the interview questions.
t- tailed test
The Likert test
2. Sub-question 2: Are the staff nurses in inpatient hospitals not
program?
2.

3. Is the problem of the staff nurses in inpatient hospitals being
antimicrobial stewardship program impacting the health of the
inpatients.
of the inpatients.
References
Allen, S. J., Wareham, K., Wang, D., Bradley, C., Hutchings,
H., Harris, W., Gravenor, M. B. (2013). Lactobacilli and
bifidobacteria in the prevention of antibiotic-associated
diarrhoea and Clostridium difficile diarrhoea in older inpatients

(PLACIDE): a randomised, double-blind, placebo-controlled,
multicentre trial. The Lancet, 382(9900), 1249-1257.
American Nurses Association/Centers for Disease Control and
Prevention (ANA/CDC) (2017).
Redefining the Antibiotic Stewardship Team: Recommendations
from the American Nurses Association/Centers for Disease
Control and Prevention Workgroup on the Role of Registered
Nurses in Hospital Antibiotic Stewardship Practices.
http://www.nursingworld.org/ANA-CDC-
AntibioticStewardship-WhitePaper
Al-Tawfiq, J. A., Abed, M. S., Al-Yami, N., & Birrer, R. B.
(2013). Promoting and sustaining a hospital-wide, multifaceted
hand hygiene program resulted in significant reduction in health
care-associated infections. American journal of infection
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Arciola, C. R., Campoccia, D., Ehrlich, G. D., & Montanaro, L.
(2015). Biofilm-based implant infections in orthopaedics
Biofilm-based healthcare-associated infections (pp. 29-46):
Springer.
Barlam, T. F., Cosgrove, S. E., Abbo, L. M., MacDougall, C.,
Schuetz, A. N., Septimus, E. J., ... & Hamilton, C. W. (2016).
Implementing an antibiotic stewardship program: guidelines by
the Infectious Diseases Society of America and the Society for
Healthcare Epidemiology of America. Clinical Infectious
Diseases, 62(10), e51-e77.
Barlam, T. F., Cosgrove, S. E., Abbo, L. M., MacDougall, C.,
Schuetz, A. N., Septimus, E. J., . . . Fishman, N. O. (2016).
Implementing an antibiotic stewardship program: guidelines by
the Infectious Diseases Society of America and the Society for
Healthcare Epidemiology of America. Clinical Infectious
Diseases, 62(10), e51-e77.
Baur, D., Gladstone, B. P., Burkert, F., Carrara, E., Foschi, F.,
Döbele, S., & Tacconelli, E. (2017). Articles: Effect of
antibiotic stewardship on the incidence of infection and
colonisation with antibiotic-resistant bacteria and Clostridium
difficile infection: a systematic review and meta-analysis. The

Lancet Infectious Diseases, 17990-1001. doi:10.1016/S1473-
3099(17)30325-0
Becerra, M. B., Becerra, B. J., Banta, J. E., & Safdar, N.
(2015). Impact of Clostridium difficile infection among
pneumonia and urinary tract infection hospitalizations: an
analysis of the Nationwide Inpatient Sample. BMC infectious
diseases, 15(1), 254.
Bentahar, O., & Cameron, R. (2015). Design and
Implementation of a Mixed Method Research Study in Project
Management. Electronic Journal of Business Research Methods,
13(1).
Borde, J., Litterst, S., Ruhnke, M., Feik, R., Hübner, J., deWith,
K., & ... Kern, W. (2015). Implementing an intensified
antibiotic stewardship programme targeting cephalosporin and
fluoroquinolone use in a 200-bed community hospital in
Germany. Infection, 43(1), 45-50. doi:10.1007/s15010-014-
0693-2
Cailes, B., Vergnano, S., Kortsalioudaki, C., Heath, P., &
Sharland, M. (2015). The current and future roles of neonatal
infection surveillance programmes in combating antimicrobial
resistance. Early human development, 91(11), 613-618.
Centers for Disease Control and Prevention (CDC). (2017).
Healthcare-associated infections (HAIs).
https://www.cdc.gov/hai/index.html
Centers for Disease Control and Prevention (CDC) (2017).
National Center for Health Statistics.
National Hospital Care Survey.
https://www.cdc.gov/nchs/nhcs/index.htm
Centers for Disease Control and Prevention (CDC) (2017). Vital
signs.
https://www.cdc.gov/vitalsigns/index.html
Centers for Disease Control and Prevention (CDC) (2017).
National Center for Health Statistics.
National Hospital Care Survey.
https://www.cdc.gov/nchs/nhcs/index.htm
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EVALUATION: EMPIRICAL RESEARCH 2
EVALUATION: EMPIRICAL RESEARCH 7
Evaluation: Empirical Research
Running head: EVALUATION: EMPIRICAL RESEARCH 1

