Evidence-based Practice Proposal Final

Evidence-based Practice Proposal Final
Abstract
In the contemporary medical world, the nursing shortage is not a new phenomenon. The American Association of Colleges of Nursing, (2014) is of the opinion that the proportion of nurses in the USA will significantly decrease between 2009 and 2030. As such, the purpose of this evidence-based project is to determine the efficacy of transformational leadership to improve nursing retention levels. The nurses in the study setting will receive education on transformational leadership before the evaluation of the nursing retention levels.

Fundamental to the collection of data will be the MLQ-5 questionnaire. After the determination of the effectiveness of transformational leadership in improving nursing retention, organization-wide adoption of the practice change will ensue.

Key words: transformational leadership, nursing retention, nursing shortage

Evidence-based Practice Proposal Final

In the contemporary medical world, the nursing shortage is not a new phenomenon. The American Association of Colleges of Nursing, (2014) is of the opinion that the proportion of nurses in the USA will significantly decrease between 2009 and 2030. Such is the case given the increased number of staff turnover, and the aging nursing staff. A situation of this kind is undesirable due to the associated poor outcomes as well as the inability to offer quality care linked to the increased workload. That said, strategies to increase nursing retention are of the essence if the situation is to change for the better. A case in point of strategies widely utilized is the adoption of good leadership styles such as transformational leadership that inspires the nurses’ intent of remaining in the same work place (Lenhart, 2017). In essence, this paper seeks to build a case for the efficacy of transformational leadership in improving nursing retention.

Organizational Culture and Readiness Assessment

Central to the successful implementation of evidence-based practice (EBP) in any institution is the determination of the organizational level of preparedness. Such is the case given that no one is ready to start a change that will ultimately collapse because of failure to establish the readiness of an organization to embrace the change. That said, this paper seeks to establish the readiness of an organization in embracing an EBP intervention (transformational leadership). Also, of the essence to the evaluation is the determination of the possible project facilitators and impediments, strategies for integrating clinical inquiry, the reasoning for survey category scores as well as the measures for improving the noted weak points.

Organization Preparedness Level

Concisely, the targeted organization’s readiness for EBP project implementation is of a moderate level. That is the case given the moderate scores realized in the survey of the organizational level of preparedness. The rationale for the moderate level of preparedness is the organization’s predominant reliance on EBP as well as the moderate scorings highlighted in most of the survey categories.

Facilitators and Barriers

Of utmost significance to the determination of the organizational level of readiness for EBP implementation are the likely project facilitators and impediments. Identification of this kind is vital since it enables one to establish the drivers of the successful implementation of EBP in an institution. Among the facilitators noted in the evaluation is the institutional culture of supporting and participating in the EBP movement within the hospital. Such is the case given the moderate level of stakeholder commitment to the movement. Additionally, the consistency of the EBP project with the hospital’s mission is another driver for successful implementation. That is for sure since the transformational leadership spearheaded in the EBP project offers a means of partnership that the organization strives to attain in its mission statement (Texas Department of State Health Services, 2013).

Also, from the evaluation, EBP institutionalization is likely to face certain hindrances. A befitting example is the absence of an administrator’s unwavering support for EBP within the hospital. Hirschman, Shaid, McCauley, Pauly, and Naylor, (2015) denote that absence of an administrator’s unwavering support for EBP will possibly lead to resistance against the implementation of the project. Additionally, the small number of EBP champions especially nurse educators is likely to impede the implementation of the EBP project. Given the likelihood of such barriers, failure of project institutionalization is inevitable.

Incorporation of Clinical Inquiry

Of utmost significance to the incorporation of clinical inquiry within this institution are the Agency for Healthcare Research and Quality’s call for major stakeholders to query the existent systems instead of embracing their establishment. Such questioning creates an environment of clinical inquiry (Agency for Healthcare Research and Quality, 2014).

The rationale for Survey Category Scores

Precisely, the survey areas with high ratings are EBP alignment with the hospital’s mission statement and the level of practice. The EBP’s alignment with the institution’s mission statement has a high rating given that transformational leadership contributes to the partnership the organization strives to achieve. The wide extent of EBP practice indicated by the rating realized is down to the presence of the institutional culture that encourages the translation of research into practice.

