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Application Details

Your Application Number. If you do not know your number, please email FaithThomas@DAISYFoundation.org

Date of Application:

Amount Requested (up to $2,500. Please do not include $ sign):

Project Title:

SHORT Name of EBP project (50 characters maximum. If this title is different than the one you submitted with your Letter of Intent, please add the word NEW):

Is this project directed to the treatment of patients/families with cancer or auto-immune disease?

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

From (choose date from calendar):

To (choose date from calendar):

Project Lead Information:

First Name:

Last Name:

Credentials:

Title:

Email:

Phone:

We support studies conducted by nurses who are both inexperienced and experienced in research and EBP. Please tell us your level of experience. (This will have no bearing on the evaluation of your application. It is for our information only.)

Additional Team Members/Investigators

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

Do you have additional Team Members/Investigators to add?

How many team members/Investigators do you wish to add?

Additional Team Member/Investigator #1

First Name:

Last Name:

Credentials:

Title:

Role of Team Member:

Email:

Phone:

Additional Team Member/Investigator #2

First Name:

Last Name:

Credentials:

Title:

Role of Team Member:

Email:

Phone:

Additional Team Member/Investigator #3

First Name:

Last Name:

Credentials:

Title:

Role of Team Member:

Email:

Phone:

Additional Team Member/Investigator #4

First Name:

Last Name:

Credentials:

Title:

Role of Team Member:

Email:

Phone:

Additional Team Member/Investigator #5

First Name:

Last Name:

Credentials:

Title:

Role of Team Member:

Email:

Phone:

Payment Information:

To whom will the check be written if you are approved? (An institution or a fund at your institution, only. Not to an individual.)

Institution Name:

Attention:

Street:

Department/mail stop/PO box, etc.:

City:

Country:

State:

Provinces:

State/Province:

Postal Code:

Institutional Official

Is there is an Institutional Official (IO), who should receive copies of funding approval and report requests?

Institutional Official: Contact Information

First Name:

Last Name:

Credentials:

Title:

Email:

Phone:

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.

Have you identified a Project Mentor in your organization or community?

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

First Name:

Last Name:

Credentials:

Mentor's Insitution:

Title/Position in institution:

Email:

Phone:

IRB Information:

Are human subjects involved?

Has IRB approval been granted?

Enter the IRB Identification Number (Please upload your proof of IRB approval at the end of this application):

If IRB approval is pending, on what date is approval anticipated?

Is your project IRB-exempt? If so, please upload your IRB exemption letter below.

Please complete the following proposal. Please number your references throughout. (For example, “Cholesterol is comprised of two values(3)”. Then, please use APA format and detail your corresponding references on an attachment. (For example, Smith and Jones, 2012.)

Purpose

Purpose of the project (Maximum 200 words):

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

Background (Maximum 400 words):

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.)

EBP Model: Which EBP process model for literature synthesis, translation of your initiative into practice and evaluation of your outcomes will you follow to structure your work? (e.g. Iowa Model, Johns Hopkins Model, or another model in use at your organization)

Proposed Change

Describe the Proposed Change (Maximum 500 words):

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

Are you using a copyrighted tool or instrument that requires permission from the author, publisher, or organization, etc. who created it?

If you are using a tool that requires permission, please confirm that you have permission now to use the tools you propose

From whom do you have permission? Please list tools and permissions granted. Be sure to upload your tool or instrument at the end of this form (directions below) and written permission to use it.

Implementation Plan

Implementation Plan (Maximum 400 words):

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

Outcomes (400 words maximum):

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

Evaluation Plan (Maximum 400 words):

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

How will clinical nurses be engaged in this project? (Maximum 250 words)

NOTE ABOVE

Describe in detail how clinical/staff nurses will be involved in this project. 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.

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).

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 (see below)

Budget

Timeline

Tools or instruments you are using

Interview formats, discussion guides, etc.

Consent Forms- if consent forms are required for IRB approval, they must be submitted with this application.

References (detail the sources of your assumptions and literature review)

Applicant's resume or CV. Please highlight funded and unfunded studies and EBP projects.

Permission to use the tools or instruments

If you have a Mentor, the Mentor's biosketch or abbreviated CV. This should include the Mentor's accomplishments/experience/academic training as they relate to this project.

Proof of IRB approval or letter of exemption if you have it. If you do not have input from your IRB, you may apply and provide the approval prior to DAISY's funding of the grant.

