Staff Nurse Lack of Knowledge and Opioid Use at the Veteran Administration
Posted: January 5th, 2023
Abstract
Staff Nurse Lack of Knowledge and Opioid Use at the Veteran Administration
by
Proposal Submitted in Partial Fulfillment
of the Requirements for the Degree of
Doctor of Nursing Practice
November 2021
Abstract
The problem identified in this DNP project is the nurses’ lack of knowledge regarding pain management, and the use of opioids in the VA hospital where the project will commence. Researchers have attributed inappropriate opioid prescription and pain management in VA patients to nurses’ lack of knowledge regarding responsible use of opioid and best opioid administration practices. The purpose of this DNP project is to plan, implement, and evaluate an evidence- based CE program on pain management (CEPM), including appropriate use of opioid medication, for nursing staff at the local VA hospital. A knowledge gap exists between VA nurses’ expertise in the realm of pain management, and the appropriate prescription of opioids, while best practices can be found in the literature about evidence-based pain management including the use of opioids. The practice-focused questions that will drive this project include understanding what evidence demonstrates nurses’ lack of knowledge; what evidence supports educating nurses; and whether there be an increase in knowledge related to pain management, and opioid addiction after implementation of a CE program. Potential implications include (a) patients may be impacted positively; (b) better pain management (c) improved health outcomes in pain management; and (d) reduced rates of addiction, and opioid misuse or overdose.
Staff Nurse Lack of Knowledge and Opioid Use at the Veteran Administration
by
Proposal Submitted in Partial Fulfillment
of the Requirements for the Degree of
Doctor of Nursing Practice
November 2021
Dedication
Starts here – when added…
Acknowledgments
Table of Contents
List of Tables. PAGEREF _Toc63963880 \h4
List of FiguresPAGEREF _Toc63963881 \h5
Section 1: Nature of the ProjectPAGEREF _Toc63963882 \h1
IntroductionPAGEREF _Toc63963883 \h1
Problem StatementPAGEREF _Toc63963884 \h2
Purpose StatementPAGEREF _Toc63963885 \h3
Nature of the Doctoral ProjectPAGEREF _Toc63963886 \h4
Sources of EvidencePAGEREF _Toc63963887 \h4
ApproachPAGEREF _Toc63963888 \h5
SignificancePAGEREF _Toc63963889 \h7
SummaryPAGEREF _Toc63963890 \h8
Section 2: Background and ContextPAGEREF _Toc63963891 \h10
IntroductionPAGEREF _Toc63963892 \h10
Analysis, Design, Development, Implementation, and Evaluation (ADDIE) ModelPAGEREF _Toc63963893 \h10
DefinitionsPAGEREF _Toc63963894 \h13
Educating Nurses about Opioids and Pain ManagementPAGEREF _Toc63963896 \h16
Local Background and ContextPAGEREF _Toc63963897 \h18
Role of the DNP StudentPAGEREF _Toc63963898 \h20
Role of the Content ExpertsPAGEREF _Toc63963899 \h21
SummaryPAGEREF _Toc63963900 \h21
Section 3: Collection and Analysis of EvidencePAGEREF _Toc63963901 \h23
IntroductionPAGEREF _Toc63963902 \h23
Practice-Focused QuestionPAGEREF _Toc63963903 \h24
Sources of EvidencePAGEREF _Toc63963904 \h24
Sources of Evidence Generated for the ProjectPAGEREF _Toc63963905 \h24
Sources of Evidence Generated by the ProjectPAGEREF _Toc63963906 \h24
Analysis and SynthesisPAGEREF _Toc63963907 \h27
Curriculum Plan Evaluation by Content Experts SummaryPAGEREF _Toc63963908 \h27
Pre/Posttest Content Expert Validity Index Scale AnalysisPAGEREF _Toc63963909 \h27
Summary of the Evaluation of the Staff Education Program by ParticipantsPAGEREF _Toc63963910 \h27
Pretest/Posttest Change in Knowledge Results by ParticipantsPAGEREF _Toc63963911 \h28
SummaryPAGEREF _Toc63963913 \h28
ReferencesPAGEREF _Toc63963914 \h30
Appendix B: Literature Review MatrixPAGEREF _Toc63963916 \h37
Appendix C: Curriculum PlanPAGEREF _Toc63963917 \h38
Appendix D: Evaluation of the Curriculum Plan by Content ExpertsPAGEREF _Toc63963918 \h39
Appendix E: Curriculum Plan Evaluation by Content Experts SummaryPAGEREF _Toc63963919 \h40
Appendix F: Pretest PosttestPAGEREF _Toc63963920 \h41
Appendix G: Pretest/Posttest Content Validation by Content ExpertsPAGEREF _Toc63963921 \h42
Appendix H: Pre/Posttest Content Expert Validity Index Scale AnalysisPAGEREF _Toc63963922 \h44
Appendix I: Content Expert LetterPAGEREF _Toc63963923 \h45
Appendix J: Presentation of Education ProgramPAGEREF _Toc63963924 \h46
Appendix K: Evaluation of the Staff Education Program by ParticipantsPAGEREF _Toc63963925 \h47
Appendix N: Pretest/Posttest Change in Knowledge Results by ParticipantsPAGEREF _Toc63963928 \h50
Appendix O: Continuing Education ApplicationPAGEREF _Toc63963929 \h51
Table 2. Another Sample TablePAGEREF _Toc41650548 \hError: Reference source not found
The List of Tables must be updated to reflect any tables in your document. If you do not have any tables, delete this page (including the page break at the end of the page).
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Figure 1. i-CVI PainManagementScale. PAGEREF _Toc63960247 \hError: Reference source not found
Section 1: Nature of the Project
Prescription opioids are comprised of clinically approved drugs derived from the poppy plant which is also utilized for the synthesis of heroin, one of the most dangerous and addictive opioids [National Institute on Drug Abuse (NIDA), 2019]. Due to an increase in the use of opioids in treating chronic pain in the United States (US), addiction, diversion, and opioid overdose deaths has increased significantly over the past two decades (Alford, et al., 2016; Tiffany et al., 2015). The underlying reason for opioid misuse and addiction, diversion, and overdose is its widespread clinical use in treatment of moderate to severe pain, and in fact they turn out to be highly addictive (NIDA, 2019). Misuse of prescription opioids used for pain relief occurs when prescription opioids are used in a way or dose other than prescribed, for example, taking someone else’s prescribed opioids or taking prescription opioids without pain (NIDA, 2019). According to The National Institute of Drug Abuse (NIDA) (2019), common prescription opioids used in the United States are hydrocodone (Vicodin®), oxycodone (OxyContin®, Percocet®), oxymorphone (Opana®), morphine (Kadian®, Avinza®), codeine, and fentanyl ().