On the other hand, low scores were realized in survey categories of commitment of administrators to EBP, and a limited number of EBP champions that are nurses. The ratings in these areas were possibly down to partial support and lack of interest respectively.

Measures for Improving Weak Areas

Central to the improvement of the weak areas is various measures. A befitting example of such strategies is lobbying administrative support through spending more time in demystifying their misunderstanding about the EBP movement (Hirschman, et al., 2015).

On the other hand, Hirschman, et al., (2015) are of the opinion that creation of awareness among the various stakeholders can solve the challenge of few EBP champions within the organization. Creation of awareness is possible by holding discussions with stakeholders on the significance of EBP.

Problem background

Of utmost significance in the study setting is the reduced number of nursing staffs over the past few years, which has resulted in remaining nurses working overtime to offset the challenge of shortage. Globally, the situation is the same and thus nursing leaders have continuously sought to improve nurse retention by developing strategies for retaining the few available nurses. In line with this aspiration of leaders, trial of innovative leadership styles such as transformative leadership is vital given their indisputable success record noted in other healthcare organizations (Malloch, 2014).

Stakeholders and Change agents

Central to the implementation of the project are several stakeholders and change champions. The key stakeholders are nurses working in high acuity in-patient settings (both advanced practice nurses and staff nurses), and nurse leaders. On the other hand, the change champions include nurses working in high acuity in-patient settings (both advanced practice and staff nurses) and nurse leaders. Concisely, the success of this project will rely on the involvement of these stakeholders and thus lobbying for their support is vital.

PICOT Question

The PICOT question that will optimize the achievement of the EBP’s purpose and specific objectives is:

“In nurses working in an inpatient setting with high acuity, does the use of transformational compared to transactional leadership style increase the rate of nursing retention over one year?”

Purpose

Fundamental to this quality improvement project is the establishment of the efficacy of transformational leadership in improving nursing retention in in-patient settings with high acuity. Primarily, this is the sole and main project purpose as well as the overall goal.

Project Objectives

Of the essence to the realization of the overall EBP’s goal are two specific objectives, namely:

To establish the association between transformational leadership and nursing retention
To investigate the commonly adopted behaviors in transformational leaders

Relevance of the Project to Nurses

The implementation of this EBP project (transformational leadership) yields several benefits to nurses. Such is the case given that institutionalization of transformational leadership will result in nurses that have increased job satisfaction given the good relations they share with transformational leaders. Consequently, the number of staff turnover will start reducing because the nurses have contentment with their jobs. Notwithstanding, the EBP will optimize the provision of quality healthcare and achievement of positive patient outcomes such as patient safety as well as high staff satisfaction levels (Moneke, &Umeh, 2013). Clearly, with such benefits, significant improvement of nursing practice is inevitable with this project implementation.

Literature Support

Currently, the number of nurses in the USA is on a downward trajectory given the increased staff turnover as well as aging nursing population. Such a trend necessitates the development of new ways to remedy the situation. A befitting example of such strategies is the utilization of innovative leadership styles such as transformational leadership for the improvement of nursing retention. Primarily, this section of the paper seeks to provide practical details of the efficacy of transformational leadership on bettering nursing retention. Central to the analysis are various aspects, namely,evidence synthesis, search strategy for evidence and description of internal and external validity.

Search Strategy

Of utmost significance to the adopted search strategy was the use of two online databases, namely, CINAHL and PubMed. The keywords used for the literature search in both databases included transformational leadership, retention, intent to stay, intent to leave, and nurse turnover. The limiters used to increase the accuracy and relevancy of studies included in the literature review included English language, and studies carried out between 2013 and 2018. Five studies met these criteria and thus considered for inclusion in this literature review.