Additional Documentation

If you have additional documentation that you would like to provide, you may upload it here. Please name each document/file to clearly indicate what it is.

Additional 1

Additional 2

Additional 3

Additional 4

Additional 5

Additional 6

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 project
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 project 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 project in their marketing materials to help promote the grant program.
That I will submit my project 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 project.

Signed ________________________________________ Date_________________________

FOR YOUR CHIEF NURSING OFFICER OR OTHER SENIOR ADMINISTRATOR:

I fully support __________________________________, Project Lead of the EBP project 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:

Checklist

Now that you have completed your proposal, please review it and check off each of the following requirements:Your project is an Evidence-based Practice Project (EBP), not a Quality Improvement project (QI)Your Purpose statement contains the patient population matching The DAISY Foundation's mission, clinical problem, evidence-based intervention or practice change and desired outcome.Your Team includes staff nurses in project leadership roles, change agent(s) and an EBP expert as a mentor.Your Background describes why this is a priority for patients/families and the organization.Your Background describes a synthesis of the evidence establishing the need to address the clinical issue (e.g., cited prevalence of the clinical problem), the benefit of the intervention, and expected impact on process and outcome indicators. Evidence is cited that is current and comprehensive. If a practice guideline is part of the evidence synthesis you include a brief summary of the strengths and limitations as identified by your critique (e.g., using the AGREE Instrument - link to http://www.agreetrust.org/ or http://www.agreetrust.org/wp-content/uploads/2013/10/AGREE-II-Users-Manual-and-23-item-Instrument_2009_UPDATE_2013.pdf). If a practice guideline is used, you include a synthesis of more recent evidence (including research and EBP) that has been reported subsequent to the date of the evidence review within the guideline.Your EBP Process Model provides direction for project development and planning. Commonly-used models include the Iowa Model, Johns Hopkins Model, or another model used in your organization.Your Proposed change describes the procedure for the use of the evidence-based practice being introduced such that any nurse reader would be able to use the procedure as intended. Please see the sample EBP proposal for ideas when describing the desired practice, timing within patient encounters (e.g., week 4 of radiation therapy) and use of tools to engage patients and clinicians.Your Implementation Plan describes a multi-faceted approach to engage clinicians and patients in use of the practice change. Do not limit implementation to education of clinicians, as additional implementation strategies will be needed. Consider a re-infusion plan along with a plan to promote initial adoption.Your Process evaluation is included in the evaluation plan and describes the key process measures/indicators including a general definition (e.g., patient activity practices will be collected by interviewing patients to self-report the frequency and time spent walking, gardening, household chores, work, and other forms of physical activity over the past week), how data will be collected, planned data analysis and reporting. Examples of process measures include clinician knowledge, clinician feedback on implementation tools, clinical practices used by clinicians, patient knowledge or patient health behaviors. Preliminary data may be helpful but is not required.Your Outcome evaluation is included in the evaluation plan and describes the key outcome measures/indicators including 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), how data will be collected, planned data analysis and reporting. Examples of outcome measures include patient symptoms related to cancer or cancer treatment. Preliminary data may be helpful but is not required.Your Attachments include ALL the tools to assist the clinician in engaging patients to participate in the practice change.Your Attachments include ALL the tools used for data collection.Your Attachments include all letters granting permission for use of tools.Your Attachments includes a timeline that uses the format described above. It includes the steps of the EBP process following development of the tools supporting the practice change (i.e., Copying of patient materials, copying of data collection tools, staff training about practice change, core group work to promote adoption of the practice change, reinfusion plans, monitoring progress, data collection, data entry, data cleaning and analysis, Interim and Final Reports to The DAISY Foundation, etc.)Your Attachments include a budget for materials and tools needed to engage patient in the practice change, train clinicians and complete the evaluation. You have used the format described above.Your Attachments includes the letter of agreement with The DAISY Foundation, signed by you and your CNO or other administrative leader.Your Attachments includes the list of references cited within the application.Your Attachments include the CV of the applicant and EBP mentor.

Acknowledgemnt

By checking this box and submitting the online form, you agree to The DAISY Foundation collecting and storing your personal contact information. We may contact you if we have questions about your submission or to discuss next steps. To learn more, please read our Privacy Policy.

I Agree

Please allow a few minutes for the form to process. If the form becomes stuck on "please wait" or you are not re-directed to another page after you hit submit, please email Christina Johnson at ChristinaJohnson@DAISYFoundation.org to confirm we have received your submission. Thank you!

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