Many veterans face clinical issues related to pain due to injuries sustained during combat when on active duty (Gellad, et al., 2017). Opioids are often prescribed for pain management, which in some cases have led to high rates of opioid addiction (Califf, Woodcock, &Ostroff, 2016; Compton, Jones, & Baldwin, 2016; Kaye et al., 2017), particularly among the veteran population (Chaudhary & Compton, 2017, Pasero, Quinlan- Colwell, Rae, Broglio, & Drew, 2016). Nurses should play a key role in addressing the issue of opioid addiction among the veteran population due to their role in managing opioid prescriptions, addressing pain management, and helping to prevent as well as treat opioid addiction (Gellad et al., 2017; Olivia et al., 2018; Pasero et al., 2016). However, researchers have identified a lack of knowledge among nurses regarding opioid addiction, and the causes of addiction (Gellad et al., 2017; Olivia et al., 2018).
Therefore, the purpose of this Doctor of Nursing Practice (DNP) project will be to plan, implement, and evaluate a continuing education (CE) program on pain management and opioid addiction for the staff nurses of the VA hospital for which the project is being developed. The proposed project may contribute to social change by addressing and potentially improving the nursing staff’s knowledge regarding pain management as well as increase the awareness surrounding the use of opioids in the VA hospital. By improving the nursing staffs’ knowledge, the proposed project may help to improve the nurses’ ability to manage opioid prescriptions properly for proper pain management, and to prevent opioid addiction and overdose among VA patients. This introductory part discusses i) the statement of the problem, ii) the purpose of the study, iii) the nature of the postgraduate project, and iv) the project’s significance.
The purpose of this DNP project is to plan, implement, and evaluate an evidence- based CE program on pain management (CEPM), including appropriate use of opioid medication, for nursing staff at the local VA hospital. A knowledge gap exists between VA nurses’ expertise in the realm of pain management, and the appropriate prescription of opioids, while best practices can be found in the literature about evidence-based pain management including the use of opioids (Chaudhary & Compton, 2017; Gellad et al., 2017; Kay et al., 2018; Olivia et al., 2018; Pasero et al., 2016; Snow & Wynn, 2018). The project aims at educating nurses regarding opioid prescriptions in the face of a changing health care environment coupled with the growing need for better practices in pain management (American Nursing Association, 2015). The meaningful gap-in-practice that will be addressed in this project is the gap between evidence-based pain management practices, and the implementation of these pain management mechanisms. Specifically, the gap-in-practice that will be addressed in this project the implementation of evidence-based practices for pain management, and prescription of opioid medication.
The practice-focused questions that will drive this project are:
1. What evidence from the literature demonstrates nurses’ lack of knowledge regarding pain management strategies, and the clinical use of opioids?
2. What evidence from the literature supports educating nurses about pain management to facilitate best practice/s in the care of their patients?
3. Will there be an increase in knowledge related to pain management, and opioid addiction after implementation of a CE program as evidenced by a pre-test or post-test?
The proposed DNP will, therefore, address the identified gap by increasing the awareness among VA nurses with regards to pain management and appropriate prescription of opioids, while reducing the improper prescription of opioids for pain management among VA patients.
Nature of the Doctoral Project
There are two areas of evidence to be presented in this DNP. One area includes the sources obtained to support the DNP. Throughout the DNP project process, a review of the literature will be conducted to provide background, and context for the DNP. The review of the literature will include compilation and assimilation of the pre-existing knowledge in this domain from peer-reviewed publications, journal articles, as well as doctoral dissertations and master’s theses. To ensure the relevance of the articles selected for the review, the majority of the sources reviewed should have been published between 2015 and 2020. The presentation of relevant literature is included in Section 2.
The second area is the evidence produced after the implementation of the program, and the results of the program. After IRB approval is granted for the CEPM, during the planning step evidence will be produced following the evaluation of the curriculum by the content experts, and the content validation index of the pre-test or post-test items will be presented. Evidence-based on the pre-test or post-test results following the implementation of the project, and the evaluation of the program by participants will conclude the project.
After IRB approval is granted for the CEPM, evidence will be produced during the planning step in the form of formative evaluation by the content experts of the curriculum, and the content validation index of the pre-test or post-test items will be discussed will also serve as the summative evidence for the project. Finally, the content experts will complete and summarize evaluation of the project, process, and my leadership.
Following the Walden University Manual for Staff Education , the CEPM will follow the steps of the manual and incorporate the phases of the Analysis, Design, Development, Implementation, and Evaluation (ADDIE) (see Appendix A) to develop the CE program. The education will include planning, implementation, and evaluation of the program.
Step 1 Planning
The CEPM will involve an analysis as well as a designing phase, in which the problem will be defined after being assessed by the departmental chair to determine if the project meets the requirements of a DNP staff educational project. A review of the literature will be ongoing throughout the project (see Appendix B) and graded using the, Bernadette Mazurek Melnyk and Ellen Fineout-Overholt’s tool[A1] (Buccheri & Sharifi, 2017).Upon approval of the proposal for this DNP, a continuing education application will be submitted to the site.
The analysis and design phase will be followed by a development phase in which the content and materials will be developed to include an evidence-based curriculum plan from the evidence (see Appendix C). This will include an evaluation of the curriculum plan by content experts (see Appendix D) as well the curriculum plan by content expert’s summary (see Appendix E). The curriculum will include objectives, content, evidence from the literature, method of presentation, and method of evaluation. I will also develop a pre-test or post-test process from the objectives and content of the curriculum (see Appendix F, G, and H). A PhD expert in assessment will review the construction of the test items. The second expert will be identified from the Veteran Hospital. An individual in leadership role belonging to the Veteran Hospital will be selected as an additional expert (see content expert letter in Appendix I). Site authorization will be obtained for the Veteran Hospital in which this study will be conducted. I have already discussed the project with the authorities of Veteran Hospital for the initial approval of the program. Endorsement from the project site and the IRB board will be originated via Form A, and when endorsement is established the project will progress. Finally, a PowerPoint presentation of the project will be developed (AppendixJ).
