Evidence-Based Practice Grant Application Form

| Resume a previously saved form
Resume Later

In order to be able to resume this form later, please enter your email and choose a password.

Application Details







Projected Dates of Project:  We realize that you may not have precise dates at this time.  Your best guess will suffice.



Principal Investigator Information:







Additional Team Members/Investigators
If there are additional people on your team please add them below- you may list up to 5 total


Additional Team Member/Investigator #1







Additional Team Member/Investigator #2







Additional Team Member/Investigator #3







Additional Team Member/Investigator #4







Additional Team Member/Investigator #5







Payment Information:











Institutional Official: If there is an Institutional Official (IO), who should receive copies of funding approval and report requests, please complete the information below.






Mentor Information
We strongly encourage our applicants to have mentors for their work, especially if you are not a highly experienced researcher. Hopefully a mentor will be available in your own institution or a nearby college/school of nursing.

Mentor: If you have a project mentor, please enter their information below:







IRB Information:





Please complete the following proposal. Use the APA format for references, citing the author and publication year in parentheses. (For example, Smith and Jones, 2012.) Then detail your references on an attachment.


To determine the number of words you are using, type in a Word document first and use word count.  Then copy/paste into the form below.

Purpose


NOTE ABOVE: Be as specific as you can (Example: Less strong: we want to determine if a patient/family education program works - Stronger: Determine if there is an improvement in patient/family satisfaction with discharge education after implementation of a computer-based medication education program).

Include the patient/family Population (i.e., only matching DAISY Foundation mission), clinical Problem, evidence-based Intervention for the practice change and desired Outcome.

Background

NOTE ABOVE
  • Describe the current clinical problem that you propose to change and cite appropriate evidence. Preliminary data from you organization may be included.
  • Who is the target audience? (e.g. what group of patients/family will be the focus of the project?)
  • Describe why this is a priority for these patients or families.
  • Describe how this project will benefit cancer or auto-immune disease patients and/or family, in keeping with DAISY Foundation’s stated goal, and how this project addresses the priorities of the J. Patrick Barnes Grant program.
  • Cite and summarize evidence (e.g., patient focused data from Quality Improvement/establishing a need, practice guidelines and more recently published research and research supporting the practice change) to support the need for a change, and also cite evidence to support the need for the initiative you are proposing.
  • Upload a list of references as an attachment to the application. (Uploading is explained below.)

Proposed Change

NOTE ABOVE

  • List step-by-step how the change will be implemented. Please see the sample EBP proposal for ideas when describing the desired practice.  
  • Describe timing within patient encounters (e.g., week 4 of radiation therapy) and use of tools to engage patients and clinicians.
  • When will you evaluate the outcomes of the change?
  • This description should be detailed enough that another organization could independently replicate your project.
  • The tools of the practice change must be ready to use and attached.

Permissions



Implementation Plan

NOTE ABOVE
  • Outline and use a phased implementation plan. A phased approach to implementation that prepares clinicians, assisting them with adoption of the EBP and re-infusion is required. One resource to provide direction is: Cullen, L. & Adams, S. (2012). Planning for Implementation of Evidence-Based Practice. Journal of Nursing Administration 42(4), 222-230.
  • Include a multi-faceted approach to implementation
  • Staff education can be included but must not be the only implementation strategy
Outcomes

NOTE ABOVE

Outcome measures include 1) a definition (e.g., patients will be asked to rate their fatigue on a 0-10 scale using Brief Fatigue Inventory (used with permission, The University of Texas MD Anderson Cancer Center, 1997), 2) how data will be collected (e.g., hard copy of patient questionnaire), 3) planned data analysis, and 4) reporting. Examples of outcome measures include patient symptoms related to cancer or cancer treatment. 