Evidence Summary

Chan, Tam, Lung, Wong, and Chau, (2013) in their systematic review aimed at establishing reasons for nurses’ intent to leave their current employment. Central to the determination of their findings was the use of electronic databases in which they identified English studies concerned with their aim. Precisely, the researchers identified nurse staff ratios, organizational commitment, leadership styles such as participative leadership, and supportive education programs as important factors influencing nurse retention. The study’s strength was the ability to measure the intended variables. Notwithstanding, the study had intact internal and external research validity.

In another systematic review, the researchers aimed establishing the efficacy of strategies utilized in retaining nurses. The review identified twelve relevant studies in which they targeted to establish factors that affect nurse retention. Most of the included studies showed high nursing retention levels when strategies such as participatory leadership, mentorship and orientation were readily available (Lartey, Cummings, &Profetto-McGrath, 2014). Primarily, the transformational leadership envisages participatory leadership, mentorship and orientation, which are attributed to the high nursing retention levels. The study had the strength of measuring the intended variables. The internal and external validity of this research was not in question given their intactness.

Also, in another non-experimental quantitative research, the study pioneers targeted to establish the association between critical care nurses’ organizational commitment and their job satisfaction. In this study, the researchers concluded the need for leaders implementing strategies that will increase job satisfaction levels of their subordinates if the latter are to stay in the same organization for the unforeseeable future (Moneke, &Umeh, 2013).As its strength, the study was able to measure the intended research variables. A small sample size in this non-experimental study was a weakness that limited generalization of results. Such a weakness and the restriction of the research to critical care nurses further affects the external validity of this study given the small sample size limits generalization of the findings. However, the study’s internal validity was not in question.

Notwithstanding, Nei, Anderson, and Litwiller, (2014) in their meta-analysis aimed at identifying the reasons of nurse turnover. Central to the meta-analysis were 106 primary studies that addressed this issue. The meta-analysis established that supportive leadership, employee engagement and network centrality to be the most predominant factors influencing nurse turnover. Other variables noted to affect nurse retention include job strain, control and complexity, motivating factors (rewards), work-family conflict as well as team cohesion. A predominant strength noted in this study was its ability to measure the intended research variables.Moreover, this research had intact internal and external research validity.

Lastly, in another research conducted in 56 Belgian acute hospitals, the researchers aimed at examining the influence of nursing environments on nurses’ retention. The study established that 29.5% of the 3186 surveyed had intent of leaving their area of work (Van den Heede, Florquin, Bruyneel, Aiken, Diya, Lesaffre, &Sermeus, 2013). Central to the nurses’ intent to leave their hospitals were two factors, namely, nurse staff ratios and nursing practice environments. A nurse environment characterized by participative leadership, supportive education programs as well as nursing career growth opportunities translated to a motivated workforce and thereby high nursing retention levels.The ability to measure the intended research variables was strength of this study. A limitation noted in thisstudy is the limited number of voluntary participants and bias. Such a limited number of voluntary participants affected the external validity of the study since generalization of the findings was not possible (Van den Heede, Florquin, Bruyneel, Aiken, Diya, Lesaffre, &Sermeus, 2013).

Solution Description

Based on the evidence across the reviewed and appraised studies, it is beyond doubt that adoption of transformational leadership behaviors is necessary for the resolution of the challenge of low nursing retention levels. Given such indispensability of transformational leadership to increase rates of nursing retention levels,this section of the EBP project seeks to build a case on how innovative leadership styles such as transformational leadership (proposed in the PICOT question) can ease the challenge of low nursing retention levels.Precisely, the PICOT question on focus is: “In nurses working in an inpatient setting with high acuity, does use of transformational compared to transactional leadership style increase the rate of nursing retention over one year?”. Central to the analysis is the detailed account of the proposed solution, its alignment with the organizational culture, and the expected outcomes.

Proposed Solution

Of significance to the resolution of the nursing retention problem noted in the study setting is the use of transformational leadership behaviors within the confines of complexity leadership theory (CLT). Malloch, (2014) is of the opinion that utilization of transformational behaviors within CLT in various settings has shown to increase the level of job satisfaction of nurses and intent to remain within the same institution. Given such efficacy, it is worth using the transformational leadership behaviors in improving the nursing retention rates within this institution.