Step 2 Implementation
In this step, I will confirm the functional state of the necessary materials required for nursing education (Jones, 2014). The program, along with the information of the pre-test and post-test, will be presented to the nursing staff participants. The CEPM will follow the steps advanced in the Manual for Staff Education by Walden University. Specifically, in the development of the CE program, a structured sequence will be employed, which will have i) an analysis phase, ii) a design phase, ii) a development phase, iv) an implementation phase, and v) an evaluation phase, as provided for in the ADDIE model (see Appendix A) (Danks, 2011).
Step 3Evaluation
There are three areas of evaluation for this project. The first will be provided by the content experts during the planning step and will include a formative evaluation of the curriculum plan and content validation of the individual pretest/posttest items. Secondly, impact evaluations will occur during the implementation step of the project and will include the change in knowledge from pretest to posttest and the evaluation of the educational program related to the objectives by participants. Finally, upon completion of the project the content experts will also complete a summary evaluation of the project, process, and my leadership.
The stakeholders involved include nursing staff, Veteran Hospital administrators and VA patients. Patients may be impacted positively if nursing staff improve their knowledge on pain management. Better pain management as addressed in this project has the potential to positively contribute to nursing practice because the increased knowledge and awareness of VA nursing staff may result in improved health outcomes in pain management, reduced rates of addiction, and opioid misuse or overdose. During the evaluation of the project, if the project is found to be successful in improving nursing staff knowledge, this project model may be replicated and implemented in other VA hospitals throughout the United States to improve the well-being and health of VA patients. The improved care in pain management and appropriate opioid use will bring about positive social change, and will contribute to better health outcomes for veterans in need of care improving their physical, mental, and emotional well-being.
The purpose of this DNP project is to plan, implement, and evaluate an evidence- based CE program on pain management (CEPM), raising awareness of the appropriate use of opioid medication among nursing staff at the local VA hospital. The majority of the US population who are prescribed opioids for pain management includes veterans, which has led to an increase in opioid addiction amongst them. There is a lack of knowledge among nurses regrading proper prescription of opioids for pain management. The CEPM will follow the steps in the Walden University Staff Education manual incorporating the ADDIE model (see Appendix A) in the CE program meant for dissemination of clinical knowledgeand focused to provide veterans at VA hospitals with improved pain management care. In this chapter, the introduction, problem declaration, purpose declaration, queries, scope of project, method, and implication of the project were described. In Section 2, the background and context of the project will be presented. In Section 2, the ADDIE model will be discussed, a review of relevant literature, in addition with an in-depth review of the background, and the context related to this proposed project, will be presented. My role and the role of the content experts will also be discussed in detail.
As described in this section, the ADDIE model will be used in this DNP to address the issue of lack of awareness and knowledge in the domain of pain management and opioid prescription among nursing staff associated with VA. The purpose of this DNP is to develop, implement, and evaluate an evidence-based CE program on pain management (CEPM), with focus on appropriate use of opioid medication amongst nursing staff at the local VA hospital. Therefore, this DNP may improve VA nurses’ knowledge of pain management, and augment appropriate prescription of opioids, and reduce the improper prescription of opioids for pain management among VA patients. In the following Section 2, the sources of evidence, collection and analysis of evidence, and ethical considerations for this DNP and its introduction, ADDIE model, relevance to nursing practice, local background and context, and my role and the role of the content experts will be described.
Section 2: Background and Context
The problem identified in this DNP project is the nurses’ lack of knowledge regarding pain management and the use of opioids in the VA hospital for which the project will take place.
The practice-focused questions that will drive this project are:
- What evidence from the literature demonstrates nurses’ lack of knowledge regarding pain management strategies, and the clinical use of opioids?
- What evidence from the literature supports educating nurses about pain management to facilitate best practice/s in the care of their patients?
- Will there be an increase in knowledge related to pain management, and opioid addiction after implementation of a CE program as evidenced by a pre-test or post-test?
The purpose of this DNP project is to develop, implement, and evaluate an evidence-based CE program on pain management (CEPM), and facilitate appropriate use of opioid medication, for nursing staff at the local VA hospital. The proposed project will, therefore, address the identified gap by improving VA nurses’ knowledge of pain management, and facilitate appropriate prescription of opioids by reducing the improper prescription of opioids for pain management among VA patients.
Analysis, Design, Development, Implementation, and Evaluation (ADDIE) Model
The conceptual framework guiding the development of an evidence- based CE program on pain management (CEPM) program is founded on the ADDIE model, which is an acronym for sequential steps categorized by analyzing, designing, developing, implementing and evaluating a continuing education program. The U.S. Army developed the model’s concept initially, while the Center for Educational Technology at Florida State University refined it into its current form, as illustrated in Appendix A (Branson et al., 1975; Göksu et al., 2017). ADDIE is an instructional design and project management tool that allows for the development, testing, and evaluation throughout the process to improve the performance of the project. The ADDIE model has been commonly used to develop education programs (Jones, 2014), and most instructional design models are developed based on the ADDIE model (Göksu et al., 2017). The components of ADDIE are:
- Analyze: Conduct needs analysis
- Design: Design support model
- Develop: Develop work functions
- Implement: Implement the key work functions
- Evaluate: Evaluate the impact of each function (Danks, 2011)
In the context of CE for nurses, Hsu, Lee-Hsieh, Turton, and Cheng (2014) used the ADDIE model to develop online courses on caring for hospital nurses in Taiwan. The examiners began by creating an inquiry that used interviews with patients and nurses to recognize thoughtful and insensible behaviors (Hsu et al., 2014). These tools were also used by patients to evaluate nurses. The results of the study yielded positive self-evaluation in nurses, while no differences were found in patient evaluations pre- and post-course (Hsu et al., 2014). Based on these findings, the researchers concluded that the ADDIE model is useful since, the model provides a way to use research data, and presents results to introduce organizational change.
The ADDIE model has also been applied in a more recent study in developing the skills of nurses on the undergraduate level in a study by Oh et al. (2019). In this case, Oh et al. (2019) details about an online course on nursing informatics, which uses the flipped learning approach and incorporates film clips. Specifically, ADDIE provided the researchers with the ability to evaluate the effectiveness of the method of teaching, and to analyze student responses. The study’s outcome was the upgrading in the understanding of the core concepts of nursing informatics. Besides, the students in the study noted that they would recommend the instructional course to their colleagues (Oh, 2019).
