Running head: INTENTIONAL CARE GRANT PROPOSAL

Intentional Care: Strengthening Nurses Critical Thinking Skills for Improved Patient Safety
American Nurses Foundation (ANF) Nursing Research Grant Proposal
NUR 624 Grant Proposal Seminar
Katherine E. deS
State University of New York Polytechnic
December 4, 2014

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Cover Letter
December 4th, 2014
American Nurses Foundation
Nursing Research Review Committee
8515 Georgia Avenue
Suite 400
Silver Springs, MD 20910

What does it mean to think like a nurse? Approaching complex medical problems with
disciplined, skillful reasoning allows the experienced practitioner to have that sixth sense when
something is going wrong with a patient and intervene early to obtain the best outcomes. Nurses who
think with skillful reasoning are the lifeblood of our healthcare system. By tirelessly monitoring,
evaluating, and educating patients, they respond with lifesaving care and send out the alert for help when
it is urgently needed.
Unfortunately, in todays healthcare environment, nurses are constantly having their critical
thinking skills undermined by overwhelming electronic task lists, nursing shortages, and increasing
patient acuity. New nurses are taught to go to the patients task list as a source of truth, rather than their
own assessment skills. Without the ability to hone critical thinking skills, and with an overreliance on
technology, research shows that nurses recognize patient deterioration later and have worse outcomes
than those who actively practice critical thinking skills (Blake & Young, 2014). Patients, in turn, suffer
when warning signs go unnoticed. In the dynamic practice of healthcare, it is essential that nurses can
rapidly adjust to change and approach any scenario with disciplined, skillful assessment.
At Northern Dutchess Hospital, we urgently want to help our nurses reach their full critical
thinking potential, both for their own job satisfaction and for our patients safety. To this end, we kindly
request your consideration for the American Nurses Foundation Nursing Research Grant in the Amount of
$5000. This grant, combined with contributions from our Hospital, will be used to purchase simulation

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equipment and statistically study the effect that a formalized critical thinking program for
Medical/Surgical nurses would have on the number of adverse patient outcomes, particularly rapid
response and code blue situations. This program would span two years, with six months dedicated to
program initiation and launch, one year of didactic and simulation-based critical thinking training, and six
months spent gathering data to determine the effectiveness of the program and its effect on patient
outcomes. As the Senior Nurse Educator for the Hospital, I will work closely with our Chief Nursing
Officer and the Director of Quality Systems to develop real-world scenarios that gives our nurses the
opportunity to practice their skills in a supportive, educational environment.
Since both the American Nurses Foundation and Northern Dutchess Hospital care deeply about
enhancing patient outcomes and supporting nurses, we feel our program entitled Intentional Care:
Strengthening Nurses Critical Thinking Skills for Improved Patient Safety will be a perfect fit for your
grant. Not only will this program seek to improve patient safety and nursing prestige in our own
community hospital, but the research we are able to conduct with your generous assistance will benefit
other institutions seeking to decrease adverse patient events and improve their nursing quality. On behalf
of our Hospital, I thank you for your consideration of our request. Should you have any further questions,
please do not hesitate to contact me.

Sincerely,

Katherine E. deS
Katherine E. deS, BSN, RNC
Senior Nurse Educator
Northern Dutchess Hospital

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Project Abstract
Applicant: Northern Dutchess Hospital, Rhinebeck, New York
Project Title: Intentional Care: Strengthening Nurses Critical Thinking Skills for Improved
Patient Safety
Industry Focus: Health Care
Funding Requested: $5000
Project Description: The goal of the Intentional Care Project is to develop a formalized critical
thinking training program at a small regional hospital in order to improve patient safety
indicators. This formalized training, consisting of online scenario training modules and hands-on
simulation sessions will equip nurses with the skills to critically approach and respond to
decompensating patient scenarios. Research has shown that nurses with improved critical
thinking skills identify signs and symptoms of patient decompensation sooner, initiate
appropriate interventions quicker, and communicate better with the healthcare team (Blake &
Young, 2014).
Target Groups: RNs and LPNs employed on the Northern Dutchess Hospital Medical/Surgical
Unit. On this unit, 17% of the nurses are men, while 83% are women. There are three LPNs, 28
Associate or Diploma Program graduates, and 17 BSNs. Twenty are full-time employees, twelve
are part-time employees, and 16 are per diem employees.
In-Kind Donations: $166,365

