NUR4093 Module 4 capstone evaluation plan example

One Outcome, Three Processes and a Balancing Measure: When and How the Bowel Protocol Will Be Read

Student Name

American College of Education

NUR4093: Senior Capstone Experience for Nursing

Module 4 Assignment

Instructor Name

March 22, 2027

Why the Measure Is Fixed First

The capstone's problem, carried unchanged from the first module, concerns elective hip and knee replacement patients on a 26-bed orthopedic unit: at baseline, 37 of 80 patients, or 46 percent, went from surgery to midnight at the close of day three with no stool recorded. The unit and all figures are the same composite used throughout the capstone. The implementation plan in the previous module replaces docusate with scheduled senna as the default, adds bowel status charting every shift and introduces a nurse-led escalation on day two. This module decides how the capstone will know whether that plan worked.

The measures are fixed now, before the protocol goes live, for a practical and an ethical reason. Practically, the outcome must be defined exactly as it was at baseline or no comparison is possible. Ethically, a measure chosen after the results are known invites the choice of whichever measure looks best. Writing the measures down in advance is a small act of honesty that protects the capstone from its author's hopes.

A Framework for the Measures

Donabedian (1988) argued that three kinds of information reveal the quality of care: structure, the settings and resources in which care is given; process, what is actually done in giving and receiving care; and outcome, the effects of care on patients. He argued that the three are linked, good structure making good process more likely and good process making good outcomes more likely, and that a sound evaluation examines more than one. For this capstone, the framework is useful because a disappointing outcome could be caused by a protocol that works but was not followed, or by a protocol that was followed but does not work, and only process measures can tell those apart.

Structure is addressed in the plan itself: the order set change, the new flowsheet row and the education sessions. The evaluation therefore concentrates on process and outcome, with one balancing measure to catch harm the protocol might cause.

The Measures

The outcome measure is the share of eligible patients whose flowsheet shows no stool at any point before midnight ending the third day after surgery. The numerator is the number of such patients; the denominator is all adults admitted for elective primary hip or knee replacement during the measurement period who remain on the unit through day three; patients discharged earlier are excluded, as they were at baseline. The data source is the bowel movement entries on the nursing flowsheet. The target is 25 percent or lower, roughly halving the baseline, which is ambitious but consistent with the size of change seen when a bowel protocol replaces inconsistent practice. A secondary outcome, the median time from the end of surgery to the first documented bowel movement, will show whether bowel function returns earlier even among patients who do not cross the day-three line.

Three process measures show whether the protocol was followed. The first is the proportion of eligible patients who received senna on the evening of surgery, from the medication administration record, with a target of 90 percent. The second is the proportion of nursing shifts on which the new bowel status row was completed, from the flowsheet, with a target of 85 percent. The third is the proportion of patients still waiting for a first stool when day two closes who received the escalation dose of polyethylene glycol within the following shift, with a target of 80 percent.

The balancing measure is the proportion of patients with two or more loose stools, types 6 or 7 on the stool form scale, in any 24-hour period. Loose stools are the most likely harm of a stronger default regimen, and they carry their own risks for patients who are walking with a new joint and a walker. A protocol that halves constipation and doubles incontinence has not improved care; the balancing measure is there to catch exactly that trade.

When the Measures Will Be Read

The measures will be read at three levels of frequency. Weekly, from go-live in week six, the student will plot the day-three outcome and the three process measures on run charts, one point per week. Perla et al. (2011) describe the run chart as a simple way to learn from data displayed in time order, and they give rules for telling a real signal from chance, for example six or more points in a row on one side of the median, or five or more points in a row that keep rising or keep falling. Using those rules prevents the team from celebrating or abandoning the protocol on the basis of one good or bad week.

Formally, the outcome will be compared with the baseline at two fixed points. The first comparison, at week ten, will include roughly the first 25 patients and is a check on direction and on the balancing measure rather than a test of effect, since the sample is too small to show a difference reliably. The second, at week eighteen, will include about 75 patients, close to the baseline sample of 80, and will compare the proportions using a chi-square test. The capstone will report both the statistical result and the absolute difference in percentage points, because a reduction from 46 to 30 percent would matter to patients even if it did not reach statistical significance in a sample this size.

The balancing measure will be reviewed weekly. If more than 15 percent of patients in any two consecutive weeks have two or more loose stools in a day, the student, pharmacist and physician assistant champion will review the hold parameter before continuing.

Collecting the Data Without Extra Work

Every measure in this plan comes from documentation nurses already complete or will complete as part of the protocol, so the evaluation adds no separate data collection for the staff. The medication administration record supplies the senna and polyethylene glycol doses, and the new flowsheet row supplies bowel movement times and stool form. Stool form is recorded with the seven-type scale developed by Lewis and Heaton (1997), who showed that stool form tracks intestinal transit time, which makes it a reasonable bedside proxy for how the bowel is responding. The student will extract the data twice a week from a report built by the informatics nurse, using a simple spreadsheet with one row per patient.

The accuracy of the measures depends on the documentation, and documentation is itself something the protocol is trying to change. In a comparable project, a bowel management protocol with a new chart and staff education in an intensive care unit increased bowel care documentation significantly, while its effect on constipation itself was smaller and less certain (McPeake et al., 2011). That finding is a caution for this capstone: an apparent change in the outcome could partly reflect better charting rather than more bowel movements. The shift completion measure will help separate the two, because a jump in documentation without a matching change in bowel movement times would point to recording rather than physiology.

Conclusion

The evaluation plan fixes one outcome defined exactly as at baseline, three process measures that show whether the protocol was followed, a balancing measure for the harm it could cause and the times at which each will be read. Using Donabedian's framework separates a protocol that failed from a protocol that was not used. Run charts will show the pattern week by week, and two formal comparisons will judge the effect with a sample close to the baseline. Every choice is made before the first dose of senna is given, so that the capstone's result will be something the unit can trust.

References

Donabedian, A. (1988). The quality of care: How can it be assessed? JAMA, 260(12), 1743-1748. https://doi.org/10.1001/jama.1988.03410120089033

Lewis, S. J., & Heaton, K. W. (1997). Stool form scale as a useful guide to intestinal transit time. Scandinavian Journal of Gastroenterology, 32(9), 920-924. https://doi.org/10.3109/00365529709011203

McPeake, J., Gilmour, H., & MacIntosh, G. (2011). The implementation of a bowel management protocol in an adult intensive care unit. Nursing in Critical Care, 16(5), 235-242. https://doi.org/10.1111/j.1478-5153.2011.00451.x

Perla, R. J., Provost, L. P., & Murray, S. K. (2011). The run chart: A simple analytical tool for learning from variation in healthcare processes. BMJ Quality & Safety, 20(1), 46-51. https://doi.org/10.1136/bmjqs.2009.037895