Evaluation: Empirical Research
Introduction
The primary purpose of the research study has been to evaluate
if, in adult patients with Central Venous Catheters (CVC),
interventional staff education about hub hygiene provided to
RN’s who access the CVC impact Central Line-Associated
Bloodstream Infections (CLABSI) rates compared to pre and
post-intervention assessments over a two-month period.
CLABSI rates will be compared to the Patient Safety
Component from the Centers for Disease Control and
Prevention’s (CDC) National Healthcare Safety
Network’s (NHSN) that includes identifying the causation and
surveillance methods to track device-associated infections
(Centers for Disease Control and Prevention, 2016). In
addressing the issue and providing the answer the to the
research question, this researcher will examine the literature
available on the stated topic. Some of the research articles on
the subject show similarities regarding research approaches and
themes and some have differences. The researcher also looked
for evidence that suggests that the data supported the
conclusion, and, in some studies, the findings answered the
research question.
Evaluation of Research
Regarding similarity in the theme, the researcher did find some
regularity in the articles by O’Neil et al. and Salma et al. In the
research study, “A Central Line Care Maintenance Bundle for
the Prevention of Central Line-Associated Bloodstream
Infection in Non-Intensive Care Unit Setting,” O’Neil et al.
(2016) have suggested that there is a higher rate of compliance
with optimal dressing care practices in the control group against
the expectations. The primary theme of the research study has

been the degree of hygiene maintained by nursing professionals
in the context of caregiving in a central line care maintenance
setting. In the research study a 12-month study was conducted
by Caroline and associates to establish the effectiveness of a
central line care maintenance bundle in the reduction of Central
Line–Associated Bloodstream Infection (CLABSIs) in general
medicine wards. They substantiated their research by
disseminating educative guidelines and proper hands-on training
for catheter insertion and care for nurses of the experimental
group against those of a control group, along with asepsis
(hygiene and evaluation of microbiological data). The trained
nurses were instructed to examine the central line dressings
twice a week for secureness or any purulent discharge. The
results of the study revealed higher rates of compliance in
optimal dressing care practices in the control group against the
expectations. They exemplified a marginal reduction in the
incidence of CLABSIs in the intervention group over the control
group. The study lacks documentation of dating the dressing
changes-a key factor in CLABSI prevention. Moreover, the
research is restricted to a small number of patients, so the
efficacy of the staff re-education cannot be standardized or
generalized. But despite the limitations, the theme of the study
has been observed to have been reverberated in the research
study, “Implementation of central venous catheter bundle in an
intensive care unit in Kuwait: Effect on central line-associated
bloodstream infections.” Salma et al. (2016) have also
emphasized hygiene factors and the chances of emergence of
central line-associated bloodstream infections. Resounding this
concern, the research study conducted by O’Neil et al. Salma et
al. also focuses on the importance of maintaining hygiene
regarding avoiding central line-associated bloodstream
infections. In the research study, Salma et al. (2016) also stress
the importance of proper hand hygiene; precautions upon
insertion; antisepsis using chlorhexidine; selection of an
appropriate site for the catheter insertion; and review and
documentation of all the measures. It must be noted that in the