Primarily, the transformational leadership behaviors within the confines of CLT entails three types of leading, namely, administrative, enabling, and adaptive leadership. Central to the development of these behaviors are two strategies that are the worth noting. Firstly, nursing leaders within the study area will undergo a 2-hour education session for the entire study period. The education session will mainly target to enlighten the participants of the study on the practical details of transformational leadership as envisaged within the CLT framework. Also, the session will seek to inculcate a drive among the participants of setting individual goals. According to Marquis, and Huston, (2015) goal setting is a crucial characteristic of transformational leaders, which enables them to achieve their ultimate vision.

The second step for accomplishing the transformational leadership behaviors is the individual coaching of the nurse leaders. Coaching is a fundamental strategy used by managers and leaders to inspire desired behaviors that are vital for realization of set goals (Weiss, &Tappen, 2015). The individual coaching will occur every two weeks throughout the study period. During the coaching session, the coach will discuss with the participant about the self-evaluation and assessor results, supervise, and follow-up a participant. Notwithstanding, further reading resources and role-playing will form part of the coaching sessions.

Organization Culture

The proposed solution is consistent with the organizational culture since it resonates with the mission statement of the institution. Such is the case given that the transformational leadership seeks to institutionalize teamwork within the study setting, which is in line with the organizational mission of creating partnerships (Texas Department of State Health Services, 2013). Given such an alignment with the institutional mission statement, it is indisputable that utilization of transformational leadership behaviors is line with the culture of the study setting.

Expected Outcomes

The expected outcomes for this project based on the PICOT question as well other studies include nursing retention rate, intent to stay, turnover and staff satisfaction levels. Nursing retention rate is the primary outcome of interest. On the contrary, turnover and staff satisfaction levels are the secondary outcomes that may become pivotal during project evaluation.

Fundamental to the achievement of these outcomes is the use Multifactor Leadership Questionnaire Form 5x-Short (MLQ5). That is the case given its proven reliability and validity across systematic reviews focusing on this issue.

Also, worth noting are the possible barriers to the realization of the expected outcomes. A case in point of likely hindrances is the partial administrative commitment to EBP projects. Such a situation is likely to slow the realization of the expected outcomes due to the resistance posed by the administration. Additionally, failure of the institutional leaders to embrace change is another likely hindrance to the achievement of the expected outcomes (Hirschman, Shaid, McCauley, Pauly, & Naylor, 2015).

Lastly, the realization of the outcome of interest influences various health indicators in ways that are worth mention. For instance, increased nursing retention level if achieved by use of transformational leadership, it translates to quality care. That is for sure since high nursing retention levels means hospitals can have appropriate nurse-patient ratios. Consequently, the nurses are able to meet individual patient’s needs in a timely manner, which is a component of quality care (Lenhart, 2017). As such, realization of improved nursing retention positively affects the quality of care.

Implementation Plan

Fundamental to any successful project is the development of an implementation plan that specifies the steps to follow in institutionalizing it (Stanhope, & Lancaster, 2014). That said, this section seeks to describe the implementation plan that will guide the rolling out of a project targeting to inculcate transformational leadership behaviors for the improvement of nursing retention rates in a hospital located in Texas. Central to this implementation plan are various aspects that will form part of this analysis.

Change Model

Of significance to the implementation plan of any evidence-based practice (EBP) project is the use of a change model that will offer guidance to the institutionalization. Examples of the theoretical frameworks commonly utilized in EBP projects include but not limited to the ARCC model, Roger’s diffusion of innovation, Iowa model, Duck’s change curve model, Stetler’s utilization model,and transtheoretical model of health behavior change (Nilsen, 2015). In essence, this section focuses on the Iowa model of EBP, which will guide the implementation of a project targeting to inculcate transformational leadership behaviors for improvement of nursing retention. Primarily, the Iowa model is the change model of choice for this EBP given its applicability in a wide variety of specialty areas and large organizations (Schaffer, Sandau, &Diedrick, 2013). Notwithstanding, the emphasis of the Iowa model on organization change makes it suitable for the proposedpractice change, which focuses on the whole organization. That said, this analysis will focus on the systematic scrutiny of the 6steps of Iowa model as shown in Appendix C.