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Statement of Need
Quality Department data and nursing literature identify lack of critical thinking skills
as one of the key components in patient adverse events. The number of In-Depth Analyses
(IDAs) and near-misses that cited improper nursing judgment as a direct cause of patient harm
has increased.

Proposed Solution
In response to this identified need, we propose the institution of the Intentional Care
critical thinking program, which combines techniques of skillful reasoning with critical thinking
simulation scenarios. At the conclusion of the Intentional Care program, we anticipate nurses
will be able to identify signs and symptoms of patient deterioration faster, start appropriate
interventions faster, and verbalize a higher level of comfort in caring for the decompensating
patient. This ability to intervene quicker and more effectively will improve the safety indicators
for our patients and decrease the number of adverse events for which lack of critical thinking is
identified as a root cause.

Project Description
The reality of having to do more with less in todays healthcare environment has taken
its toll on the men and women who work so hard to care for patients and provide high quality
nursing care. This constant clutter of tasks has left many staff nurses feeling burned out and
overwhelmed by higher censuses and sicker patients. Task saturation has been shown to
contribute to a poor teamwork environment and poor decision-making abilities (Davis et al.,
2014). At the same time, adoption of electronic health records has shifted the focus of nursing
from well thought out assessment, to filling out boxes requested on an electronic form.

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Decisions for care, too often, are made by tasks that appear on a computer, rather than a nurses
own professional judgment. In this environment, a nurses ability to utilize critical thinking
skills erodes, and this atrophy is having a very real effect on patient safety.
At our Hospital, in-depth analyses (IDAs) of adverse events have shown an increase in
cases where poor nursing recognition of deteriorating patients contributed to negative patient
outcomes. In 62% of the IDAs and error reports reviewed by our Quality Systems Department,
failure to recognize and critically interpret early signs of decompensation led to a significantly
worse outcome for the patient than what would have been predicted had those warning signs
been recognized. In these cases, an inability to critically analyze a situation contributed to an
adverse safety event. To help combat these adverse events, and to help the staff work smarter
rather than harder, the Hospital has decided to launch a new program entitled Intentional Care:
Strengthening Nurses Critical Thinking Skills for Improved Patient Safety. Research has shown
that nurses with improved critical thinking skills identify signs and symptoms of patient
decompensation sooner, initiate appropriate interventions quicker, and communicate better with
the healthcare team (Blake & Young, 2014). This program will also include a committee of
nursing staff and administration, whose aim is to break down the barriers that hinder critical
analysis of a patients situation, such as computer charting overload, communication issues, and
alarm fatigue.
This program teaches the theory and tools of skillful reasoning, while also practicing
these skills in monthly deteriorating patient scenarios. As a small, community hospital, we
require this grant funding to acquire the additional training materials and staff necessary for this
project. The funds from the grant will go toward purchasing specific simulation equipment, such
as the patient vital signs simulator, that will allow staff nurses to have first-hand experience

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intervening in the case of a deteriorating patient. Staff will be able to critically analyze whether
their interventions are working, and determine the most appropriate course of action. The nurse
Educator will be able to critique staff choices and guide critical thinking skills in an environment
that does not compromise patient safety. Grant funds will also be used for the creation of
didactic materials, such as workbooks. Funds will also be used to research the effectiveness of
this program, so that the results can be shared with the wider healthcare community. We plan to
establish the effectiveness of such a program by measuring staff members critical thinking
abilities using an established measurement tool created by The Foundation for Critical Thinking,
and comparing adverse event rates before and after program implementation.
The program will take place over a two year time frame, to allow for adequate roll-out
planning, as well as time to gather sufficient data to statistically measure the impact of the
program on patient safety statistics. Phase One will encompass project kick-off, and will allow
the team to gather and purchase the necessary equipment as well as establish training materials
and meeting schedules. Phase Two will be five months of project planning. During this time,
senior staff will be recruited for simulation training, training equipment and simulation rooms
will be established, and curriculum will be developed under the guidance of the Hospitals
Senior Nurse Educator, who has seven years of simulation training experience in the hospital
setting. Project launch will take place in Phase Three when training is rolled out to the staff.
Training sessions will be assigned to staff, and ongoing debriefing sessions will take place to
evaluate what is going well and what needs improvement. In Phase Four, the team will work
with the Quality Systems Analyst to compare statistical data of patient safety indicators before
and after program implementation.