As reflected in the findings of these studies, the ADDIE model is effective in not only developing projects to improve the knowledge, and skills of learners but is also useful in receiving feedback to evaluate the effectiveness of the course, as well as participant satisfaction after the conclusion of the course or intervention (Oh, 2019). The ADDIE model will help me in designing a program that will potentially meet the specific needs of nurses improving their knowledge of proper opioid prescription, and opioid addiction. In this process, the ADDIE model provides the structure to analyze, develop, and refine the model so that the learning outcomes can be improved by making changes to the model (Danks, 2011). In the case of the proposed DNP, this process will be important to develop, implement, and evaluate the course.
Diversion. Diversion of prescription opioids refers to the misuse of opioids due to an individual passing on their prescription or falsifying a prescription (Alford, et al., 2016; Tiffany, Wilder, Miler, &Winhusen, 2015).
Naloxone. A short-acting opioid antagonist that has been approved by the Food and Drug Administration (FDA) for the reversal of opioid overdose (Tiffany et al., 2015). According to Tiffany et al. (2015), Naloxone can be administered through several injection avenues, including intranasally, subcutaneously, intramuscularly, and intravenously.
Opioid. Includes prescription and non-prescription analgesics. Prescription analgesics include buprenorphine, codeine, darvocet, darvon, demerol, dilaudid, fioricet, fiorinal, hydrocodone, methadone, morphine, oxycontin, percocet, percodan, propoxyphene, talwin, tylenol with codeine, tylox, ultram, and vicodin (Barry et al., 2018).
Opioid addiction. Also referred to as opioid use disorder or more generally as drug use disorder/ substance use disorder. Addiction relates to the dependence on the use of opioids and is associated with withdrawal symptoms (Barry et al., 2018; Gellad et al., 2017).
Opioid misuse. Misuse of prescription opioids refers to the use of prescription opioids in a way or dose other than prescribed; taking someone else’s prescribed opioids; and taking prescription opioids for the effect it causes rather than for pain (NIDA, 2019).
Opioid overdose. An opioid overdose occurs when an individual is exposed to a lethal dose of the opioid which causes life-threatening symptoms or even death. Overdose of opioid medication often causes breathing to slow or even stop, which can decrease the amount of oxygen that reaches the brain, and may result in coma, permanent brain damage, or death (NIDA, 2019).
Relevance to Nursing Practice since Nurses Lack Knowledge on Pain Management and the Use of Opioids
The relevance of this project is significant to nurses in the process of proper pain management, proper use of opioids, prevention, and management of subsequent opioid problems. As has been mentioned, the major problem is nurses’ lack of knowledge regarding pain management and the use of opioids, which evidently contributes to the opioid crisis as well as poor pain outcomes in patients (Barry et al., 2018). Therefore, the project will directly address the lack of knowledge and thus at the end of the project, the nurses will be able to provide proper prescription for the right level of pain, avoid excessive and unnecessary use of opioids, and increase patient centered focus on the pain to determine alternative approaches to managing the pain. This study will thus be of relevance through having a direct impact on the knowledge of nurses.
Nurses play a central role in helping patients to manage opioid addiction. Their knowledge and understanding will be crucial in helping patients reduce dependency on opioids and in future make better decisions to aid these patients on how to manage pain. Nurses can utilize existing alternatives as well as be in a position to develop new methods of pain management after this project; hence the relevance of the project is further increased.
Besides being informative and increasing knowledge, the relevance of this project is expected to go beyond and inspire nurses to be proactive and engage in advocacy for the patients. After understanding how their knowledge of prescription of opioids for pain contributes to poor pain management and opioid addiction in patients, nurses will be inspired to engage in improving the well-being of their patients through encouraging the patients directly as well as advocating for changes in regulations and laws to make it harder to access opioids and easier to utilize alternative medications for pain management.
The project will be of importance to patients once nurses get to understand their role in proper pain management. The patients will benefit from unnecessary opioid use, proper pain management to facilitate safe healing, as well as improved health and well-being. The benefits of patients in reduced opioid addiction will have a wider impact on the society through improved social and economic outcomes of the people who are affected by constant pain as a result or poor management or the opioid addiction problem. Furthermore, the government, both local and federal will benefit from a lower number of people becoming addicted.
The current patients who will be directly affected by the outcomes of the CE program to educate nurses on pain management and opioid use are veterans based on the location of the hospital site. Veterans are a particularly vulnerable group to social, economic, and psychological problems, especially those returning home after serving in deployments overseas, conflict regions, and combat zones (Gellad et al., 2017). Veterans are also directly vulnerable to direct physical injuries from training or combat, and thus are highly susceptible to pain (Olivia et al., 2018). This makes pain management an essential part of knowledge for nurses. Therefore, this project upon successful nurse education on the problems of pain management and opioid use will in turn provide improved outcomes for veterans through increasing their quality of life by reducing addiction and ensuring a pain free life.
Educating Nurses about Opioids and Pain Management
The development of projects for the continued education, and training of nurses are being studied to address the issue of opioid addiction, and improper prescription of opioids for pain management among veterans. For instance, Niemtzow et al. (2018) developed and implemented the Acupuncture Training Across Clinical Settings (ATACS) to provide acupuncture training to staff in the Military Health System (MSH), and Veterans Health Administration (VHA). Providers were trained on acupuncture, as an additional non-pharmacological pain management option to address the issue of prescribing opioids for pain management among veterans. The curriculum content and structure were developed, and refined over the course of the project. Participants were provided hands-on training and coached for improving skill proficiency, and thereafter providers were asked to complete an evaluation survey on their experience with ATACS (Niemtzow et al., 2018). The results of the study showed that over a period of nineteen months 2,712 providers completed the training, and due to an increased demand for training, additional training faculty were trained and recruited to deliver the courses (Niemtzow et al., 2018). The participants expressed high satisfaction with the courses (Niemtzow et al., 2018). Niemtzow et al. (2018) also identified a need for additional research on examining the effectiveness of these techniques in real-life settings and outcomes.
Bounthavong et al. (2019) evaluated the implementation of academic detailing, along with the Opioid Overdose Education and Naloxone Distribution (OEND) program which aimed at increasing naloxone access to prevent opioid overdose mortality in veterans. Unlike the proposed DNP, Bounthavong et al. (2019) used a retrospective cohort design with fixed effect models. However, the study focused on academic detailing, which represents outreach education for health care professionals, in the context of raising clinical awareness regarding naloxone (Bounthavong et al., 2019). The researchers found that the implementation was not uniform, and led to different levels of intervention which impacted the clinical use and prescription of naloxone however, there was a positive relationship between academic detailing and naloxone prescribing (Bounthavong et al., 2019). Specifically, providers that were exposed to academic detailing were more likely to prescribe naloxone. Based on these findings, Bounthavong et al. (2019) concluded that the importance of academic detailing must be highlighted, and the implementation process must be considered to improve the effectiveness of the intervention.