Identification of Practice Question.At the heart of this step is the encouragement of healthcare professionals to identify clinical practice questions that can undergo the EBP process. The practice questions often originate from problem-focused and knowledge-centered triggers (Schaffer, Sandau, &Diedrick, 2013). In relation to this step of the Iowa model, the project pioneers will seek to encourage the current organizational staff to question the established processes of the organization. Precisely, the project coordinators will develop postersthat will invite the nurses to question the rationale of established practices.

Determination of Whether or not the Topic is an Organizational Priority.According to Grove, Burns, and Gray, (2014) not every practice question can form the basis of undertaking an EBP process. As such, there is need for determining issues of highest priority if the organization support is not to be in question. An issue considered as pressing will ordinarily command support from the organization’s stakeholders. In this case, the PICOT question adopted meets this criterion and thus considered for undergoing the EBP process.

Formation of a Team for Search, Critique, and Synthesize of Available Evidence.Following the determination of the topic’s priority status and organizational commitment to the resolution of the identified, there is a need to develop teams. The team will search, appraise and synthesize the readily available literature addressing the formulated clinical question (Melnyk, &Fineout-Overholt, 2015). In this case, the team will majorly constitute theproject coordinators as well as the nurse leaders and nurses working in high acuity in-patient settings.

Determination of the Sufficiency of the Evidence.During this stage, the team will seek to assess the adequacy of the evidence gathered. Such a determination is of the essence since it enables the team to identify high quality research that supports the implementation of the practice change. Notwithstanding, the absence of high-quality evidence will inform either the team’s reliance on lower level of evidence or intention to conduct a research seeking to better available evidence (Schmidt, & Brown, 2014).

Pilot the Recommended Practice Change. Upon the ascertainment of the adequacy of the evidence, the project developers have to roll out the practice change as a pilot study to establish its feasibility and efficacy of the EBP project. Melnyk, andFineout-Overholt, (2015) are of the opinion that such a roll out is necessary since it enables the project champions to identify issues that might affect the success of the EBP project once rolled out in the whole of the organization.Prior to the roll out, the researchers will seek to establish baseline data and outcomes of interest for the evaluation during the pilot study.

Evaluate Pilot Success. Evaluation of the pilot success forms the last step of the Iowa model that enables one to determine the need for disseminating the results as well as implementation of the change into practice (Schaffer, Sandau, &Diedrick, 2013). The evaluative data used in the pilot is vital for determining the success of the practice change. Upon establishment of the efficacy of the practice change in the pilot, dissemination of the findings and organization-wide implementation of the EBP will ensue simultaneously.

Setting/Potential Subjects

Primarily, the setting for this project is a healthcare facility located in Texas. The organization’s mission statement is to create partnership with others as it provides healthcare services. The potential and targeted subjects for the study are the departmental nurse leaders that are readily accessible in this facility on a daily basis. The institutional leaders rely mainly on transactional leadership characterized with vertical communication and reward/punitive measures (Texas Department of State Health Services, 2013).

Prior to the initiation of the implementation, the pioneers will seek the University and hospital Institution Review Boards’ approval for carrying out the project. Notwithstanding, the researchers will seek consent from the targeted participants for the inclusion in the study. Failure of such approval may hinder the success of the project.

Timeline

The full implementation of this project will need a one-year period for successful completion of all the required project activities such as training, data collection and mentorship activities. The breakdown of activities during this timeline is as shown in AppendixD.

Resources

Central to the implementation of this project are various resources that are worth mention. A case in point is the human resource, mainly institutional nurse leaders who will take lead roles of implementing the EBP project. On the contrary, the fiscal resources required for the implementation include education materials such as the MLQ5 training manual and license ($150), as well as workbooks ($65). Other resources used in developing MLQ5 assessments, and during coaching sessions did not incur financial costs.

Methods/Instruments

Of significance to the monitoring of the project is the use of the Multifactor Leadership Questionnaire Form 5x-Short (MLQ5). The MLQ5 is a questionnaire with 45 assessment items on leadership behaviors. It uses a Likert-scale of score 0-4. Validity and reliability of this tool is beyond question given its proven status across systematic reviews (Smith, Nichols, Green, & Sun, 2016).