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The overall budget for this project is $171,365. Of this, $166,365 is being donated by the
Hospital. Salaries for the Educator, Senior Staff Assistants, and a Quality System Analyst total
$100,800. A certified Laerdal trainer will cost $7000. Equipment for the skills lab totals
$63,879. Printed materials total $600. With the help of your $5000 grant, we can work together
to keep our patients, our communities, and ourselves safe.

Budget

Intentional Care Budget

Grant Request
Salaries
Quality Systems Analyst
Nurse Educator
Staff Attendees
Senior Staff Assistants
Contractual Services
Laerdal Trainer
Equipment
NLN Congestive Heart Failure Overload Scenario
NLN CVA - Ischemic Stroke Scenario
COPD Spontaneous Pneumothorax Scenario
SimPad All-In-One Patient Monitor License
Computer for Simulated Patient Monitor HP
Pavilion SlimLine Desktop
Computer Monitor for Simulated Patient Monitor
Nursing Anne, SimMan, Simpad, Scenarios
Licenses for Critical Thinking Evaluation
Total Equipment
Materials & Supplies
Printed Materials
Total Materials & Supplies
Project Subtotal
Indirect Cost or Overhead @ %
Project Total

Donation

Project Total

$2,000
$25,000
$56,000
$17,880

$99,880

$7,000

$7,000

$295
$295
$295
$1,100
$250
$100
$60,000
$544
$63,885
$471

$129
$600
$171,365
$171,365

Budget Justification
Salaries
Quality Systems Analyst This activity will require the Quality Systems Analyst to research
rates of adverse events prior to and after implementation of the Critical Thinking Program. The

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analyst will need to determine whether there was any decrease in the overall rate of adverse
events, as well as whether there was a decrease in adverse events of topics that were covered
during the training. Upon consultation with the analyst, it was determined that this could be
done for a lump sum of $2000.
Institution Contribution The Institution will cover the cost of the Nurse Educators salary and
provide a sufficient workload to accomplish activity tasks during regular working hours. The
Institution will also cover the salaries of nurses while they attend the training sessions.
Estimated value of contribution - $40,000.

Fringe Benefits There are no fringe benefits associated with this project.

Consultants The Institution will cover the cost of a Professional Laerdal Trainer to come
onsite and set up the simulators, as well as train the Educator on proper use of the simulators.
Estimated value of contribution - $7,000.

Equipment
Equipment consists of National League of Nursing Certified Simulation Scenarios that
correlate with past adverse events at our facility. These scenarios are particularly well suited for
decompensating patient scenarios that will be used during the critical thinking simulations. The
SimPad Patient Monitor allows staff to see real time vital sign changes and is necessary for
maintaining a realistic atmosphere for simulation and fostering independent critical thinking.
Costs for all of these items were obtained from a quote from our Institutions Laerdal
representative.

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Institutional Contribution The Institution will provide all medical equipment necessary for
successful simulation sessions. It will also provide funds for the purchase of a Laerdal SimMan
Simulator, a Laerdal Nursing Anne Simulator, a SimPad, NLN MedSurg Nursing Scenarios, and
a Laerdal Obstetrics Upgrade. Estimated value of contribution - $60,000.
Materials & Supplies
The cost for printed materials covers the printed patient report sheets that will be used for
the training, as well as debriefing forms to be used as a tool for discussion after the simulation
session. It will also be put toward the cost of organizing and writing up research on the
effectiveness of this Critical Thinking Program. Costs for this were obtained by consulting our
print shop for estimates based on an estimate of 50 participating nurses. Asking $115 from
requested grant.
Institutional Contribution - Institution will cover any additional costs incurrent for printables,
promotional materials, posterboards, and instructional booklets. Estimated value of contribution
- $500.