study conducted by Salma et al. (2016) it was revealed that a
significant decline in the incidence of CLABSIs in CVC
patients and had advocated the efficacy of Central Venous Line
Bundle (CVLB) in reducing the morbidity and cost in CLABSIs.
The research, however, lacks documentation on the care of CVC
post insertion site to prevent CLABSIs and only emphasize on
the hygienic measures as a cleansing of the site with
chlorhexidine and use of hand washing before the examination.
The study was further restricted to a single adult ICU with no
considerations to the financial cost of CLABSIs. Notably, if the
previous studies show similarities regarding research theme
then in the research study, “Interventions to improve
professional adherence to guidelines for prevention of device-
related infections,” Flodgren et al. (2013) has failed established
a way in which the conclusion could have provided an answer to
the research question. Though in this study, the theme has also
been infection prevention, the conclusion has been
inappropriate in providing answers to the research question.
This can be argued by citing the fact that though Flodgren et al.
(2013) highlighted the occurrence of secondary infections being
a common phenomenon in hospitals, especially in patients with
central or peripheral lines, they concluded with insufficient
evidence to establish an effective counteractant to curtail the
high number of the hospital-acquired contagions. The research
by Flogren and his team primarily relies on researched literature
rather than their practical implications and thereby, fails to
render an effective intervention for CLABSIs. But it has been
observed that in the research study, “Nursing Practice for
Prevention of Central Line Associated Blood Stream Infection
(CLABSI) in A Pediatric Intensive Care Unit,” Elbilgahy et al.
(2015) strives to provide data that supports their conclusion.
Interestingly in the study by Esposito, Guillari, & Angelillo
(2017), “Knowledge, attitudes, and practice on the prevention of
central line-associated bloodstream infections among nurses in
oncological care: A cross-sectional study in an area of southern
Italy,” provides some answers to some specific research

questions. Like Hentrich et al. (2017) in “Central venous
catheter-related infections in hematology and oncology: 2012
updated guidelines on diagnosis, management, and prevention
of the Infectious Diseases Working Party of the German Society
of Hematology and Medical Oncology” fails to document the
optimal therapeutic measures to reduce Catheter-related
infection (CRI) and the management of Catheter-related
bloodstream infection (CRBSI), after the removal of the
catheter. Similarly, the studies rely on opinions rather the
practical applications or documentation of blood sampling for
microbial infections.
Conclusion
Considering the research studies and observing some flaws in
all the reviews it becomes quite imperative for the researcher to
ask the authors about how to provide a solution that would be
effective in preventing the concerned type and mode of
contamination. Almost all the research studies have suffered
from limitations, and due to such limitations it becomes quite
essential to ask the authors regarding the way in which the
deficiencies could be addressed, and the concerned types of
contamination can be prevented. It should be noted that the
purpose of this quantitative project is to establish a relation
between the occurrence of CLABSIs and staff training,
reinforcement, and proper hygiene for Central Venous Catheters
(CVCs) inserted in the hospital setting. Proper hygiene will be
defined as the use of hand washing before the application of a
central line and utilize antiseptic techniques at the insertion
site. The goal is the reduction of CLABIs in patients with
central line catheters. The authors should be asked how such a
goal could be accomplished overcoming the limitations with
which the research studies were conducted.
Despite the observed limitations in the research studies, the
evidence obtained from the studies can be used efficiently to
refine the PICOT question, and it can also come to the aid of
the researcher regarding formulating and implementing the DPI
project. The PICOT question, “In adult patients with CVC, does