Process

The delivery of the proposed solution (transformational leadership behaviors) will occur in two phases. The first phase entails a 2-hour education session, which will target to teach the study participants about transformational leadership and drive them to formulate individual goals as envisaged in this type of leadership (Marquis, & Huston, 2015). The second step will entail individual coaching of the nurse leaders, which will occur twice in a month.

Of importance to the data collection is the MLQ5, which is necessary for self and three raters’ assessments. Self- and rater- assessment will take place prior and after rolling out of the intervention to establish pre- and post-intervention MLQ5 scores. The storage of data gathered from the participants will be in the computer and backed up in flash disks by the project developers. Lastly, the Statistical Package of Social Sciences (SPSS) will aid in the analysis of the computed data.

Barriers

The possible barriers that one may contend with when implementing this project include partial administrative commitment to EBP projects and resistance to change. According to Hirschman, Shaid, McCauley, Pauly, and Naylor, (2015), the project developers can offset such challenges by taking time to lobby for support of the project. Also, they should explain to the stakeholders the details of the project and its benefits to them. By so doing, the administrative support will increase and the resistance to change will dissipate.

Feasibility

With reference to the resources required to complete this project, it is beyond doubt that this project is feasible. Such is the case given that the total amount of the needed resources is approximately $300, which is affordable to this institution. The details of the budget are as shown in Appendix H.

Beyond the Initial Implementation

Following the project implementation, the developers will evaluate its success in improving the nursing retention rates within the institution by revisiting the evaluation data. An improved nursing retention rate will be suggestive of the need to retain the practice change as well as disseminate the results for adoption in other areas. However, failure of the project to improve the nursing retention rates will warrant the revision or in extreme cases project’s discontinuation.

Evaluation of the Process

Central to the management of a project are various steps, in which evaluation is one of them. Evaluation is significant to the determination of the project’s success of achieving its set goals (Stanhope, & Lancaster, 2014). Thus, creation of an evaluation plan is vital to the success of a particular project. In essence, this section seeks to lay out the evaluation plan of the EBP project seeking to inculcate transformational leadership behaviors among nurses working in high acuity in-patient settings. Of significance to the plan are several issues, which include but not limited to evaluation methods, rationale for the adopted tools of outcome measures, and implications for nursing practice and future research.

Outcomes

Fundamental to the measurement of the project expected outcomes (nursing retention rate, intent to stay, turnover and staff satisfaction levels) is the utilization of the Multifactor Leadership Questionnaire Form 5x-Short (MLQ5). The MLQ5 is a questionnaire comprising of 45 assessment items on leadership behaviors. The validity, reliability and applicability of this tool are beyond doubt given the existence of various studies justifying the same. For instance, according to Smith, Nichols, Green, and Sun, (2016) the MLQ5 is a proven tool with high validity and reliability levels, which is applicable in the measurement of leadership behaviors among individuals. Given such evidence, the use of the MLQ5 in the measurement of expected outcomes in this project is thus indisputable.

Melnyk and Fineout-Overhold, (2015) are of the opinion that the measurement of a project’s expected outcomes is vital in the determination of the extent of achievement of the project’s objectives. Likewise, the outcome measures of this EBP project will reflect the extent of achievement of the project objectives. For instance, increased nurses’ intent to stay and high nursing retention rates post-EBP project will be suggestive of the achievement of project’s objective of determining the efficacy of transformational leadership in increasing the nursing retention.

Lastly, in the event of outcomes failing to yield positive results, the project pioneers will use certain backup strategies that are worth mention. A case in point of such strategies is the revision of the project. For instance, the project developers can revisit the set objectives to determine the attainability of the same. Notwithstanding, the failure of achieving positive results may necessitate the discontinuation of the project in extreme cases.