Timeline:
Phase 1 Project Initiation (One Month):

Kickoff meeting. Meet with nursing management, staff development management, IT

management, quality systems, and any other appropriate parties. Hold informational staff
meetings with hospital staff to discuss program. All involved parties.

Contact Hospital Public Relations Department to organize community PR for program.

Senior Management/PR Department.

Purchase equipment outlined in needs assessment, for example: SimPad Patient

Simulation Monitor license (simulated vital signs monitor). Assigned to Nurse Educator.

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Create course paperwork and educational materials, including case studies for Hospital
Learning Software. Design decompensating patient scenarios in computer simulation
program. Assigned to Nurse Educator.

Completion of documentation related to pre-program adverse event rate. Assigned to

Quality Department.

Preparation of Simulation Room. Assigned to Nurse Educator/Facilities Department.

Phase 2 Project Planning (5 months):

Installation of training equipment in Simulation Room. Assigned to Nurse Educator/IT

Department.

Recruit Senior Staff to assist with simulation sessions. Assigned to Nursing

Management.

Develop course curriculum

Phase 3 Project Launch at Month 6:

Training roll-out. Set up for mandatory tri-monthly training sessions regarding critical
thinking scenarios, case studies, and hands-on assessment practice. Assigned to Nurse
Educator.

Assign staff to attend scheduled sessions. Assigned to Nurse Managers.

Debriefing. Meeting between Nursing Education, Nursing Management, and IT to

determine what is going well in the project and what is not. Reexamine any problem
issues prior to continuing program.

Phase 4 Project Performance (1 year 6 months):

Continuation of program with quarterly training sessions and bimonthly case studies in
Learning Management Software.

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At completion of program, Quality Systems to gather data related to adverse patient

outcomes.

Comparison to be made to pre-program and post-program adverse outcomes. Assigned

to Quality Systems.

Evaluation
Two Parts:
1. Utilization of a pre- and posttest to measure critical thinking abilities before and after the
one year course. Purchase Online Critical Thinking Basic Concepts Test from the
Foundation for Critical Thinking at $8 per license x 52 licenses = $544 (48 RNs, 1
Educator, 1 Manager, 2 Extra for new hires).
2. Statistical comparison of pre-defined patient adverse events, which include medication
errors, patient falls, hospital acquired infections, hospital acquired Stage 3 or 4 pressure
ulcers, or IDAs (In Depth Analysis) revealing faulty nursing judgment before and after
implementation of the program.

Summary
Thank you for your consideration of our request. In conclusion, we believe that the
institution of our Intentional Care critical thinking program will allow staff nurses to identify
signs and symptoms of patient deterioration faster, start appropriate interventions faster, and
verbalize a higher level of comfort in caring for the decompensating patient. In doing so, we
hope to not only increase the caliber of patient care at our Hospital, but to contribute to the body
of research aimed at creating safer, more effective health care delivery systems.

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References:
Blake, N. & Young, C. (2014). How to be an effective charge nurse. Advanced Healthcare
Network . Retrieved from: http://www.nursingadvanceweb.com
Davis, B., Welch, K., Walsh-Hart, S., Hanseman, D., Petro, M., Gerlach, T., Dorlac, W., Collins,
J., & Pritts, T. (2014). Effective teamwork and communication mitigate task saturation in
simulated critical care air transport team missions. Military Medicine, 179(8), 19-23.
doi:10.7205/MILMED-D-13-00240
The Foundation for Critical Thinking (2013). The International Critical Thinking Test.
Retrieved from http://www.criticalthinking.org/pages/international-critical-thinkingtest/619