As reflected in the results of these studies, the use of CE programs to increase clinical staff knowledge can improve the clinical outcomes. Therefore, evidence supports the use of a practice-focused project to improve nursing staff knowledge which is the primary focus of the proposed DNP. One limitation described by Niemtzow et al. (2018), which has also been addressed in chapter one is that the results of the proposed DNP will involve evaluation of the effectiveness of the DNP on nursing staff outcomes with the help of pre-test or post-test and participant surveys. Additional research evaluating the association between training programs and reductions in opioid addiction would be necessary to determine the effectiveness of these training on patient outcomes. In the following section, the phases of analysis, design, development, implementation, and evaluation of the DNP using the ADDIE model (see Appendix A) will be further described as related to the proposed DNP as part of the methodology.
As a CE project, the research design for this proposed project will follow the Walden University Staff Education Manual . As described in Chapter 1, the project will follow the ADDIE model. The ADDIE model has been selected for use in this project because it has been commonly used to develop education programs (Jones, 2014). The outcome of this project will include a literature review matrix, curriculum on opioid addiction for nursing staff, and a pre-test/post-test. The curriculum, summative of the project, process, my leadership, content of the pre-test/post-test will be evaluated by content experts prior to its implementation, along with the validation of test items. If implemented, the project will include the results of the pre-test/post-test and will also present the evaluation report of the CEU program as assesses by the participants through the use of a participant survey.
The development of projects for the continued education and training of nurses has been used in studies to address the issue of opioid addiction, and improper prescription of opioids for pain management among veterans. For instance, Niemtzow et al. (2018) developed and implemented the Acupuncture Training A Cross Clinical Settings (ATACS) to training staff in the Military Health System (MSH) and Veterans Health Administration (VHA) in acupuncture for pain relief. Health-care providers were trained on acupuncture as an additional non-pharmacological pain management option to address the issue of indiscriminate prescription of opioids for pain management among veterans. The curriculum content and structure will be developed and refined over the course of the project. Participants will be provided hands-on training and coached for improving skill proficiency, and thereafter providers were asked to complete an evaluation survey on their experience with ATACS (Niemtzow et al., 2018). The results of the study showed that over a period of nineteen months 2,712 providers completed the training, and due to an increased demand for training, additional training faculty were trained and recruited to deliver the courses (Niemtzow et al., 2018). The participants of the study reported by Niemtzow and group expressed high satisfaction with the courses (Niemtzow et al., 2018). Niemtzow et al. (2018) also identified a need for additional research examining the effectiveness of these techniques in real-life settings and outcomes.
In a more recent study, Bounthavong et al. (2019) evaluated the implementation of academic detailing of the Opioid Overdose Education and Naloxone Distribution (OEND) program which was aimed at increasing access to naloxone to prevent opioid overdose mortality in veterans. Unlike the proposed project to be conducted, Bounthavong et al. (2019) used a retrospective cohort design with fixed effects models. However, the study focused on academic detailing, which represents outreach education for health care professionals, in the context of raising clinical awareness regarding naloxone (Bounthavong et al., 2019). The researchers found that the implementation was not uniform, and led to different levels of intervention which impacted the clinical use and prescription of naloxone however, there was a positive relationship between academic detailing and naloxone prescribing (Bounthavong et al., 2019). Specifically, providers that were exposed to academic detailing were more likely to prescribe naloxone. Based on these findings, Bounthavong et al. (2019) concluded that the importance of academic detailing must be highlighted, and the implementation process must be carefully considered to improve the effectiveness of the intervention.
As reflected from the results of these studies, the use of CE programs to increase clinical staff knowledge can result in improved clinical outcomes. Therefore, there is substantial evidence that supports the use of a practice-focused project to improve nursing staff knowledge, which is also the focus of the proposed project. One limitation described by Niemtzow et al. (2018), which has also been addressed in chapter one is that the results of the proposed DNP will involve evaluation of the effectiveness of the DNP on nursing staff outcomes with the help of pre-test or post-test and participant surveys. Additional research evaluating the association between training programs and reductions in opioid addiction would be necessary to determine the effectiveness of these training on patient outcomes. In the following section, the phases of analysis, design, development, implementation, and evaluation of the DNP using the ADDIE model (see Appendix A) will be further described as related to the proposed DNP as part of the methodology.
Content experts will support the evaluative process of the project with the major stakeholders being the nurses who will ultimately improve their practice of providing the best care to patients and their families. In addition, the project is aligned to Walden University’s mission of promoting positive social change. The University reiterates its mission through its “A Mission of Change” statement that reads, in part: “Through online programs that reflect current market trends and promote positive social change, Walden is committed to helping you achieve your goals, enabling you to make a difference in your career and community as a Walden graduate (Walden University)”(Walker, 2017).
Incorporating the phases of the ADDIE model within the planning, implementation, and evaluation steps of the Walden University Staff Education Manual will provide a formal framework for this project. Content experts will support the evaluative process of the project with the major stakeholders being the nurses who will ultimately improve their practice of providing best care to patients and families.
The several issues discussed in this section include the relevance of the evidence-based continuing education program and its associated project development to nursing practice. It details the utility of the ADDIE model in such projects. The section also places the project into context of the setting by providing an overview of the local background. Notwithstanding, the section outlines the role played by the Doctor of Nursing Practice (DNP) student in this project. As described in this section, the ADDIE model will be used in this DNP project to address the issue of lack of adequate knowledge in the context of pain management and opioid prescription among nursing staff in the VA context. The purpose of this DNP is to develop, implement, and evaluate an evidence-based CE program on pain management (CEPM), including appropriate use of opioid medication, for nursing staff at the local VA hospital. This DNP therefore may improve the VA nurses’ knowledge of pain management and lead to more appropriate prescription of opioids reducing the improper prescription of opioids for pain management among VA patients. In Section 3 to follow, the sources of evidence, collection, analysis of evidence, and ethical considerations for this DNP will be described. Specifically, in Section 3, I will present the practice-focused questions that will guide the evidence from the literature to develop the CEEBP in this project. The participants in this project are content experts, and the nurses who will receive the education. An analysis and synthesis of the evidence generated from the project will be put forth, and all participants of this study will be protected through the adherence to the IRB guidelines which will conclude Section 3.