Implications for Practice and Future Research

Based on the success of the transformational leadership in improving nursing retention rates, various implications for practice and future research are evident and worth noting. A befitting example of such implications is the need for adopting transformational leadership behaviors among individuals seeking to increase the intent of nurses to remain at the same workplace. Such is the case given the existent evidence indicating increased nursing rates after leaders’ utilization of transformational leadership behaviors (Lenhart, 2017; Malloch, 2014). Also, an implication drawn for future research relates to the strategies used for developing specific transformational leadership behaviors that one ought to adopt to improve nursing retention. Such is the case given the failure of studies to identify these specific strategies for adopting transformational leadership behaviors.

Conclusion

Concisely, this paper aimed at providing practical details of the efficacy of transformational leadership on bettering nursing retention. A learning point drawn from the analysis is the need for leaders adopting innovative leadership styles such as transformational leadership if they are to increase the nurses’ intent to stay in the organization. As such, going forward, there is need for such a consideration if nursing retention level is to remain high.

References

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Appendix A: Critical Appraisal Checklist

Methods

Design – RCT / controlled not randomized / cohort / case series / case report / prospective vs. retrospective

Setting – type of hospital / location

Study Population – number / inclusion criteria / exclusion criteria, screening/enrollment methods, number screened vs number enrolled

Description of prognostic factors considered

Analysis – statistical models

Outcomes – primary and secondary

Follow-up – duration / completeness, accounting of study participants

Validity

Was the study sample clearly defined, representative of clinical practice, and captured at a similar point in disease progression?

Was duration of follow-up sufficient? Were all participants accounted for?

Were outcome criteria objective and unbiased?

Were participants in the study treated similarly?

Do the study population characteristics describe your study participants?

Results

How likely are the outcomes during a specified period of follow-up?

How precise are the likelihood estimates?

Appendix B: Evaluation Table

Citation: Authors, Date of Publication and Title	Conceptual Framework	Design/ Method	Sample/Setting	Major Variables Studied and Their Definitions	Measurement of Major Variables	Data Analysis	Study Findings	Strength of the Evidence (Level of evidence and quality study strengths and weaknesses
Chan, Z.C.Y., Tam, W., Lung, M., Wong, W., &Chau, C. (2013).A systematic literature review of nurse shortage and the intention to leave.	Absent	Systematic review	18 studies were included		Independent variable: Nurse staff ratios, organizational commitment, leadership styles such as participative leadership, and supportive education programs Dependent variable: nursing retention	Literature review		Data extraction and synthesis	Nurse staff ratios, organizational commitment, leadership styles such as participative leadership, and supportive education programs are important factors influencing nurse retention.	Level I.The study’s strength was the ability to measure the intended variables
Lartey, S., Cummings, G., &Profetto-McGrath, J. (2013). Interventions that promote retention of experienced registered nurses in health care settings: A systematic review.	Absent	Systematic review	12 quantitative studies were included		Independent variable: participatory leadership, mentorship and orientation Dependent variable: Nursing retention	Literature review		Correlation studies	Transformational leadership envisages participatory leadership, mentorship and orientation, which are attributed to the high nursing retention levels.	Level I. The study had the strength of measuring the intended variables.
Moneke, N., &Umeh, O. (2013). How leadership behaviors impact critical care nurse job satisfaction.	Maslow’s Hierarchy of Needs; Dual Factor Theory; Domain of Leadership Practices	Descriptive study	Initial N = 137 N = 112 (81.7%) Setting: critical care units (including ED) in large, acute care, nonprofit in New York City.		Independent variables: Leadership practices or style, Organizational commitmentDependent variables: Job satisfaction, Organizational commitment	Leadership practice scale Inventory: 30 items/5 domains of LP/S, 1-10 Likert scale Organizational commitmentQuestionnaire: 18 items, 1-7 Likert scale Job in General Questionnaire: 18 items, yes/no/cannot decide		Pearson correlation, Multiple regression, ANOVA	The researchers concluded the need for leaders implementing strategies that will increase job satisfaction levels of their subordinates if the latter are to stay in the same organization for the unforeseeable future	Level II Strength: the study was able to measure the intended research variables. Weakness: A small sample size in this non-experimental study limited generalization of results.
Nei, D., Anderson, L.S., &Litwiller, B. (2014).Promoting retention of nurses: A meta-analytic examination of causes of nurse turnover.	Absent	Meta-analysis	106 primary studies were included		Independent variables: Supportive and communicative leadership, network centrality, and organizational commitment Dependent variables: nurse turnover	Literature review		Correlation studies	Supportive leadership, employee engagement and network centrality are the most predominant factors influencing nurse turnover.	Level I. A predominant strength noted in this study was its ability to measure the intended research variables.
Van den Heede, K., Florquin, M., Bruyneel, L., Aiken, L., Diya, L., Lesaffre, E, &Sermeus, W. (2013).Effective strategies for nurse retention in acute hospitals: A mixed method study.	Organizational Dynamics Paradigm of Nurse Retention; Grounded Theory	Sequential Mixed Method: C-S data and grounded theory methodology	N= 3186 m response rate/hospital = 72% Setting: Quantitative: 272 randomly selected nursing units in 56 Belgian acute care hospitals, 4-6 units/hospital. Qualitative: 6 hospitals Inclusion: All Belgian acute hospitals invited; RN providing direct patient care; Exclusion: RN on maternity, extended sick or study leave		Independent variables: nurse staffing/ratios, Emergency department, Work environmentDependent variables: Intent to leave	Organizational Profile Survey): Provided bed size, teaching status, and technology level; no further details provided. Practice Environment Scale of the Nursing Work Index: 32 items, 1- 4 Likert scale Researcher developed questions for Qualitative Study interviews focused on Work environment, Job satisfaction, Burnout, Intent to leave		SAS v.9.2 Logistic regression analyses using Generalized Estimation Equation approach. Qual: Items mapped to 5 Magnet Hospital components, performed by 1 researcher and validated by 2 other researchers.	A nurse environment characterized by participative leadership, supportive education programs as well as nursing career growth opportunities translated to a motivated workforce and thereby high nursing retention levels.	LevelI. Strength: ability to measure the intended research variables Weakness: Limited number of voluntary participants and bias