interventional staff education about hub hygiene provided to
RN’s who access the CVC impact CLABSI rates compared to
pre and post-intervention assessments over a two-month
period?”, can be well defined by the application of the evidence
gathered from the research studies. It should be noted that the
evidence has provided a proper answer to the PICOT question
by supporting the fact that interventional staff education about
hub hygiene (supplied to RN’s who access the CVC) does
impact CLABSI rates when compared to pre- and post-
intervention assessments. CLABSI rates will be compared to
Patient Safety Component from the Centers for Disease Control
and Prevention’s (CDC) National Healthcare Safety
Network’s (NHSN) that includes identifying the causation and
surveillance methods to track device-associated infections
(Centers for Disease Control and Prevention, 2016). Congruence
between the evidence and the elements in the PICOT is
necessary for providing a valid means for helping the researcher
in coming to a practical conclusion regarding an answer to the
PICOT question.
References
Centers for Disease Control and Prevention. (2016). Central
Line-associated Bloodstream Infection (CLABSI) | HAI | CDC.
Retrieved from https://www.cdc.gov/hai/bsi/bsi.html
Esposito, M. R., Guillari, A., & Angelillo, I. F. (2017).
Knowledge, attitudes, and practice on the prevention of central

line-associated bloodstream infections among nurses in
Italy. PLOS ONE, 12(6), e0180473. doi:
10.1371/journal.pone.0180473
Elbilgahy, A. A., Davidson, P. M., Sharps Mohamed, P. W., &
Elassmy, M. (2015). Nursing Practice for Prevention of Central
Line Associated Blood Stream Infection (CLABSI) in A
Pediatric Intensive Care Unit. IOSR Journal of Nursing and
Health Science (IOSR-JNHS), 5(6), 150-154.
Esposito, M. R., Guillari, A., & Angelillo, I. F. (2017).
Knowledge, attitudes, and practice on the prevention of central
line-associated bloodstream infections among nurses in
Italy.
Flodgren, G., Conterno, L. O., Mayhew, A., Omar, O.,
Pereira, C. R., & Shepperd, S. (2013). Interventions to improve
professional adherence to guidelines for prevention of device-
related infections. Cochrane Database of Systematic Reviews.
Hentrich, M., Schalk, E., Schmidt-Hieber, M., Chaberny, I.,
Mousset, S., Buchheidt, D., … Karthaus, M. (2014). Central
venous catheter-related infections in hematology and oncology:
2012 updated guidelines on diagnosis, management, and
prevention of the Infectious Diseases Working Party of the
German Society of Hematology and Medical Oncology. Annals
of Oncology, 25(5), 936-947. doi:10.1093/annonc/mdt545
O’Neil, C., Ball, K., Wood, H., McMullen, K., Kremer, P.,
Jafarzadeh, S. R., … Warren, D. (2016). A Central Line Care
Maintenance Bundle for the Prevention of Central Line–
Associated Bloodstream Infection in Non–Intensive Care Unit
Settings. Infection Control & Hospital Epidemiology, 37(06),
692-698.
Salama, M. F., Jamal, W., Al Mousa, H., & Rotimi, V. (2016).
Implementation of central venous catheter bundle in an
intensive care unit in Kuwait: Effect on central line-associated
bloodstream infections. Journal of Infection and Public Health,
9(1), 34-41.

THE 10 STRATEGIC POINTS FOR THE PROSPECTUS, 21
THE 10 STRATEGIC POINTS FOR THE PROSPECTUS, 28
DPI Project Milestone:10 Strategic Points for the Prospectus,
Proposal, and Direct Practice Improvement Project
Running head: THE 10 STRATEGIC POINTS FOR THE
PROSPECTUS, 1
The 10 Strategic Points for the Prospectus, Proposal, and Direct
Practice Improvement Project
The 10 Strategic Points
Broad Topic Area
1. Broad Topic Area:
The topic taken into consideration is the Central Line-
Associated Bloodstream Infections (CLABSIs) and prevention
Introduction
2. Introduction
· The paper is an analysis of the CLABSIs infection and how
best the infection can be prevented or even eliminated among
patients.
· The infection is characterized by a catheter gaining entry into
the bloodstream, greatly affecting either the inferior or the
superior vena cava or the vessels of the neck.
· The location of the catheter makes entry of pathogens into the
bloodstream very occasional. Patients thus become sick easily.
· The risk factors associated with the infection can result from

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