Section 3: Collection and Analysis of Evidence
The Doctor of Nursing Practice (DNP) project identified the lack of knowledge in nurses regarding the management of pain and the appropriate use of opioids in a VA hospital as the problem. To address this problem, this DNP project is purposed to plan, implement, and evaluate an evidence-based CE program on pain management (CEPM) for appropriate use of opioid medication, for nursing staff at the local VA hospital.
Researchers have identified a need for additional research to fill the gap in the literature concerning VA nurses, and their knowledge of responsible opioid use and best practices (Gellad et al., 2017; Olivia et al., 2018). Olivia et al. (2018) revealed that nurses were not always adequately informed of responsible practices with opioids or the prescribing of opioids. Additionally, the authors found that nurses were not always able to discern when other types of medications would work in lieu of opioids, which could substantially reduce the number of veterans who misuse opioids, while also reducing opioid-based mortalities (Olivia et al., 2018). As presented in Section 2, over the past two decades, dangerous and inappropriate use of opioid medication has significantly risen, which has led to the need for dissemination of adequate knowledge to both caregivers and patients for curbing these adverse effects. This proposed DNP project will specifically focus on improving the prescribing of opioids and encourage appropriate use of opioids among veterans by addressing the lack of knowledge amongst nursing staff at a local VA hospital. Section 3 of this paper will address the practice-focused questions, the sources of evidence generated for and by the project with ethical considerations, and the methods of analysis and synthesis.
The practice-focused questions to be addressed in this DNP are:
1. What evidence from the literature demonstrates nurses’ lack of knowledge regarding pain management strategies, and the clinical use of opioids?
2. What evidence from the literature supports educating nurses about pain management to facilitate best practice/s in the care of their patients?
3. Will there be an increase in knowledge related to pain management, and opioid addiction after implementation of a CE program as evidenced by a pre-test or post-test?
Sources of Evidence Generated for the Project
In this project, databases, and search engines such as Google Scholar, PubMed, and other sources will be used to conduct searches for literature relevant to the proposed project. A literature review matrix (see Appendix B) will be developed using sources of evidence to address the first practice-focused question and graded using levels of evidence as described by the Melnyk et al. (2010). To ensure the relevance of the articles selected for the review of relevant literature, the majority of the sources reviewed will be published between 2015 and 2020.
Sources of Evidence Generated by the Project
- Curriculum Plan (see Appendix C)
- Evaluation of Curriculum by Content Experts (see Appendix D)
- Pretest/Posttest (see Appendix F)
- Pre/Posttest Content Validation by Content Experts (see AppendixG)
- Evaluation of the Staff Education Program by Participants (see Appendix K)
- Summary Evaluation of the Staff Education Project by Content Experts (Appendix L)
Participants
The participants for the DNP will include the content experts for the formative evaluation of the curriculum and the content validation of pretest/posttest items. They will also provide a summaryevaluation upon conclusion of the program to cover the project, process, and my leadership. The second group of participants will be the staff who will participate in the education program and provide impact evidence from the CE program evaluation and evidence revealed from the change in knowledge from pretest to the post-test.
Procedures
The procedures to be used in the project are detailed in this sub-section. Templates for the project have been developed by the chair of my committee for organizational purposes only therefore no reliability and validity are needed.
Content Validity Index Scoring Instrument.Content validity is a critical requirement for educators seeking high-quality measurements of test items. A scale with high-degree content validity must contain an appropriate quantity of items about the specific topic of interest. The Content Validity Index Scoring Instrument will be used for the pretest/posttest items in this project[A2] .
Content Expert Packet.The Content Expert Packet will include the Content Expert Letter (see Appendix I), the Literature Review Matrix (see Appendix B), the Curriculum Plan (see AppendixC), theEvaluation of the Curriculum Plan by Content Experts (see Appendix D), the Pretest/Posttest (see Appendix F), and the Pre/Posttest Content Validation by Content Experts (see Appendix G). The items in content expert packet will be identified only by numerical code within the packet with no CE identifying information. The packet will be delivered anonymously to each CE by a colleague. The CEs will have a week to complete their work and they will return the packet to the identified colleague who will return to my mailbox for analysis and synthesis.
Evaluation of the Staff Education Program by Participants.(see Appendix K). Upon completion of the staff education project, participants will complete an impact evaluation of the program related to curriculum objectives. I will assign a member of the group to gather the evaluations in a blank envelope after I leave the room. That person will deliver the envelope to my mailbox after which I will analyzethe results.
Summary Evaluation of the Staff Education Project by Content Experts.(see AppendixL). After completion of the project, I will distribute the Summary Evaluation of the Staff Education Project to the CEs. There will be no identifying marks on the evaluations. Each CE will return the completed form to my mailbox anonymously afterwhich I will analyse the results.
Protection
The protection for this DNP project will be ensured by adherence to the Walden University IRB guidelines. All work will be anonymous. The pretest/posttest will be numerical only. All written material will be kept in a locked file for five years and then shredded. There should be no anticipated outliers or missing information for this DNPproject. Protections will also be ensured through use of DNP Staff Education Project ManualSite agreement form.
Curriculum Plan Evaluation by Content Experts Summary
The curriculum evaluation will becompleted by the CEs using a “met” or “not met” dichotomous scale. The results of the three evaluations will be quantitatively averaged using the Content Expert Evaluation of the Curriculum Plan Summary (see Appendix E).
Pre/Posttest Content Expert Validity Index Scale Analysis
Each item will be validated by content experts using a Likert scale, and the analysis will be computed resulting in the content validation index score and reported on the Results of Pre/Posttest Content Expert Validity Index Scale Analysis(see Appendix H).
Summary of the Evaluation of the Staff Education Program by Participants
The educational program will be evaluated by nurse staff participants using a dichotomous response of “met” or “not met” in relation to each of the objectives. The results will be reported on the Summary of the Evaluation of the Staff Education Program by Participants(see Appendix M) and analyzed using descriptive statistics measuring the extent to which the objectives were met or not met using frequency counts and percentages.