Appendix C: Conceptual Framework (Iowa Model)

Appendix D: Timeline

Tasks	1 and 2	3 and 4	5 and 6	7 and 8	9 and 10	11 and 12
Month 1 and 2 · Obtain guidelines for initiation of work on the capstone project proposal
Month 3 and 4 Prepare and submit capstone proposal for chair to review
Month5and 6 · Defend proposal · Apply for IRB approval · Make final revisions in the capstone proposal for submission to chair and committee member for review
Month 7 and 8 · Identify volunteers to participate in Capstone Project · Organize Capstone Proposal for implementation · Implement Capstone Proposal
Month 9 and 10 · Collect data for project · Data analysis
Month 11 and 12 Evaluation						X

Appendix E: Resource List

Type of Resource	Example
Man	Healthcare personnel
Material	1. Workbooks 2. Education materials such as MLQ5 training manual and license 3. Paper and ink for developing MLQ5 assessments
Money	$300
Machine	Computer Projector Printer

Appendix F: Proposal Instrument

	Pre-intervention	Post-intervention
Idealized Influence – Attributed
Idealized Influence – Behavior
Inspirational Motivation
Intellectual Stimulation
Individual Consideration
Contingent Reward
Management by Exception – Active
Management by Exception – Passive
Laissez-faire
Effectiveness
Satisfaction

Appendix G: Data Collection Tool (MLQ-5 Questionnaire)

	Pre-intervention	Post-intervention
Idealized Influence – Attributed
Idealized Influence – Behavior
Inspirational Motivation
Intellectual Stimulation
Individual Consideration
Contingent Reward
Management by Exception – Active
Management by Exception – Passive
Laissez-faire
Effectiveness
Satisfaction

Appendix H: Budget

Note: Zero budget given the readily availability of resources

Item	Cost
Materials 4. Workbooks 5. Education materials such as MLQ5 training manual and license 6. Paper and ink for developing MLQ5 assessments	$65 $ 150 $0
Machine (Computer, Projector and Printer)	$0
Man (Training cost)	$75

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