Evaluation Plan

NOTE ABOVE

  • Describe in detail how you will evaluate the outcomes of your initiative. Be as specific as possible on what your outcome measures are (e.g., pre-to-post change in item 1-5 of the Brief Fatigue Inventory (include citation and permission) will be used to evaluate the effectiveness of the intervention).
  • Include a brief description of the sample size and identification of the usual care group and the EBP or practice change group. Include a brief description of the sample and sample size for clinicians participating.
  • Process measures include clinician knowledge, clinician feedback on implementation with tools/resources, clinical practices used by clinicians, patient knowledge or patient health behaviors.
  • The process measures include 1) a general definition (e.g., patient activity practices will be collected by interviewing patients to obtain their self-reported frequency and time spent walking, gardening, doing household chores, work, and other forms of physical activity over the past week), 2) how data will be collected (e.g., patient interview), 3) planned data analysis (e.g., percent change in physical activity, paired t-test) and 4) reporting (e.g., report to unit council, quality committee).
  • Evaluation includes process measures (e.g., how you evaluated that the nurses were actually performing the change in practice) and outcome measures/endpoints in this section (e.g., pre -post evaluation of patient/family symptoms)
  • Preliminary data may be helpful but is not required.
Clinical Nurse Engagement

NOTE ABOVE

  • Describe in detail how clinical/staff nurses will be involved in this study. E.g. in conceptualization, data collection, analysis, reporting. This is a very important component of your proposal.
Timeline

Detail your proposed step-by-step timeline, following this example. Your plan should not exceed 12 months.

Study Timeframe


Your Timeline:

Create a spreadsheet identical to the one above to present your project’s timeline. Include additional steps from the EBP process model you identified previously as guiding this project work.  Please upload your timeline at the end of this application.

Proposed Budget

Funds are available for direct expenses only. Institutional overhead may not be included. Provide budget using the following chart and describe/provide justification for how you will use the grant funding to support your project (e.g., cost for reproduction of booklets - 500 booklets @ $2/booklet = $1000).  If the funding level offered by The DAISY Foundation is not adequate for your project, please email bonniebarnes@DAISYFoundation.org to discuss.

budget


Your Budget:

Create a spreadsheet identical to the one above to present your project’s budget.  Please upload your budget below.

Documentation

DOCUMENTATION – Upload the documents listed below.












Letter of Agreement

Please copy and paste this onto your institution’s letterhead.  Fill in the blanks, print it out and sign it. Your Chief Nursing Officer or other Senior Administrator's signature is also required as an indication of her/his support of your work. 


Then scan it into your computer, and upload with this application.  Your application is not complete without this document.

Letter of Agreement:

I, __________________________________________, Team Leader/Project Leader/Principal Investigator of the  project entitled _________________________________________________, commit the following to The DAISY Foundation in return for funding I request of $____________:

 

  • That funds will be used only for direct expenses as detailed in the budget provided in my application
  • That I will inform The DAISY Foundation of the actual start date of this study
  • That a check for any unused funds will be sent to The DAISY Foundation within 90 days of the project’s completion
  • That I will communicate in writing to The DAISY Foundation if my project is terminated before completion
  • That an interim report will be submitted 6 months after funding and a final report submitted within 90 days of the project’s completion. These reports will be submitted through The DAISY Foundation website.
  • That the report of my study may be posted on The DAISY Foundation website, if the Foundation chooses to do so.
  • That the DAISY Foundation is permitted to use my name/those of my team members and institution and the title and summary of my study in their marketing materials to help promote the grant program.
  • That I will submit my study to the Virginia Henderson Library of Sigma Theta Tau International within 30 days of filing my final report with The DAISY Foundation.
  • That I will credit funding from The DAISY Foundation upon publication/presentation of this research, using the authorized DAISY Foundation logo to be provided by The Foundation.
  • That The DAISY Foundation may not be held liable for any risk to the subjects of this study.

 

Signed ________________________________________                           Date_________________________

 

 

 FOR YOUR CHIEF NURSING OFFICER OR OTHER SENIOR ADMINISTRATOR:

 

I fully support __________________________________, Principal Investigator of the study entitled ___________________________________________________ in her/his implementation of this project.

 

Furthermore, I attest to the fact that nurse clinicians/staff nurses will be involved in this work, as described in the application.

 

Signed__________________________________________________

 

Title____________________________________________________

 

Date___________________________________________________

Application Checklist
Now that you have completed your proposal, please review it and check off each of the following requirements:

Acknowledgemnt

If the form becomes stuck on "please wait" or you are not re-directed to our to another page after you hit submit, please email Erin Ascher at ErinAscher@DAISYFoundation.org to confirm we have received your submission. Thank you!

Contact Information