Pretest/Posttest Change in Knowledge Results by Participants
Pretest/Posttest Change in Knowledge by Participants (see Appendix N) will be analyzed using SPSS and reported using descriptive statistics to represent the percentage of improvement in individuals, and inferential statistics using a paired t-test for group change in knowledge.All of the pertinent information from the procedure and analysis and synthesis topics will be included in the Continuing Education Application (see Appendix O)
Summary Evaluation Results of the Staff Education Project, Process, and My Leadership by Content Experts
The findings from the summary evaluation by the CEs will be compiled in the Summary Evaluation Results of the Staff Education Project, Process, and My Leadership by Content Experts(see Appendix P). The summary evaluation will include a thematic summary of responses to help me in future staff education projects.
Section 3 reviewed the DNP project identified problem, related to the practice-focused questions which will be addressed by thesources of evidence to support the implementation of the project and produceevidence generated by the project.The procedures for collecting the evidence will including identifying and supporting the use of CEs and the staff nurse participants who will receive the educationassuring. Protection of all persons involve and adherence to the Walden University IRB guidelines was addressed. Finally the analysis and synthesis of evidence was discussed the findings and implications of which will be presented in Section 4. As well, in Section 4, the recommendations resulting from the findings, the role of the CEs, and the strengths and limitations of the project will be discussed.
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Buccheri, R. K., & Sharifi, C. (2017). Critical appraisal tools and reporting guidelines for evidence‐based practice. Worldviews on Evidence‐Based Nursing, 14(6), 463-472. https://doi.org/10.1111/wvn.12258.
Califf, R. M., Woodcock, J., & Ostroff, S. (2016). A proactive response to prescription opioid abuse. New England Journal of Medicine, 374(15), 1480-1485. https://doi.org/10.1056/NEJMsr1601307.
Chaudhary, S., & Compton, P. (2017). Use of risk mitigation practices by family nurse practitioners prescribing opioids for the management of chronic nonmalignant pain. Substance Abuse, 38(1), 95-104. https://doi.org/10.1080/08897077.2016.1265038.
Compton, W. M., Jones, C. M., & Baldwin, G. T. (2016). Relationship between nonmedical prescription-opioid use and heroin use. New England Journal of Medicine, 374(2), 154-163. https://doi.org/10.1056/NEJMra1508490.
Danks, S. (2011). The ADDIE Model: Designing, Evaluating Instructional Coach Effectiveness. ASQ Primary and Secondary Education Brief, 4(5), 1-6. Retrieved from http://asq.org/edu/2011/09/process-management/the-addie-model-designing-evaluating-instructional-coach-effectiveness.pdf.
Devonshire, E., & Nicholas, M. K. (2018). Continuing education in pain management: using a competency framework to guide professional development. Pain Reports, 3(5), e688. https://doi.org/10.1097%2FPR9.0000000000000688.
Gellad, W. F., Good, C. B., & Shulkin, D. J. (2017). Addressing the opioid epidemic in the United States: Lessons from the Department of Veterans Affairs. JAMA Internal Medicine, 177(5), 611-612. https://doi.org/10.1001/jamainternmed.2017.0147.
Göksu, I., Özcan, K. V., Çakir, R., & Göktas, Y. (2017). Content Analysis of Research Trends in Instructional Design Models: 1999-2014. Journal of Learning Design, 10(2), 85-109. https://doi.org/10.5204/jld.v10i2.288.
Gupta, K. K., Attri, J. P., Singh, A., Kaur, H. & Kaur, G. (2016). Basic concepts for sample size calculation: Critical step for any clinical trials! Saudi Journal of Anesthesia, 10(3), 328-331. https://doi.org/10.4103/1658-354X.174918.
Hadlandsmyth, K., Mosher, H., Vander Weg, M. W., & Lund, B. C. (2018). Decline in prescription opioids attributable to decreases in long-term use: A retrospective study in the Veterans Health Administration 2010–2016. Journal of General Internal Medicine, 33(6), 818-824. https://doi.org/10.1007/s11606-017-4283-8.
Herr, K., St Marie, B., Gordon, D. B., Paice, J. A., Watt-Watson, J., Stevens, B. J., Bakerjian, D. & Young, H. M. (2015). An interprofessional consensus of core competencies for prelicensure education in pain management: Curriculum application for nursing. Journal of Nursing Education, 54(6), 317-327. https://doi.org/10.3928/01484834-20150515-02.
Hsu, T. C., Lee-Hsieh, J., Turton, M. A., & Cheng, S. F. (2014). Using the ADDIE model to develop online continuing education courses on caring for nurses in Taiwan. The Journal of Continuing Education in Nursing, 45(3), 124–31. https://doi.org/10.3928/00220124-20140219-04.
Jones, B. A. (2014). ADDIE model (Instructional Design). Jones, B. A. (2014). ADDIE model (instructional design). Retrieved from http://citeseerx.ist.psu.edu/viewdoc/summary? https://doi.org/10.1.1.572.4041.
Kay, C., Wozniak, E., Ching, A., & Bernstein, J. (2018). Pain agreements and healthcare utilization in a Veterans Affairs primary care population: A retrospective chart review. Pain and Therapy, 7(121), 121-126. https://doi.org/10.1007/s40122-018-0098-5.
Kaye, A. D., Jones, M. R., Kaye, A. M., Ripoll, J. G., Jones, D. E., Galan, V., Beakley, B. D., Calixto, F., Bolden, J. L., Urman, R. D. & Manchikanti, L. (2017). Prescription opioid abuse in chronic pain: An updated review of opioid abuse predictors and strategies to curb opioid abuse (Part 2). Pain Physician Journal, 20(2S), S111-S133. Retrieved from https://www.researchgate.net/profile/Juan_Ripoll/publication/313902967_.
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Niemtzow, R., Baxter, J., Gallagher, R. M., Pock, A., Calabria, K., Drake, D. … & Buckenmaier, C. (2018). Building Capacity for complementary and integrative medicine through a large, cross-agency, acupuncture training program: Lessons learned from a military health system and Veterans Health Administration Joint Initiative Project. Military Medicine, 183(11-12), e486-e493. https://doi.org/10.1093/milmed/usy028.
Oh, J., Kim, S-J., Kim, S., Kang, K-A., Kan, J., & Bartlett, R. (2019). Development and evaluation of flipped learning using film clips within a nursing informatics course. Japan Journal of Nursing Science, 385-395. https://doi.org/10.1111/jjns.12245.
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Appendix A: Analysis, Design, Development, Implementation, and Evaluation (ADDIE) Model
ADDIE model.
- Analyze: Conduct needs analysis
- Design: Design support model
- Develop: Develop work functions
- Implement: Implement the key work functions
Source: (Danks, 2011)
Appendix B: Literature Review Matrix
Melnyk, Bernadette Mazurek, and Ellen Fineout-Overholt’s tool, (permission pending)
DNP Project Title:Staff Nurse Lack of Knowledge and Opioid Use at the Veteran Administration
Student: Cathy Ramey
| Reference | Theoretical/ Conceptual Framework | Research Question(s)/ Hypotheses | Research Methodology | Analysis & Results | Conclusions | Grading the Evidence | |||||
Melnyk, B., Overholt, E., Stillwell, S., & Williamson, K. (2010). The seven steps of evidence-based practice. American Journal of Nursing, 110(1), 51-53.
.
Appendix D: Evaluation of the Curriculum Plan by Content Experts
Date:
Student:
Content Expert Letter:
Products for Review: Curriculum Plan, Complete Curriculum Content, Literature Review Matrix
Instructions: Please review each objective related to the curriculum plan, content and matrix. The answer will be a met or not met with comments if there is a problem understanding the content or if the content does not speak to the objective. At the conclusion of this educational experience, the participant will be able to:
| Objective Number | Objective Statement | Met | Not Met | Comment |
| 1 | ||||
| 2 | ||||
| 3 | ||||
| 4 | ||||
| 5 | ||||
| etc | ||||
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Appendix E: Curriculum Plan Evaluation by Content Experts Summary
Met = 1 Not Met = 2
At the conclusion of this educational experience, learners will be able to:
| Objective Number and Statement | Evaluator A | Evaluator B | Evaluator C | Average Score |
| 1. | ||||
| 2. | ||||
| 3. | ||||
| 4. | ||||
| 5. | ||||
| 6. |
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Appendix G: Pretest/Posttest Content Validation by Content Experts
Title of Project:
Student:
Respondent No. (A, B, C)
Accompanying Packet: Curriculum Plan, Pretest/Posttest with answers, Pretest/Posttest Expert Content Validation Form
INSTRUCTIONS: Please check each item to see if the question is representative of the course objective and the correct answer is reflected in the course content.
Test Item # 1 2 3 4
1 Not Relevant __ Somewhat Relevant__ Relevant___ Very Relevant__
Comments:
2 Not Relevant__ Somewhat Relevant__ Relevant___ Very Relevant__
Comments:
3 Not Relevant__ Somewhat Relevant__ Relevant___ Very Relevant__
Comments:
4 Not Relevant__ Somewhat Relevant__ Relevant___ Very Relevant__
Comments:
5. Not Relevant__ Somewhat Relevant__ Relevant___ Very Relevant__
Comments:
6 Not Relevant__ Somewhat Relevant__ Relevant Very Relevant__
Comments:
7 Not Relevant__ Somewhat Relevant__ Relevant Very Relevant__
Comments:
8 Not Relevant__ Somewhat Relevant__ Relevant Very Relevant__
Comments:
9 Not Relevant__ Somewhat Relevant__ Relevant Very Relevant__
Comments:
10 Not Relevant__ Somewhat Relevant__ Relevant Very Relevant__
Comments:
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Appendix H: Pre/Posttest Content Expert Validity Index Scale Analysis
Rating on X-Items Scale by Three Experts on a 4-point Likert Scale
| Pretest/Posttest Items | Expert 1 | Expert 2 | Expert 3 | Total rating | Item CVI |
| 1 | |||||
| 2 | |||||
| 3 | |||||
| 4 | |||||
| 5 | |||||
| 6 | |||||
| Continue for as many items as you have. Total | |||||
| Proportion Relevant | S-CVI |
I-CVI, item-level content validity index.
S-CVI/UA, scale-level content validity index, universal agreement calculation method Adopted from Polit, D. F., & Beck, C. T. (2006). The content validity index.
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Appendix I: Content Expert Letter
Appendix J: Presentation of Education Program
Appendix K: Evaluation of the Staff Education Program by Participants
| Objective Statement | Were the objectives met? Please circle. | Comments |
| Yes No | ||
| Yes No | ||
| Yes No | ||
| Yes No | ||
| Yes No | ||
| Additional Comments: |
Appendix L: Summary Evaluation of the Staff Education Project by Content Experts
Title of Project:
Student:
Thank you for completing the Summary Evaluation on my project. Please complete and send anonymously via interoffice mail to:
- Content Expert Approach
- Please describe the effectiveness (or not) of this project in terms of communication, and desired outcomes etc.
- How do you feel about your involvement as a content expert member for this project?
- What aspects of the content expert process would you like to see improved?
- There were outcome products involved in this project including an educational curriculum and pre/ posttest.
- Describe your involvement in participating in the development/approval of the products.
- Share how you might have liked to have participated in another way in developing/approving the products.
- The role of the student was to be the leader of the project.
- As a leader how did the student direct you to meet the project goals?
- How did the leader support the you in meeting the project goals?
- Please offer suggestions for improvement.
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Appendix M: Summary of the Evaluation of the Staff Education Program by Participants
Appendix N: Pretest/Posttest Change in Knowledge Results by Participants
Appendix O: Continuing Education Application
Title of Project:
Student:
Thank you for completing the Summary Evaluation on my project. Please complete and send anonymously via interoffice mail to:
- Content Expert Approach
- Please describe the effectiveness (or not) of this project in terms of communication, and desired outcomes etc.
| Evaluator A | Evaluator B | Evaluator C |
- How do you feel about your involvement as a content expert member for this project?
| Evaluator A | Evaluator B | Evaluator C |
- What aspects of the content expert process would you like to see improved?
| Evaluator A | Evaluator B | Evaluator C |
- There were outcome products involved in this project including an educational curriculum and pre/ posttest.
- Describe your involvement in participating in the development/approval of the products.
| Evaluator A | Evaluator B | Evaluator C |
- Share how you might have liked to have participated in another way in developing/approving the products.
| Evaluator A | Evaluator B | Evaluator C |
- The role of the student was to be the leader of the project.
- As a leader how did the student direct you to meet the project goals?
| Evaluator A | Evaluator B | Evaluator C |
- How did the leader support the you in meeting the project goals?
| Evaluator A | Evaluator B | Evaluator C |
- Please offer suggestions for improvement.
| Evaluator A | Evaluator B | Evaluator C |
Moon/Aug 2020
cite
cite polit and add to references
[A3]Substituted with book with content validity from the same authors
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